| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy does not have written procedures covering all its professional services and processes. Such as near miss and dispensing incident reporting. And for its complaints procedures. Pharmacy team members do not always follow the written procedures. Such as processes for dispensing into multi-compartment compliance packs. This increases risks in the way the team works. |
Clear written updated procedures to be implemented for near miss, dispensing incident reporting and read and signed by all dispensary staff with easily accessible recording templates at the main dispensing computer. |
03/02/2020 | 03/02/2020 |
| 1.2 | Pharmacy team members record some mistakes that happen. But the records are not consistent. And they sometimes record no errors for several months. They do not regularly take learning from the mistakes. And, they do not routinely analyse the information they collect or make changes to help prevent mistakes happening again. |
Responsible pharmacists to record near misses at time of identifying an error on the available template by the main dispensing computer and discuss with the member of staff. |
03/02/2020 | 03/02/2020 |
| 1.6 | The pharmacy keeps most of the records required by law. But, it does not keep other records that help the team to identify and manage risks with its services. For example, the pharmacy doesn’t always keep up-to-date records of stock balances for some controlled drugs. When complete these help manage safe and effective services. |
Every Monday members of the dispensary team to check and complete records of stock balances for all fast-moving controlled drugs and monthly balance records for the rest of the controlled drugs within the CD cabinet. |
03/02/2020 | 03/02/2020 |
| 4.2 | The pharmacy doesn't manage all its services appropriately. It delivers medicines to people without adequate controls or audit trails in place. And, it does not adequately assess or manage the risks of posting medicines or leaving them unattended. |
Clear daily written records for every single medication delivery to patients with a signature from the receiving individual on completion with the records kept for audit purposes. When patients request posting of medicines or have a specific request a dated note attached onto the patients PMR with details of the request after initially consulting with the responsible pharmacist the suitability of the request. |
03/02/2020 | 03/02/2020 |
| 4.3 | The pharmacy does not store all its medicines appropriately. Some medicines are not stored in the manufacturer's original packs. And the batch numbers and expiry dates cannot be identified. Pharmacy team members don’t regularly check the expiry date on medicines. And, there is evidence of out of date medicines on the shelves. So, there is a risk they can supply medicines to people that may not be safe to use. |
Medicines on the pharmacy shelves to only include stock in the manufacturer’s original container. Any mixed batches with unidentifiable medicines with regards to batch number and expiry date to be removed and destroyed. All staff members including locums to be briefed regularly on the correct dispensing and storage process. |
03/02/2020 | 03/02/2020 |
Pharmacy inspections
Inspection reports and learning from inspections