WOMEN AND NEWBORN HEALTH SERVICE
King Edward Memorial Hospital
CLINICAL GUIDELINES
COMMUNITY MIDWIFERY PROGRAM
STANDARD PROTOCOLS
STORAGE AND TRANSPORTATION OF
MEDICATIONS
STORAGE AND TRANSPORTATION OF MEDICATIONS
PROTOCOL
Medication storage requirements:
Medication
Syntocinon
Syntometrine
Ergometrine
Misoprostol
Lignocaine
Vitamin K
Anti D
Benzylpenicillin
Hartmann’s solution
Temperature
2 - 8 degrees Celsius
2 - 8 degrees Celsius
2 - 8 degrees Celsius
< 25 degrees Celsius
< 25 degrees Celsius
< 25 degrees Celsius
2 – 8 degrees Celsius
< 25 degrees Celsius
<30 degrees Celsius
Environment
Must be kept dry
Protected from light
Protected from light
Procedure
For transportation of medication requiring storage between 2 – 8 degrees Celsius
prepare the container as described below
Ice Packs
 Ice packs are water filled and require at least 24 hours in a freezing compartment of a
domestic refrigerator to freeze. They must not contain other chemicals that increase
risk of freezing medication solutions.
 Prior to use, remove ice packs from the freezer and lay out the ice packs in a single
row on their sides (where possible) leaving a 5cm space around each ice pack to
allow maximum air exposure to reduce ‘conditioning’ time.
 Wait until ice packs begin to sweat. This will take up to one hour.
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The ice pack is ‘conditioned’ as soon as water begins to ‘slosh’ about slightly inside
the ice pack. ‘Conditioning’ is important to minimise the risk of damaging solutions
through freezing.
The ice packs are to be replaced at the beginning of each day.
Packing an Esky (cool box/bag)
The diagram below is to be used as a guide when using a hard esky. If using a soft esky it
must be packed to have no air gaps and sufficient cold packs to maintain the temperatures
as above.
health.wa.gov.au
2015
CMP 8.1
All guidelines should be read in conjunction with the Disclaimer at the beginning of this section
Page 1 of 3
Transportation of medications requiring storage between +2°C and +8°C
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Refrigerated medications, which are to be transported outside the building where
they are stored, must be monitored with a minimum/maximum thermometer that will
indicate exposure to <0°C and temperatures > +8°C when packed and in transit, to
ensure the temperature range is maintained between +2°C and +8°C.
Handling and transportation time should be kept to a minimum to ensure that they
remain refrigerated at all times.
Medications must be stored in plastic containers so that the solutions do not come
into contact with the ice packs which are at freezing temperature.
Ensure the contents of the esky are secure so that they cannot move around during
transportation.
Place the esky out of direct sunlight – for example in the car boot or within the birth
bag.
A temperature monitoring device (supplied to all midwives) should be used to record
the minimum and maximum temperature range of the refrigerated medication during
the transportation process. The monitoring device should be placed in the middle of
the package of refrigerated medication. If using a minimum / maximum thermometer
to monitor temperatures during transportation, temperatures should be recorded
daily on a medication fridge/esky temperature record sheet (see attached) which is
provided to all midwives.
The minimum/maximum thermometer must be checked daily on return to the staff
member’s base/home and if a temperature breach has occurred, the process below
must be followed.
Management of a cold chain breach
 A breach of cold chain integrity must be reported to the CMP manager on call and the
midwife must change the affected drugs immediately.
CMP 8.1
CMP 1.1.2
All guidelines should be read in conjunction with the Disclaimer at the beginning of this section
Page 2 of 3
Page 2
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On site storage
Refrigeration:
The refrigerator is to be used exclusively for storage of medications and must be
lockable or in a locked office. The door must seal well and the refrigerator must be
placed away from direct sunlight.
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The refrigerator’s power source is to be clearly marked in a way to prevent the
refrigerator from being accidentally unplugged or turned off.
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The medications are to be stored in their original packaging, within the refrigerator.
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A medication fridge/esky temperature record sheet (see attached) is to be utilised to
record the refrigerator temperature in degrees Celsius. The minimum and maximum
temperature is to be recorded daily during the period of occupancy of the work
environment.
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Refrigerator breakdowns are to be reported to the manager immediately and
alternative arrangements for monitored storage of medications are to be found.
Storage by midwives
The midwife shall store all medications in her fridge overnight in a locked box
(provided to all Midwives).
REFERENCES / STANDARDs
1.National Vaccine Storage Guidelines, Strive for 5, Commonwealth of Australia 2005 Seto, J, Marra F, 2007 Chain
Management of Vaccines.
2.Daily Vaccine Fridge Temperature Recordings, Immunisation Program, department of Health. 2006
National Standards – 1- Care Provided by the Clinical Workforce is Guided by Current Best Practice
Legislation – Poison’s Act 1964
Poison’s Regulations 1965
Related Guidelines / Policies – CMP Medications Standing Orders
Other related documents – KEMH Clinical Guidelines
RESPONSIBILITY
Policy Sponsor
Nursing & Midwifery Director OGCCU
Initial Endorsement
June 2009
Last Reviewed
July 2014
Last Amended
Review date
July 2017
Do not keep printed versions of guidelines as currency of information cannot be guaranteed. Access
the current version from the WNHS website.
Department of Health Western Australia 2015
Copyright disclaimer available at: http://www.kemh.health.wa.gov.au/general/disclaimer.htm
CMP 8.1
CMP 1.1.2
All guidelines should be read in conjunction with the Disclaimer at the beginning of this section
Page 3 of 3
Page 3