| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy does not adequately identify and manage all the risks with providing its services. Team members do not access the most up-to-date written procedures to support them in providing the pharmacy's services. And they do not follow a robust process to record and monitor the mistakes they make during the dispensing process. There is evidence that some risks associated with information governance and record keeping have gone unrecognised. |
SOP folder to be checked to ensure the most recent version of all current procedures is in place. All members of the team to read all SOPs applicable to their role & sign the confirmation sheets to indicate they have done so. All members of the dispensary team briefed on how to complete the near miss log themselves where they were involved in the incorrect dispensing. Pharmacist Manager to review the near miss log at the end of the month & discuss findings with the team. A copy of the near miss log is to be sent to Superintendent Pharmacist at the end of each month, once the review has been undertaken. All members of the dispensary team shown how to enter details of dispensing errors to submit to SuperOffice. Practice leaflets to be sent to branch to advise patients of complaints procedure. Reminder to all Responsible Pharmacists of the requirement to sign out at the end of the day, rather than let it lapse on system at midnight. |
22/09/2021 | 05/10/2021 |
| 2.4 | The pharmacy relies heavily on informal processes which do not promote a culture of openness and shared learning. This has the potential to impact both on the safety of pharmacy services and the wellbeing of the pharmacy team. |
Ensure annual appraisals are reinstated for all members of the team. Ensure near miss logs are discussed as a team each month to facilitate learning. Review whistleblowing policy & HR procedures to ensure they are sufficiently robust to protect staff & encourage reporting of concerns of any nature. |
22/09/2021 | 05/10/2021 |
Pharmacy inspections
Inspection reports and learning from inspections