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Pharmacy inspections

Inspection reports and learning from inspections

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Using adverse incidents to make improvements to stock management at a COVID-19 vaccination centre

Pharmacy type


Pharmacy context


Relevant standards

  • 1.2 - The safety and quality of pharmacy services are regularly reviewed and monitored

Why this is notable practice

The pharmacy uses information from adverse incidents and other pharmacies to continually share learning. And to make changes to the way the COVID-19 vaccination service operates.

How the pharmacy did this

The lead pharmacist and Superintendent pharmacist (SI) had regular meetings with team members working at the COVID-19 vaccination centre. They used the meetings to ask for feedback about what had gone well and what they could do to improve the service. In addition, they used information from NHS England and other service providers to continually review their own procedures.

The lead pharmacist had noticed that some vaccinators were administering a different number of COVID-19 vaccinations from the same size vial. In order to get the most from each vial and prevent wastage, they had developed a docket which was issued to the vaccinator when they started to use a new vial. The vaccinator ticked a box on the docket when they drew up a dose and handed the docket back to the lead pharmacist when they returned the empty vial. The lead pharmacist also carried out observation audits throughout the day. These focussed on drawing up and vaccination techniques.

The team had also implemented a new procedure so there was an audit trail for the fridge key. The fridge key was stored securely overnight and signed out to a member of the team in the morning. If that team member left the premises, they were required to sign the key over to another member of the team. This ensured that the COVID-19 vaccination stock was stored securely, but also accessible.

What difference this made to patients

The pharmacy has good processes for ensuring the safe and smooth running of its COVID-19 vaccination service. It is taking regular opportunities to continually review and update its procedures. This provides assurance the pharmacy is managing its service and vaccination stock well. And ensures that the maximum use is made of each vial of vaccine so more people can be vaccinated.

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