| 19/11/2021 |
Failing to maintain controlled drug running balances and investigate discrepancies. |
Governance, Lack of key knowledge and a failure to learn, Responsiveness |
Principle 1. Governance, Principle 4. Services, including medicines management |
1.1, 1.6, 4.3 |
The pharmacy does not always manage its high-risk controlled drug medicines as it should. It does not act appropriately when discovering a balance discrepancy within its controlled drug register. And it does not follow due process to investigate and account for the discrepancy. It does not identify the risks which come from this poor controlled drug management. And there is also an absence of shared learning to help prevent similar adverse events from happening again. |
Details
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| 16/11/2021 |
Effectively using near miss records and regular reviews to reduce the risk of mistakes being made. |
Customer and patient focus, Governance, Outcomes for patients, Proactive approach, Responsiveness |
Principle 1. Governance, Principle 2. Staff |
1.1, 1.2, 2.4 |
The pharmacy has effective processes for reviewing any mistakes it makes. And it takes action to prevent them from happening again. Team members reflect on whether the learning and improvements from previous reviews have been sustained. And they continue to look for new ways to improve the safety and effectiveness of the pharmacy’s services. |
Details
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| 16/11/2021 |
Understanding how to sell over-the-counter codeine-containing medicines safely |
Customer and patient focus, Governance, Outcomes for patients |
Principle 1. Governance, Principle 4. Services, including medicines management |
1.1, 4.2 |
The pharmacy assesses the risk of selling codeine-containing medicines. And it has safeguards in place to monitor the sales of these medicines. Pharmacy team members have a good awareness of the potential for misuse of these higher risk medicines. And they sell these medicines appropriately with additional advice. |
Details
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| 11/10/2021 |
Using automation to support the safe and efficient preparation of multi-compartment compliance packs. |
Efficiency of processes, Governance, Innovation, Responsiveness |
Principle 1. Governance, Principle 4. Services, including medicines management |
1.1, 1.2, 4.2, 4.3 |
The pharmacy invests in automation to support the pharmacy team in assembling compliance packs. The system is risk assessed regularly and has in-built safety checks to reduce the risk of human error. |
Details
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| 25/08/2021 |
Using national guidance to inform the delivery of specialist pharmacy services |
Customer and patient focus, Efficiency of processes, Governance, Outcomes for patients, Proactive approach |
Principle 1. Governance |
1.2 |
The pharmacy uses recognised guidance for planning its EHC and OC services. It has internal and external stakeholders who monitor the content of these plans against this guidance. |
Details
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| 25/08/2021 |
Supporting vulnerable people in decision making |
Customer and patient focus, Governance, Outcomes for patients, Proactive approach, Responsiveness |
Principle 1. Governance |
1.8 |
The pharmacy uses respected guidance to help vulnerable people to make their own decisions about contraception. This includes assessing people’s ability to understand and agree to any contraceptive treatment. And it allows them to express their own wishes. |
Details
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| 22/07/2021 |
Using contrasting colour background to make the contents of multi-compartment compliance packs more visible for dispensing and checking. |
Customer and patient focus, Governance, Outcomes for patients, Proactive approach, Responsiveness |
Principle 4. Services, including medicines management |
4.2 |
The pharmacy is finding ways of making the dispensing and checking of multi-compartment compliance packs safer and more efficient. |
Details
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| 22/07/2021 |
Using regular newsletters to share learning, promote feedback and engage team members in identifying LASA medicines and other risks related to patient safety. |
Customer and patient focus, Governance, Leadership, Outcomes for patients, Proactive approach, Responsiveness |
Principle 1. Governance, Principle 2. Staff |
1.2, 2.4 |
The pharmacy owner regularly reminds its team members to be open and honest when reporting mistakes. The owner undertakes regular safety reviews of error reporting across its pharmacies. And it uses the information from these reviews to share learning through engaging newsletters. These help to maintain a clear safety culture. And it supports team members in identifying improvements to patient safety. |
Details
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| 22/07/2021 |
Providing healthy living advice and tailored information to people that are using an online prescribing service. |
Customer and patient focus, Governance, Outcomes for patients, Proactive approach |
Principle 4. Services, including medicines management |
4.1, 4.2 |
The pharmacy does not see people face-to-face. But it still considers the additional healthy living advice that people using its services may need. And it actively signposts people to helpful information and to other healthcare providers. |
Details
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| 22/07/2021 |
Optimising effective communication between an online prescribing service and the person’s usual GP. |
Customer and patient focus, Governance, Outcomes for patients, Proactive approach |
Principle 1. Governance, Principle 4. Services, including medicines management |
1.1, 1.2, 4.2 |
The pharmacy obtains consent to inform the person’s usual GP when medicines are prescribed through its online prescribing service. It verifies the information people provide when completing the consultation questionnaires. This ensures people receive medicines that are appropriate for them. |
Details
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| 21/07/2021 |
Using continual review processes to help improve safety when handing out assembled medicine |
Governance, Outcomes for patients |
Principle 1. Governance, Principle 4. Services, including medicines management |
1.1, 4.3 |
The pharmacy uses continual review processes to identify and manage risks associated with supplying medicines to people. It takes timely action to implement changes designed to reduce risk when supplying medicines. |
Details
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| 08/06/2021 |
Use of ‘reflective statements' to improve dispensing following near misses. |
Efficiency of processes, Governance, Outcomes for patients, Responsiveness |
Principle 1. Governance, Principle 2. Staff, Principle 4. Services, including medicines management |
1.1, 1.2, 2.4, 4.2 |
The pharmacy conducts meaningful reviews of mistakes made during the dispensing process. This has driven changes to the pharmacy practices. And has made the whole team more mindful when dispensing. The team uses the company’s processes for review in a way which enhances individual learning. |
Details
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| 20/04/2021 |
Using peer review processes to help support the learning and continual professional development of Pharmacist Independent Prescribers |
Added value, Customer and patient focus, Efficiency of processes, Governance, Innovation, Leadership, Outcomes for patients, Proactive approach, Responsiveness |
Principle 2. Staff |
2.2, 2.4 |
The pharmacist independent prescriber (PIP) is actively using communication channels with PIP colleagues to share practice, to learn from each other and develop further. This broadens the scope of their practice, therefore increasing access to safe and effective treatment for a growing range of symptoms and conditions, for people in different locations. |
Details
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| 06/04/2021 |
Ensuring the way medicines are supplied meets the needs of the patient |
Customer and patient focus, Governance, Outcomes for patients |
Principle 1. Governance, Principle 4. Services, including medicines management |
1.1, 1.2, 4.2 |
The pharmacy has systems in place to ensure the provision of medicines in multi-compartment compliance packs is suitable for the person requesting the service. It provides alternate support to people identified as requiring help with taking their medicines when the supply of compliance packs is not appropriate for the person. |
Details
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| 07/03/2021 |
Reviewing how over-the-counter medicines which may be liable to abuse or misuse are sold |
Customer and patient focus, Governance, Proactive approach, Responsiveness |
Principle 1. Governance, Principle 2. Staff, Principle 4. Services, including medicines management |
1.1, 1.2, 2.2, 2.4, 4.2, 4.3 |
The pharmacy is supporting its team members' learning and development associated with requests for higher-risk over-the-counter medicines. This is directly in response to media coverage of GPhC enforcement action against pharmacies around the unsafe supply of codeine linctus. |
Details
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| 20/03/2020 |
Failure to act on health and safety concerns |
Governance, Responsiveness |
Principle 1. Governance, Principle 2. Staff, Principle 3. Premises |
1.1, 2.5, 3.1 |
The pharmacy does not have a working fire alarm. And people in the pharmacy can’t hear the alarm in the adjoining health centre. This poses a health and safety risk to both staff and people visiting the pharmacy and adjoining health centre. The pharmacy does not have an appropriate waste management contract in place. This means that waste is accumulating and poses a risk to staff and the surrounding environment, where it is stored. |
Details
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| 31/12/2019 |
Equipment installed in a location where people’s privacy is not adequately protected |
Governance, Outcomes for patients |
Principle 5. Equipment and facilities |
5.3 |
The privacy and dignity of people who use the supervised consumption service is compromised by the position of the equipment and automated software system, used for dispensing and recording their medication. |
Details
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| 20/12/2019 |
Application of safety and quality monitoring processes to support shared learning |
Efficiency of processes, Governance, Leadership |
Principle 1. Governance |
1.2 |
Pharmacy team members act openly and honestly by sharing information when mistakes happen. And they engage fully in shared learning processes to help reduce identified risks. |
Details
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| 20/12/2019 |
Commitment to continual learning |
Governance, Leadership, Proactive approach, Responsiveness |
Principle 2. Staff |
2.2, 2.4, 2.5 |
Pharmacy team members are encouraged to develop skills relevant to their roles through continual training. And they use the skills they have learnt when engaging with people and providing pharmacy services. They are open to learning following their mistakes. And they work effectively together to ensure the pharmacy operates in accordance with professional standards. |
Details
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| 20/12/2019 |
Effective shared learning arrangements to improve patient safety. And continual development of the pharmacy team |
Efficiency of processes, Governance, Leadership, Outcomes for patients, Proactive approach, Responsiveness |
Principle 1. Governance, Principle 2. Staff |
1.2, 1.3, 2.2, 2.3 |
The pharmacy has robust safety processes. And its team members are committed to sharing learning to help continuously drive improvement. Pharmacy team members have clearly defined roles and responsibilities. And the pharmacy manages the risks associated with delegating its tasks well, through regular audit. The pharmacy has robust learning and development strategies which encourage pharmacy team members to expand their knowledge and skills. Pharmacy team members demonstrate how they apply their professional judgement and learning by working in specialised roles focussed on improving outcomes for the people using the pharmacy's services. |
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