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Pharmacy inspections

Inspection reports and learning from inspections

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Comprehensive monitoring and review mechanisms to minimise risks supported by a learning culture

Pharmacy type


Pharmacy context

A pharmacy located next to a health centre in a residential area. The pharmacy dispenses on average 6000 items per month. As well as core services the pharmacy offers Smoking cessation; Medicine Use Reviews, New Medicines Service, dressings for nurses and flu vaccinations (NHS and private); and methadone/buprenorphine on instalment prescriptions.

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

Near miss records and errors are consistently reviewed to improve the safety and quality of services.

How the pharmacy did this

Near misses were highlighted to the person making the error, rectified and recorded first on a near miss log and then put onto a patient safety software system. At the end of each month the team held a patient safety review of the incidents. If a member of staff had made more than 5 near misses they were asked them to complete a root cause analysis and re-read the relevant SOPs.

As a result of a review the team had labelled shelf edges and highlighted to staff the need to check quantities as well as checking the expiry dates on bottles. The pharmacy team discussed near misses and trends within the pharmacy and those incidents which occurred in other branches. Dispensing incidents were entered on to the system and forwarded to head office. Staff would alert the responsible pharmacist who would rectify the issue to the patient’s satisfaction, check that the patient was ok and supply them with the correct medication.

On submission of the electronic report the branch were notified of any next steps that they needed to complete. As a result of an incident where a different patient’s prescription was handed out, staff had been required to re-do the Information Governance training module.

A recent incident in which the incorrect patient’s controlled drug patches were handed to the delivery driver was picked up by the branch before the driver delivered the medication. Since the incident CDs were checked by the RP, the dispenser and the driver and bag labels were attached to the form; following the medication being delivered the RP had to sign the delivery note. The team had also noticed that more errors occurred during the busiest period, between 3pm and 4pm and so the RP ensured during this time he did not check any repeat prescriptions, instead concentrating on walk in prescriptions and patients.

What difference this made to patients

Through detailed analysis of trends in near misses and dispensing incidents the pharmacy is able to take effective action to reduce such occurrences, sharing learning on a reciprocal basis with other branches.

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