Reflective Learning Hub
Lets have a look at some of our recent inspections. Consent to use the following images for learning purposes was granted!
Pharmacy sink used as DOOP bin
We found blisters of Levothyroxine tablets and Omeprazole capsules in a pharmacy sink. We also found about three unknown tablets dissolving in the sink. No one could explain why tablets where in the sink and not in the DOOP bins. The inspectors made sure they educated staff on the importance of safe disposal of medicine.
Fridge out of range
Fridge temperature had slightly gone up and the alarm was beeping. No one did anything about it and when asked they mentioned that it would go off on its own. I asked staff what system to follow when temperatures are out of range and no one could answer
Dirt accumulation
This inspection revealed the build up of dirt and dust on dispensary shelves and medicine boxes. A cleaning rota was there but the tasks where not being carried out
No expiry date
Staff were dispensing Nitrofurantoin from a cartoon of medicine that a patient had not collected. This box and the the tablet blisters inside did not have any expiry date.
No near miss recorded
This is a near miss log last recorded in January 2025. The inspection was done in June 2025. This means that the pharmacy did not record any near misses for five months. There were missing records from previous months too. There was no reflection/learning/clinical governance meetings conducted after errors were made.
Private Rxs thrown away
This pharmacy was throwing away private rxs for the weight loss injections Mounjaro. Inspectors had to let them know they needed to be kept for a minimum of two years. Staff had thrown them in the confidential waste bin and managed to retrieve some of the rxs. They were not keeping the entries in the private rx register too.
Confidential waste in consultation room
This picture was taken in a consultation room. That red bag on the floor had patient returns and patient information could be accessed. Needles had been accepted and controlled drugs schedule 2 had not been passed to the pharmacist to store in the cabinet awaiting destruction. That bag had been in the room for two months.
Food mixed with medicine
The two pharmacies represent just a sample of our findings. We inspected several pharmacy fridges and found food mixed in with medicine. In these two pharmacies we found milk, orange juice and French fries. The fries were defrosting and had made all the medicine packaging wet. The most common food items found on our inspections have been milk and sandwitches. What was worrying was finding milk/ juice dripping on to medicine fridge packaging . Inspectors asked staff to remove their food items. Some of the stock in the first fridge was warm due to fridge overload. Overloading a pharmacy fridge can lead to poor air circulation, potentially causing medicine to degrade or become ineffective . This can also make it difficult to maintain the correct temperature range further increasing the risk of medication spoilage or safety concerns.
CD Balance Check - One year ago
This inspection was carried out in 2025. This picture is part of a controlled drug register. We have had to remove confidential information. You can see clearly that the last entry was in 2023 and the balance in the book for Zomorph 30mg capsules is 49. This means that a CD balance check has not been carried out for over a year and a half. The stock was also out of date and had not been segregated. The inspector ensured segregation was done immediately to avoid it being dispensed to a patient.
Confidential waste in the general waste bin
On this inspection day we found all cartoons of medicine from patient returned drugs with patient information disposed in the general waste. There had been no attempt whatsoever to remove/blank out the patient information. We have found this a common trend in most pharmacies. The reason given was that they were very busy and the process would be time consuming . Inspectors asked staff to correct this immediately. The inspectors reminded staff on the importance of data protection and patient confidentiality.
Overpacked and frozen medicine
The fridge was overpacked at the bottom shelf. Most of the medicine packaging were frozen. The middle section was clear. Inspectors asked staff to move some of the stock to the middle section and away from the back and sides where temperatures can be colder. A couple of insulin packs were found out of date . Fridge temperature had not been recorded for two days.
Confidential waste piling
These bags of confidential waste had not been disposed for five months. They were in the consultation room on the day of the inspection. Any member of the public that came for a consulation could access/ read other patients' information. A similar case was encountered in a different pharmacy where confidential waste was piled on the front counter. All visitors to the pharmacy had access to other patients' information. The inspectors asked to move the waste to a different location and staff were asked to contact the collection waste service. Collection was scheduled two days later.
Confidential information made public
This pharmacy had DOOP bins with bottles showing lables with patient information. This box is used for methadone bottle disposal for patients on supervised consumption. Instead of blanking out the patient's information it is thrown in bins like that. When the pharmacist manager was asked why, she mentioned that methadone patients normally come with very soiled hands and she didn't want to touch the bottles. In other pharmacies the reason given was that the waste was going for incineration anyway. The inspector had to educate on data protection.
Shredder not working so no data protection
We found several owing slips and bag labels in the general waste bin. The reason given was the shredder was not working. Staff were asked to retrieve all the patient information and dispose of it in the confidential waste.
Missing CDs not reported
There was a discrepancy of 49 Medikinet 5mg tablets which was never investigated . The matter was never reported to the accountable officer. The pharmacist was not aware of the process to take . The area manager come round once in a while and he was also not aware of the missing CDS. The investigator informed staff about the requirement to investigate CD discrepancies and report all incidents and concerns involving CDs to the NHS board Controlled Drugs Accountable Officer.
Passwords- Free access
In almost half of the inspections we have carried out this year , passwords have been stuck on computer monitors. In some cases, pharmacies have created a wall of passwords. Smartcards have also been stuck with passwords. The pharmacy staff with the smartcard picture were using this card but the person in question had left the company. After the inspection the company took the card away and applied for staff to have their own smartcards to use.
Dispensing errors corner turned into a dumping site
The inspectors found a pile of dispensing errors on this corner. When they looked on Pharmapod which is the dispensing error reporting platform , none of the errors had been reported. Inspectors called the staff involved and some of the staff were not aware they had made those errors.
There is no point pharmacy staff collecting dispensing errors on a corner if they don't report, reflect and learn from their mistakes. The inspectors encouraged a culture of reporting errors and learning from them. The pharmacy was encouraged to carry out clinical governance meetings and dispensing errors could be one of things discussed in those CG meetings.
Expired end of life medication administered
The following picture shows out of date medicine that were on the shelf. The company does have a date checking system in place but the staff are not following it. The reason given in most pharmacies was the fact that they were not finding time to date check. The inspector then date checked the CDs and found Morphine out of date. When the CD register was opened unfortunately a patient had been given some from the expired stock the previous day and had administered some. The stock was segregated , new stock ordered and given out , CD error reported and staff learnt the importance of date checking.
Expired CDs segregated but no record of it
Expired CDs found in the cabinet. The white book is the CD destruction record book. The last entry on there was in 2022. There was no other CD record book found on site. This means that the pharmacist segregated the expired stock which is good but did not record it in the register. The person meant to come and destroy them was not informed. The CDs have been in the cabinet for six months. This is bad practice.