Medwyn Pharmacy (1091204) - Improvement action plan

The pharmacy isn’t recording the controlled drugs it receives or supplies in the controlled drug (CD) register as it needs to by law. This has been happening for a few months. And the CD register isn’t always available for inspection at the registered pharmacy premises as the law requires it to be.

Immediate Action:
The controlled drug (CD) register will be returned to the registered pharmacy premises immediately, and will remain on-site at all times in accordance with legal requirements.

CD Accountable Officer (CDAO):
The matter will be reported immediately to the CDAO outlining the concern and recovery plan.

Backlog:
The CD entries will be brought up to date with immediate effect in the register and under the guidance of CDAO. Entries will be made on the day of receipt or supply of the CDs or the next day.

Standard Operating Procedure (SOP):
A new, robust SOP for CDs will be implemented. This will clearly mandate that all entries in the CD register will be made on the day of supply or receipt.

Enhanced "Double-Check" Audit:
Implement a weekly double-check audit where a second pharmacist or a designated staff member will verify the CD entries against the physical stock and invoices to ensure accuracy.

Additional pharmacist cover:
Additional pharmacist cover will be arranged so the Superintendent Pharmacist can dedicate uninterrupted time to complete the above tasks within the required 10-day timeframe.