| Effective use of monitoring and review mechanisms and a culture of learning from incidents. |
Governance, Leadership, Proactive approach |
Principle 1. Governance, Principle 2. Staff |
1.2, 2.4 |
The pharmacy employs good review and monitoring processes, so that the risks associated with pharmacy services are identified and managed. This includes sharing of learning from near misses across all branches. |
Details
|
| A culture of continuous learning. |
Added value, Customer and patient focus, Efficiency of processes, Governance, Leadership, Outcomes for patients, Proactive approach, Responsiveness |
Principle 1. Governance |
1.2 |
Systematic monitoring and review mechanisms are in place, including checking compliance against GPhC pharmacy standards, demonstrating a culture of continuous learning. |
Details
|
| Challenging the quality of prescribing. |
Added value, Customer and patient focus, Efficiency of processes, Governance, Leadership, Outcomes for patients, Proactive approach |
Principle 1. Governance |
1.2 |
Systematic and regular review of service delivery demonstrates a culture of learning, leading to improvements in the safety and quality of services. For example, an audit into prescriptions returned to the prescribing GP has led to improved tracking and follow up of such prescriptions. |
Details
|
| Monitored dosage system and care home services. |
Efficiency of processes, Governance |
Principle 1. Governance, Principle 4. Services, including medicines management |
1.1, 1.2, 4.2 |
Monitored Dosage Systems (MDS) are assembled and checked in a well organised dedicated centre in line with the standard operating procedure (SOP). The team are separate to the main dispensary team and can work without the distractions of the retail environment. Good records of communications are made between the care home/GPs and the pharmacy, and within the pharmacy team. Dedicated patient safety reviews tailored to the care home centre are completed. |
Details
|
| Absence of standard operating procedures for the services provided by the pharmacy |
Customer and patient focus, Efficiency of processes, Governance, Lack of key knowledge and a failure to learn, Leadership |
Principle 1. Governance, Principle 3. Premises, Principle 5. Equipment and facilities |
1.1, 1.2, 3.4, 5.1, 5.2 |
A closed pharmacy commenced operations without having appropriate arrangements and procedures in place for identifying and managing the specific risks presented by this pharmacy. |
Details
|
| Insufficient staffing level |
Customer and patient focus, Governance, Lack of key knowledge and a failure to learn, Leadership, Outcomes for patients, Responsiveness |
Principle 1. Governance, Principle 2. Staff, Principle 4. Services, including medicines management |
1.2, 2.1, 4.3 |
The level of trained staff is inadequate for the safe operation of pharmacy services. This is leading to a chaotic working environment, routine training and date checking not taking place and long delays for patients awaiting their medication. |
Details
|
| Management of controlled drugs |
Efficiency of processes, Governance, Lack of key knowledge and a failure to learn, Leadership |
Principle 1. Governance |
1.1, 1.2, 1.6 |
There are inadequate governance arrangements particularly in respect of controlled drugs (CDs) . A range of standard operating procedures define the processes and procedures at the pharmacy, however most of these are out of date and a review is needed to ensure they reflect current pharmacy practices and are adhered to by staff. Not all near-misses and errors are recorded and reviewed to ensure that all of the emerging risks are managed. Not all of the necessary records are being maintained and CDs are not properly managed. |
Details
|
| Clinical governance audits |
Customer and patient focus, Governance |
Principle 1. Governance, Principle 2. Staff |
1.2, 2.2 |
The pharmacy reviews and continually monitors the safety and effectiveness of its services through regular audit and it tracks team member’s completion of training to ensure their knowledge is up to date |
Details
|
| Weaknesses in monitoring and review mechanisms and non-compliance with SOPs |
Governance, Lack of key knowledge and a failure to learn, Leadership |
Principle 1. Governance |
1.1, 1.2 |
There are no procedures in place to record and learn from dispensing incidents and near misses are very infrequently recorded and the pharmacy team cannot demonstrate any learning from these. The Standard operating procedures (SOPs) that were in place for some dispensary tasks were not followed, including that for Monitored dosage system (MDS) trays. |
Details
|
| Weaknesses in monitoring and review mechanisms and poor knowledge of safeguarding |
Customer and patient focus, Governance, Lack of key knowledge and a failure to learn, Leadership |
Principle 1. Governance |
1.1, 1.2, 1.8 |
The pharmacy team are not working in accordance with their Standard Operating Procedures (SOPs) and they have not read or signed these. Staff are unclear about the pharmacy’s operating procedures and current practice, for example, for safeguarding vulnerable people. |
Details
|
| Insufficient staffing level and weaknesses in monitoring and review mechanisms |
Customer and patient focus, Governance, Leadership, Outcomes for patients, Responsiveness |
Principle 1. Governance, Principle 2. Staff, Principle 3. Premises, Principle 4. Services, including medicines management, Principle 5. Equipment and facilities |
1.1, 1.2, 1.3, 1.6, 1.7, 1.8, 2.1, 2.2, 2.4, 3.2, 3.5, 4.1, 4.2, 4.3, 4.4, 5.3 |
There are poor governance procedures in place and an insufficient level of staff for the services provided. Overall, there is inadequate assurance that risks are identified and managed and that procedures are reviewed and monitored. Stock is haphazardly and unsafely stored. Schedule 2 controlled drugs are delivered against faxed prescriptions with no assurance that these have not also been supplied by local pharmacy. There are insufficient employed staff to safely provide the services offered by the pharmacy. Many of the staff are newly employed, unsure of their responsibilities and unable to make professional judgements. The trainees are not supported with their learning and there is no overall culture of learning at the pharmacy. Record-keeping is poor and some staff do not understand safeguarding issues. Patient-sensitive information is not kept securely. Some areas are in need of routine maintenance and repair and the temperature in parts of the dispensary is too high for the safe storage of medicines. |
Details
|
| Effective use of monitoring and review mechanisms and a culture of learning from incidents. |
Customer and patient focus, Efficiency of processes, Governance |
Principle 1. Governance, Principle 4. Services, including medicines management |
1.1, 1.2, 4.2 |
Continuous, proactive and systematic review of risks are used to identify trends, inform review of procedures and training and inform improvements in service delivery. Systematic monitoring and review mechanisms are in place, demonstrating a culture of continuous learning and leading to improvements in the safety and quality of services. |
Details
|
| Weaknesses in monitoring and review mechanisms, including the capacity of the premises to cope with the increased workload and non-compliance with SOPs |
Customer and patient focus, Efficiency of processes, Governance, Lack of key knowledge and a failure to learn, Leadership |
Principle 1. Governance |
1.1, 1.2 |
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. |
Details
|
| Insufficient staffing level |
Customer and patient focus, Governance, Leadership, Outcomes for patients, Responsiveness |
Principle 1. Governance, Principle 2. Staff, Principle 4. Services, including medicines management, Principle 5. Equipment and facilities |
1.1, 1.2, 1.4, 2.1, 2.5, 4.1, 4.2, 4.3, 5.1 |
The main risk in this pharmacy was lack of staff, resulting in many routine activities not being undertaken, high staff stress levels, increased prescription waiting times resulting in many patients in the pharmacy waiting for prescriptions, and cluttered dispensary due to stock arriving and not being put away in a timely manner. |
Details
|
| Comprehensive monitoring and review mechanisms to minimise risks supported by a learning culture |
Efficiency of processes, Governance, Leadership, Proactive approach |
Principle 1. Governance |
1.1, 1.2 |
Near miss records and errors are consistently reviewed to improve the safety and quality of services. |
Details
|
| Effective use of monitoring and review mechanisms and a culture of learning from incidents. |
Customer and patient focus, Efficiency of processes, Governance, Leadership, Proactive approach |
Principle 1. Governance |
1.1, 1.2 |
Dispensing accuracy is constantly monitored and reviewed and there is a robust system in place to deal with, discuss and improve practice following incidents. There is evidence that the pharmacy team seek to identify, manage and minimise risks with trends being analysed. |
Details
|
| Segregation of different dispensing services |
Added value, Customer and patient focus, Efficiency of processes, Governance, Leadership, Outcomes for patients, Proactive approach |
Principle 1. Governance, Principle 4. Services, including medicines management |
1.1, 1.2, 4.2 |
The pharmacy demonstrates a robust and systematic approach to clinical governance. Risks are proactively identified and managed through a variety of working procedures. There is a strong culture of shared learning and risk reduction actions being applied in the pharmacy due to systematic review processes in place. Staff demonstrate a clear understanding of their roles and these are documented within SOPs. |
Details
|
| Effective use of monitoring and review mechanisms and a culture of learning from incidents. |
Efficiency of processes, Governance |
Principle 1. Governance |
1.2 |
Practices and procedures are monitored on an ongoing basis and action is taken so that risks are managed and services improve. |
Details
|
| Effective use of monitoring and review mechanisms and a culture of learning from incidents. |
Efficiency of processes, Governance, Leadership, Proactive approach |
Principle 1. Governance |
1.2 |
Continual review mechanisms are used to identify patterns or trends and establish individual coaching needs. |
Details
|
| Management of high risk services and a culture of continuous learning |
Customer and patient focus, Efficiency of processes, Governance, Leadership |
Principle 1. Governance, Principle 4. Services, including medicines management |
1.1, 1.2, 1.3, 1.6, 4.2 |
High-risk activities are proactively identified and the risks effectively managed, including risks to patients receiving the substance misuse service. Systematic monitoring and review mechanisms are in place demonstrating a culture of continuous learning, including the annual objective review of SOPs and sharing of learning. There is clear role definition and the pharmacy manages risk when tasks are delegated to members of the team. |
Details
|
