Effective use of monitoring and review mechanisms and a culture of learning from incidents.

Pharmacy type

Community

Pharmacy context

A town centre pharmacy that provided a range of services to a mixed population with a significant demand for ‘walk-in’ prescription services due to its close proximity to two local surgeries. A prescription collection service was provided to both of the surgeries with a free repeat prescription service provided to a few local residents. A delivery service was provided three times a day with one mainly used for emergency supplies. The opening hours were Monday to Friday 8.30am to 6.00pm and Saturday 9.00am to 1.00pm. Approximately, 6500 items per month (10 Monitored Dosage System (MDS) trays), Minor Ailments Service, Chronic Medication Service (CMS), and Smoking cessation service.

Relevant standards

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

Why this is notable practice

Practices and procedures are monitored on an ongoing basis and action is taken so that risks are managed and services improve.

How the pharmacy did this

A dispensing signature audit trail was in place and staff signed ‘dispensed by’ and ‘checked by’ boxes on medicine labels to confirm they had completed the activity. This audit trail was also used to identify staff when dispensing errors were detected, so that individuals could reflect and avoid the same errors happening in the future. Each member of staff recorded and reviewed their own near-misses on a weekly basis so there was more awareness about mistakes and improved staff accountability. When one of the dispensers had identified an increase in the number of quantity errors she had made she ensured that she circled the quantity on the original container as an additional check. Near-miss records were completed and a monthly analysis was carried out to provide staff with the opportunity to identify any emerging concerns and any action that was needed. Action had been taken due to a few prescription ‘hand-out’ errors with staff now ticking the name and address at the time of supply. The staff were complying with the new ‘hand-out’ SOP, which included additional steps to avoid errors, such as checking the name and address at the time the prescription was requested and again at the time of hand-out. Staff were proactive at managing selection errors and a local ‘top 6’ had been developed and was being displayed in a prominent area on the dispensing bench, so that staff were reminded. Staff had agreed to record the ‘top 6’ products on the pharmacy information form (PIF), for example Quinine/Quetiapine, so that all staff took extra care including the checking pharmacist. The ‘top 6’ list was then updated every few months.

What difference this made to patients

Dispensing incidents were investigated and documented so that remedial action could be taken to avoid the same incident happening in the future.