Weaknesses in monitoring and review mechanisms, including the capacity of the premises to cope with the increased workload and non-compliance with SOPs

Pharmacy type

Community

Pharmacy context

A community pharmacy located on a main road in a suburb of a medium-sized town. The pharmacy is open 6 days a week. It dispenses NHS prescriptions and sells a range of over-the-counter medicines. It also supplies medicines in multi-compartment medicine trays to people who live in their own homes.

Relevant standards

• 1.1 - The risks associated with providing pharmacy services are identified and managed
• 1.2 - The safety and quality of pharmacy services are regularly reviewed and monitored

Why this is poor practice

The pharmacy doesn’t manage risks adequately and the way it operates and stores its medicines increases the risk of mistakes happening. It has procedures in place but these are not always followed and are not reviewed regularly. Additionally, it doesn’t review its services when things go wrong and the pharmacy does not have sufficient capacity to provide the volume of services it does.

What the shortcomings are

The pharmacy’s dispensing volume has increased significantly in recent years. The pharmacy provided a monitored dosage system (MDS) dispensing service despite the superintendent pharmacist's acknowledgement that the dispensary was too small for this. The dispensary was disorganised and did not have the space to accommodate the additional workload and extra pharmaceutical stock. Several split packs of medicines were found to contain stock from different batches and manufacturers and some expired medicines were amongst in-date stock. Prescription-only medicines and pharmacy medicines were found on self-selection next to the pharmacy counter. Some assembled MDS trays and prescriptions were left on the pharmacy counter in easy reach of the public. Staff, including the superintendent pharmacist, were not always following the SOPs; for example, prescriptions for appliances and some external products were not labelled before being supplied to patients. Whilst SOPs were in place for dispensing errors and near misses, these were not being followed; dispensing errors and near misses were not recorded, reviewed or analysed.

What improvements are required

The dispensary needs to be enlarged and re-organised to cater for the increase in the pharmacy’s dispensing workload. The pharmacy team needs to make sure the pharmacy’s medicines are stored appropriately, securely and tidily. The pharmacy’s procedures need to be reviewed and members of the pharmacy team need to follow them; for example, labelling products supplied to people against prescriptions. The pharmacy team needs to record the mistakes its makes and review them to learn from them and help prevent them happening again.