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Pharmacy inspections

Inspection reports and learning from inspections

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Identification and management of risks to dispensing processes

Pharmacy type


Pharmacy context

A busy city centre pharmacy that is open 365 days a year, including late into the evening. The pharmacy dispenses NHS and private prescriptions. It offers a number of services to support people in managing minor illnesses and long-term conditions. It also supplies medicines in multi-compartmental medicine packs to people who live in their own homes and to people in residential care 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

Why this is notable practice

The pharmacy applies systematic processes when delivering all its services. These processes are continually monitored and used to drive up standards. The pharmacy uses innovative technology to substantially reduce risks to patient safety. It has a strong culture of sharing learning with its team, and with other healthcare organisations. This helps to ensure its services are always provided safely.

How the pharmacy did this

Near-miss and dispensing incident rates were continually monitored. These were low, largely due to the pharmacy’s investment in a dispensing robot. The pharmacy had continual safety checks in place when inputting information into the robot. And near-misses involving this technology were monitored closely with action taken to reduce risk when required. For example, the pharmacy has implemented several changes to the way it entered split-packs of medicines into the robot to reduce the risk of a quantity error occurring. A near-miss record was available in each part of the dispensary, including a record used by delivery drivers. Pharmacy team members discussed near-misses weekly, these meetings were led by pharmacy technicians who acted as team leaders. The superintendent pharmacist had overall accountability for completing regular trend analysis reviews of all mistakes. Posters in the dispensary were used to encourage safe dispensing practice with improvement actions highlighted in novel ways to prompt staff interest. For example, one poster was titled. ‘Five small steps for a giant leap in patient safety’.

The pharmacy had controlled drug (CD) discrepancy reporting forms located next to the CD register. The form was completed each time a discrepancy was found. It provided details of the discrepancy along with the actions taken to investigate it. These reports were given to the superintendent pharmacist to help identify training needs. The pharmacy team members demonstrated improvement actions they had implemented following this training.

The pharmacy reported dispensing incidents and shared anonymous details of these reports with the ‘National Reporting and Learning System’. This helped inform shared learning across pharmacies nationally. It also used information from local and national sources to inform the risk management of its services. The pharmacy also routinely shared learning related to mistakes with prescribers and local healthcare organisations. It had introduced calculation cards which accompanied the prescription until the final accuracy check. And prompted the pharmacist to check the calculation independently. Pharmacy team members received routine and refresher training on calculations.

The pharmacy carried out risk assessments prior to implementing new services. The risk assessment included staff training, assessing space requirements for the service and equipment required. The pharmacy also completed daily monitoring checks of staffing levels and skill mix across the working day, legal requirements such as record keeping and physical security checks of the premises.

The pharmacy’s standard operating procedures (SOPs) were up to date and include a clear date of implementation and review. National guidance and safety information to support staff was available alongside SOPs. A SOP was in place for each of the pharmacy’s services and staff completed a declaration and training to confirm they had understood these.

What difference this made to patients

People benefit from the high-quality control standards the pharmacy applies through every aspect of its work. This means there is minimal risk of something going wrong and the pharmacy’s approach to shared learning helps to continually drive up the standard of services that people receive.

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