| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.3 | The pharmacy does not support team members to fully understand their roles and responsibilities and what tasks they can and can't complete without a responsible pharmacist (RP) signed in. This blurs some lines of accountability within the pharmacy. |
SOPs to be reviewed with staff members so roles and responsibilities are clear to staff. SOP on accuracy check to be updated to include PMR accuracy check. |
15/08/2024 | 02/09/2024 |
| 1.6 | The pharmacy does not keep appropriate records for all the private prescriptions it dispenses. It does not have effective processes to ensure its RP record is an accurate reflection of when a RP is on duty, or to ensure entries in the RP record are made personally by the RP. The pharmacy does not always make timely records when it receives and destroys some higher-risk patient-returned medicines. |
Private prescriptions for all services such as vit B12 and travel vaccines to be dispensed on PMR. Records of private prescriptions for travel vaccinations to be produced as paper copies. RP register kept as handwritten RP book rather than PMR version. Therefore records are more accurate and can only be made by the RP. Patient returned CDs to be entered on receipt, ensure staff are aware to segregate CDs for entry into patient CD return register and destruction entries kept up to date |
15/08/2024 | 02/09/2024 |
| 4.3 | The pharmacy does not have effective monitoring processes to ensure its refrigerators are storing medicines at the correct temperatures. It has not appropriately considered this monitoring requirement when assessing the risks of providing its vaccination services. The pharmacy does not always store higher-risk medicines requiring secure storage correctly. And its current processes do not ensure a pharmacist has direct supervision over these medicines. |
Fridge temperatures to be recorded daily. Secure cabinet key storage reviewed to ensure access to higher-risk medicines requiring safe custody is supervised by a pharmacist. Higher-risk medicine stock levels reduced to ensure sufficient space within the existing secure cabinet. This has been done by reducing some excess stock and forthcoming changes to workload. Going forward stock levels to be monitored with each balance check to ensure no excessive excess stock is held. AAH rep contacted regarding morning delivery time rescheduling to ensure deliveries are made during pharmacy opening hours. Pharmacy staff to ensure stock is not accepted before RP is present. |
30/08/2024 | 02/09/2024 |
Pharmacy inspections
Inspection reports and learning from inspections