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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

The pharmacy is located on a high street provides services to a varied population of mainly elderly patients and young mothers. It dispenses approximately 6500 NHS prescription items. In addition to NHS essential services, the pharmacy offers a range of services including medicines use reviews (MUR), the NHS New Medicines Service(NMS), nicotine replacement therapy voucher dispensing, seasonal 'flu vaccinations via NHS and private patient group direction (PGD), emergency contraception via NHS PGD, supervised consumption and Monitored Dosage Systems (MDS).

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

Why this is notable practice

Continuous, proactive and systematic review of risks are used to identify trends, inform review of procedures and training and inform improvements in service delivery. Systematic monitoring and review mechanisms are in place, demonstrating a culture of continuous learning and leading to improvements in the safety and quality of services.

How the pharmacy did this

A procedure was in place for the handling of dispensing incidents. Such incidents were recorded on an electronic system. Feedback as a result of dispensing incidents was given to the team when incidents were identified and also discussed as part of the monthly patient safety review. The manager would reassess staff competence by observation after an incident occurred and address any training needs that were necessary.

Regular audits were carried out and findings for improvement fed back to staff verbally and by way of a branch diary. A recent audit had been carried out to compare the rate of errors occurring in manually dispensed prescriptions with prescriptions scanned via the Electronic Pharmacy Service system. The results showed that there was a vast reduction in the number of incidents if prescriptions were scanned rather than manually entered in to the pharmacy system. As a result, the team now ensured that all prescriptions with a barcode were scanned and not entered manually, where possible.

The team received a bulletin approximately every month from the company professional standards team, communicating professional issues and learning from across the organisation as a result of near miss and error analysis. This also provided best practice guidance on various topics and case studies based on real incidents that had occurred and what needed to be learned as a result. Staff read the bulletin and signed the front of each bulletin to record that they had done so.

The RP or technician completed a weekly clinical governance checklist ensuring that aspects, such as CD security, SOPs and dispensary date checking procedures, were being fully complied with and any actions for improvement documented.

What difference this made to patients

Well established procedures clinical governance processes including application of learning from dispensing incidents and errors, audits and reflective practice from across the company support the focus on patient safety.

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