Square Pharmacy (1097504) - Improvement action plan

The pharmacy does not maintain all its records in accordance with requirements, particularly its records about controlled drugs.

Since the inspection, the Pharmacist and Pharmacy Technician have spent a lot of extra time on evenings and weekends updating the CDs registers and are continuing to do so. This has been done by going through the whole CD folder one by one and using the PMR system and the online portals from our suppliers. This has included doing balance checks on all medicines, writing up old logs that weren’t written in over the past year, and making new books for branded and generic medicines where it was required. Any crossing out has been amended in the proper way trying to make it as clear as possible. Balance checks have been written on individual lines and new books have been created where there was previously only sheets. Once the CDs are all up to date we are considering going on electronic registers so that it can be linked to the PMR system and it will also avoid handwritten mistakes. Balance checks will then be done every 1 to 2 weeks and the pharmacist and technician will share the workload between them and make sure CDs are entered in and out as quickly as possible. A new Dispensing procedure has been made and signed by all staff which includes all the necessary checks that need to be done while dispensing. Near misses are now being written down but we have noticed a significant improvement in dispensing errors since the discussion has been had about dispensing with the staff.