| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy doesn’t adequately manage all the risks with its services. This includes pharmacy team members working in an untidy and cluttered dispensary. And there is an increased risk of mistakes by the way the pharmacy stores and manages its medicines. The pharmacy doesn’t have complete and up-to-date written procedures that reflect the pharmacy’s current practice. Team members do not always follow the procedures. And some team members have not read them. |
Team effort to eliminate unnecessary clutter and improve workflow. Team members will read and sign revised SOPs to confirm understanding. |
01/12/2022 | 30/11/2022 |
| 1.2 | Pharmacy team members do not have robust arrangements to learn from mistakes. They do not record or analyse their mistakes. And they do not routinely make changes to their practices to help make the pharmacy's services safer. |
More frequent (Weekly) record of Near Miss Log with learning points (e.g., LASA errors) discussed via Team Meetings. To revive an open and honest team discussion when things go wrong and document same. Full report of Medication Errors within ProScript along with sharing reporting to Learn from Patient Safety Events (LPSE) Website. Action learning and change practice. Review changes. SOP to reflect practice to be read and signed by all. |
01/12/2022 | 30/11/2022 |
| 3.1 | The pharmacy is cluttered and untidy. Pharmacy team members do not use the limited space available efficiently. And some areas have insufficient lighting. This introduces significant unnecessary risks. |
Team to urgently look at space allocation with aim to reduce clutter and improve safety/efficiency of dispensing process. Engage electrical contractor to improve lighting upstairs. Arrange for a larger CD cabinet to be fitted so that storage and identification is easier and safer. |
01/12/2022 | 30/11/2022 |
| 4.3 | The pharmacy does not have adequately robust processes for managing and storing its medicines, including checking expiry dates. And there is evidence of out-of-date medicines on the shelves. The pharmacy does not always store medicines prepared in multi-compartment compliance packs safely. So, there is a risk it may supply medicines to the wrong person. And it does not keep all its medicines in the original packs, increasing the risk of errors. |
Revise Date Checking SOP after engagement with the whole team to make this more functional and deliverable.
Team to remove and dispose of split pack medication that has limited/unclear batch number/expiry date appended. Different batches will not be stored within same pack. Revised SOP to be read and signed by all.
|
01/12/2022 | 30/11/2022 |
Pharmacy inspections
Inspection reports and learning from inspections