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Pharmacy inspections

Inspection reports and learning from inspections

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Effective use of monitoring and review mechanisms and a culture of learning from incidents.

Pharmacy type


Pharmacy context

This community pharmacy is located on a retail park. The pharmacy is open 100 hours each week and dispenses approximately 6,500 NHS items per month (including supply of methadone and buprenorphine via supervised consumption and domiciliary dosage system (DDS) trays) and over 50 private prescriptions. The pharmacy offers Medicines Use Reviews (MURs), New Medicines Service (NMS), supply of medicines through a minor ailments scheme and flu vaccinations.

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

The pharmacy demonstrates a robust and systematic approach to clinical governance. Risks to pharmacy services are proactively identified and managed. Systematic review procedures are applied with risk reduction actions implemented routinely.

How the pharmacy did this

The team demonstrated risk management tools that were in routine use.

Tubs were used for prescriptions to mitigate the risk of cross contamination of medicines between prescriptions. Dispensing audit trails were in place both on prescription forms and on medicine labels. The quad grid on the prescription form identified who had handed out the assembled medicine.

Prescriptions for walk-in patients were prioritised and brought to the direct attention of the responsible pharmacist. Medicines owed to patients were dispensed into red baskets to clearly identify them.

‘Pharmacist information forms’ (PIFs) were used to identify key information such as changes to patient’s medicine regimens and eligibility for services. The PIF remained with the prescription until all medicines had been supplied to the patient.

Laminated cards were used to prompt additional checks for cold chain medicines, controlled drugs (CDs) and high risk medicines such as warfarin and methotrexate. These cards were also placed with prescriptions in the retrieval system to alert staff to refer patients to the pharmacist for additional counselling.

Near misses were recorded on personal near miss trackers for each member of the dispensing team. These had encouraged personal review of near misses as well as shared learning. Staff in training roles identified how the trackers formed part of their learning approach.

Details of historic incident reporting were available monthly and used to identify actions required to reduce the risk of similar incidents occurring e.g. comprehensive identity checks when handing out medicines to avoid future risk of handout errors had been applied. The team demonstrated actions taken to reduce risk following reviews, including reviewing stock placement and stock levels in the dispensary drawers and avoiding multi-tasking. Action plans were regularly reviewed to assess their effectiveness.

Trend analysis from near misses and incidents was used to identify key drugs each month that required additional care and attention. When prescriptions for these drugs were dispensed the person involved in the dispensing process marked this on the PIF to provide assurance that it had been recognised as a medicine at high risk of error and checked accordingly.

What difference this made to patients

The pharmacy team’s continual review of the effectiveness of action plans arising from errors and incidents has reduced the risk of similar issues arising in future.

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