Owen's Chemist (1029532) - Improvement action plan

The pharmacy team does not follow a process to record details of mistakes made during the dispensing process. The team cannot demonstrate any learning from mistakes made or any changes made to the way the pharmacy operates to improve patient safety.

To address this, the pharmacy will implement a structured and transparent system to ensure that all near misses are recorded, reviewed, and acted upon. All staff will be re-trained that clearly outlines how and when 1.2 The pharmacy team does not follow a process to record details of mistakes made during the dispensing process. The team cannot demonstrate any learning from mistakes made or any changes made to the way the pharmacy operates to improve patient safety. To address this, the pharmacy will implement a structured and transparent system to ensure that all near misses are recorded, reviewed, and acted upon. All staff will be re-trained that clearly outlines how and when near misses must be recorded, who is responsible for documenting them, and how the information will be used to support learning and improvement. All members of the pharmacy team will be trained on this new SOP within one week to ensure full understanding and compliance.
From this point forward, every near miss identified during the dispensing process will be recorded promptly—ideally immediately, but no later than the end of the working day. Each record will include details such as the date, the name of the medicine involved, the type of error, who identified it, and any contributory factors. The responsible pharmacist will oversee this process to ensure accuracy and consistency.
To encourage learning and prevent recurrence, the pharmacy will hold monthly near miss review meetings. During these meetings, the team will review all near miss entries, identify common themes or trends (for example, look-alike/sound-alike drugs, interruptions, or staffing levels), and agree on specific actions to minimise future risk. Minutes of these meetings will be documented to demonstrate review and follow-up.
Any learning or system improvements identified through these reviews will be implemented promptly. Examples may include rearranging the dispensary to separate similar-looking products, adding shelf-edge warnings or labels, updating SOPs, or revising checking processes. The outcomes of these changes and the key learning points will be communicated to all staff during regular team briefings or displayed on a “Learning from Near Misses” board within the dispensary to ensure the entire team benefits from shared learning.
To maintain oversight, the responsible pharmacist or superintendent will conduct a quarterly audit of the near miss recording process to ensure it is being followed consistently and that identified actions are being implemented effectively. This will also help track improvements over time and demonstrate a proactive approach to patient safety and continuous quality improvement.
By implementing these steps, the pharmacy aims to create a culture of openness and learning, ensuring that mistakes are used as opportunities to strengthen processes and prevent harm. The expected outcomes include consistent recording of all near misses, clear evidence of learning and action, and a demonstrable improvement in patient safety in line with GPhC standards.

The pharmacy consultation room is cluttered and untidy, and so does not portray a professional healthcare image. An entrance door to the room is unable to be fully closed and so there is a risk people's private conversations about their health may be overheard by other people present in the retail area.

In response to this, the pharmacy has immediately informed the landlord of the flooding issue and the condition of the staff toilet, as these fall under the landlord’s responsibility for building maintenance and structural repairs. The landlord has been made aware in writing of the urgency of the matter, and we are awaiting an update and confirmation of their plan to carry out the necessary permanent repairs.
While awaiting the landlord’s action, the pharmacy has taken temporary corrective measures to ensure the premises remain safe and functional. A qualified contractor has been called in to assess and carry out repairs and drying works in the basement to reduce the immediate hazard caused by the flooding. The affected areas are being cleaned, disinfected, and sealed off as appropriate to prevent access until they are safe to use.
In relation to the toilet facilities, contractors have also been instructed to carry out repairs to restore them to a usable and hygienic condition. This includes temporary fixes to plumbing, cleaning, and ensuring basic functionality so that staff have access to adequate facilities while awaiting full repair by the landlord.
The responsible pharmacist will continue to monitor the situation daily and record the condition of the facilities in the pharmacy’s premises maintenance log until the issue is fully resolved. Any deterioration or safety concern will be reported immediately to the landlord and escalated if necessary.
The pharmacy is committed to maintaining a safe working environment for all team members and ensuring compliance with health and safety and GPhC premises standards. These temporary measures will remain in place until the landlord completes the permanent structural repairs and confirms the area is safe and compliant for full use.