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Pharmacy inspections

Inspection reports and learning from inspections

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Segregation of different dispensing services

Pharmacy type


Pharmacy context

The pharmacy is situated on a high street and is open Monday- Saturday 0830-1730 and Sunday 1000-1600. In addition to providing essential NHS services the pharmacy offers Medicines Use Reviews (MURs) and New Medicines Service (NMS). The pharmacy also offers malaria prevention treatment through a private service and the seasonal flu vaccination service. The pharmacy dispenses approximately 14,000 NHS items per month (including domiciliary dosage system (DDS) trays to community based patients) and a small number of private prescriptions and veterinary prescriptions. Included in the NHS figures is the supply of medicines in. The pharmacy provides care home services to 7 homes.

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
  • 4.2 - Pharmacy services are managed and delivered safely and effectively

Why this is notable practice

The pharmacy demonstrates a robust and systematic approach to clinical governance. Risks are proactively identified and managed through a variety of working procedures. There is a strong culture of shared learning and risk reduction actions being applied in the pharmacy due to systematic review processes in place. Staff demonstrate a clear understanding of their roles and these are documented within SOPs.

How the pharmacy did this

The pharmacy had four separate areas for dispensing medicines. The main dispensary and a free repeat prescription service (FRPS) room were located on the ground floor level of the pharmacy and the care home services (CHS) room and DDS room were located on the first floor of the pharmacy. Workflow between the different areas was well organised with risks managed, for example, tubs were used throughout the dispensing process to reduce the risk of cross contamination of medicines between prescriptions.

In the main, the dispensary pharmacists focused on waiting prescriptions requiring checking. Pharmacist Information Forms (PIFS) were in place and identified new medicines, changes to medicine regimens, warnings and eligibility for services. A random audit of prescription forms held in the retrieval filing system confirmed that PIF forms were routinely completed and held with the prescription up until the point of handout.

Cards for high risk medicines, such as cold chain medicines, controlled drugs (CDs) and warfarin, were held with prescriptions to inform extra steps at the point of handout.

There was a full set of procedures in place for the services provided including care home dispensing and DDS. Full audit trails and progress logs were in place to manage these services. Each patient had their own record in place which was updated with notes and details of tracked changes. Patients on high risk medicines were routinely monitored and these were not supplied in trays. Any changes to medicines were robustly managed with formal confirmation forms sent to the prescriber and signed to ensure the change was intended; these had been implemented following staff feedback. Dispensing audit trails were in place for the service and descriptions of medicines inside trays were routinely provided. A holding system for assembled trays allowed strict monitoring of delivery and collection which in turn helped to identify concerns if patients did not attended to collect.

With the CHS, appropriate checks were made against the previous month’s medication administration record (MAR) sheet and patient record form during the priming process. Queries were followed up with telephone calls to the surgery with formal query forms completed if they required follow up with either the home or surgery. Pharmacists were provided with the prescription, new and previous MAR, completed PIF and medicine labels when completing the clinical check. A separate communication book was in place for each home. Prescriptions were picked and dispensed individually for each patient and held in separate tubs along with the prescription, PIF and MAR. Dispensing audit trails were in place through the use of quad stamps and signatures on medicine labels. Patient information leaflets were provided every month for new medicines and each care home had a file for these and the pharmacy team provided updates when new leaflets were supplied. Supporting documentation, such as INR request forms, which informed monitoring checks prior to medicines being dispensed and body maps for the application of creams and patches, were in place. Interim prescriptions were faxed by the homes and a copy of the fax was given to a pharmacist with the original prescription to ensure all details were correct upon receipt of the original; faxes were then held in the CHS for 13 weeks. No CDs were dispensed against faxes.

Near misses were routinely recorded after feedback from the accuracy checker. A dispenser demonstrated near miss records and explained how feedback helped prompt reflection and formed part of a monthly patient safety review (PSR) process which was led by the ACT and manager; pharmacists were able to contribute to the PSR process. Each team had their own PSR discussion led by the ACT with risks specific to each service identified and action plans produced to contribute to risk reduction actions. Examples of recent risk reduction actions included putting a white box inside a tub when a prescription called for a split pack of medicines to help reduce the risk of quantity errors. In the CHS dispensary an acronym using the word ‘MAINS’ (Medication, Amount, Instructions, Name and Address, Spelling) was applied to inform checks along the dispensing process.

What difference this made to patients

Clear separation of dispensing for different groups of patients throughout the process, supported by use of robust clinical checks reduces risks of errors impacting on patient safety.

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