Kevin Thomas Pharmacy (1043843) - Improvement action plan

Pharmacy services are not always managed safely and effectively:
- Dispensing labels do not always include a complete audit trail and there is a risk that this might prevent a full analysis of dispensing incidents
- Patient information leaflets are not routinely supplied with MDS trays and there is a risk that patients might not have access to all the information they need to make informed decisions about their own treatment.
- Some prescriptions are delivered through letterboxes and there is a risk that this may compromise confidentiality and increase the risk of errors
- Supplies of medicines are sometimes made against unsigned faxed prescriptions and there is a risk that these supplies are not made legally or in accordance with the directions of a prescriber

Staff have been advised that ALL dispensing labels should contain the initials of the dispenser and final checker(pharmacist/ACT).

Pharmacists/ACTs advised that ALL community Nomad trays should be supplied with patient information leaflets at least once a month. SOP will be updated to reflect this.

We have recently taken the decision not to post any medicine deliveries unless it is absolutely necessary or at the specific request of the patient. ALL deliveries require a signature. We are in the process of developing a consent form for patients to sign which would allow us to post medication at their request but only in an emergency or where there are mitigating circumstances (i.e. patient bed bound).

This has been discussed in a group meeting and ALL pharmacists have been told NOT to dispense any drugs, including controlled drugs, from an unsigned facsimile. This includes Pregabalin and Gabapentin in light of their recent change in legal status.