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Pharmacy inspections

Inspection reports and learning from inspections

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Effectively using near miss records and regular reviews to reduce the risk of mistakes being made.

Pharmacy type


Pharmacy context

This is a supermarket pharmacy. It sells over-the-counter medicines and dispenses NHS and private prescriptions. The pharmacy team offers advice to people about minor illnesses and long-term conditions. The pharmacy offers a range of NHS services. It also supplies medicines in multi-compartment compliance aids to people living in their own homes.

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
  • 2.4 - There is a culture of openness, honesty and learning

Why this is notable practice

The pharmacy has effective processes for reviewing any mistakes it makes. And it takes action to prevent them from happening again. Team members reflect on whether the learning and improvements from previous reviews have been sustained. And they continue to look for new ways to improve the safety and effectiveness of the pharmacy’s services.

How the pharmacy did this

The pharmacy kept records of all of its mistakes. And the responsible pharmacist (RP) reviewed them each month. The RP stored the monthly reviews alongside the pharmacy’s records of its mistakes. And of the actions identified at the time to achieve improvement. When completing the monthly review, the RP looked at previous reviews and action plans to check that the actions had been implemented. And to check that any changes made had been effective.

In previous months, there had been an increase in mistakes involving the supply of part packs. During the review process the pharmacy had introduced several different ways to help team members to embed a quantity check into the dispensing process. But whilst the number of mistakes had reduced, they still occurred. As a result, each month the pharmacy had continued to look for new solutions to ensure that the quantities dispensed were correct. The team finally found that, for them, the most effective way of ensuring that quantities were correct was to dispense medicines that were not prescribed in complete packs, into white dispensing boxes. This had made it more obvious to the pharmacist and the person receiving the medicine that it was not a complete pack. Since making this change, mistakes of this type had significantly reduced.

What difference this made to patients

The pharmacy’s approach to conducting an effective review of its mistakes means that the patient receives a more efficient, effective and safe service.

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