Inspire Pharmacy (9011381) - Improvement action plan

The pharmacy does not have adequate systems in place to identify and manage risks such as suitable standard operating procedures, risk assessments prior to initiating new services and procedures in place to learn from dispensing incidents.

Fully implement Reportsmart module of the Pharmsmart suite of programmes to report near misses, incidents, prescription interventions, safety conversations and action safety alerts. These will then be reviewed each month, to produce a monthly report which will be shared with the team on a monthly basis, to learn from all of the above.

Carry out a risk assessment for high-risk OTC medicines which are sold online.

All SOPs require reviewing, updating and tailoring to suit a Distance selling environment. As a priority, we will complete this for all SOPs associated with:
• Controlled Drugs
• High risk OTC online sales
• Responsible Pharmacist regulations
• Incident reporting, Near misses and patient safety
• Stock handling
• Cold chain medicines

The pharmacy does not manage and store medicines in a secure and organised manner. It does not properly restrict unauthorised access to some medicines. The pharmacy cannot provide assurance that the temperature of all the medical fridges are appropriately monitored. Some medicines in the pharmacy are not stored in their original packaging and have not been appropriately labelled.

Signs placed on the pharmacy doors, to remind staff to keep doors locked to prevent unauthorised access.
Management team to continually remind staff to keep external doors locked.

Fit a push bar door lock to the fire door, so it locks automatically when closed

Fit a lock on the shutter door which locks automatically when the shutter is pulled down

Keypad door lock on the dispatch room door so there is a second locked door to get through before entry to the dispensary

CD key to be kept on the Pharmacist’s person or in the designated locked safe, with only authorised staff having access to this

Add the second fridge to the Pharmsmart monitoring system, so it prompts each day to record the temperature for the second fridge, as well as the first fridge

All stock totes to be checked and any loose tablets or strips that have been cut to be removed and duped.

Manager’s monthly audit to be devised, to check each month that the systems put in place are embedded into practice

Feedback and action points from inspection to be shared with the team in the next staff meeting, so all staff are aware of what actions need to be taken, and practice changed going forward