KinWell Pharmacy (1042793) - Improvement action plan

The pharmacy does not always maintain accurate records as required. Records of higher-risk medicines that are returned to the pharmacy are not recorded in a timely manner. There are some records of controlled drug supplies which do not accurately reflect each individual episode of dispensing. And the pharmacy does not maintain consistent records of the checks it makes on running balance of controlled drugs against actual stock. Supplies of medicines using patient group directions (PGDs) are not recorded in the patient medication record. And there are many missing entries in the Responsible Pharmacist (RP) record of when the RP ceases duties at the end of the working day.

Standard Operating Procedures (SOPs) to be updated to require same-day recording of all returned higher-risk medicines before storage or disposal. All staff to receive training on the updated SOP.

SOP reinforced to require separate and complete controlled drug (CD) register entries for every supply at the time of handout. Pharmacist in charge to carry out weekly checks of CD register entries and document findings.

Introduce a weekly documented CD balance check comparing physical stock with running balances. A standardised CD balance check log to be implemented and retained. Patient Group Direction (PGD) SOP updated to require all PGD supplies to be recorded on the patient medication record (PMR) at the time of supply. Refresher training provided to relevant staff. Monthly spot checks to be carried out.

Implement an end-of-day responsible pharmacist (RP) checklist including mandatory completion of cessation time. Reminder signage displayed near RP log. Monthly checks of RP records to be undertaken.