This document is a draft - before using any part of this material, Practices should check the

contents and adapt the text to suit their circumstances and style.

DISPENSARY STANDARD OPERATING PROCEDURES TOOLKIT

INTRODUCTION
As part of the changes to the arrangements for dispensing doctors for April 2006, agreed as
part of the GMS changes in 2006/07, the Dispensary Services Quality Scheme ('the Scheme')
came into effect on 26th September 2006. The Scheme rewards Practices financially for
providing high quality services to their dispensing patients.

Practices which sign up to the Scheme must meet key quality requirements, one of which is to
develop and maintain a set of Standard Operating Procedures ('SOPs') which reflect good
professional practice and cover all dispensary procedures. SOPs must be reviewed and
updated at least once every 12 months and whenever dispensing procedures are amended.

This toolkit gives Practices a starting point for the development of its SOPs. There are
variations in the way Practices run their Dispensaries - the examples below give broad
guidelines and will need to be adjusted to reflect the way your Dispensary operates.

CONTENT OF A TYPICAL SOP

Content of each SOP will be specific to the needs of the individual Dispensary, and will
depend on local needs and staff competencies. In overview, a typical SOP will include:

 Purpose – what the SOP is for

 Scope – what the SOP covers
 Process or procedure – detailed steps which are to be taken
 Responsibilities – who is responsible for what, including delegation and back-up
arrangements
 Review arrangements – how often, or under what circumstances, the SOP is to be
reviewed

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  Risks – details of things that could go wrong, how to minimise such risks, and the
procedure for recording significant events
 Acceptance – signatures of relevant staff

A SET OF TYPICAL SOPs

A typical set of SOPs is likely to comprise the following:

 Receiving prescriptions
 Pharmaceutical assessment – validity, safety and clinical appropriateness
 Interventions and problem solving
 Assembly and labelling
 Accuracy checking
 Transfer to the patient

On the following pages are some draft suggestions for the contents of the typical SOPs noted
above. These suggestions are intended purely as a basis for thought and discussion; First
Practice Management can accept no responsibility for the way in which these drafts may be
used by Practices.

In addition, a blank template sheet for developing further SOPs is at Appendix A.

Other relevant documents:

[*]
 Significant Events toolkit
[*]
 Confidentiality Policy (Dispensers)
[*]
 Dispensary Risk Management Policy
[*]
 Dispensary Staff Training/Competency Records

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SOP: RECEIVING PRESCRIPTIONS. Version no. and date
Purpose: what the SOP is for, e.g.:
To set out procedures for the accurate and timely handing of prescriptions
Scope: what the SOP covers, e.g.:
The handling of acute and repeat NHS and private prescriptions
Process/procedure: detailed steps which are to be taken, e.g.:
Greeting patient and checking identity
Check that Parts 1, 2 and 3 on the reverse of the prescription have been completed
appropriately/correctly
Checking that prescribed items are in stock (and refer to the process for ordering out
of stock items)
Advise patient of anticipated waiting time
Put prescription in the queue for dispensing
Responsibilities: who is responsible for what, including delegation and back-up
arrangements (e.g. in case of holidays/sickness etc.), e.g.:
All Dispensary staff also note arrangements for sickness/holiday cover
Review: how often, or under what circumstances, the SOP is to be reviewed, e.g.:
The SOP will be reviewed annually, next review due:
It will also be reviewed in the event of any of the following:
 Changes in relevant legislation or recommended guidance
 Changes in staffing
 Following an error or significant event
Risks: details of things that could go wrong, how to minimise such risks, and the procedure
for recording significant events, e.g.:
Patient identification errors (e.g. popular names like Smith)
Acceptance:
Signatures (dated) of relevant staff:

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SOP: PHARMACEUTICAL ASSESSMENT - VALIDITY/SAFETY/CLINICAL
APPROPRIATENESS. Version no. and date
Purpose: what the SOP is for, e.g.:
To ensure that all prescriptions dispensed are safe, clinically appropriate, legally valid,
and cost-effective
Scope: what the SOP covers, e.g.:
All acute and repeat NHS and private prescriptions
Process/procedure: detailed steps which are to be taken, e.g.:
Check the prescription has been signed/dated and is an original*
Check for compliance with the Practice formulary*
Check appropriateness of dosage/form/patient’s condition/duplication of other
medication/drug interactions/side effects**
Responsibilities: who is responsible for what, including delegation and back-up
arrangements (e.g. in case of holidays/sickness etc.), e.g.:
Items marked * Dispenser
Items marked ** Prescribing doctor
Review: how often, or under what circumstances, the SOP is to be reviewed, e.g.:
The SOP will be reviewed annually, next review due:
It will also be reviewed in the event of any of the following:
 Changes in relevant legislation or recommended guidance
 Changes in staffing
 Following an error or significant event
Risks: details of things that could go wrong, how to minimise such risks, and the procedure
for recording significant events, e.g.:
Errors due to drugs with unfamiliar names/dosages
Interactions with other medication
Acceptance:
Signatures (dated) of relevant staff:

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SOP: INTERVENTIONS AND PROBLEM SOLVING. Version no. and date
Purpose: what the SOP is for, e.g.:
To ensure that interventions are dealt with appropriately and promptly, and that
patience confidence in the prescriber is maintained
Scope: what the SOP covers, e.g.:
All interventions and problem for all NHS and private prescriptions
Process/procedure: detailed steps which are to be taken, e.g.:
If an anomaly is identified:
Ask patient if appropriate
Check sources of reference (e.g. published reference books – BNF, MIMS etc., or
manufacturer’s literature or helpline)
Refer to Prescribing doctor
Advise patient if there is likely to be a delay, or if items are out of stock
Record details; follow Significant Event Reporting procedure where appropriate
Responsibilities: who is responsible for what, including delegation and back-up
arrangements (e.g. in case of holidays/sickness etc.), e.g.:
Dispensing doctor and/or Dispenser
Review: how often, or under what circumstances, the SOP is to be reviewed, e.g.:
The SOP will be reviewed annually, next review due:
It will also be reviewed in the event of any of the following:
 Changes in relevant legislation or recommended guidance
 Changes in staffing
 Following an error or significant event
Risks: details of things that could go wrong, how to minimise such risks, and the procedure
for recording significant events, e.g.:
Unable to resolve in reasonable timescale
Acceptance:
Signatures (dated) of relevant staff:

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For use within your practice only. You are not permitted to supply this to any other organisation.
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SOP: ASSEMBLY AND LABELLING. Version no. and date
Purpose: what the SOP is for, e.g.:
To ensure that dispensed prescriptions have been assembled and labelled accurately before
being transferred to the patient
Scope: what the SOP covers, e.g.:
The labelling and assembly of acute and repeat NHS and private prescriptions
Note any exceptions.
Process/procedure: detailed steps which are to be taken, e.g.:
Check source of prescription (electronic or manual) and print labels accordingly
Check quantity/length of course
Check any drug interaction warnings and seek guidance/record appropriately
Check dosage instructions on label are correct and easy to understand
Check handing of drugs/protective clothing/cleanliness
Select product/check strength/check formulation
Check expiry dates
If appropriate count out correct number of units and place in appropriate container
Follow xxx procedure if insufficient stock
Include relevant information leaflets
For private prescriptions, calculate price
Pass on for checking
Responsibilities: who is responsible for what, including delegation and back-up arrangements (e.g. in
case of holidays/sickness etc.), e.g.:
All Dispensing staff also note arrangements for sickness/holiday cover
Review: how often, or under what circumstances, the SOP is to be reviewed, e.g.:
The SOP will be reviewed annually, next review due:
It will also be reviewed in the event of any of the following:
 Changes in relevant legislation or recommended guidance
 Changes in staffing
 Following an error or significant event
Risks: details of things that could go wrong, how to minimise such risks, and the procedure for
recording significant events, e.g.:
Errors due to drugs with similar names or similar packaging
Errors due to drugs with unfamiliar names/dosages
Acceptance:
Signatures (dated) of relevant staff:

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SOP: ACCURACY CHECKING. Version no. and date
Purpose: what the SOP is for, e.g.:
To ensure that dispensed prescriptions have been assembled and labelled accurately
before being transferred to the patient
Scope: what the SOP covers, e.g.:
Covers the way in which prescriptions that have been assembled and labelled are
checked for accuracy before passing to patient
Process/procedure: detailed steps which are to be taken, e.g.:
For each item on the prescription check:
> drug name, strength, quantity, form, expiry date, dosage instructions, labelling and
label warnings
> multiple packs are all the same
> leaflets/PILs
If correct, tick ‘checked by’ box, place items in bag, annotate special storage
requirements and add spoons etc. as necessary. Staple prescription to bag
Place bag ready for transfer to patient
Record errors and report to Dispenser/Dispensing doctor. Follow Significant Event
Reporting procedure where appropriate
Responsibilities: who is responsible for what, including delegation and back-up
arrangements (e.g. in case of holidays/sickness etc.), e.g.:
Dispensary staff
Review: how often, or under what circumstances, the SOP is to be reviewed, e.g.:
The SOP will be reviewed annually, next review due:
It will also be reviewed in the event of any of the following:
 Changes in relevant legislation or recommended guidance
 Changes in staffing
 Following an error or significant event
Risks: details of things that could go wrong, how to minimise such risks, and the procedure
for recording significant events, e.g.:
Lack of attention to detail (assumption that it’s correct)
Acceptance:
Signatures (dated) of relevant staff:

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SOP: TRANSFER OF ITEMS TO THE PATIENT. Version no. and date
Purpose: what the SOP is for, e.g.:
To ensure that patients receive the dispensed items intended for them and with
sufficient information to enable them to use the items effectively
Scope: what the SOP covers, e.g.:
Covers the transfer of all dispensed prescriptions to patients (or their representatives)
Process/procedure: detailed steps which are to be taken, e.g.:
Call patient and check identity
Check patient understands how to take the prescribed medication and is aware of side
effects
Check that Parts 1, 2 and 3 on the reverse of the prescription have been completed
appropriately/correctly
Ensure prescription charge had been paid where appropriate
Place prescription for filing and complete registers (Controlled Drugs etc.)
Responsibilities: who is responsible for what, including delegation and back-up
arrangements (e.g. in case of holidays/sickness etc.), e.g.:
All Dispensary staff
Review: how often, or under what circumstances, the SOP is to be reviewed, e.g.:
The SOP will be reviewed annually, next review due:
It will also be reviewed in the event of any of the following:
 Changes in relevant legislation or recommended guidance
 Changes in staffing
 Following an error or significant event
Risks: details of things that could go wrong, how to minimise such risks, and the procedure
for recording significant events, e.g.:
Patient identification errors (e.g. popular names like Smith)
Patients who are hard of hearing or for whom English is not their first language
Acceptance:
Signatures (dated) of relevant staff:

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Resources

British Association Dispensary Services Quality Scheme

BMA - Dispensary Services Quality Scheme, August 2006

Dispensing Doctors’ Association

http://www.dispensingdoctor.org

Appendix A follows on the next page >>>

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Appendix A – SOP template

SOP: name
Purpose: what the SOP is for

Scope: what the SOP covers

Process/procedure: detailed steps which are to be taken

Responsibilities: who is responsible for what, including delegation and back-up

arrangements (e.g. in case of holidays/sickness etc.)

Review: how often, or under what circumstances, the SOP is to be reviewed

Example text:
The SOP will be reviewed:
Annually, next review due:
It will also be reviewed in the event of any of the following:
 Changes in relevant legislation or recommended guidance
 Changes in staffing
 Following an error or significant event
Risks: details of things that could go wrong, how to minimise such risks, and the procedure
for recording significant events

Acceptance:
Signatures (dated) of relevant staff:

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For use within your practice only. You are not permitted to supply this to any other organisation.
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