Dunamis Pharmacy (1102323) - Improvement action plan

The pharmacy does not keep all of its records complete and accurate. This includes incomplete responsible pharmacist records and inaccurate records for some higher-risk medicines requiring safe storage.

Dispensing standard operating procedures (SOPs) - the review process to be completed with any alterations updated. A staff training plan to be put in place to ensure all staff are aware of any changes (documented training update) by end Nov 2024.

Robotic Dispensing SOP - The manufacturer to be contacted to provide an outline SOP which can be modified to local use. All team members involved in the use of this equipment to read and implement best practice in use. Where this is not available, Superintendent Pharmacist (SI) will write an appropriate SOP and share with the team.

Responsible Pharmacist (RP) Records - entries showing time of ceased duties will be implemented. A reminder will be sent to all locums at the point of booking. Regular checks will be made on the records and feedback given as necessary.

Controlled drug (CD) balances - a full audit of the CD register will be undertaken and any unsolved discrepancies reported to the Controlled Drugs Accountable Officer (CDAO). Going forward a full CD audit will be carried out by an appropriate member of the team every 2 weeks as per SOP.

Private Prescriptions - All team members involved in the processing of this prescription type will be reminded of the full requirements for recording.