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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

A community pharmacy in the centre of a village. Core activity is NHS dispensing; up to 10,000 items are dispensed per month. Seventy patients are supplied medication in a Monitored Dosage System (MDS) and the pharmacy serves a 40 bed care home. Medicine Use Reviews (MURs), including domiciliary MURs, and New Medicine Service checks are provided. A small number of patients receive instalment supplies of buprenorphine or methadone. Services offered under patient group directions include seasonal flu vaccinations (private and NHS), emergency hormonal contraception, Medicines Use reviews and a minor ailments service. The pharmacy also offers prescription deliveries.

Relevant standards

  • 1.2 - The safety and quality of pharmacy services are regularly reviewed and monitored

Why this is notable practice

Continual review mechanisms are used to identify patterns or trends and establish individual coaching needs.

How the pharmacy did this

Medicines were observed being dispensed with reference to the prescription. Baskets were used to prevent transfer of items between patients. An audit trail on dispensed prescriptions meant it was possible to identify which member of staff was involved in dispensing and checking each prescription. Prescriptions were retained with dispensed items until collected.

Interactions and counselling notes were added to prescriptions so that patients could be given appropriate advice at point of handout. Dates were highlighted on prescriptions for controlled drugs (CDs) to minimise the risk of their supply beyond the valid date of the prescription. Prescriptions for schedule 2 and 3 CDs were kept in a designated area of the dispensary and not dispensed until the patient came to collect. The dispensing location was chosen as it was away from other distractions in the dispensary.

Near misses were brought to the attention of the dispenser who was asked to rectify their own mistakes where possible; such events were recorded and discussed with the individual. There was consideration of possible contributing factors. Near miss records were recorded regularly and routinely reviewed for patterns or trends each month; staff were subsequently briefed on the outcomes. Reviews had identified individual coaching needs for members of the team, and were based on a scoring system for the significance of the near misses. One dispenser regularly selected Lustral instead of losartan and vice versa. To combat this, the dispenser asked a colleague to check her selection before progressing and a shelf edge note was attached to the storage location for these items.

Dispensing errors were recorded electronically and reported to head office. Records included possible contributing factors and next steps to prevent recurrence. Errors were discussed amongst the team to minimise the risk of recurrence and there was an procedure for dealing with errors. Learning from incidents reported was shared across the company. Staff referred to a list of common picking errors and adopted a triple check process with these to minimise the risk of errors reaching patients.

What difference this made to patients

Documented processes and governance routines identify and manage risks associated with pharmacy services to protect the safety and well-being of patients and the public. Proactive review mechanisms of adverse events enable these to be used as opportunities to learn from and improve services.

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