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Pharmacy inspections

Inspection reports and learning from inspections

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Understanding how to sell over-the-counter codeine-containing medicines safely

Pharmacy type


Pharmacy context

This is a pharmacy on a busy road, close to a town centre. The pharmacy's main focus is to dispense NHS prescriptions and it delivers many medicines to people's homes. It sells a range of over-the-counter medicines and the team advises and supports people with minor illnesses.  

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 pharmacy assesses the risk of selling codeine-containing medicines. And it has safeguards in place to monitor the sales of these medicines. Pharmacy team members have a good awareness of the potential for misuse of these higher risk medicines. And they sell these medicines appropriately with additional advice.

How the pharmacy did this

The pharmacy had stopped selling codeine linctus over the counter. Following this, the pharmacy reviewed its processes and training on other codeine-containing over-the-counter medicines. It introduced a new standard operating procedure to help team members gather all the relevant information before referring the sale to the responsible pharmacist. All team members completed a learning module on codeine, so they had a better understanding about its use in pain relief.

Pharmacy team members used a written checklist when managing a request for these higher risk medicines. This checklist included the need to ensure the responsible pharmacist personally authorised each sale. This process helped to make sure that team members asked the relevant questions consistently and each sale was accompanied with advice. Team members documented when they refused a sale to a person and why. They signposted these people to their GP surgery or other healthcare professional. The pharmacy used the information on the checklist at the end of each month to complete an audit of sales. It also completed a monthly audit of wholesaler purchases of codeine-containing medicines. This meant it had full information to monitor both the receipt and supply of these medicines.

What difference this made to patients

Team members understand the importance of assessing people’s individual needs when selling codeine-containing medicines and in helping to protect vulnerable people. They provide people with appropriate information to help them take these medicines safely. The pharmacy team signposts people to other healthcare professionals when required so they can get the support they need.

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