Standard operating procedure

Medication Supply & Cold Chain Procedure

The step-by-step procedure for sourcing, storing, supplying and posting weight-management medicines - in particular refrigerated glucagon-like peptide-1 (GLP-1) receptor agonists - so that every product is supplied only against a valid prescription from a registered pharmacy or licensed wholesaler, kept within its labelled storage conditions throughout the cold chain, and recorded against the patient who receives it.

For Weight Loss ClinicRef BS-WEI-SOP-010See a sample (PDF) →
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  • Mapped to the CQC standards
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What's inside

This standard operating procedure is fully drafted and structured, ready to brand and complete for your service. It covers:

  • 1. Purpose
  • 2. Scope
  • 3. Definitions and abbreviations
  • 4. Responsibilities
  • 5. Equipment and materials
  • 6. Procedure
  • 7. Cold-chain excursions, delayed, lost or compromised deliveries
  • 8. Records
  • 9. Related documents
  • 10. Review and version control
  • 11. Disclaimer

Legislation & standards it maps to

  • Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 12 (Safe care and treatment)
  • The Human Medicines Regulations 2012
  • The relevant Summary of Product Characteristics (SmPC) storage requirements for the specific product supplied, together with Medicines and Healthcare products Regulatory Agency (MHRA) guidance
  • Medicines and Healthcare products Regulatory Agency (MHRA) guidance on the control and monitoring of storage and transportation temperatures of medicines
  • Medicines and Healthcare products Regulatory Agency (MHRA) guidance on distance selling and the online supply of medicines
  • General Pharmaceutical Council (GPhC) Standards for registered pharmacies, and guidance for registered pharmacies providing pharmacy services at a distance, including on the internet
  • Good Distribution Practice for medicinal products, as applied in the United Kingdom

Who it applies to

All staff at [Organisation Name] involved in sourcing, ordering, receiving, storing, dispensing, packing, posting, delivering, monitoring or recording the supply of weight-management medicines, including the registered manager, the responsible pharmacist or [Insert Job Title] where a pharmacy is involved, prescribers, dispensing and pharmacy support staff, and any administrative or dispatch staff who handle stock or deliveries.

Glossary

Plain-English explanations of the technical terms and legislation used in this document.

Batch number
A code on a medicine pack that identifies the production run it came from, so a specific group of products can be traced and recalled if needed.
Care Quality Commission (CQC)
The independent regulator of health and social care services in England.
Cold chain
The unbroken system of refrigerated storage, monitoring and transport that keeps a medicine within its safe temperature range, usually 2 to 8 degrees Celsius, all the way from the supplier to the patient.
Cold-chain excursion
Any time a refrigerated medicine goes outside its allowed temperature range, or stays out of the fridge for longer than permitted, whether in storage or in transit.
Conditioned coolant
Ice or gel packs that have been brought to the correct temperature before packing, so they keep a parcel cool without freezing the medicine.
Contemporaneous record
A note written at the time an action is carried out, rather than from memory later, so the record is accurate and reliable.
Controlled drug
A medicine whose supply, storage and records are tightly restricted by law because of its potential for misuse.
Decontamination
The combined process of cleaning, disinfecting and, where needed, sterilising equipment so it is safe to reuse.
Dispensing
Preparing and supplying a medicine to a named patient against a valid prescription.
General Pharmaceutical Council (GPhC)
The body that registers and regulates pharmacists, pharmacy technicians and pharmacies in Great Britain.
GLP-1 receptor agonist
A type of injectable weight-management medicine (glucagon-like peptide-1 receptor agonist) that is usually supplied refrigerated and can only stay out of the fridge for a limited time.
Good Distribution Practice
The agreed standards for storing, transporting and handling medicines so their quality is protected from the manufacturer to the patient.
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
The regulations setting the fundamental standards that providers of regulated health and care must meet, including Regulation 12 on safe care and treatment.
Human Medicines Regulations 2012
The main United Kingdom law governing how medicines for people are licensed, supplied, sold and labelled.
In-use stability window
The limited period a medicine may safely be kept out of the fridge once it has been removed, as set out in its Summary of Product Characteristics.
Infection prevention and control (IPC)
The measures used to stop infection spreading between patients, staff and visitors.
Licensed wholesaler
A company that holds an official authorisation (a wholesale dealer's licence) allowing it to buy and supply medicines in bulk in the United Kingdom.
Maximum and minimum thermometer
A thermometer that records the highest and lowest temperatures reached since it was last reset, used to confirm a fridge stayed within range overnight.
Medicines and Healthcare products Regulatory Agency (MHRA)
The United Kingdom body responsible for regulating medicines and medical devices, including storage and temperature guidance, recalls and safety alerts.
Near miss
An event that could have caused harm but did not, by chance or because it was caught in time.
Patient information leaflet
The printed leaflet supplied with a medicine that explains how to use and store it safely and what side effects to watch for.
Prescriber
A health professional legally allowed to authorise a medicine for a patient, such as a doctor, or a nurse or pharmacist with prescribing qualifications.
Prescription-only medicine (POM)
A medicine that may lawfully be supplied only on the instruction of an appropriate prescriber.
Quarantine
Keeping suspect, recalled, expired or returned stock clearly separated so it cannot be supplied until a decision is made about it.
Reconciliation
Checking that the amount of stock recorded matches the amount physically present, and investigating any difference.
Registered manager
The person registered with the regulator as responsible for the day-to-day running of a service.
Registered pharmacy
A pharmacy registered with the General Pharmaceutical Council and supervised by a responsible pharmacist.
Responsible pharmacist
The pharmacist legally in charge of the safe and effective running of a pharmacy at a given time.
Risk assessment
A structured check identifying what could cause harm and what is being done to prevent it.
Sharps
Needles, blades and other items that can cut or puncture the skin.
Sharps bin
A puncture-proof container for safely throwing away used needles and other sharp items.
Standard Operating Procedure (SOP)
A written, step-by-step instruction describing how a particular task is to be carried out consistently and safely.
Stock rotation
Arranging and using stock so that items closest to their expiry date are supplied first.
Summary of Product Characteristics (SmPC)
The official document for each licensed medicine that sets out, among other things, its approved use, dosing, storage conditions and shelf life.
Titration
Gradually adjusting the dose of a medicine, usually building it up in steps, to reach the right level for a patient.
Validated cold-chain packaging
Insulated packaging with coolant that has been tested to keep its contents within 2 to 8 degrees Celsius for a set time and conditions, used for posting refrigerated medicines.
Wholesale dealer's authorisation
The official licence a company must hold to lawfully buy, store and supply medicines wholesale in the United Kingdom.

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  4. Add the optional updates subscription and we keep it current as guidance changes.

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