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Pharmacy inspections

Inspection reports and learning from inspections

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Application of safety and quality monitoring processes to support shared learning

Pharmacy type


Pharmacy context

This is a family run pharmacy located close to the centre of town. The pharmacy sells over-the-counter medicines and dispenses NHS and private prescriptions. The pharmacy offers advice on the management of minor illnesses and long-term conditions. It also supplies medicines in multi-compartmental compliance packs to people living in their own homes.

Relevant standards

  • 1.2 - The safety and quality of pharmacy services are regularly reviewed and monitored

Why this is notable practice

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.

How the pharmacy did this

The pharmacy supported student placements from a local university. This also provided pharmacy team members with the opportunity to test their own understanding of SOPs. For example, a pharmacy team member would show the student how a task was completed. The student then read the SOP and they were asked to identify if what they were shown reflected the contents of the SOP. The team identified this as a good learning tool and it provided the opportunity for feedback and shared learning. The pharmacy technician had additional responsibilities to support her role within the team. For example, completing controlled drug (CD) balance checks.

Pharmacy team members took ownership of their mistakes by engaging in feedback at the time they occurred and completing near-miss records. Entries in the near-miss record included identification of contributory factors and actions taken to reduce risk. For example, ‘take extra care with controlled drug (CD) prescriptions when busy’. Reporting rates were consistent, they rose when pharmacy students and pre-registration pharmacists commenced placements at the pharmacy, as expected. Pharmacy team members discussed how self-reporting and correction of their mistakes assisted their learning. The SI reviewed near misses monthly and provided the team with safety reports. The reports included trend analysis of the types of mistakes taking place. The team engaged in reviews and contributed ideas to manage identified risks. For example, the team had separated gabapentin 300mg capsules from other strengths of gabapentin to reduce the risk of picking error. And pharmacy team members ticked information on the medicine box prior to taking ownership of their work and passing it on for the final accuracy check.

The pharmacy had an incident reporting procedure in place. The RP, who was the SI, provided evidence of incident reporting. Reports included a reflection of the error, a route cause analysis, learning points and actions. The pharmacy had implemented actions following reported errors. For example, it had established additional checks when a person started on methadone. And it had shared learning and improvement actions with the substance misuse provider following an incident.

What difference this made to patients

The pharmacy promotes continual learning and reflection amongst its team to help drive up patient safety standards. And it shares learning from incidents with other healthcare organisations. This provides both the pharmacy and other healthcare organisations with oppurtunities to improve the safety of the services they provide to people.

Highlighted standards

We have identified the standards most likely and least likely to be met in inspections, and highlighted examples of notable practice for each of these standards; to help everyone learn from others and to support continuous improvement:

  1. 1.1 Risk management
  2. 1.2 Reviewing and monitoring the safety of services
  3. 4.2 Safe and effective service delivery
  4. 4.3 Sourcing and safe, secure management of medicines and devices
  5. 2.2 Staff skills and qualifications