St Stephen Pharmacy (9011657) - Improvement action plan

The pharmacy does not make records of mistakes that are made when supplying medicines. And it does not review patient safety issues. There is evidence that mistakes are being repeated as the pharmacy team have not implemented changes following errors and learned from them.

A new Near Miss and Error Log has been introduced at the dispensary. All staff now record every near miss and error at the point it occurs. A weekly review of near misses will be carried out by the pharmacist on duty to identify any patterns and agree on actions to prevent recurrence. A monthly patient safety meeting will be held with the whole team to discuss trends, learning points, and update SOPs where needed.

Key learning outcomes will be displayed on the staff noticeboard to reinforce awareness. SOPs relating to dispensing, accuracy checking, and error reporting have been reviewed and updated to reflect these new procedures. All staff have received refresher training on how to record incidents and implement learning. New starters will receive this training as part of their induction.