| 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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| 17/08/2019 |
Management of the risks associated with distance selling of medication liable to addiction or abuse, using online prescribers. |
Customer and patient focus, Governance, Lack of key knowledge and a failure to learn, Leadership |
Principle 1. Governance, Principle 4. Services, including medicines management |
1.1, 1.8, 4.2 |
Vulnerable patients have been supplied with medicines that are not clinically appropriate, excessive in quantity, and which have resulted in patient harm, or other serious risk to patient safety. |
Details
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| 17/08/2019 |
Inadequate identification and management of the risks associated with the provision of medicines to people overseas. |
Customer and patient focus, Governance, Lack of key knowledge and a failure to learn, Leadership, Outcomes for patients |
Principle 1. Governance, Principle 3. Premises, Principle 4. Services, including medicines management |
1.1, 1.2, 1.3, 1.6, 1.8, 3.1, 4.2, 4.3 |
The pharmacy does not adequately identify and manage the risks associated with the provision of medicines to people overseas. It does not check the identity of patients, or ensure that higher‐risk medicines, including methotrexate and misoprostol, are supplied safely. Pharmacy professionals involved in the supply of medicines overseas do not fully understand their responsibilities or accountabilities. The pharmacy does not make accurate or complete records about the supplies it makes of prescription‐only medicines to patients overseas. It also does not adequately monitor the temperature of medicines which require cold storage. |
Details
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| 07/08/2019 |
Inadequate risk assessment of monitored dosage system dispensing in a closed pharmacy |
Efficiency of processes, Governance, Lack of key knowledge and a failure to learn, Outcomes for patients |
Principle 4. Services, including medicines management |
4.2 |
The pharmacy has not assessed the risks associated with the supply of multi-compartmental compliance devices to people. The devices are not labelled appropriately, and some are labelled and assembled before the prescription arrives at the pharmacy. There is a risk that people will not receive the correct information they require to take their medicine safely. There is also a risk that changes to medicine regimens may not be checked or addressed. |
Details
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| 07/08/2019 |
Weaknesses in the identification and management of risks to patient safety. |
Customer and patient focus, Governance, Lack of key knowledge and a failure to learn, Leadership, Outcomes for patients |
Principle 1. Governance |
1.1, 1.6, 1.7 |
The pharmacy has not risk assessed how some parts of the pharmacy service provided by a third-party supplier are managed. Nor does it monitor information provided on its website. This means that there is little assurance that the pharmacy is protecting the safety and wellbeing of people who may access its services through the website. |
Details
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| 07/08/2019 |
Lack of assurance about the safety of remote dispensing services. |
Customer and patient focus, Governance, Lack of key knowledge and a failure to learn, Leadership, Outcomes for patients |
Principle 1. Governance, Principle 4. Services, including medicines management |
1.1, 1.5, 1.8, 4.2 |
The pharmacy has no assurance that the remote prescribing service it uses is safe. It has not checked that the prescribers it works with are competent, can lawfully issue prescriptions to people in the UK and are covered by appropriate indemnity arrangements. |
Details
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| 07/08/2019 |
Preventing abuse of medication |
Customer and patient focus, Governance, Lack of key knowledge and a failure to learn, Leadership, Outcomes for patients |
Principle 1. Governance, Principle 4. Services, including medicines management |
1.1, 1.5, 1.8, 4.2 |
The pharmacy is not following its own policies and procedures intended to prevent abuse of medication. |
Details
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| 07/08/2019 |
Insufficient information to enable an informed decision about treatment and about how to raise concerns. |
Customer and patient focus, Governance, Lack of key knowledge and a failure to learn, Leadership, Outcomes for patients |
Principle 1. Governance, Principle 4. Services, including medicines management |
1.1, 1.5, 1.8, 4.2 |
There is insufficient information for the public about the prescribing service to make an informed decision, or raise concerns about the quality of the service. |
Details
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| 07/08/2019 |
Obtaining consent from a patient's regular doctor to supply appropriate medicines. |
Customer and patient focus, Governance, Lack of key knowledge and a failure to learn, Leadership, Outcomes for patients |
Principle 1. Governance, Principle 4. Services, including medicines management |
1.1, 1.8, 4.2 |
The pharmacy supplies medicines without informing the patient's regular doctor or making sure they agree to the supply. This is a risk because people's conditions might not be properly monitored, and their use of medication may not be appropriately controlled. |
Details
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| 07/08/2019 |
Lack of assurance about the safety of remote dispensing services. |
Customer and patient focus, Governance, Lack of key knowledge and a failure to learn, Leadership, Outcomes for patients |
Principle 1. Governance, Principle 4. Services, including medicines management |
1.1, 1.8, 4.2 |
The pharmacy does not make enough checks to ensure medicines are appropriate for the people they supply. And it supplies some medicines which may not be appropriate for supply via a remote consultation because they require physical examination, blood tests or monitoring. |
Details
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| 07/08/2019 |
Inadequate arrangements for learning from mistakes and errors. |
Governance, Lack of key knowledge and a failure to learn |
Principle 1. Governance |
1.2 |
The pharmacy team doesn't have any procedures to follow to make sure they adequately respond to mistakes. And they don't record mistakes or review why they happened. So, they do not have the information to identify patterns and help reduce similar mistakes in the future. |
Details
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| 07/08/2019 |
Poor management of Controlled Drugs |
Efficiency of processes, Governance, Lack of key knowledge and a failure to learn |
Principle 1. Governance, Principle 4. Services, including medicines management |
1.6, 4.3 |
Poor management of CDs with a lack of maintenance of CD registers and inadequate arrangements for destruction of returned CDs |
Details
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| 16/07/2019 |
Weaknesses in monitoring and review mechanisms, including the capacity of the premises to cope with the increased workload and non-compliance with SOPs |
Customer and patient focus, Efficiency of processes, Governance, Lack of key knowledge and a failure to learn, Leadership |
Principle 1. Governance |
1.1, 1.2 |
The pharmacy doesn’t manage risks adequately and the way it operates and stores its medicines increases the risk of mistakes happening. It has procedures in place but these are not always followed and are not reviewed regularly. Additionally, it doesn’t review its services when things go wrong and the pharmacy does not have sufficient capacity to provide the volume of services it does. |
Details
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| 15/07/2019 |
Insufficient staffing level |
Efficiency of processes, Governance, Lack of key knowledge and a failure to learn, Leadership |
Principle 1. Governance, Principle 2. Staff, Principle 4. Services, including medicines management |
1.1, 2.1, 4.2, 4.3 |
There are insufficient staff to provide safe and effective pharmacy services. |
Details
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| 15/07/2019 |
Weaknesses in monitoring and review mechanisms and non-compliance with SOPs |
Governance, Lack of key knowledge and a failure to learn, Leadership |
Principle 1. Governance |
1.1, 1.2 |
There are no procedures in place to record and learn from dispensing incidents and near misses are very infrequently recorded and the pharmacy team cannot demonstrate any learning from these. The Standard operating procedures (SOPs) that were in place for some dispensary tasks were not followed, including that for Monitored dosage system (MDS) trays. |
Details
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| 15/07/2019 |
Weaknesses in monitoring and review mechanisms and poor knowledge of safeguarding |
Customer and patient focus, Governance, Lack of key knowledge and a failure to learn, Leadership |
Principle 1. Governance |
1.1, 1.2, 1.8 |
The pharmacy team are not working in accordance with their Standard Operating Procedures (SOPs) and they have not read or signed these. Staff are unclear about the pharmacy’s operating procedures and current practice, for example, for safeguarding vulnerable people. |
Details
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| 15/07/2019 |
Patients’ feedback about their experience of pharmacy’s services not acted upon. |
Customer and patient focus, Governance, Lack of key knowledge and a failure to learn, Leadership, Responsiveness |
Principle 1. Governance |
1.4, 1.7, 1.8 |
The pharmacy does not respond appropriately to feedback from people. |
Details
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| 15/07/2019 |
Absence of standard operating procedures for the services provided by the pharmacy |
Customer and patient focus, Efficiency of processes, Governance, Lack of key knowledge and a failure to learn, Leadership |
Principle 1. Governance, Principle 3. Premises, Principle 5. Equipment and facilities |
1.1, 1.2, 3.4, 5.1, 5.2 |
A closed pharmacy commenced operations without having appropriate arrangements and procedures in place for identifying and managing the specific risks presented by this pharmacy. |
Details
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| 15/07/2019 |
Weaknesses in monitoring and review mechanisms and an absence of key standard operating procedures. |
Customer and patient focus, Efficiency of processes, Governance, Lack of key knowledge and a failure to learn, Leadership, Outcomes for patients, Responsiveness |
Principle 1. Governance, Principle 4. Services, including medicines management |
1.5, 1.7, 1.8, 4.2, 4.4 |
The pharmacy’s governance arrangements are unclear. The pharmacy’s Standard Operating Procedures do not cover all aspects of service provision, so staff were not clear what is expected of them. This was particularly the case in respect of dealing with incidents and near misses, sale of medicines, safeguarding and protecting patient confidentiality. |
Details
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| 15/07/2019 |
Insufficient staffing level |
Customer and patient focus, Governance, Lack of key knowledge and a failure to learn, Leadership, Outcomes for patients, Responsiveness |
Principle 1. Governance, Principle 2. Staff, Principle 4. Services, including medicines management |
1.2, 2.1, 4.3 |
The level of trained staff is inadequate for the safe operation of pharmacy services. This is leading to a chaotic working environment, routine training and date checking not taking place and long delays for patients awaiting their medication. |
Details
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