| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy has a set of standard operating procedures (SOPs) to support its team members when conducting pharmacy tasks. But some SOPs are missing or do not reflect current working practices. Such as managing dispensing errors and using an automatic dispensing pump to dispense higher-risk liquid medicines. And team members could not refer to written procedures when unsure about record keeping and delivering prescriptions. So, the pharmacy does not have complete procedures to support its team members to ensure pharmacy tasks are completed accurately and efficiently. |
The pharmacy has now introduced a Methameasure standard operating procedure (SOP) for safe use of the automatic dispensing pump, a Dispensing Error Log SOP, and a Near Miss SOP to strengthen incident management and learning. Existing procedures were also updated, including the Controlled Drug (CD) Register SOP and the Delivery & Posting of Medicines SOP, ensuring staff have clear guidance for CD handling, record keeping, and delivery processes. All SOPs now align with how the pharmacy operates day to day, and staff have signed to confirm they have read and understood the updated procedures. This ensures the team is supported by complete, current, and robust documentation across all key areas of practice. |
02/06/2026 | 08/05/2026 |