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Pharmacy inspections

Inspection reports and learning from inspections

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Safety of high risk services

Pharmacy type


Pharmacy context

The pharmacy is located on a busy high street and serves a mixed local population. The pharmacy dispenses just under 4,000 items a month and provides Medicine Use Reviews (MURs), needle exchange, substance misuse treatment, New Medicine Services (NMS), stop smoking, Monitored Dosage System trays, prescription collection and the Flu vaccine (private and NHS).

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 substance misuse service and the needle exchange service are managed safely, reducing the risk of patients receiving the wrong medication or receiving a needle-stick injury.

How the pharmacy did this

Methadone instalments were dispensed in advance for the week; this minimised risk of distractions. Instalments for individual patients were separated in the Controlled Drugs cabinet using plastic dividers. Boxes of dispensed instalments of Buprenorphine tablets were also labelled with the patients’ initials and date of collection; this provided an additional check to ensure the tablets were supplied to the correct patient at the right time. The sharps bin for the needle exchange service was stored in the dispensary. Protective eye wear, gloves and a tray for customers to place their sharps bins in were available for staff to use. The relevant SOP’s were displayed near the sharps bin for staff to easily refer to.

What difference this made to patients

High risk patients, such as those receiving substance misuse services and those using the needle exchange service, are protected through practices designed to reduce potential risk of injury or harm.

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