Nuchem Pharmacy (1031137) - Improvement action plan

The pharmacy does not have a robust process for checking the expiry dates of its medicines. There is evidence that some out-of-date medicines have been supplied. Some expired medicines were found in with current stock. And the pharmacy does not keep clear records about when it has checked the expiry dates of its stock.

1) Staff Scope of Practice, Governance & Training a. Reallocation of Date-Checking Duties; Previous Process: Date-checking and stock put-away were distributed across the wider pharmacy team. Internal review identified that this created inconsistencies in process adherence, oversight, and record-keeping. Corrective Action: Dispensary date checking and stock management duties to be reallocated exclusively to two qualified named members of the dispensing team to maintain strict quality control, clear accountability, and robust record-keeping. OTC date-checking and stock management duties to be performed by Medicine Counter Assistant. Stock Room & Back of Pharmacy date checking and patient return medicine management duties to be performed by staff and supporting team. b. Personnel Briefings: Formal 1-on-1 briefings to be completed with every team member to reinforce role boundaries, individual responsibilities, and lines of accountability within the dispensary. c. Protected Training Time: Establish protected, mandatory training sessions every Thursday afternoon. This guarantees staff dedicated time to complete, document, and review their formal training modules without operational interruption. The Date checking SOP No:12 and Records Management and Retention SOP No:54 to be revisited to start. 2) Stock Control & Date-Checking Systems: a. Immediate 100% Stock Audit: Conduct a complete, baseline audit of all stock across dispensary shelves, retail areas, medicine fridges, CD cupboard, stock rooms and quarantine stores. All expired or short-dated stock removed, logged, and disposed of via standard pharmaceutical waste streams. b. Sectional Matrix & Rolling Cycle: Update the Stock Management and Date Checking Standard Operating Procedure (SOP). Date checking to be divided into structured weekly sections, ensuring 100% of pharmacy stock is audited every three months, monitored and verified by the Responsible Pharmacist at each quarter for ongoing compliance. c. Formalized Documentation: Implement a centralized Date-Checking Logbook. Staff must record the audit date, exact shelf section inspected, short-dated stock identified, and their signature/initials. d. Visual Alert System: Introduce high visibility red/orange alert stickers applied directly to any stock with less than 6 months remaining shelf life to highlight the short expiry. The quarantine area will soon close. Moving forward, we will no longer store expired medicines for reps. We will keep only the boxes and will dispose of the medicines in the usual manner e. Team Briefing & Final Safety Checks: This has already been part of process so all personnel to be re-briefed on updated SOPs, emphasizing mandatory double checking of expiry dates during both the picking phase and the final accuracy check as a robust secondary safety barrier.