K Pharmacy (1039596) - Improvement action plan

The pharmacy team members don’t make any records following dispensing incidents. And, they don't make any changes to the way they work. The pharmacy team members do not record, discuss or analyse all near miss errors that happen. They do not always make changes to help prevent mistakes happening again. So, they may miss opportunities to learn and make their services safer.

Following the inspection, an immediate team meeting was held to determine the reasoning of why a comprehensive record of errors was not being maintained prior to the inspection date.

After determining these contributory factors, a full explanation surrounding the importance of near miss error documentation was provided to the entire pharmacy team and a new SOP guiding the reporting, documentation and evaluation of near miss errors was introduced.
Following this, all team members had agreed that a change in error documentation, reporting and evaluation was vital in preventing recurrent errors within the pharmacy’s working and have modified their working practices to record all near miss errors that have occurred since the inspection date.

As part of the reviewed pharmacy practice, all near miss errors that occur within our pharmacy are communicated to the entire pharmacy team immediately after initial recognition. Alongside this, the near miss errors of each month are pre-evaluated and discussed in greater detail within monthly meetings to ensure any future error reduction action encompasses the views and opinions of all pharmacy team members thus, increasing the likelihood of its long-lasting implementation.

After this discussion, each of the near miss error recording sheets are stored within the appropriate folder within the dispensary for future reference.

Some pharmacy records required by law and to assure the safety of services are incomplete and inaccurate. This includes register entries and fridge temperature records.

Since the inspection, the errors recognised within private prescription record have all been corrected and issues regarding the controlled drug registers have also all been rectified.

As part of the review of our pharmacy processes, all controlled drug register entries will now be made at the time of providing the medication to either the patient or upon receiving confirmation from our delivery driver that a successful delivery has been made. In the rare instance where this is not possible, the record will be made later within the same day to ensure a contemporaneous audit is maintained.

As mentioned previously, the details encompassed within each entry of the private prescription record have been reviewed to include: three different dates: the date on the private prescription, the date the prescription has been dispensed and the date the patient has collected the item/s on the private prescription. The significance of this information being recorded at the point of dispensing has been communicated to the entire pharmacy team in conjunction to this, all private prescription records retrospective to the inspection date have also been corrected.

A two-step approach has been adopted within the pharmacy to prevent the unintentional provision of expired medication to patients. Firstly, a designated booklet has be created to detail specific medicines nearing their expiry date (Within 1 month of expiry). Through documenting this, it will support a more efficient method in monitoring which medications requiring disposal at a nearing date.

In addition to this, a separate shelf within the dispensary has been allocated to only store those medications within 1 month of their expiry date. Through implementing this new practice, it is hoped that it would assist in further reducing the risk of the sale/dispensing of unsuitable, expired medication to patients.

Prior to the inspection date, a designated folder had been allocated to archive documentation surrounding the previous public health campaigns undertaken within the pharmacy. However, it was clear that not all staff members were clear of the area in which it was stored. To rectify this, all members of the pharmacy team have been re-informed of the material kept within this folder, its location within the pharmacy and the need for its continued maintenance within the future.

Since the inspection date, the fridge temperature monitoring document has been reviewed and a twice daily pre-scheduled assessment of the fridge temperature has been introduced within the pharmacy to ensure the required temperature is maintained. These newly introduced steps will occur in conjunction with the monitoring performed by the automated electronic thermometer already installed within the pharmacy.

This electronic thermometer would allow for a monthly report of 24-hour temperature recordings would be automatically upload and stored online. Following each month, a monthly report/ chart will be printed, checked and filed away in the designated folder. During the charging process of the electronic monitor a separate document has been created to ensure continuous monitoring of fridge temperatures.

The pharmacy usually has enough staff with the right qualifications for the services it provides. But, sometimes the team does not have the necessary skills to effectively fulfil their roles. This means the pharmacist and team members are under pressure to complete all tasks in a timely manner. And there is a lack of planning to make sure tasks are complete when the nominated team member is not working.

A new, innovative procedure has been implemented to assist in supporting and guiding all members of the pharmacy team in, documenting and reflecting upon each of the qualifications gained as part of their employment. This has been further supported by the production of a tailored template document that would require each staff member to document a summary of their learning, the skills they believed to have gained from their qualification and methods in which they hope to integrate these into their normal working practice. Both of these new processes have been communicated as a mandatory requirement for all future qualifications completed by any member of the pharmacy team.

Further to this, all staff members will now also be required to attend a pre-scheduled meeting with the superintendent pharmacist/responsible pharmacist to review their progress following the completion of a qualification (This will be documented and archived using a meeting record document). This will provide an opportunity for each team member to discuss their learning experience and work with the superintendent pharmacist/responsible pharmacist to reflect upon their learning thus, supporting more long-lasting implementation.

With the interests of providing a greater degree of clarity relating the job roles, a collection of checklist documents listing the delegated tasks have been produced on a individualistic basis, and agreed with each team member. It is hoped that this additional resource would assist in improving the efficiency of pharmacy working as well as, optimising the unique skillset of each team member.

In the event of team member being absent, an enhanced planning system has been initiated within the pharmacy to assist in role delegation. This would involve the clear delegation of job roles to other members of the pharmacy team and the documentation of this onto a pre-made template. With this additional process, it is hoped the disruption associated with the absence of team member upon the workflow of a pharmacy is minimised.