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Pharmacy inspections

Inspection reports and learning from inspections

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Using near miss data to help manage risk during the COVID-19 pandemic

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 is able to identify the impact that the increased workload caused by the COVID-19 pandemic is having on the team. It is using its procedures for capturing and reviewing near miss errors so that it can share information and learn from them. And it is adapting its processes to help reduce the risk of making mistakes in future.

How the pharmacy did this

The superintendent pharmacist (SI) had reviewed the near miss error log over the last couple of weeks during the increased workload caused by the COVID-19 pandemic. And had found an increase in the number of errors. The SI found that errors were most often caused when the team were rushing to get prescriptions completed. The SI had discussed this with the team and reminded them to slow down. The SI had also used the information to look at staffing levels and skill mix in the pharmacy. As a result, the pharmacy had reviewed the number of team members working at any given time. It had reduced its opening hours so team members could finish earlier. And come back to work well rested.

What difference this made to patients

Pharmacy team members spot and manage risk during the dispensing process. And they are continuing to learn from their mistakes and improve. This means people continue to receive their medicines safely during a time when the pharmacy is seeing a significant increase in demand for its dispensing service.

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