| 1.1 |
The pharmacy has insufficient evidence to show that it has adequately considered the risks associated with providing its services. The pharmacy has made a number of errors recently which might have been avoided if it had more thoroughly assessed those risks. |
Risk assessment has been readdressed in the following ways:
1. Along with 1.2 below we are establishing a regular Learning Zone programmed into the weeks’ timetable to reinforce the most common in-pharmacy errors i.e.
a. Picking Stock and common similarly named drugs errors
b. PMR Dispensing – checking the prescription to ensure Right Patient, Right Drug, Right dose, Right Instructions
c. Physical labelling – checking for Right Label-Right Drug, label placement so as not to obscure relevant on packaging Patient Information
2. Vulnerabilities in Dispensing Software are recorded and passed to the Application providers with respect to
a. Crashes and Error messages
b. Slow-downs or lag causing potential drug entry issues against patient records as well as increasing pressure on staff due to the excess time taken to complete straightforward tasks.
c. If no positive outcome regarding the reports to the application provider are received then further investigation will be requested for a permanent fix and if this is not achievable then a full written explanation will be required from them with regards to steps they have already and will be being taken to address the issues.
3. Stock Supply Issues – Alliance have proved unreliable in many aspects of their wholesale supplies to us.
a. Out of Stock Issues are numerous and poorly managed by the wholesaler
b. Stock Restrictions are not tailored or scaled to our usage and thus cause excessive additional efforts to overcome. The Stock Rationing Team are unresponsive and are effectively preventing patients from receiving medication, whilst taking no consideration of clinical needs
c. Deliveries, particularly those in the afternoon are irregular in terms of the time they are actually delivered, often placing significant stress on staff at the end of the day.
d. Missing Deliveries or items missing from within deliveries are frequent and often significantly affect the dispensing task.
3.1 Several formal complaints have been made, none of which have produced any significant improvement to the service received from Alliance so far. They are aware of the issues both with deliveries and within their organisation and warehouse operations. We have been promised that this is under review.
3.2 Despite the above. We remain unconvinced that the issues will be significantly improved and thus escalation of the complaint is being made direct to the MHRA
3.3 Alternative Wholesalers have been considered however those available are suffering from the same stock availability issues and being less flexible than Alliance in terms of regularity of deliveries (AAH)
3.4 Consequently this does represent a significant and ongoing risk that we will continue to attempt to plan for and mitigate
4. Alternative “linked@ EPS-PMR-Dispensing systems that remove manual prescription processing tasks are being examined with a view to replacing the most problematic application we currently utilise – this being the system from which the reported errors have been dispensed. |
02/02/2023 |
15/02/2023 |
| 1.2 |
Patient safety incidents are inadequately recorded with no evidence of reflection upon the possible causes, or of any clear learnings from those incidents. There is little evidence of any action being taken to help prevent similar mistakes being repeated. |
Use of the PSNC reporting portal will continue alongside an upgraded Near Miss log system that will be used to establish increased Staff Briefings specifically aimed at learning from these incidents and best practice to avoid such events occurring again through reflection and discussion. Additional training will target specific areas identified in the report |
02/02/2023 |
15/02/2023 |
| 1.6 |
The pharmacy does not keep adequate records of its controlled drugs (CDs), they are untidy, disorganised and in some cases inaccurate. Some entries have been altered without the pharmacy making it sufficiently clear who made the alteration, why they did so or when. The pharmacy destroys some CDs without having authorisation. It also does not ensure that CD records are always available for inspection upon request.
The pharmacy repeatedly fails to maintain a contemporaneous, accurate and complete record of the responsible pharmacist on duty. |
Controlled Drug recording is currently subject to a tight review to establish whether a switch to an online CD Register – PharmCD, a propriety product – currently on trial against a refreshed physical CD register system.
The current preference is online, since the disorganisation of the current paper-based system is immediately addressed and alleviated.
The current balances will be carried over to the new system and fresh records will be kept from that point on.
The local CDAO has been contacted for advice and the online report will outline those issues reported by the Inspection.
Responsible Pharmacist logging is reverting to paper for the accessible records since the online records provided by the RXWeb PMR have demonstrated that they require additional overheads in order to provide the required logs and they do not appear to be operating as we have previously been advised |
02/02/2023 |
15/02/2023 |
| 4.2 |
The pharmacy does not do enough to make sure that people in an at-risk group are adequately warned about the risks involved in taking high-risk medicines such as those containing valproates. |
Sodium Valproate letters are periodically sent out to the few clients that we provide medications for that this particular medication can have an impact on. Most of those patients are in Care facilities and only some have capacity and fit within the at-risk age-group. We will increase the frequency of distributing these letters. |
02/02/2023 |
15/02/2023 |
