| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 4.2 | The pharmacy's digital system includes barcode-scanning technology to facilitate accuracy checks during dispensing. But the way team members are using the system increases the risk of medication being labelled inappropriately, and puts patient safety at risk |
AOM has discussed this with the staff member involved. And the risk to patient safety identified has been discussed with the pharmacist and staff member. A retraining of the software has been organised with the PMR trainer for new pharmacist and new staff |
27/04/2026 | 27/04/2026 |
| 1.2 | Pharmacy team members do not routinely record or discuss mistakes they make when dispensing medicines. So, the pharmacy is unable to demonstrate how it learns from things that go wrong and the actions it takes to prevent mistakes happening again. |
A near miss error log has been reprinted and staff and pharmacist have been retrained on how to use the log. The AOM and superintendent will be working with the new branch pharmacist to ensure this is compliant month on month and also will review errors with the branch manager. |
27/04/2026 | 27/04/2026 |
| 1.1 | The pharmacy does not have documented procedures for all key activities being carried out by pharmacy team members. For example, there is no procedure available to help team members dispense medicines safely using barcode-scanning technology. And there is evidence that team members do not work consistently and follow a process that introduces unnecessary risks into the dispensing process. |
The AOM will visit the site to view the SOPs on the branch SOPsmart account and ensure all SOPs are visible. She will tick off the company checklist to ensure every SOP is present. Any missing SOPs will be relayed back to the superintendent to reupload back on to the system and AOM will check this can be viewed on site. AOM will ensure all staff have read and understood each SOP. |
27/04/2026 | 27/04/2026 |
| 1.6 | The pharmacy does not maintain a complete and accurate record of private prescriptions that it dispenses, as required by law. |
The new pharmacy manager has been retrained on where to record all private POM prescriptions. This has to be recorded on the POMsmart – which is part of PharmSmart. |
27/04/2026 | 27/04/2026 |