| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | While the pharmacy team were able to show that they could dispense a prescription accurately the pharmacy is not identifying and managing all the risks associated with its pharmacy services. Some of its standard operating procedures (SOPs) had not been reviewed in a timely way and the pharmacy does not have an SOP in place for deblistering its medicines as part of its assembly of multi-compartment compliance packs. |
All SOPs surrounding MDS will be relooked at by all staff working within the MDS department, signed and understood. An SOP has been produced for the deblistering and the assembling of MDS and all staff working within the department will read and sign. Which will be followed by all staff who are part of the assembly of multi-compartment compliance packs. All SOPs will be reviewed regularly and updated according to any changes required for optimum patient safety which will be read and signed by all relevant staff. There will be a log of deblistered medications that will contain all relevant identifiable information. |
25/04/2025 | 07/05/2025 |
| 1.2 | The pharmacy is not able to show that it has processes in place to adequately review and monitor the safety and quality of the services provided. For example, it could not show that dispensing incidents were reviewed adequately and improvement actions taken to prevent similar events happening in the future. |
The near miss log will be updated regularly with near misses containing all relevant information. Any dispensing incidents will now have reports logged and printed. Introducing regular review meetings with staff members to monitor their errors monthly. This will allow us to discuss and reduce any errors that are being made. The types of errors will be identified, and a root cause analysis will be done to prevent recurrence. |
25/04/2025 | 07/05/2025 |
| 4.3 | The safety of medicines is compromised by inadequate management arrangements. The pharmacy has not given sufficient consideration of the risks of removing from and storing medicines outside of their original blister packs. And |
Using the SPS website https://www.sps.nhs.uk/home/tools/medicines-in-compliance-aids-stability-tool/ Staff will be educated on the reasons why a medication cannot be deblistered. Going forward mixed batches will be prevented and be separated according to brand, expiry date and batch number. Any split packs will have the relevant batch and expiry on it to ensure that it is safe for use and identifiable for recall if needed. |
25/04/2025 | 07/05/2025 |
| 4.4 | Although the pharmacist could explain the actions taken when a medicine recall was received there were no records to show that action had been taken. |
MHRA medication recall updates will be logged, printed and signed when updates are sent from MHRA GOV. Any recalls will be implemented according to the changes and any medication recalled will not be dispensed out and disposed of. We will have a protocol to inform staff and branches of any medication that has been recalled preventing administration of recalled medication. |
25/04/2025 | 07/05/2025 |
Pharmacy inspections
Inspection reports and learning from inspections