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National Patient Safety Agency

Frontline services urged to follow latest guidance on vaccine storage

21 JANUARY 2010


New guidance, produced by the National Patient Safety Agency (NPSA) and frontline services across England and Wales, has been published today aimed at ensuring clinicians store vaccines at the recommended manufacturer temperature range.


The Rapid Response Report issued to all NHS acute and community organisations, as well as the independent sector, follows details received by the NPSA of 260 reported patient safety incidents between 1 January 2005 and 1 April 2009 of incorrect vaccine storage.  During this time, 50 million doses of childhood vaccines were distributed across the UK.


Issues included a delay in storage of vaccines, storage at wrong temperature range, fridge switched off or broken as well as no temperature monitoring.  It is not known if any of these incidents led to significant harm to the patient.


Today’s RRR calls on frontline services to ensure:


·        that all departments and providers (including independent contractors) who hold vaccine stocks have been issued with guidance relating to Vaccine Cold Chain Storage;


·        procedures are in place to ensure correct working practices are being followed.  This would include reviewing refrigerator temperature at regular intervals which would highlight if vaccines had been stored outside manufacturers’ recommended temperature ranges, before they are given to patients;


·        policies are in place for remedial action where vaccines are stored outside manufacturers’ recommended temperature ranges, and ensure departments and providers are aware of these.


This latest Rapid Response Report follows the NPSA being alerted to a safety incident that showed childhood vaccines had been stored incorrectly at a GP practice, potentially resulting in reduced efficiency of some vaccines.


Subsequent local audit showed that this may not have been an isolated incident. 


The NPSA’s Head of Primary Care, Dr Bruce Warner, explained: “Thousands of vaccines are administered safely to patients of all ages each day.  However, we have received reports of preventable incidents where vaccines have been stored at incorrect temperatures which in some cases can significantly reduce their effectiveness.


"Our recommended actions within this latest Rapid Response Report should make systems more safer for patients.”


To view the guidance, please visit: www.npsa.nhs.uk/nrls/alerts-and-directives/rapidrr/




Note to editors:



  1. Media enquiries to the NPSA Press Office:

Simon Morgan – 020 7927 9580 / simon.morgan@npsa.nhs.uk

Dinah Lartey – 020 7927 9351 / dinah.lartey@npsa.nhs.uk

Out of hours – 0788 411 5956


  1. The National Patient Safety Agency (NPSA) is an Arm’s Length Body of the Department of Health. It encompasses three divisions; the National Research Ethics Service, the National Reporting and Learning Service and the National Clinical Assessment Service. Each has its own sphere of expertise to improve patient outcomes. The NPSA’s vision is to lead and contribute to improved, safe patient care by informing, supporting and influencing healthcare individuals and organisations. For more information visit: www.nrls.npsa.nhs.uk.