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Pharmacy inspections

Inspection reports and learning from inspections

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Implementing a tracking system for COVID-19 vaccination stock

Pharmacy type


Pharmacy context


Relevant standards

  • 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 acts on its risk assessments and it has a system in place to monitor the time that each vial of the COVID-19 vaccination has been out of the medical fridge. This ensures that vaccinators use the contents of each vial within the recommended six-hour period following removal from the cold chain environment.

How the pharmacy did this

The Superintendent Pharmacist reviewed the risks associated with operating a COVID-19 vaccination service prior to launching the service. And during this process identified that administering a vaccination from a vial that had been out of the medical fridge for more than the recommended six-hours was a risk. The pharmacy team mitigated this risk by developing a vial logging system.

The logging system involved the pharmacy numbering all vials of the vaccine. Team members recorded the time they removed each vial from the medical fridge, and the time they used the last dose from each vial. The person responsible for monitoring the vial log had oversight of which vials had not been returned. And was able to act to ensure they were used in time. This meant people always received vaccinations that had been stored in accordance with the manufacturer’s instructions and no vaccines were wasted.

What difference this made to patients

The pharmacy’s system ensures it is able to maximise the number of people it vaccinates. And people can feel assured they are receiving vaccines which are stored and handled correctly.

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