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Pharmacy inspections

Inspection reports and learning from inspections

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Comprehensive monitoring and review mechanisms to minimise risks to patients.

Pharmacy type


Pharmacy context

The pharmacy is located by the entrance of a supermarket. It dispenses approximately 10,500 items a month. The pharmacy provides a range of services including dispensing NHS and private prescriptions, Medicine Use Reviews (MURs), New Medicine Services (NMS), supervised doses of methadone and buprenorphine, needle exchange, Flu vaccinations, supplies of erectile dysfunction products, Malaria tablets and Ventolin inhalers against Patient Group Directions (PGDs), health checks such as blood pressure monitoring and supplies of over the counter medication (OTC) via a minor ailments scheme. The pharmacy also holds stocks of palliative care medicines.

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
  • 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

The risks associated with the provision of pharmacy services are actively identified and managed to ensure the safety and quality of these services. Information from reviews is used to inform changes to practice to help maintain the safety and quality of pharmacy services. Audit trails and date checking ensure pharmacy services are managed and delivered safely and effectively. Good systems are used to support the safe storage and management of medicinal items. This helps to ensure that the medicines and appliances supplied are fit for purpose.

How the pharmacy did this

Methadone and buprenorphine were supplied to approximately 20 patients. Methadone doses were prepared in advance to reduce the workload pressure of dispensing at the time of supply. Prepared doses were stored in separate baskets for each patient in the controlled drugs (CD) cabinet. Prescriptions were stored in alphabetical order in a dedicated folder. Details on the prescriptions such as sugar free formulation or supervised doses were highlighted. Additional information such as communications from patients’ prescribers or key workers was kept with the prescriptions. Sugar free and original methadone were stored in separate CD cabinets. On spotting a near miss the pharmacist miss asked the person involved to identify, rectify the error and make an entry in the near miss log. A weekly review of near misses took place with information from this captured on a specific form. The review was undertaken by the resident pharmacist and signed off by them and their store line manager.

Dispensing incidents were recorded electronically with a detailed audit trail including what had happened, why and the actions taken. Feedback was provided to the team at the time of the incident. One report recorded that Sando K had been dispensed instead of Slow K. The patient had identified the error, contacted the pharmacy and the correct product supplied. The pharmacy colleagues had been informed of the error, asked to go through the SOPs again and to double check the items when selecting. A note was put on the patient’s record (PMR) to alert everyone to the incident. In addition ‘caution when selecting’ stickers were attached to the drawers holding these product and the two products separated. Caution stickers were used for products that had been identified as regularly picked in error such as allopurinol and amlodipine An internal safety audit was performed every 12 months by a group of colleagues separate to the pharmacy. This covered a number of areas including compliance with legal and governance requirements such as CD registers and near miss records. A weekly legal compliance form was also completed by the resident pharmacist and covered areas such as completion of the RP log and whether the team were complying with Data Protection requirements.

An audit trail was kept of repeat prescription collections so that missing items or prescriptions could be identified and chased up with the surgery. Checked by/dispensed by boxes were on the dispensing labels and a sample of completed prescriptions looked at found that they were used.

Date checking was regularly performed and a record of the activity kept. Short dated stock was identified by the use of an orange sticker with the expiry date written on attached to the packaging and a rubber band placed round the products. The stickers were placed on the forward facing section of the packaging so that the person selecting the product could see the expiry date. A list of products due to expire each month was also kept. No out of date stock was found.

What difference this made to patients

Continual identification and monitoring of risks and implementation of effective controls, supported by audit trails, inform changes to practice to help maintain the safety and quality of pharmacy services provided 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