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Pharmacy inspections

Inspection reports and learning from inspections

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Management of the risks associated with distance selling of medication liable to addiction or abuse, using online prescribers.

Pharmacy type

Internet / Distance Selling

Pharmacy context

This online pharmacy dispenses private prescriptions originating from an online prescribing service owned by the same company. People access services remotely and are not able to enter the premises. The pharmacy does not dispense NHS prescriptions or offer other NHS services. It is expanding the range of over-the-counter medicines that people can buy.​

Relevant standards

  • 1.1 - The risks associated with providing pharmacy services are identified and managed
  • 1.8 - Children and vulnerable adults are safeguarded
  • 4.2 - Pharmacy services are managed and delivered safely and effectively

Why this is poor practice

Vulnerable patients have been supplied with medicines that are not clinically appropriate, excessive in quantity, and which have resulted in patient harm, or other serious risk to patient safety.

What the shortcomings are

There are inadequate identity checks to ensure the person supplied with the medication is who they claim to be. The pharmacy does not obtain all relevant information from people receiving medication to check the supply of medicines against a prescription is safe, and appropriate to make, taking account of their age and gender, other medicines supplied, and the particular risks associated with the medication being supplied. Processes and checks in place to identify requests for medication that are inappropriate, including those where there is a higher risk of addiction or abuse are weak. This includes not being able to identify multiple orders to the same or a similar address, or orders using the same payment details. Inadequate procedures to ensure that the professional authorising the supply is aware of whether relevant information about the prescription has been shared with other healthcare professionals to make an informed decision to supply.

What improvements are required

Strenthened identification and management of risks, including implementation of more robust procedures, processes and checks on the identity of patients, identification of potential addiction or abuse and confirmation that professionals authorising supply have all the relevant information to make an informed decision to supply.

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