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Pharmacy inspections

Inspection reports and learning from inspections

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Effective use of risk assessments to identify potential patient safety risks.

Pharmacy type


Pharmacy context

A pharmacy set in a mixed demographic, within a large residential area with a significant proportion of elderly customers. Activity was 10,000 items per month; 1900 minor ailment service (eMAS) items per month; 32 Methadone. 97% of patients were registered for the Chronic Medication Service (CMS).

Relevant standards

  • 1.1 - The risks associated with providing pharmacy services are identified and managed
  • 4.2 - Pharmacy services are managed and delivered safely and effectively
  • 4.3 - Medicines and medical devices are: obtained from a reputable source; safe and fit for purpose; stored securely; safeguarded from unauthorized access; supplied to the patient safely; and disposed of safely and securely

Why this is notable practice

The pharmacy proactively identifies and manages risks through a range of methods, including, having designated areas for separating activities; flagging specific patients needing counselling or more than one prescription; and tracking the progress of prescriptions.

How the pharmacy did this

Dispensers used brightly coloured cards to relay important information to the pharmacist and other staff about patient’s care. Pharmacy Information Forms (PIFs) were used to highlight patients, for example, when a new medicine had been prescribed and patients were eligible for CMS. A texting service ensured that patients were alerted when their medication was ready for collection. Dispensing benches were organised so that activities were safe. Benches at the rear of the pharmacy provided ample space to safely dispense monitored dosage system trays and Methadone and there was a designated bench used to dispense the repeat prescriptions that arrived from the GP practice. The prescriptions were placed on the shelf above and then taken by the Accuracy Checking Technician (ACT) to the designated ACT bench, where they were checked.

Prescriptions were placed into coloured baskets so that staff knew what service the patient was receiving; red baskets for the pharmacy collection service; white baskets for walk-in customers and those calling back.

When a patient had been provided with more than one prescription, this was marked at the top of each of their prescriptions. The pharmacist checked the prescription at the checking bench and then checked again when handing out to the patient. CDs and insulin prescriptions were kept in clear bags and were shown to the patient to confirm what was expected. Patients were invited to register with the collection service and asked if they would like to receive a text message to inform them that their prescription was ready.

There were four compliant CD cabinets and each had been organised to minimise selection errors; the sugar free and sugar containing Methadone, and the out of date/patient returned CDs had been separated and highlighted.

Returned medicines were emptied into a designated tray and checked before being disposed of in yellow containers. The staff knew to identify returned CDs and informed the pharmacist so that they were immediately placed in safe custody.

What difference this made to patients

Pharmacy services are managed to reduce risk of dispensing errors and supply of unsafe medication.

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