| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy has not completed robust risk assessments for all of its services. This includes aesthetics products, including botulinum toxins, and unlicensed controlled drugs. And it is not able to show that the risks associated with supplying these treatments are being effectively managed. |
• Risk assessments will be completed for provision of non-surgical aesthetic treatments and supply of unlicensed controlled drugs. The outcome of these assessments will be reviewed alongside the service specific SOPs already in place and any additional actions to mitigate risk will be incorporated into current practise. • A review will be conducted of pharmacy services and a schedule will be defined to ensure that any outstanding risk assessments are in place. |
17/10/2023 | 17/10/2023 |
| 1.2 | The pharmacy does not proactively audit or review the quality and safety of its services. It does not have adequate systems in place to identify trends to prompt effective interventions. There are no systems to audit the higher-risk and higher volume medicines it supplies. And no systems to effectively identify and challenge overprescribing and oversupply. |
• Monthly audits to be initiated to review near miss and incidents that have occurred. • Pharmacist intervention log to be created and audited monthly including evidence of over prescribing interventions if observed. • Monthly audit of controlled drug stock checks – stock checks are conducted weekly. On a monthly basis the weekly stock checks will be reviewed. • Audit of services provided will be conducted by review of intervention logs, incident/complaint investigations and risk assessment and SOP review. • Appropriate actions identified from each audit will be documented in an audit report and timelines assigned for completion of each action identified. |
17/10/2023 | 17/10/2023 |
Pharmacy inspections
Inspection reports and learning from inspections