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Pharmacy inspections

Inspection reports and learning from inspections

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Developing an assessment tool to support the care of people suffering an anaphylactic reaction to a vaccination

Pharmacy type


Pharmacy context


Relevant standards

  • 4.2 - Pharmacy services are managed and delivered safely and effectively

Why this is notable practice

The pharmacy is using continual learning and reflection processes to support good clinical record keeping. And to help ensure consistency in the way team members manage people who may experience an anaphylactic reaction following a vaccination.

How the pharmacy did this

As part of its ongoing learning and reflection processes, the pharmacy team had explored how it had managed a recent incident when a person had experienced an anaphylactic reaction following a vaccination. Although these types of reactions were very rare, the team identified a need to increase learning relating to potential adverse reactions to the COVID-19 vaccination. The learning built on vaccinators own knowledge from previous training, and information contained within the COVID-19 vaccination national protocol. Learning also included identification of the side effect of adrenaline, and signs of adrenaline overdose. The pharmacy also used the learning as an opportunity to develop a clinical observation sheet with a view of supporting team members treating an adverse reaction to a vaccine.

The pharmacy used the National Early Warning Score (NEWS) 2 assessment tool to help develop its own clinical observation sheet. The NEWS2 model advocated a system to standardise the assessment and response to acute illness. The pharmacy’s own sheet included space for regular observations relating to oxygen saturation levels, respiratory rate, blood pressure, pulse rate, temperature and an assessment of the patient’s conscious state. The sheet prompted clinical record keeping whilst the team waited for an ambulance to attend. It also supported team members in providing information to the ambulance crew calmly and efficiently when they arrived on site. And provided a greater understanding of the full range of symptoms caused by such reactions.

What difference this made to patients

Pharmacy team members are well trained to provide acute care in the case of a medical emergency at the pharmacy’s vaccination site. Although rare, should a person suffer an anaphylactic reaction to a vaccine, the pharmacy has good processes to support the management of the emergency. And to ensure consistent care is provided to the patient whilst waiting for an ambulance to arrive.

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