Download Adherence to Standard Opertaing Procedure for

YELVERTON SURGERY
AUDIT REPORT
ADHERENCE TO SOP
FOR ASSEMBLING,
LABELLING &
Bagging FOR ITEMS
DISPENSED
REPORTED BY: SARAH GILES
DATE REPORT PRODUCED: MARCH 2015
Background
Errors in patients’ medications can occur at any stage of the dispensary process;
prescribing, labelling, dispensing and administration.
In January 2005 the Government introduced a requirement for all pharmacies to have
SOPs in place, covering the Dispensing Process operation of the pharmacy. The
requirement was introduced to comply with Clinical Governance in Pharmacy. By having
SOPs in place pharmacists are able to show that they operate systems of practice which
are safe and which encourage continuous improvement. The Dispensary Services
Quality Scheme (2006) as part of the GMS contract further enforced this by stating that
all dispensaries must have standard operating procedures (SOPs) in place that reflect
both good professional practice, as well as the procedures that are actually performed
by the practice. SOPs should be followed routinely for all dispensing related activities.
SOPs should be specific to the practice and should set out in writing what should be
done, when, where and by whom.
This audit is being conducted by Julie & Sarah to demonstrate whether the SOP for
assembling, labelling and checking represents current practice and that staff are working
to the SOP. The SOP will be reviewed and amended if necessary; if amendments are
required, staff will be trained and educated to ensure compliance with the new version.
Items waiting for collection that have been assembled, labelled and checked will be
audited for a week. All bags, labels and items will be checked according to the audit
measures that have been agreed and set.
Aim & Objectives
To ensure all staff working in the dispensary are working to the SOP for assembling,
labelling and checking of all items dispensed. To reduce the incidence of dispensing
errors and to assess the accuracy and effectiveness of the SOP to ensure it represents
current practice.
Standards
100 % of all items to be checked against prescription:
 Medication
 Dose
 Amount/volume
The expiry date is checked on all medication in the bag to ensure they are within date
Labels on all items are checked against details on prescription
If part packs have been dispensed, check to see if they have a Patient Information
Leaflet
The top left hand corner of the prescription to be checked to ensure it has been initialled
by the member of staff bagging up
Bag checked to ensure it is sealed
Methodology
Items waiting for collection that had been assembled, labelled and checked were audited
for a week. A random check was carried out each day. All bags, labels and items were
checked according to the standards above. The results were recorded on a data
collection form. (see appendix 1)
Conclusions
There were a number of prescriptions which were not being initialled when bagged.
It was obvious that a member of staff was not following the Standard Operating
Procedure.
Action Plan


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All dispensing staff will be required to read through and re-sign the Standard
Operating Procedure.
Results will be raised at a staff meeting.
Patients will be informed of the results of the audit through the patient newsletter.
Appendices

Data Collection Form