Deane Pharmacy (1091193) - Improvement action plan

The pharmacy does not sufficiently identify and address key risks to patient safety from its activities and services. For example, it does not ensure that its team members follow the standard operating procedures or are familiar with them. This means pharmacy services may not be delivered in a safe and effective manner.

Pharmacy services to be revisited and risk assessed and all professional and non-professional staff to read, understand and sign/re-sign the SOP’s (standard operating procedures) and adhere to compliance. Measures to be put in place to identify patient safety risks for example regular use of near miss logs to aid regular learning meetings to ensure compliance. Responsible pharmacist to make sure staff follow and understand the relevant SOP’s relevant to their job roles and the job in hand.

Areas of the pharmacy including the dispensary are cluttered and disorganised. And this could increase the risk of dispensing errors. The floor space is cluttered which creates a trip hazard.

To manage risks associated with clutter and disorganised dispensary to be monitored by RP. Importance of Health and safety has been re-enforced .The team have now de-cluttered the floor space. Stock delivered from wholesalers are put away on the shelves within a reasonable time. Cleanliness to be maintained at a high level both in the dispensary and shop area. Access into the dispensary must only be authorised by RP.
Level of cleanliness will be to reflect a professional, Clean, tidy and well organised premises. All pharmacy fixtures and fittings are well maintained and will be kept in good order. Lighting, heating, plumbing and alarm system are regularly tested and kept in good working order by approved qualified contractors.

The pharmacy does not always store its medicines securely and in accordance with legislation. And it cannot show that it always stores medicines which require refrigeration appropriately.

Procedures for regular Fridge temperature monitoring together with appropriate records has been instituted so that all RP’s follow the same procedure for regular monitoring of fridge temperatures and documentation. Records have been put in place to ensure monitoring fridge temperature levels remain within the 2C–8C window.
SOP will be re-visited by professional and support staff, all stocks of medicines to be kept in original manufacturer’s containers. Medicines should be stored in original packs or labelled with batch numbers/expiry dates — odd tablets should not be transferred from their original pack onto the dispensary shelf.
To ensure that all dispensary deliveries from the wholesalers are received in the dispensary and signed for in the dispensary to ensure safe storage of medicines in the dispensary area. This procedure will be added to the SOP for receiving stocks. This procedure will be monitored by the responsible pharmacist.