| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.2 | The pharmacy could show it had taken some specific remedial actions in response to when something had gone wrong. But it was unable to demonstrate that its team adequately analysed and learned from mistakes to make improvements to the safety and quality of the wider service they provided. For example, the pharmacy could not show that its team were aware of and were always following its written procedures about dealing with dispensing mistakes. And the pharmacy couldn’t show that near misses were used routinely as opportunities to identify improvements in the pharmacy’s ways of working. |
Monthly reviews of near miss in a team huddle have begun and previous reviews all done. Evidence to follow to show action. We are also going to ensure all dispensing errors once the incident report and LFPSE is done has been discussed with the team. |
07/01/2026 | 06/01/2026 |
| 4.3 | There was separation of some look-a-like, sound-a-like stock medicines on the dispensary shelves to reduce risk. But there were several examples seen of medicines with similar names being stored in a disorganised way, with several different medicines often placed on top of each other with little or no separation. And it was unclear that all team members putting stock away were fully aware of the potential risks posed by medicines with similar names or packaging. This increases the risk of the wrong medicine being picked from the shelf and being supplied to a patient. |
We have discussed as a team the new LASA materials released recently and also will ensure shelves are labelled and stock separated appropriately to avoid disorganisation of stock on shelves. |
07/01/2026 | 06/01/2026 |
Pharmacy inspections
Inspection reports and learning from inspections