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Pharmacy inspections

Inspection reports and learning from inspections

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Using regular newsletters to share learning, promote feedback and engage team members in identifying LASA medicines and other risks related to patient safety.

Pharmacy type


Pharmacy context

This community pharmacy dispenses both NHS and private prescriptions. It supplies some medicines in multi-compartment compliance packs. And it offers a medicines' delivery service to vulnerable people. The pharmacy provides substance misuse services. And the pharmacy team provide advice on minor ailments and medicines' use. ​

Relevant standards

  • 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

Why this is notable practice

The pharmacy owner regularly reminds its team members to be open and honest when reporting mistakes. The owner undertakes regular safety reviews of error reporting across its pharmacies. And it uses the information from these reviews to share learning through engaging newsletters. These help to maintain a clear safety culture. And it supports team members in identifying improvements to patient safety.

How the pharmacy did this

Pharmacy teams recorded and submitted safety information to the superintendent pharmacist’s (SI’s) office. They had the option of using an electronic system or a paper-based system depending on what worked best in each pharmacy. The SI carried out regular safety reviews and produced a report of the findings. The report included the lessons that had been learnt to help reduce risks. Mistakes were categorised to support learning, such as labelling, strength and formulation mistakes. And the reports were published in the company’s regular newsletter.

The newsletters were engaging and prompted reflection on both a personal and a team level. In the most recent newsletter, a prize was offered to the pharmacy team that successfully completed a ‘look-alike and sound-alike’ (LASA) based wordsearch quiz. Nine drug names were hidden in the wordsearch and the clue was ‘common medicines that were often mixed up at the time of dispensing’. This approach helped team members to identify the LASA medicines and to think about the steps their own pharmacy took to reduce the risk of the medicines being involved in a patient safety incident.

What difference this made to patients

People using the pharmacy receive a safe service which is continually monitored. They are served by team members who do their upmost to reduce the risk or errors through shared learning and improvements.

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