Sample policy · GP

Vaccination and cold chain policy (gp)

1. Purpose

This policy sets out how the Practice orders, receives, stores, transports, administers and disposes of vaccines while maintaining cold-chain assurance.

It also covers fridge failure, temperature excursions, wrong vaccine administration, omissions and Yellow Card reporting.

2. Sources to verify before adoption

3. Scope

This policy applies to:

It applies to NHS vaccination programmes and private vaccination services where the Practice provides them.

4. Cold-chain process

The Practice follows a documented cold-chain process for every vaccine.

4.1 Ordering and receipt

Staff order vaccines through the approved route.

On receipt, staff record:

Staff place vaccines in the approved fridge promptly and escalate any concern about delivery condition.

4.2 Fridge storage

Vaccines are stored only in approved vaccine fridges.

The Practice keeps each fridge:

Staff check current UKHSA Green Book chapter 3 and CQC source material for exact storage requirements before adoption.

4.3 Temperature monitoring

The Practice records vaccine-fridge temperatures according to the local procedure.

The temperature record includes:

Staff do not adjust or ignore readings without recording the reason and action taken.

4.4 Transport

Where the Practice transports vaccines, the Cold Chain Lead sets a written transport process.

The process records:

The Practice verifies transport process against current Green Book chapter 3 source material before adoption.

5. Cold-chain failure and quarantine

The Practice treats fridge failure, transport excursion and unexplained temperature reading as a cold-chain incident.

Staff:

The Practice verifies batch quarantine wording and decision routes against current UKHSA Green Book chapter 3 and local commissioning guidance before adoption.

6. Vaccine incidents and Yellow Card reporting

The Practice records vaccine incidents as incidents.

This includes:

Where an adverse event or medicine-safety concern may need Yellow Card reporting, staff check the current GOV.UK Yellow Card route and record the decision.

Where wrong vaccine or significant omission creates patient-safety risk, staff:

7. Responsibilities

8. Recording requirements

The Practice keeps the following records:

Records are kept in the Practice governance records or clinical system according to the local procedure.

9. Audit cadence

The Practice uses the following Verivius default audit rhythm unless current source material requires more frequent review:

Audit findings are recorded as improvement actions with an owner and review date.

10. Version control and review date

The Practice keeps a controlled copy of this policy. The footer or document-control table records:

11. Related records

Review cadence: annual or on regulatory change, whichever sooner. Owner: Registered Manager.

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Last reviewed 21 May 2026