West St Leonards Pharmacy (1036267) - Improvement action plan

The pharmacy records mistakes that are made and identified during the dispensing process. But it cannot always demonstrate that it appropriately documents and learns from dispensing mistakes where the medicine has been received by a person. So, the pharmacy may be missing out on opportunities to learn and make the pharmacy's services safer.

The pharmacy has reviewed its incident reporting procedures and will ensure that all dispensing incidents, including those where the medicine has reached the patient, are fully documented in a designated incident log. The record will include details of the incident, contributory factors, actions taken, learning outcomes, and any changes implemented to reduce the risk of recurrence. All pharmacists and staff members will be reminded of the importance of promptly reporting and documenting dispensing incidents. A team discussion and refresher training will be completed to reinforce the pharmacy’s learning culture and patient safety responsibilities. The superintendent pharmacist will conduct regular monthly reviews of incident records to identify trends, share learning with the team, and ensure that any required improvements are implemented and maintained. The pharmacy will also review and update relevant SOPs to ensure there is a clear process for recording, reviewing, and learning from dispensing incidents.