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Pharmacy inspections

Inspection reports and learning from inspections

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Safe supply of high risk medication

Pharmacy type


Pharmacy context

The pharmacy is located in the outpatients department of a hospital. The pharmacy is registered to provide dispensed medications to two local mental health trusts via local service level agreements (SLA). The SLAs constitute a large proportion of the pharmacy activity with 4200 prescription items per month being dispensed to a number of other hospitals.

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

The supplies made as part of the registerable activities are done so in an organised manner and complete audit trails are in place to ensure that problems can be swiftly identified.

How the pharmacy did this

Prescriptions dispensed within the pharmacy were done so in trays in order to keep them separate and reduce the risk of medications being mixed up. Trays were colour coded for each Trust and work for each Trust was dispensed on separate benches so that there was a defined workflow in the pharmacy and to further reduce the risk of medications being mixed up. Prescriptions were received from the pharmacy teams based at the each mental health trust via secure fax. Once in the pharmacy, prescriptions received a second clinical check from the RP who then signed the prescription for authorisation of dispensing. Prescriptions were routinely signed by the labeller, dispenser and accuracy checker so that a full audit trail was available. Once checked, completed prescriptions were filed in secure bags ready for transport. Each bag was colour coded dependent on the Trust and all bags were also individually numbered. The number of the bag in which medication was placed was recorded on the prescription for audit purposes. The transport driver signed for each bag that was taken for delivery and a copy of this form was retained within the pharmacy for reference. Nursing staff at each hospital also signed for medication once it was received on the ward. Clozapine patients each had a profile which recorded details of supply and blood results. A point of care blood analysis system was in place, meaning that clozapine was dispensed in anticipation of the clozapine clinic and blood results were checked in clinic and retrospectively documented. Dispensed medications were issued to the clozapine clinic along with a list of clinic patients. Clinic nurses recorded the details of supply and this record was kept in the pharmacy for the purpose of an audit trail.

What difference this made to patients

The safety of patients on high risk medication, including anti-psychotic drugs, is protected through robust recording and audit trails.

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