Pharmacy team members do not keep accurate records of balances of controlled drugs. They do not check the stock balances regularly. And, they do not act to quickly resolve any discrepancies they find. There may be a risk the team members do not identify any errors in dispensing in a timely manner.
All CD registers have now been balanced. The Pharmacists have gone through each register and corresponding patient medication records and supplier invoices in order to find the discrepancies. There are two registers which are still imbalanced; for this the Pharmacist has contacted the superintendent for next steps and further advice. The CD balances are now checked on a weekly basis, both methadone and all other CDs. Methadone balance is carried out on a Wednesday and all other CDs on a Friday. All staff have been made aware of the discrepancies and know the significance of keeping on top of the balances. Therefore, an additional step has been added into the dispensing process: all staff dispensing any CDs MUST now record the remaining balance in the cabinet on the CD prescription. It is then ensured that this matches what the register says upon entering the prescription. Furthermore, all patient returned CDs have now been destroyed. The Pharmacist will be contacting the Accountable Officer in order to destroy the expired CD stock.