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Pharmacy inspections

Inspection reports and learning from inspections

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Use of ‘reflective statements' to improve dispensing following near misses.

Pharmacy type


Pharmacy context

Th​e pharmacy is next-door to a doctors' surgery and was purpose built in 2020. It is the only pharmacy in the village. The pharmacy provides NHS dispensing, mainly for patients of the local surgery, as well as multi-compartment compliance packs to some people. They also provide information about medicines and​ sell over-the counter medicines. 

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
  • 2.4 - There is a culture of openness, honesty and learning
  • 4.2 - Pharmacy services are managed and delivered safely and effectively

Why this is notable practice

The pharmacy conducts meaningful reviews of mistakes made during the dispensing process. This has driven changes to the pharmacy practices. And has made the whole team more mindful when dispensing. The team uses the company’s processes for review in a way which enhances individual learning.

How the pharmacy did this

The company’s written procedures stated that team members should log any mistakes they made during the dispensing process (near misses) in order to learn from them. They logged any issues and regularly discussed trends and learning from these near misses. If an error was made, which had reached the public, reflective statements were used to identify what had gone wrong and how the team could try to prevent a recurrence.

The team had adapted the way it used these reflective statements. It did this by asking team members to complete a reflective statement when they made near misses of a similar nature on three or more occasions. This made them think more deeply about why the mistake occurred, and what processes could be put in place to prevent a recurrence.

For example, the team had found that the storage location for a bag of assembled medicines awaiting collection was not always recorded on the prescription. This meant the medicine was difficult to find, made the team look inefficient to the person collecting it, and kept people waiting longer than necessary in the pharmacy.

Another example was that one team member picked the wrong strength of medicine to dispense on more than one occasion. The team member identified that they had a lapse of concentration after the first near miss. But since having to reflect on the causes and consequences they realised the mistakes were made at the same time of day, possibly due to low blood sugar levels, so regular breaks were important to help with concentration. The team member had also identified the potential health consequences of supplying a person with the wrong strength of medicine. Both of these reflections had made the team member more self-aware when dispensing, particularly when dispensing close to the time of an upcoming break.

What difference this made to patients

Engaging in the process of writing a reflective statement makes team members more mindful when they are dispensing. This is because they have thought about the cause and consequence of their mistakes. In turn this means that the dispensing service is more frequently reviewed and is safer and more efficient for people.

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