| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.2 | Pharmacy team members do not adequately learn from mistakes they make when dispensing. This includes not making records of mistakes and not discussing and learning from them to improve patient safety. |
Ensure the pharmacy team (2PA and 1 TPA) understands how to record near miss on Datix and access Datix and log in to review. AOM to monitor on weekly visits that near misses are recorded on Datix regularly. Ensure Patient Safety Report (PSR) is completed and a patient safety huddle is completed at least once a month. AOM to monitor that the PSR is completed monthly and to discuss key learning from the PSR with the pharmacy team. |
19/06/2024 | 14/06/2024 |
| 2.1 | The pharmacy does not always have a sufficient number of suitably trained team members to manage the dispensing workload safely. |
Review the staffing rota for the next 4 weeks and ensure appropriate cover throughout. Complete a staffing and capability review to identify any concerns and ensure appropriate staffing profile. Organise out of hours working to clear the backlog to tidy and correctly store excess stock. Review MDS work planner and ensure appropriate support is provided to the team to dispense medication into MDS. Arrange out of hours work in the interim period to ensure workload is managed effectively. |
05/06/2024 | 14/06/2024 |
| 3.1 | Several areas of the pharmacy premises are excessively cluttered and untidy. This increases the risk of a trip or a fall and compromises safe dispensing. |
Review the model day/staffing rota of the pharmacy as per 2.1. Provide additional support to the pharmacy team and organise out of hours work to allow them to: - Declutter the pharmacy Ensure colleagues are aware of the appropriate stock ordering process. To set up a cleaning rota Ensure colleagues are following the model day rota (e.g. cleaning, stock ordering) |
19/06/2024 | 14/06/2024 |
| 4.3 | The pharmacy stores and manages its medicines in a way that increases the risk of mistakes occurring during dispensing. And it does not have effective arrangements to identify, check and remove medicine stock which has expired. |
As per 3.1: - ensure all stock received from the wholesaler is stored correctly on the dispensary shelves. Ensure date checking is completed regularly as per company schedule by both direct observation on frequent visits and remotely by reviewing management information reports. Tidy the dispensary shelves to minimise the risk of any selection errors. |
05/06/2024 | 14/06/2024 |
Pharmacy inspections
Inspection reports and learning from inspections