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Pharmacy inspections

Inspection reports and learning from inspections

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Inadequate arrangements for learning from mistakes and errors.

Pharmacy type


Pharmacy context

The pharmacy provides dispensing services at a distance, which means people cannot access the pharmacy premises. People can access the pharmacy website and contact the pharmacy by telephone. The pharmacy dispenses NHS prescriptions. The pharmacy requests prescriptions on behalf of people. And it delivers medication to people’s homes.

Relevant standards

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

Why this is poor practice

The pharmacy team doesn't have any procedures to follow to make sure they adequately respond to mistakes. And they don't record mistakes or review why they happened. So, they do not have the information to identify patterns and help reduce similar mistakes in the future.

What the shortcomings are

On most occasions the pharmacist when checking prescriptions and spotting an error asked the team member involved to find and correct the mistake. The pharmacy didn’t keep records of these errors. And it didn’t have a SOP to cover the management of near miss errors or one for dispensing incidents. The pharmacy had no arrangements to support the team members to review and learn from their own errors. The Superintendent Pharmacist stated that there had not been any dispensing incidents. The team identified that most errors were labelling mistakes often caused by the team not spotting that the prescription details had changed.

What improvements are required

The pharmacy should ensure it has documented procedures for learning from mistakes and errors to prevent recurrences.

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