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Vaccine storage | Signal

Reference number
1104 H
Issue date24 September 2009

This ‘Signal’ is about problems with breaking cold chain for vaccines in general practices and other settings.


Extract from incident reported to the RLS:
“Fridge in nurses room temperature log shows temperatures out of range, i.e. outside 2-8oC. Older records show 0 in March and July up to 13. Fridge stock including vaccines to be ineffective due to these temperatures. Flu stock found to be stored in the food fridge, no temperature records kept or available.”


The National Reporting and Learning Service (NRLS) is aware of local situations where vaccines have been stored outside recommended temperature range, resulting in unviable vaccines and potentially large patient recall programmes. 


A review of the Reporting and Learning System (RLS) showed 269 incidents, mainly in general practice settings, but also community clinics, hospitals and out-of-hours services.


Key issues included fridges showing wrong temperature range; temperatures recorded and not acted on; delay in getting batches in fridges following transport; broken fridges and inappropriate storage.  


No major harm was reported in these incidents – by definition, the outcome would not be immediate (such as a child not being immunised), but this raises important issues about safe systems.


Learning from local investigations highlight gaps in staff knowledge and accountability, plus confusion on practical issues, such as use of reset button on thermometer and positioning of temperature probes. Staff are reminded of national guidance on safe storage of vaccines.


The NRLS is also carrying out a wider thematic review of vaccine safety, including wrong vaccine errors, out-of-date vaccines and poor preparation.  


We would like to know if you have carried out local audits of fridge temperatures or had to take action due to a break in the cold chain. Were any patients unprotected as a result? We would also welcome a real push on reporting vaccination issues to the RLS over the forthcoming flu season, as this evidence may help to shape future guidance.


Please contact us.


Signals are notifications of key risks emerging from review of serious incidents reported and shared by the NRLS.


Relevant to: general practice, medication



Short Survey on the value and effectiveness of Signals

This is a pilot project. To assess the value and effectiveness of Signals, we would be grateful if you and your staff could take a few minutes to answer a short survey. We would like to know if you have found Signals useful and how it could be developed further to suit your needs.