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Pharmacy inspections

Inspection reports and learning from inspections

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Using different colour codes to map out the patient journey for different vaccines at a vaccination site

Pharmacy type


Pharmacy context


Relevant standards

  • 1.1 - The risks associated with providing pharmacy services are identified and managed

Why this is notable practice

The pharmacy recognises the potential risks with providing two different types of vaccine to people. And the need to ensure that people are given the correct one. So, it has created two separate patient journeys and colour coded each one. This means that it is clear to people and staff which vaccine is required for each person.

How the pharmacy did this

The vaccination team had printed a list of expected appointments for that day. Team members greeted people at the door when they arrived for their vaccine. Team members had a list of appointments for a specific vaccine, either Moderna or AstraZeneca (AZ). And they gave each person a coloured sticker to signify the vaccine they were to have. The pharmacy had two separate, colour coded areas for waiting or observation for each vaccine. So, after receiving their stickers people followed colour coded floor markings to the vaccination waiting areas. When their turn came a vaccinator came to collect the person. And the vaccinator checked again which vaccine they were to have before vaccinating them.

The pharmacy had three lockable clinic rooms. The clinic rooms were large enough to accommodate the record keeper, vaccinator and person being vaccinated. There was colour coded signage to each clinic room. And each clinic room was set up for a single vaccine for that day. So, the appropriate consumables and vaccine stock, vaccination team and patient were all in the same room. At the end of the day the room was cleared out. And deep cleaned.

Vaccines were stored in lockable fridges in clinic rooms. And team members monitored fridge temperatures using data loggers. The pharmacy had separate teams to administer AZ and Moderna vaccinations. And training for the teams included SOPs which had been updated in colour coding for each vaccine and included a checklist for each one. A multiple vaccine site risk assessment had been completed. And a briefing document had been prepared for team members greeting people, for record keepers and for observers. The team had a meeting ‘huddle’ at the start of each vaccination session to brief staff on which vaccination was being administered. They were also briefed on their roles and the clean‐down checklist for the end of the session.

What difference this made to patients

People are confident in the knowledge that they will be receiving the correct vaccine. The patient journey provides people with a clear and efficient pathway through the vaccination process.

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