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Pharmacy inspections

Inspection reports and learning from inspections

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Tait's Pharmacy (1109439) - Improvement action plan

Standard not met Reason Action being taken by the Pharmacy By when Notification By Pharmacy Improvements Made
1.1

The pharmacy has some historical standard operating procedures. And it chooses not to review them regularly. Some of these procedures don’t reflect current practice. And some procedures are not documented at all. The pharmacy doesn’t use them to help manage the risks to its services. The pharmacy is cluttered and untidy. It doesn’t have appropriate date checking procedures. And it removes medicines from the manufacturer’s packaging and doesn’t store these appropriately. So, the pharmacy misses opportunities to manage the risks to its services.

Existing standard operating procedures (SOPs) have been reviewed and updated, reflecting current practise. New procedures and services will have appropriate SOPs created and reminders will be set to check all SOPS regularly and update when necessary.
Following the inspector’s visit, the pharmacy was tidied and all unnecessary leaflets/ magazines and other paperwork has been disposed of appropriately. Date checking procedures have been put in. The item which had been removed from its original container (100) and put in an amber bottle had originally been dispensed for a particular patient on 30/7/19 (60) but upon delivery the family requested that a medication aid was given so this was used to dispense from for that and the subsequent month and the patient’s details were removed. In the future any packs inevitably used as such will have the manufacturer’s batch number and expiry date recorded.

05/11/2019 05/11/2019
1.2

The pharmacist does not make records of near miss errors. So, may miss opportunities to learn and to make services safer. And, there is little evidence of any changes being made to prevent mistakes happening again.

Near misses are very few and far between but the pharmacy has placed its own near miss/error log on the dispensary bench so that if there are any such occurrences in the future, they can be recorded immediately. There are existing reminders on the dispensary shelves where the pharmacist has identified potential risks so mistakes are avoided in the first instance.

05/11/2019 05/11/2019
1.6

The pharmacist consistently fails to properly maintain the responsible pharmacist log. And, she regularly does not record her absences from the pharmacy. So, she is consistently not maintaining the record in accordance with the law.

The pharmacist log is recorded electronically on the PMR system and signing in is done on all working days. Reminders have been set to sign out which was not always done previously as the system had been doing it automatically at close of business or after several minutes of screen inactivity it would log out of PMR and as the pharmacy is not busy, the computer is not on constantly. Absences will be recorded in the future.

05/11/2019 05/11/2019
4.3

The pharmacy does not have a robust process for managing the storage of its medicines and for checking the expiry dates. And there is evidence of out-of-date medicines on the shelves. The pharmacy does not always keep its medicines in the original packs. And it doesn’t label these medicines with the required details. So there is a risk the pharmacy can supply medicines that may have expired or been subject to a drug recall.

I believe the existing storage of medicines is appropriate as all medicines are grouped and stored according to their dosage form. New medicines are always checked off the invoice and placed at the bottom of or behind the existing stock so stock is regularly circulated. Medicines are checked for expiry before dispensing especially those that are not regular items. Following the inspector’s visit, all items are checked for expiry on receipt, as I have found that some common brands and generics are coming through with very short expiries, as well as at the time of dispensing. All the pharmacy stock has been date checked and reminders have been put in place to check every 3 months. All stock with less than 6 months expiry are marked as are all which have an expiry of less than 3 months (some of these are removed from the shelves if no existing patients use these).

05/11/2019 05/11/2019