This website uses cookies to help you make the most of your visit.
By continuing to browse without changing your settings, you agree to our use of cookies.
Give me more information

Pharmacy inspections

Inspection reports and learning from inspections

Skip to Content (Press Enter)

Using continual review processes to help improve safety when handing out assembled medicine

Pharmacy type


Pharmacy context

This community pharmacy is co-located with amedical practice on the outskirts of a city. The pharmacy’s main services include dispensing NHS prescriptions andselling over-the counter medicines. It also offers advice and treatment to helppeople manage minor ailments.

Relevant standards

  • 1.1 - The risks associated with providing pharmacy services are identified and managed
  • 4.3 - Medicines and medical devices are: obtained from a reputable source; safe and fit for purpose; stored securely; safeguarded from unauthorized access; supplied to the patient safely; and disposed of safely and securely

Why this is notable practice

The pharmacy uses continual review processes to identify and manage risks associated with supplying medicines to people. It takes timely action to implement changes designed to reduce risk when supplying medicines.

How the pharmacy did this

The pharmacy had identified a trend in mistakes made during the hand-out stage of the dispensing process. As part of its continual patient safety review processes it had looked at contributing factors, particularly those linked to the pandemic. For example, people were often in a rush when they visited the pharmacy. And people sometimes had to change the way they communicated when wearing face coverings.

The pharmacy team had looked at what it could do to reduce these types of incidents and recognised these incidents should be a never event. So, it completed a programme of learning to ensure that the team were following the pharmacy’s standard operating procedures. In addition to this, the pharmacist manager had worked with the superintendent pharmacist to review workflow. This review had led to a mini-refit and the introduction of a purpose built ‘hand-out’ station. The pharmacy also changed its alphabetical retrieval system to a numbered retrieval system which prompted more checks during the hand-out process.

These actions meant team members were in a better position to complete the hand-out process in a protected space. This allowed identification checks to be completed thoroughly. The changes to work-flow were continually reviewed and results to date had been positive with no further hand-out error made.

What difference this made to patients

People receive the right medicine and can raise any queries about their medicine in a suitable environment.

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