Things to do and things to know in community pharmacy across the UK
Epanutin Infatabs 50mg out of stock until November 2019 – advice from Pfizer Epanutin Infatabs 50mg (containing phenytoin) will be out of stock until November 2019 due to a manufacturing delay. The manufacturer, Pfizer, has issued advice to healthcare professionals, including pharmacists, regarding the supply issue.
Epanutin Infatabs 50mg is licensed for the following indications:
• Control of partial seizures (focal including temporal lobe) and
tonic-clonic seizures (grand mal epilepsy) or a combination of
• The prevention and treatment of seizures that occur during or
after neurosurgery and/or serious head injury.
• As a second-line treatment of trigeminal neuralgia in patients for
whom carbamazepine is ineffective or not tolerated.
Phenytoin is a Category 1 anti-epileptic drug - this means that when phenytoin is used for treatment of epilepsy, patients should be maintained on a specific brand/manufacturer’s product due to the risk that variability in therapeutic index, absorption and solubility between brands could lead to loss of seizure control.
The Medicines and Healthcare Products Regulatory Agency (MHRA) has permitted Pfizer to import stock of Dilantin Infatabs 50mg from Canada. Dilantin Infatabs 50mg contain the same active ingredient (phenytoin) as Epanutin Infatabs 50mg. However no bioequivalence data is available, and there may therefore be clinically signifi cant differences between the two brands.
Patients switched to alternative presentations should be medically supervised and monitoring of serum phenytoin levels should take
place to establish a suitable dose. Pharmacists and their teams should be aware of the following key information from Pfizer:
• Dilantin Infatabs 50mg is an unlicensed product in the UK.
• Prescribers should take into account the MHRA guidance
“Supply unlicensed medicinal products (specials)” prior to issuing
a prescription for Dilantin Infatabs 50mg.
• Pfizer has provided a summary of differences between Dilantin
and Epanutin Infatabs and prescribing information for both
products are attached to its letter to healthcare professionals.
• When ordering Epanutin Infatabs 50mg using the standard PIP code with Alliance Healthcare, pharmacy teams will receive a
message to contact Pfizer Customer Contact Centre.
Last chance to book the NPA conference in Manchester
The conference, with the theme ‘Forwards in Partnership,’ is on June
20 at the Pendulum Hotel & Manchester Conference Centre. It is
a collaboration between the NPA and Pharmacy Magazine. Health
Secretary Matt Hancock is among the line-up of speakers. NPA members
are invited to attend the AGM in Manchester on the same day. Go to
the page on the NPA site or email email@example.com.
Yellow fever vaccine guidance: Stamaril – MHRA
guidance following fatal reactions after administration
The MHRA issued a drug safety update following two reports of fatal
adverse reactions after administration of the yellow fever (YF) vaccine
• It is a live attenuated vaccine therefore it must not be
administered to a patient who may be immunosuppressed.
• It is contraindicated in the following patient groups:
- Individuals with a history of thymus dysfunction (this includes
myasthenia gravis and thymoma).
- Those who have had their thymus gland removed (thymectomy).
- Patients aged 60 years and over should only be given the YF
vaccine when there is an unavoidable and signifi cant risk of
contracting yellow fever infection.
• Healthcare professionals, including pharmacists, who administer
YF vaccine must:
- Understand the contraindications and special precautions prior to
administration –from the Summary of Product Characteristics for
- Be familiar with the YF Vaccine Centre code of practice.
• Where there is any doubt over whether a patient is
immunosuppressed, vaccination with YF vaccine should be
postponed until specialist advice is obtained.
• Immunosuppression can be due to therapy, underlying illness or
• Robust checklists and protocols should be in place for YF vaccine
administration to avoid the risk of incorrect administration that
may lead to severe/fatal side effects.
• A risk assessment should be conducted prior to vaccine
• Discuss the traveller’s medical history, details of the travel
itinerary, immune status and potential contraindications.
• A patient information leafl et should be given to the traveller.
• Suspected side effects during vaccination and any medication
error should be reported via the Yellow Card Scheme. Pharmacists
administering the YF vaccine against a patient group direction must
follow the terms of the PGD and contact the PGD provider where
Contact the NPA pharmacy services team on 01727 891 800
or email firstname.lastname@example.org
The NPA has given new evidence to government
about the financial pressures on independent pharmacies
A survey of nearly 250 NPA members
carried out in January shows that cash
flow is having a “critically negative
effect” on their ability to operate and
sustain a successful pharmacy business.
Nine in 10 said the current financial
situation is making it more difficult for
pharmacies to maintain a safe service
to patients. Many reported a drop in
The NPA presented the evidence to the
Department of Health and Social Care last
month. Chief executive Mark Lyonette said
this is to “help inform decisions about future
investment in the sector, and make the
case for improvements to the concessionary
The results provide a troubling insight into
the harsh realities on the pharmacy frontline
right now. NPA members tell us they are
really struggling with fi nances and above
all the rising cost of medicines. Our survey
confi rms that morale is suffering. This has
to change so that pharmacies can step up,
energised to meet the challenges laid out in
the NHS long-term plan.
The survey reveals:
• 54% of independent pharmacies are
“very worried about the survival” of
• 89% said that their total monthly
wholesaler bills have exceeded their NHS
payments for at least one of the last
• 64% of owners said that they had needed
to put a cash injection into the business to
maintain working capital.
• 31% said they had asked their wholesaler
for an extension to credit terms, in the last
• 69% say that cash fl ow is currently having
a “critically negative effect” on their ability
to operate & sustain a successful pharmacy
• 86% said that they had been adversely
affected, mentally or physically, by funding
cuts and escalating costs.
• 79% reported that the morale of their
pharmacy team was lower than a year ago.
The NPA recognises the limitations of this
survey – in particular the self-selecting nature
of the data pool. Nevertheless, it clearly
shows a high degree of distress for many
independents at this time.
We want Ministers and offi cials to have a
clear, unspun, picture of the situation. Just
when the NHS wants to make greater use of
community pharmacists’ skills, according to
the NHS Long term Plan, the current financial
situation is a powerful disincentive to
pharmacy owners to invest in NHS services.
NPA Director of Pharmacy, Leyla
Hannbeck, is the Medication Safety
Offi cer (MSO) for all independent
community pharmacies in England with
fewer than 50 branches. Here are some
of the key findings from the January to
There was a 29% increase in patient
safety incidents reported in the first quarter
of 2019 compared to Quarter 4 of 2018.
The submission rate of reports almost
doubled in February compared to January
and March. The quality payments scheme
may have contributed to this as a higher
number of lookalike/sound-alike incidents
were reported in February.
Five per cent of incidents were due to
prescribing errors (up from 3% during
Q4 2018), most of which involved issues
• Incorrect nystatin dosages.
• Increasing patients’ current dose half
way through their treatment and this
change not being communicated to
• Prescribing certain medicines knowing
that patients were allergic to the active
• Not following prescription requests made
by the pharmacy and/or patient directly.
The two most common error categories
reported continued to be dispensing a
wrong drug/medicine (33%) and dispensing
the wrong strength (21%). Wrong strength
incidents included a patient receiving
600mg gabapentin capsules instead of
100mg. The patient took the wrong
strength for fi ve days resulting in extreme
drowsiness. They were taken to hospital for
a full medical assessment.
Other wrong strength incidents
concerned 10, 20 and 30mg citalopram
tablets. The majority of the errors were
due to similar packaging leading to the
pharmacy segregating its stock as part of its
sharing and learning.
The majority of wrong formulation
incidents involved inhaler preparations being
dispensed incorrectly in place of dry powder,
breath actuated and/or nasal spray, and
Example of wrong dose prescribing
An incident occurred where a patient received
a double dose of methylphenidate prolonged
release tablets due to wrong dosage
instructions on the dispensing label. The
prescription originally for Delmosart prolonged
release tablets 18mg and 36mg at a dosage
instruction of once daily was instead written
as ‘Take ONE tablet TWICE a day.’ This led the
patient to experience hallucinations due to
the long acting properties of Delmosart and
the patient was taken to hospital for further
Work and environment factors continue
to be the main contributing factor, mainly
involving time pressures, distractions
and increased staff turnover. The latter
is resulting in an inappropriate skill mix
and more staff undergoing training which
ultimately leads to the pharmacist selfchecking
Although the error rate reduced by 1%
for ‘moderate harm’ compared to Quarter
4 of 2018, all the incidents involved giving
the wrong drug to patients who were
then hospitalised. One patient received
pravastatin tablets, instead of paroxetine
tablets, and took it for three weeks before
being hospitalised due to feeling ‘sick’ for
not taking the paroxetine tablets. A second
patient received amisulpride tablets 200mg
instead of amiodarone tablets 200mg,
and took it for four weeks resulting in
hospitalisation due to frequent arrhythmias.
Community pharmacy diary and
step-by-step guidance to completing
end of month submissions – dates you
need to remember
In a busy pharmacy environment it is easy to forget relevant
deadlines and dates. In addition, it is easy to forget the fi ner
details of endorsing prescriptions. The NPA ‘pharmacy diary’
resource will allow contractors to keep on top of important
dates and support them with completing their end of month
The community pharmacy diary will help you:
• Keep track of key deadlines and events.
• Remember to carry out important day-to-day and monthly tasks,
for example fi lling out the responsible pharmacist log and fridge
• Add reminders for your own key dates.
How to use the community pharmacy diary
• Each page represents one month of the year – from April 2019 to
• The two columns on the left show the day and day of month.
• The third column shows the key deadline or event.
• The last column shows ongoing daily and monthly tasks.
• For each day of the month there is space to add in your own key
dates – for example locally commissioned service claim deadline.
• The community pharmacy diary will continue to be updated as
and when new dates are published.
Three appendices have also been included within the
diary to help ensure you receive correct payment from
your end of month prescription submission:
• Appendix 1 – Checklist to ensure correct payment including top
tips for submission.
• Appendix 2 – Sorting your submission bundle.
• Appendix 3 – Completing the FP34C.
To access this resource go to
For further information, advice and support, please contact
the NPA Pharmacy Services team on 01727 891800 or email
NPA patient safety Incident Reporting Platform (IRP)
— user information
The NPA IRP, updated and launched end of October 2018, has
proven to be user-friendly. The completed form can be sent via email
helping to reduce administrative time as it can be kept for pharmacy
record keeping requirements.
Key points for using the IRP
• Patient identifi able information must not be included when
completing the report — this is especially important since the
implementation of the General Data Protection Regulation (GDPR)
on 25 May 2018.
• An option has been created for selecting ‘Look-alike sound-alike
(LASA) errors’ when a ‘wrong drug’ has been dispensed — be
aware if the ‘wrong strength’ or ‘wrong formulation’ has been
selected, it is not considered a LASA error.
• It is important that a detailed description of the patient safety
incident in the ‘describe what happened’ fi eld is provided (think
about the sequence of events and how the error was concluded)
— simply writing a brief description, for example, ‘wrong strength
given’ is not enough as it does not provide suffi cient information
for us to conduct a full and complete data analysis which is a key
part of the NPA’s role as the MSO for all community pharmacies in
England with fewer than 50 branches.
• Although the Quality Payments Scheme has ended, please
continue to use the MSO quarterly reports to demonstrate
evidence of sharing and learning.
Incentivising staff the
smart (and legal) way
Done right, employee incentives can
play a significant role in attracting
and retaining talented employees and
keeping them focused and engaged. As
well as making employees feel valued,
they can promote particular behaviours
or levels of performance that are
necessary for the organisation’s success.
However, incentives can also be
problematic; it can be easy to unwittingly
emphasise the wrong behaviours and there
are also legal pitfalls to avoid.
There are a number of things to keep in
mind to ensure an incentive scheme has the
One sure-fire way to invite problems is to
apply incentives in a way that puts certain
people at a disadvantage. While you may
wish to set certain eligibility requirements,
it’s important that any conditions placed
on entitlement to rewards are not
For example, if you’re incentivising
attendance, you need to ensure you don’t
discriminate against employees who are
absent due to pregnancy or genuine
health reasons. This will help to avoid
claims for possible discrimination at a time
when you’re trying to incentivise staff and
create a positive and motivating working
You should be realistic about what is viable
for your pharmacy. Staff perks don’t have
to break the bank. Recognition incentives,
such as simply thanking employees, a
personal note of praise or announcing an
accomplishment at a company meeting can
go a long way.
Think about the bigger picture
Ad-hoc incentives may only keep employees
motivated for so long. You should also
consider career progression opportunities
and be clear about the path to get there. For
many employees, this can count for a lot.
• Have you given employees the tools,
resources and opportunities to progress?
• Do employees understand their career
• Are you investing in training and
Not only can these measures improve
retention but working towards a clear
goal can be an effective way of enhancing
Avoid creating implied terms
Allowing incentives to become expected
can mean that these intended perks actually
become implied terms – terms that aren’t set
out in a written contract but are understood
to exist through custom and practice.
For example, if you have paid employees
an annual bonus for many years, this may,
over time, have become a contractual term.
This can be difficult to establish and will be
up to an Employment Tribunal to decide;
however, it’s defi nitely something to be
For advice on setting up a fair and
motivating incentive scheme, contact
the NPA Employment Advisory
Service on 0330 123 0558 or email
Safer community pharmacies in Northern
Ireland for staff and patients
The Northern Ireland Health and Social Care Board (HSCB)
announced a funding allocation of £1,500 per pharmacy in
January 2019 to facilitate a number of measures to help protect
pharmacists, pharmacy staff, and the public and pharmacy
premises from attacks. As part of this funding HSCB has asked
for procedures to be in place in the pharmacy covering a range
of areas to reduce the risks of aggressive, dangerous and
violent incidents in community pharmacy. Below are some key
resources to assist you in putting these measures in places to
enhance the security of your pharmacy staff and premises.
Written policies and procedures must be in place covering the
Ensure all staff are fully trained in understanding the security policies
and procedures in place. Training should be reviewed annually.
Training of the pharmacy team should cover areas such as:
• Types of security risk.
• How to operate security equipment – for example CCTV.
• Procedures for addressing a security breach in the pharmacy
and where to report crimes/attacks.
• Emergency call out procedure.
• Managing situations to prevent crimes taking place – for
example dealing with suspicious customers.
Ensure all members of your pharmacy team(s) are security-aware,
for example, understanding the need to refrain from discussing
security-sensitive matters such as closing-up procedures or who
is carrying shop/controlled drug (CD) cabinet keys in front of
• Training can be recorded in the “Staff training Log” from the NPA
“Supporting Members in Northern Ireland” pack.
• Training modules from the NPA CPD Hub on Body Language and
Communication Skills may also support staff knowledge.
Security assessment and security equipment
Complete the HSCB self-assessment (appendix 2) annually and in the
event of a security breach. Copies of the assessment should be kept in
the pharmacy and provided to HSCB when requested.
Ensure that basic security measures are in place and being
implemented. This includes ensuring doors are locked as appropriate,
premises and CD keys are kept secured, controlled stationery,
such as pharmacy vouchers, are stored securely, alarms are set
as required, key codes are not shared, ensure there is adequate
lighting at staff entrances and there are pass codes on doors. Ensure
security processes are reviewed regularly, especially in the event of
any incidents. Familiarise yourself with PSNI Safe Shop scheme for
Consider using CCTV to enhance staff safety in consultation rooms
whilst maintaining patient confi dentiality; for example, by ensuring
sound recording is not used and the camera is positioned in a way
that protects patient confi dentiality so that lip-reading cannot take
place. If CCTV is used in the consultation room, a notice must be
clearly displayed indicating that CCTV is in use. Patient consent
obtained for use of the CCTV should be documented. Ensure that the
system is operational, and procedures are in place to ensure images
captured are clear and stored securely in case a crime takes place.
Ensure an appropriate alarm system is fi tted. Some alarm systems
differentiate between the normal sounds made in your pharmacy and
those associated with a forced entry. When activated either by forced
entry when closed, or panic button when trading, the alarm can be
useful for calling for help and facilitating a response from the police.
- Ensure that the alarm is tested regularly and is fully functional.
- Ensure that the working alarm system in place covers all areas of the
pharmacy, particularly where medicines and confi dential patient
information is kept. Any keypad/alarm codes should be changed
- Where you have an external monitoring contract in place for your
alarm system, ensure that it is current, and all staff are aware of the
relevant contact details and actions to take in the event of a crime
Lone working procedure
There may be circumstances where it is not possible for staff to avoid
working on their own.
• Ellis Whittam has provided some guidance on working alone.
• Consider a chaperone when patients use the consultation area
Incident Reporting and Review
Incidents can be recorded on a template record form provided by Ellis
Whittam. If there is a security incident at your premises, members of
the pharmacy team should:
• Contact the police (and ambulance service in case of injuries).
• Try not to touch anything, or only touch minimally, to preserve
forensic evidence without contaminating it. Any spilt blood must
not be touched as there may be a risk of biological contamination
and it can damage valuable DNA evidence.
• Document full details of the event including the time, notifi ed
persons and what was observed, etc.
• Notify appropriate persons both within and outside the
organisation. This may include managers, area managers,
superintendent pharmacist, pharmacy owner, local Controlled
Drugs Accountable Offi cer (CDAO), Police CD Liaison Offi cer
(CDLO), and the local HSCB team, Pharmaceutical Society NI as
• Contact Victim Support Northern Ireland, an independent charity
which helps people affected by crime.
• Liaise with Pharmacist Advice and Support Services (PASS) who help
pharmacists and their families to manage stress.
Contact the NPA pharmacy services team on 01727 891 800 or
How often should pharmacies expect to be visited?
Pharmacies are currently inspected about once
every three years. As part of the inspection process,
pharmacies that are considered to have greater patient safety
concerns will be inspected more frequently.
How does this differ from contract monitoring visits by
the local Area Teams (England)?
Contract monitoring visits are carried out by local
Area Teams (ATs) to ensure that pharmacies are
providing Essential and Advanced Services to the required
standards and are complying with their contractual NHS
requirements. Only those pharmacies that appear in NHS
England’s pharmaceutical lists are required to undergo
contract monitoring visits. Community Pharmacy Assurance
Framework (CPAF) resources are available on the NPA
website, which can be used to help prepare for a contract
monitoring visit. All registered pharmacy premises are subject
to GPhC inspections, irrespective of whether or not they have
an NHS contract. There is some overlap between the two
types of visits. Clinical Governance, an essential service that
is monitored by ATs, includes a risk management programme
while new GPhC inspections focus heavily on patient safety
and how the pharmacy is ensuring that risks to patients are
Do the same principles, with their underpinning
standards, apply to all registered pharmacy
Yes. The five principles, with their underpinning
standards, apply to all registered pharmacy premises in
England, Scotland and Wales regardless of whether they are
a traditional pharmacy (with 40 core contractual hours), a 100
hour pharmacy or a distance-selling pharmacy. Compliance
with all of the standards across the five key principles must
I have all of my standard operating procedures in
place. Is there anything I can do to ensure that an
improvement action plan is not required?
Standard operating procedures (SOPs) are best practice
procedures that all of the pharmacy team should follow,
if it applies to them in their job role. Pharmacy teams should
be able to explain to the GPhC inspector why the SOP is in
place and provide examples or scenarios of how they follow
these. Having SOPs in place is not suffi cient — pharmacy
teams are required to demonstrate that these documents
are referred to, consistently followed, and reviewed as
In addition, examples of action where procedures have been
inadequate should be available.
What will the new inspection process be checking
The inspection will continue to confi rm that all
legal requirements are in place relating to, for
example, medicines and CD legislation, health and safety,
employment law, data protection, responsible pharmacist
(RP) regulations and SOPs as well as regulatory standards,
for example, staff training is complied with. There is also an
emphasis on the analysis of risk, particularly with respect to
What kind of evidence will GPhC inspectors be
There is no standard set of documents inspectors
are looking for. GPhC inspectors may wish to see
documented evidence that all the standards are being
complied with. They may observe interactions of the
pharmacy team with patients, and pose scenarios to check
that the team work in line with procedures. The NPA
pharmacy services toolkit ‘GPhC inspections: A show me,
tell me story’ - can be used to assist in preparing evidence
for inspectors, and confi rming that all the necessary SOPs,
records and logs are in place.
Are there any examples available of what evidence
GPhC inspectors will be looking for?
The NPA pharmacy services toolkit ‘GPhC inspections:
‘A show me, tell me story,’ provides examples of
evidence that inspectors may be looking for. Pharmacy
owners/superintendent pharmacists may wish to add
additional examples of evidence to those listed within the
resources depending on the services they offer. Inspectors
are not intending to penalise minor issues that do not pose
a signifi cant risk to patient safety but are looking to improve
pharmacy services and standards within pharmacies. Using
cleaning logs and training matrices, for example, are not
legal requirements but are instead examples of evidence of a
proactive approach to improving standards. GPhC inspectors
may also wish to see evidence from more than one source.
These FAQs were correct at the time of publishing. To read more visit www.npa.co.uk
NPA PGD Training
PGDs enable pharmacists to supply and
administer specified medicines to predefined groups of patients without a
Benefits to your business from
• Increase your footfall and your revenue
• Drive repeat demand for your services
• Expand the range of services you can
• Additional skill set for the pharmacist
• Improve the visibility of your business in
the local community profi le
• Develop your potential market
PGDs are good for your patients
• Community pharmacies are highly
• Assurance of being vaccinated by a
trained, accredited and trusted front-line
• Convenient – no appointment necessary
• Out of hours access due to extended
Types of vaccination
Please note that, although the new
requirement for face-to-face vaccination
training is now every three years to provide
the NHS flu service (except Scotland), all
pharmacists must ensure their competency to
administer parenteral vaccinations is assessed
and maintained, especially if they also provide
other NHS and/or private vaccination services.
In the event of a patient safety incident,
as part of the incident investigation, the
pharmacist’s vaccination skills competency
may be reviewed. Therefore, it is strongly
recommended that each pharmacist completes
a vaccination skills assessment each year to
self-check their own competency to provide
vaccination services, both NHS and private. For
more information, refer to the article entitled:
‘Implications for professional indemnity
regarding changes to the NHS fl u service
for 2018/19’ in the news section of the NPA
Professional indemnity insurance
Comparing insurance options and what is
suitable for your pharmacy business is often
NPA Insurance offers you a holistic and
long-term approach to the risks faced by
pharmacists. Even when you are retired
and have stopped paying your Professional
Indemnity insurance we will still cover you for
claims made while the error occurred during
the time you had the policy.
Dates and locations of the NPA’s
half-day face-to-face vaccination
23rd June Edinburgh
30th June Liverpool
7th July Newcastle
14th July Manchester and St. Albans
For further information call 01727 800 402 or
go to www.npa.co.uk/pgd
If you require cover contact the NPA’s
membership team on 01727 795914.