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Pharmacy inspections

Inspection reports and learning from inspections

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Effective shared learning arrangements to improve patient safety. And continual development of the pharmacy team

Pharmacy type


Pharmacy context

This is a hospital pharmacy. It is registered with the General Pharmaceutical Council (GPhC) for the purpose of supplying dispensing services to a separate legal entity. The pharmacy department also undertakes dispensing and medicines management services to inpatients.

Relevant standards

  • 1.2 - The safety and quality of pharmacy services are regularly reviewed and monitored
  • 1.3 - Pharmacy services are provided by staff with clearly defined roles and clear lines of accountability
  • 2.2 - Staff have the appropriate skills, qualifications and competence for their role and the tasks they carry out, or are working under the supervision of another person while they are in training
  • 2.3 - Staff can comply with their own professional and legal obligations and are empowered to exercise their professional judgement in the best interests of patients and the public

Why this is notable practice

The pharmacy has robust safety processes. And its team members are committed to sharing learning to help continuously drive improvement. Pharmacy team members have clearly defined roles and responsibilities. And the pharmacy manages the risks associated with delegating its tasks well, through regular audit.

The pharmacy has robust learning and development strategies which encourage pharmacy team members to expand their knowledge and skills. Pharmacy team members demonstrate how they apply their professional judgement and learning by working in specialised roles focussed on improving outcomes for the people using the pharmacy's services.

How the pharmacy did this

Pharmacy team members entered details of near-miss errors onto a database which sent an email to the person who had made the mistake. The pharmacy had a dedicated medication safety team. This included a medication safety technician and a medication safety officer role undertaken by a pharmacist. The medication safety technician was clearly passionate about her role and explained how there was a strong focus on learning following near-miss errors. Near-miss errors were reviewed as part of the annual appraisal process. The details of personal patterns in near-miss errors was shared with the learning and education team to help review any support required for individuals. This support included reviewing work against standard operating procedures (SOPs) and observing work practices to identify safer ways of working.

Both individual and pharmacy wide patterns in near-miss errors were analysed for trends. A formal monthly review of near-miss errors took place. And the review was followed by regular team briefings to share learning. These briefings were underpinned by notices and safety bulletins which were displayed throughout the department. Recent learning had successfully reduced quantity errors associated with the supply of antibiotics. And this had involved a review of the antibiotic policy.

The medication safety team were proactive at sharing learning following incidents to help reduce the risk of a similar event occurring. For example, ‘pharmacy lessons learnt’ bulletins were shared on the intranet and safety huddles took place each month. Pharmacy team members received emails detailing any updated guidelines or SOPs following their review after an incident.

Learning was also shared regionally and at national level. For example, the medication safety technician had presented at a national medication safety officer meeting on the pharmacy’s learnings and risk reduction strategy after an incident. On the day of inspection, the medication safety technician had led a training session relating to safety in the pharmacy. All new staff attended this session as part of their mandatory induction. And other members of the team were encouraged to attend sessions at periodic intervals to refresh their learning.

The pharmacy was committed to offering its team members learning associated with their roles. And it supported its team members in accessing this learning. For example, offering pharmacy technicians management degrees. The pharmacy was developing a clinical role for its pharmacy technicians by funding further training provided by a West Yorkshire university.

The pharmacy had increased its number of pharmacist independent prescribers since the last inspection. And pharmacists were encouraged to undertake extended roles and develop in specialist areas.

What difference this made to patients

The pharmacy demonstrates a strong culture of continual learning. And its team members demonstrate how they are committed to their roles. This means people using the pharmacy's services benefit from the enhanced skill set of its team members. Patient safety is at the forefront of the pharmacy's service delivery model. And the opportunity to share learning at national level is taken to help other pharmacies identify and manage their own risks.

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