Jhoots Pharmacy (1036356) - Improvement action plan

The pharmacy does not keep all the records required by law and does not have good governance procedures for the management of controlled drugs.

To address pharmacists occasionally forgetting to sign out of the RP Log at the end of shift, this information is being passed onto staff and a message displayed near the main screen as a daily reminder.

Regarding the management of Controlled Drugs, a considerable amount of work has been undertaken recently to improve this including:
- CD Zone on Dispensary bench where Scripts containing CDs yet to be dispensed are stored for easy access and monitoring
- Only RP allowed to open the CD Cabinet / sign in CD stock and put CD stock away
- Regular checks on scripts to quickly identify out of date CD Scripts and cancel them correctly on records
- Stock counts performed wherever possible on CDs at the time of dispensing each day
- Where possible these balance checks will be conducted by more than one person.

This has greatly improved the management of Controlled Drugs in the store and further improvements now made are to:
- Commit to weekly balance checks in addition to stock counts after each time of dispensing.
- The last CD balance check performed (all CDs except Methadone) over 2 day period resulted in correct balances for all CDs. The Zomorph 10mg capsule imbalance this was reported to CDAO on 9.8.24 Ref 57816, and the correct balance stated on the register from this date.

An investigation undertaken to identify the reason for the gross imbalance in the Methadone register showed an error where an entry of stock into the register was made incorrectly. This has now been rectified.

The Methadone SF Register had a mathematical error made which accounted for the majority part.

With regards to the issue of imbalances with large volume dispensing of Methadone, a conversation has been had with all Pharmacists to determine if they were confident that following the supervised dose being given, the blue script was immediately being filled out on the back then placed in the blue box ready for entering in the CD Register at a convenient time, and this seemed to be the case. With hindsight though, and due to the discrepancies that have happened, we will commence immediate filling in of the back of the blue script / recording same script in CD Register one at a time at the time of supervised consumption. Pharmacists and staff to be briefed regarding this on Monday / Tuesday this week.

To improve the legibility of CD entries, every effort is being made to write the daily entries in/out in as quiet a moment as possible or at end of shift to facilitate this.