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Pharmacy inspections

Inspection reports and learning from inspections

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Comprehensive monitoring and review mechanisms to minimise risks

Pharmacy type


Pharmacy context

​This was a village pharmacy dispensing around 5000 NHS items per month. The NHS items included supply to patients in Monitored Dosage (MDS) trays and services to a care home. Other NHS services provided were the standard Scottish pharmacy contract services. Services provided under PGDs were unscheduled care, smoking cessation, emergency hormonal contraception and chloramphenicol ophthalmic products. The pharmacist was an independent prescriber running a fortnightly pain clinic.

Relevant standards

  • 1.1 - The risks associated with providing pharmacy services are identified and managed
  • 1.2 - The safety and quality of pharmacy services are regularly reviewed and monitored

Why this is notable practice

There is a consistent and high quality proactive approach to minimise risk across all aspects of pharmacy service delivery. Dispensing accuracy is continually monitored and reviewed with attention given to avoiding repetition and this is shared across the organisation. All services are reviewed on an ongoing basis and changes made to ensure continuing effectiveness and safety.

How the pharmacy did this

A separate rear dispensary area was used for care home dispensing, MDS trays and methadone instalments. A folder was available at the checking bench for locum and relief pharmacists, describing and illustrating the workflow for dispensing, and containing other relevant information such as tasks and competencies of staff, to ensure smooth workflow on the regular pharmacist’s days off. This was highly visible and readily accessible for pharmacists not familiar with these premises.

A review of dispensing of non-CD instalment prescriptions had been undertaken and a new system introduced that had speeded up the process and reduced selection error. Prescription collection record cards were used and stored alphabetically in a box file from where they were retrieved when patients presented at the pharmacy. Dispensed instalments were stored alphabetically and by collection day in individual baskets which were labelled on the front with the patient's details and the day of collection in a dedicated area of the dispensary. This system was very organised with instalments and record-keeping clear and logical, reducing the chance of error.

MDS prescriptions were dispensed on a four weekly cycle with four trays dispensed at a time. These were left in a dedicated area for the pharmacist to check and seal, and medication packaging was left to facilitate this check. The packaging also remained with the completed trays and prescriptions for the life of that prescription, to ensure that medicines could be retrieved from patients if there was a recall on any item. Patient information leaflets (PILs) were supplied with the first week of each prescription. The weeks were colour-coded and patients' records were filed in pockets of the appropriate colour, and these records included dose regime, any changes or other clinical information including date and personnel involved with making and implementing changes. The colour coding facilitated smooth and ordered running of this process. Additional information such as day of delivery or collection, who ordered 'when required' medication, and authorisation to deliver to another person. Progress logs were on the dispensary wall to show what stage each prescription was at in terms of ordering, labelling and dispensing. Prescriptions were ordered when the third instalment was supplied and the order slips were attached to the folder of patient records with the date to be ordered noted and this system was working well.

Methadone instalments were dispensed weekly. When prescriptions were received they were checked for any changes or unexpected instructions and the labels for the whole duration generated – these labels and bag labels had the date of supply on them as well as the instalment number, and also had either 'supervised' or 'takeaway' on the label.

What difference this made to patients

High-risk activities are proactively identified and the risks effectively managed. Systematic monitoring and review mechanisms are in place demonstrating a culture of continuous learning and leading to improvements in safety and quality of pharmacy services.

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