| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.2 | Pharmacy team members talk about the mistakes they make to try to learn from them. But they don’t record or review them, so they may be missing opportunities to spot patterns or trends and take effective action to help prevent the same sort of things happening again. |
While a near-miss log was already in place prior to your visit, it was underutilised by the team. The SI has now made it clear to all staff that every dispensing, labelling, or clinical error — no matter how small — must be recorded in the log without exception. To embed this as routine practice, the SI has: |
04/09/2025 | 04/09/2025 |
| 1.1 | Not all members of the team can access the pharmacy's standard operating procedures (SOPs). And the SOPs do not reflect changes introduced as a result of the updated patient medication record system. This might make it more difficult for team members to work effectively and within current best practice. |
New SOPs reflecting the changes introduced with the updated patient medication record (PMR) system have already been created, published, and shared with all staff members. The Superintendent (SI) has begun sitting down with team members individually to ensure they can confidently access the SOP Manager. Where any difficulties are identified, the SI demonstrates the process again until they are comfortable. The next step is to ensure that every member of staff has read, understood, and formally signed off on each SOP to confirm their compliance. In addition, the SI is preparing a written, paper-based SOP/instruction guide detailing the process for accessing SOPs online, which will be distributed individually and stored in an easily accessible location in the dispensary. |
04/09/2025 | 04/09/2025 |
Pharmacy inspections
Inspection reports and learning from inspections