Goostrey Pharmacy (1106026) - Improvement action plan

The pharmacy does not embed a culture of learning from mistakes. Team members do not make adequate records of mistakes they make. They have no clear process to follow to report, record and learn from dispensing incidents. And they cannot demonstrate any changes they make following mistakes to make services safer.

Since the inspection, there has been a team meeting to discuss improvements as well as the imperativeness of record keeping; namely, near miss and dispensing error record keeping. All members shared ideas on how they would actively learn from mistakes within the pharmacy workplace and thus a plan has now been implemented.

SOPs for near miss record keeping has been updated and has been read and signed by all staff members within the pharmacy premises.

A complete near miss log has been ordered from EMT which is now being implemented and records of every single near miss is being recorded. Team members understand that this is not to undermine and highlight staff capabilities, but to rather demonstrate common near miss errors that can be prevented in the future.

A weekly near miss review is now also being conducted and shared in a team meeting whereby common errors for the week are highlighted and staff can conduct a plan to prevent similar errors occuring. For e.g. boxes of similar brand and thus similar appearance moved onto a different bay to prevent the wrong box picked in the dispensing process.