| 1.1 |
The pharmacy does not properly identify and manage all the risks to its services. It does not have some key documented procedures available. And of the procedures it has available, the team does not follow them all. The pharmacy does not adequately assess the risks when the team changes its ways of working, such as when the fridge thermometer breaks. |
Standard Operation Procedures.
We have updated the SOP file and ensured the staff have understood and signed them.
Dispensing Process – We have now ordered a “near miss record” book which is places at the checking bench and all errors made internally at the time of dispensing are recorded. However, at the end of each month, or when quiet time is observed, the pharmacist is expected to reflect on these errors and have a team discussion to talk about why these errors are occurring. We have at some point to separate likes sounding medicine and put “prompts” on shelf to alert the dispensing staff during the dispensing procedure. LASA medicine etc for e.g Allopurinol and Atenolol.
All internal errors/ external errors i.e those left the pharmacy will be immediately recorded using the blank templates which are now easily accessible by the staff. The staff involved in the incident will be notified immediately and they will be told to reflect on this error and action straight away. If in an event of major error i.e patient hospitalised, then for certain a full team meeting will be held. We are now going to try and attempt to use the risk assessment templates. This will allow us to reflect and improve our practice.
Room temperature thermometer has been purchased and a diligent eye kept on the room temperature to ensure the medication is kept at 20ﹾC.
Fridge medication – Originally, we removed the fridge lines following your inspection and placed them in the fridge upstairs and we monitored the temperature using the probe on a daily basis. We bought a new probe and placed in the fridge in the dispensary and recorded the temperature over the week. It seems it is in the range of 2ﹾC - 8ﹾC . Then we placed the medication back into the fridge. Going forward the fridge temperature will be taken every day. |
01/11/2021 |
29/10/2021 |
| 4.3 |
The pharmacy does not have adequately robust processes for managing the storage of its medicines and for checking expiry dates. And there is evidence of out-of-date and inappropriately stored medicines on the shelves. |
Date check for dispensary stock :
Date checking monthly basis with record sheet on display in the pharmacy and completed in each day of date checking. To complete the dispensary withing 10 days from start to finish.
We have ordered “use me first” stickers which will be placed on medicines expiring within12 months.
Red stickers will be used for those expiring in 3 months.
We will remove from the shelf, medicine expiring before the following month. E.g October 2021 will be removed in September 2021. |
01/11/2021 |
29/10/2021 |
| 4.2 |
The pharmacy does not manage aspects of dispensing as it should. It does not label its medicines as required by law. And pharmacy team members fail to recognise the impact this may have on how people access important information and support about their medicines from the pharmacy. |
Dispensing Labels :
Ordering 3 months before running out to ensure we are not in a situation where we do not meet the required guideline. We can ensure we have 60 rolls left on the day of ordering (Estimate average for 3 months) .
With regards to medicines which were kept in brown bottles we will no longer allow this and put them in the waste disposal. |
01/11/2021 |
29/10/2021 |
