Village Pharmacy (1032211) - Improvement action plan

The pharmacy lacks systems to review and manage the safety and quality of its services.

Pertaining to improving the safety and quality of the services, we aim to have monthly reviews using the improved near miss log book to discuss the common mistakes occurring in the pharmacy and therefore implement changes accordingly as a team. A monthly safety review will be undertaken to identify any patterns and make sure changes are done.
To achieve the aim relating to the staff not adhering to the written procedures, the whole team will revisit the SOP and make sure they understand, implement and update their current practice.

All staff will be signing confidentiality agreement induividually. They will be briefed again on importance of GDPR and signed record will be kept in the IG file.

The dispensing staff will have the relevant training and ensure that all the labels are up to standard before the final check by the pharmacist to complete the dispensing audit trail purposes.

The ink has been replaced to avoid sending backing sheets that are hard to read. A change will be implemented where patients will be sent the PILS with their medication every month. A file has been created for all dosette patients to make sure a change in terms of the patient's medication is stored manually as this would help with record keeping and answer any queries.

The preregistration pharmacist was made aware that de-blistered medication was not be re-used and this was conveyed to the whole team.

The accountable officer information was obtained from NHS England AT and is accessible by email or phone number. Information is stuck on the CD registers.

Patients have now started signing to indicate that they have received their delivery and the drivers have been made aware of the changes and informed about the procedures for the CD. The changes have been implemented.

The RP log on the rxweb has been disabled and changed to manual to ensure a clear audit trail and to ensure that every pharmacist logs on and off.
The nature of an emergency supply will be indicated all times when patients are given medication. The staffs have been informed and locum file updated.

The frequency of CD audit trails will be monthly or if there is a discrepancy. The patient's CD returns will be recorded soon the medication is handed into the pharmacy.

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The pharmacy team does not assemble blister packs in a way that provides an assurance that this service is undertaken safely and effectively.

High risk medicines will be highlighted on prescriptions at the point of dispensing and staff are made aware to direct patient to pharmacist for appropriate advice.

On CD prescription date of dispensing and and word CD now highlighted at the point of dispensing and all the staff has been informed to check validity of the prescription before supplying.

Prescriptions for warfarin, lithium, methotrexate etc will be highlighted at the point of dispensing and therapeutic counselling will be recorded on the PMR.

For dossett patient medicines will be stored in the original container and only what is required to make the dossett box will be popped from the blister near the time of making the dossett boxes.

All the dossett patient will be supplied with PIL.

Pharmacy team including delivery drivers has been reiterated importance of delivery SOP. Where possible always get the signature from the patient or representative especially for CD prescriptions and make appropriate record on driver drop sheet.