Temperature monitoring of medications is one of many areas regulated by The Joint Commission (TJC). Under element of performance (EP) 2 for standard MM.03.01.01, medications must be stored according to manufacturer recommendation (or, in the absence of recommendation, according to the pharmacist’s instructions). While it is not specifically stated, historically, you must demonstrate that someone checked the temperature of refrigerators and warmers where medications are stored at least every 24 hours. In addition, the California Department of Public Health (CDPH) requires an alerting system to quickly identify situations when high and low refrigerator temperature limits are exceeded. While neither TJC nor the CDPH specify using wireless temperature monitoring, it was obvious that purchasing this type of a system would be the best option for our facility to meet these expectations. Not only would it meet the CDPH’s requirement for an “alerting system,” but we also would have all temperature data recorded automatically and stored for easy access in the event of a TJC inspection.

Prior to implementing wireless temperature monitoring, our pharmacy technicians checked all medication refrigerators daily and reported any issues to the pharmacist on duty and/or the engineering department. After we were cited during a TJC inspection for not checking the medication refrigerators in the operating room when closed on the weekends, we decided to move forward with implementing a wireless temperature monitoring solution.

Since employing the system in 2006, we have been able to more easily and efficiently manage medication monitoring. In fact, we were able to purchase a new medication refrigerator before the old one reached the end of its life cycle because we can easily track how many times each refrigerator has alarmed and what corrective actions were taken, and therefore preempted the failure of the old unit. In addition, we are now able to easily achieve regulatory compliance, and when we were inspected again by TJC in 2009, the agency was satisfied with our solution for temperature monitoring of medications.

Ron Jue, PharmD, is the administrative director of clinical services at Community Hospital of Long Beach in Long Beach, California.

Documentation Procedure for Alert Resolutions at Community Hospital of Long Beach

1. Click the CheckPoint icon on the workstation desktop and enter login name to open the program.
2. User name, date, and time are automatically recorded in User Login History as a digital signature, evidencing daily temperature check.
3. If no alerts exist, close the program.
4. If a red alert exists, take corrective action as prompted by the program:
   
   1. First, select the suspected cause of the temperature deviation.
   2. Next, in the first box, enter the condition of the medications and whether their fitness for use has been compromised.
   3. In the second box, enter the corrective action taken, such as:
      1. Relocation of medication to another refrigerator, or
      2. Action taken to correct the cause of the temperature deviation, such as:
         • Monitored only, temperatures self-corrected with time
         • Adjusted temperature setting
         • Called engineering
   4. If the cause of the problem is not quickly resolved, as can be the case with mechanical failure, select “No” when queried “Is equipment working properly?” This will change the alert from red to yellow, which indicates an alert for which corrective actions are ongoing.
   5. Digitally sign by entering user login ID.
   6. After the cause of the problem is resolved, right click on the alert, select “Process Further,” enter information as prompted.
   7. Digitally sign by entering user login ID to close the alert.
   8. If the alert was due to a sensor communication problem (No Sensor Contact), determine the cause and correct, or contact the company’s system administrator if the problem persists beyond 24 hours.