| 1.2 |
The pharmacy does not keep adequate records when mistakes are made in the dispensing process and there is no evidence of learning from mistakes to improve patient safety. |
Ensure all pharmacy team and regular pharmacists are aware of how to access and record near misses and PSI on Datix.
Ensure all pharmacy team and regular pharmacists are aware of how to contact PS Team to seek professional support.
The Field Manager to review the no. of near misses recorded by the pharmacy team during the weekly catch-up/ regular visits.
Ensure all pharmacy team and regular pharmacists are aware of how to complete the monthly patient safety report.
The Field Manager to review the content of the monthly patient safety report and ensure any learning from the near misses have been reviewed.
Conduct a Patient Safety Huddle with the new team.
|
09/04/2024 |
04/04/2024 |
| 1.6 |
The pharmacy does not maintain all its legal records involving higher-risk medicines as it should. And it does not resolve identified issues in a timely manner. |
Conduct CD balance check on all items in the CD cabinet.
Report any unresolved discrepancies to the PS Team and NHS AO.
Ensure CD balance check is completed regularly.
The Field Manager to check whether CD balance check is completed during the pharmacy visits.
Discuss the importance of CD management in the Patient Safety Huddle.
|
22/03/2024 |
04/04/2024 |
| 2.1 |
The pharmacy does not always have a sufficient number of suitably trained team members to manage the dispensing workload safely. |
Complete the staffing and capacity assessment.
Ensure all new starters are up-to-date with the training and following the induction training plan.
Ensure all colleagues have completed all relevant SOPs.
Compare the current staffing situation with the operational model, MaxE.
Confirm what needs to be recruited to support the pharmacy and initiate a recruitment plan.
Recruit a team leader/permanent pharmacist to provide appropriate leadership to this pharmacy.
|
22/03/2024 |
04/04/2024 |
| 3.1 |
The pharmacy's dispensary area is excessively cluttered and untidy. This increases the risk of a trip or a fall and compromises safe dispensing. |
Arrange a cleaning and tidying-up session at the pharmacy.
Empty all boxes in the pharmacy and place the items in the designated locations in the dispensary.
Identify the miscellaneous items on the first floor. Dispose the items safely or store them in an appropriate location.
Confirm the appropriate use of the first floor at the Pharmacy.
|
09/04/2024 |
04/04/2024 |
| 4.3 |
The pharmacy does not store all its medicines appropriately. And it does not complete adequate checks of them to ensure it supplies them to people safely. |
Review the operation processes at the pharmacy to ensure stock are taken out from the totes and placed on the shelves rather than selecting medication directly out of the tote boxes to dispense.
Date-check all items in the pharmacy.
Establish a date checking rota to ensure the date checking process is followed as per company process.
Ensure fridge temperature is checked every trading day.
The Field Manager to check whether fridge temperature is checked during pharmacy visits.
Ensure all pharmacy team are aware how to escalate concerns if the fridge temperature is out of range. All pharmacy team to read SOP 18 Stock Management.
|
09/04/2024 |
04/04/2024 |
