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Pharmacy inspections

Inspection reports and learning from inspections

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Promoting a culture of openness and honesty through sharing learning when things go wrong

Pharmacy type


Pharmacy context

This is a community pharmacy in a busy health andsocial care centre. Its main services include dispensing NHS prescriptions andselling over-the-counter medicines. The pharmacy also provides some privateconsultation services, and it offers a medicine delivery service.

Relevant standards

  • 1.1 - The risks associated with providing pharmacy services are identified and managed
  • 1.2 - The safety and quality of pharmacy services are regularly reviewed and monitored
  • 2.2 - Staff have the appropriate skills, qualifications and competence for their role and the tasks they carry out, or are working under the supervision of another person while they are in training
  • 2.4 - There is a culture of openness, honesty and learning

Why this is notable practice

The pharmacy encourages its team members to act openly and honestly when things go wrong. It does this by sharing learning through regular team briefings and by supporting its team members to contribute ideas designed to reduce risk.

How the pharmacy did this

Pharmacy team members engaged well in near miss and incident reporting processes by recording their mistakes on an electronic reporting tool. The reporting tool prompted reflection about the mistake that had been made and the potential consequences. It also required team members to record learning outcomes which were designed to reduce risk.

The pharmacy encouraged all team members to keep an active learning record, and to record any personal mistakes within this record. This supported team members in developing their own learning outcomes following mistakes. A pharmacy technician reviewed these records on a one-to-one basis with team members monthly. And they were used to evidence effective learning outcomes in an annual patient safety review.

The pharmacy manager produced a team huddle briefing note weekly. This was discussed at the weekly meeting and then sent to all team members via a secure messaging group. The briefing note was designed to ensure all members of the team engaged in shared learning. A pharmacy technician held the position of clinical governance lead. They worked with the pharmacy manager and conducted a monthly review to identify trends in local near misses, dispensing and data security incidents, and medicine alerts. The review process also included the consideration of patient safety information relayed to pharmacy teams through monthly superintendent newsletters. The information was then summarised and used to inform a patient safety review meeting with the team. The meeting provided an opportunity to brainstorm actions designed to reduce risk. And the team reviewed any previously agreed actions to monitor if they were working in practice.

What difference this made to patients

The pharmacy team acts continually to identify and manage risk associated with its dispensing services. This provides assurance that the pharmacy is providing a safe service. And it reduces the risk of similar mistakes occurring.

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