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Pharmacy inspections

Inspection reports and learning from inspections

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Management of patients on high-risk medication

Pharmacy type


Pharmacy context

This was a high street pharmacy in a town of mixed demographic although the immediate area included some deprivation, dispensing around 5500 NHS items per month and a small quantity of private dispensing. The NHS items included supply to around 80 patients in Monitored Dosage System trays. Pharmaceutical services were provided for 7 care homes, totalling around 120 beds. Other NHS services provided were the standard Scottish pharmacy contract services – Chronic Medication Service (CMS), Minor Ailments Service (eMAS), smoking cessation and the gluten free food prescribing service for 1 patient. Services provided under PGDs were unscheduled care, smoking cessation, emergency hormonal contraception, chloramphenicol ophthalmic products, trimethoprim, post-immunisation paracetamol and fluconazole. A substance misuse service was provided. There was a consultation room and a discreet counselling area at the end of the medicines counter.

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

Why this is notable practice

All patients on high-risk medication had been identified and reviewed and provided with additional information to ensure they knew how to take their medication safely.

How the pharmacy did this

A recent service level agreement for substance misusers was in place including access to naloxone and signs and symptoms of overdose. Photographs and care plans were introduced for all patients as part of this. There was a high number of CMS registrations – bag labels were used to highlight suitable patients to register for NHS services, and a list of registrations was sent to the health centre for them to highlight suitable candidates for serial prescriptions. A questionnaire had been developed similar to the pharmacy care record (PCR) for interventions related to new medicines or high-risk medicines to increase accessibility of these consultations to patients. All patients on high-risk medication had been reviewed, with information booklets handed out and information given to them. Many patients had been given very little information and didn’t have the recommended literature so there had been benefit in patient education for these medicines.

What difference this made to patients

The identification and review of all patients on high risk medication has ensured that they all of them have the required information to follow the correct treatment for their condition.

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