| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.2 | The pharmacy does not report and learn from near misses and dispensing incidents. |
Near Miss Logs were present in pharmacy in Clinical Governance folder. RP notified of location of record sheets and reminded of importance of using these so near misses and incidents are learned from. All dispensing errors to be recorded and actions taken to prevent re-occurrence. |
05/08/2019 | 11/10/2019 |
| 4.2 | The pharmacy assembles and checks multi-compartment devices without reliable audit trails and stores them unlabelled and unsealed for extended periods. It supplies higher risk medicines without appropriate clinical checks and counselling. |
RP reminded to ensure that all dosettes are fully dispensed and labelled – as per SOP - before storing awaiting final checks. Not to start dispensing unless all medication and prescriptions received and present. All dispensed bags containing high risk medicines eg Lithium, Warfarin to have appropriate marking on the bag label to remind RP when handing out to counsel patient and obtain appropriate readings for PMR record. |
05/08/2019 | 11/10/2019 |
| 4.3 | The pharmacy does not always store medicines safely so it might not appropriately restrict unauthorised access. |
Due to recent increase in CD instalment dispensing pharmacy has had a storage issue during daytime. RP has contacted accountable officer to get authorisation to use safe. RP also reminded to ensure safe and CD keys are always on person at all times. |
05/08/2019 | 11/10/2019 |
Pharmacy inspections
Inspection reports and learning from inspections