Lawley Pharmacy (1087566) - Improvement action plan

The current procedures in the pharmacy are not properly implemented to ensure that risks associated with pharmacy services are adequately identified and managed.

- Work through all relevant SOP’s and update.
- Ensure only the latest SOP covering operational tasks and activities are maintained and available to all staff.
- Remove all out of date or superseded SOPs from dispensary to avoid ambiguity.
- Countersign and date any amendments made to existing SOP’s.
- Review near miss and error log procedures and ensure all staff make records accordingly.
- Meet and review near misses and error logs with staff on a monthly basis
- Whilst root cause analysis procedures are in place, ensure available for inspection and update.

The pharmacy cannot always demonstrate that it is storing and managing medicines appropriately and securely.

- Whilst all medicines are stored appropriately and routine date checking is carried out, staff to ensure date checking matrix is completed at all times.
- Pharmacy to update all staff on procedures for highlighting high risk medicines.
- Whilst the pharmacy has alert cards, they need to be more pro-actively used.
- Ensure that max/min temp for pharmacy fridges are recorded daily on new PMR system. Allocate task to two members of the dispensary team and address any IT issues that may result in failure to record.