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Pharmacy inspections

Inspection reports and learning from inspections

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Automation and digital technology

Pharmacy type


Pharmacy context

A pharmacy situated in a hospital and carrying out minimal registerable activity, including dispensing private prescriptions (5-6 private prescriptions per month). Most prescriptions were received from a private patients unit or were for specialist HIV medication. The pharmacy had over 350 staff across all departments which included the manufacturing unit, medicines information and wards. Less than a third of the workforce was involved in medicine supply.

Relevant standards

  • 1.1 - The risks associated with providing pharmacy services are identified and managed
  • 4.2 - Pharmacy services are managed and delivered safely and effectively
  • 4.3 - Medicines and medical devices are: obtained from a reputable source; safe and fit for purpose; stored securely; safeguarded from unauthorized access; supplied to the patient safely; and disposed of safely and securely

Why this is notable practice

Automation and digital technology are used to ensure pharmacy services are delivered safely and effectively.

How the pharmacy did this

The pharmacy had a barcode tracking system with the prescription first being booked in at the hatch and the patient given a ticket number. All staff also had their own individual log in details. The pharmacy were able to track who had scanned the barcode at each step of the procedure in the event that an error needed to be investigated. Dispensed and checked by boxes were used on dispensing labels. All prescriptions had three sets of initials. Baskets were used to separate prescriptions; preventing transfer of items between patients. Trays were colour coded with yellow trays used for urgent prescriptions and blue for all others. Medicines were obtained from the pharmacy stores who obtained stock from the buying office. Medicines requiring special consideration such as Controlled Drugs (CDs) were stored appropriately.

The ambient temperature in the pharmacy was constantly monitored via a wireless system which alerted nominated people if the temperature had fallen out of range. The pharmacy had an automated CD dispensing cabinet fitted. The system dispensed and labelled medication and was activated via fingerprint recognition. The advice of the Controlled Drugs Liaison Officer had been sought on the use of the automated CD cabinet. The pharmacy had still retained a traditional CD cabinet. All staff had to complete the necessary accreditation to be able to use the cabinet. The cabinets were monitored by CCTV and access was arranged by the pharmacy team. The pharmacy was also running electronic CD registers alongside paper registers with plans to stop using paper registers.

The pharmacy used a robot for dispensing. This was maintained on a quarterly basis. Stock put into the robot was entered with an expiry date of one year and short dated stock was also recorded so that it could be ejected from the robot. Short dated stock was removed from the robot at the start of the month. The system was able to monitor what stock had been used.

What difference this made to patients

Automation and digital technology are used to deliver pharmacy services to a consistent level, with key controls in place at critical points to ensure the safety of medicines dispensed to patients.

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