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Pharmacy inspections

Inspection reports and learning from inspections

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Supply and administration of naloxone injections

Pharmacy type


Pharmacy context


Relevant standards

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

Why this is notable practice

The pharmacy is in a city centre location where there are problems associated with substance misuse. It has acted on local information to increase the support it provides to people who are at risk of an accidental opioid overdose during the COVID-19 pandemic.

How the pharmacy did this

The pharmacy team members had received information about an increase in the number of opioid related overdoses due to lockdown measures during the COVID-19 pandemic. In response to this the pharmacy had trained its team members to provide supplies of naloxone injections and instructions for use to individuals at risk of overdose. The pharmacy had ordered extra supplies of naloxone injections, which they kept in an accessible location so they could issue them to people in the at-risk group.

The pharmacy had also provided extra training, in accordance with government guidelines, to some of its team members. This meant they were confident in administering naloxone directly to someone who had suffered an overdose. On two separate occasions the pre-registration pharmacist identified the signs and symptoms of opioid overdose in people presenting at the pharmacy. He had alerted the team, administered the naloxone and called for an ambulance. The individuals were revived before the ambulance arrived.

What difference this made to patients

People accessing substance misuse services benefit from the extra support provided by the pharmacy team. The team members are trained to recognise the symptoms of opioid overdose. And they act fast to administer naloxone which can reverse the effects of opioids. These actions can save someone’s life in the event of an overdose.

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