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Pharmacy inspections

Inspection reports and learning from inspections

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Al-Shafa Pharmacy (1104967) - Improvement action plan

Standard not met Reason Action being taken by the Pharmacy By when Notification By Pharmacy Improvements Made
1.2

The pharmacy has written procedures for managing errors in the dispensing process, but the team members do not fully follow them. They don’t regularly keep records of near miss errors and dispensing incidents. This is a repeated finding from the last inspection. So, the improvements the pharmacy showed after the last inspection are not being maintained. The pharmacy continues to miss opportunities for learning.

The Pharmacy is training up different members of staff to use the new electronic system so that error log entry can be made by everyone rather than the SI only.

All the locums are asked to make the error log entry and have been shown how to do it.

20/12/2021 11/01/2022
4.2

The pharmacy doesn’t have effective procedures to ensure medicines dispensed into multi-compartment compliance packs remain stable and suitable for people to take. The pharmacy leaves some dispensed medicines in unsealed packs and on top of each other for prolong periods of time. This means the medicines are at risk of moving between the packs. And contaminants may enter the packs resulting in the medication becoming unstable. This is a repeated finding from the last inspection.

The pharmacy has decided not to start a tray until all meds available.

The items will be checked by an RP prior to the tray being started. Once completed the tray will be checked by another dispenser where possible and it will be sealed and left at a designated site for the pharmacist to do the final check and bag.

20/12/2021 11/01/2022