Standard Operating

Procedures

Dispensing

Practice Name

Address

Accountable
doctor
Effective from

Date of review

www.ddandptraining.co.uk
[email protected]
Tel: 0116 2413508
Fax: 0116 2413508
Practice Name:

Standard Operating Procedures

Dispensing

Contents

Dispensary staff information………………………………………….. 3

SOP – Receiving prescriptions………………………………………. 4

SOP – Pharmaceutical assessment………………………………… 5

SOP – Assembling and labelling prescriptions…………………….. 6

SOP – Accuracy checking……………………………………………. 10

SOP – Interventions & Problem solving…………………………….. 12

SOP – Transferring dispensed items to patients…………………... 13

Dispensary staff signatures…………………………………………... 16

Date of review………………………………………………………….. 16

Disclaimer
Practices are free to use and alter any of the standard operating procedures in this document. However, practices
who choose to use the standard operating procedures, do so at their own risk. Before using the standard operating
procedures practices should check and ensure that the standard operating procedures are appropriate for their
practice. DD&P Training Services Ltd does not accept any liability or responsibility for any harm caused by the use of
these standard operating procedures.

Important note
These standard operating procedures must not be copied or distributed without the prior written consent of DD&P
Training Services Ltd. They may only be used by practices that have downloaded this document from
www.ddandptraining.co.uk.

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Dispensary staff information

Name Contact details Qualifications Date
competency
assessment
completed

NVQ Level 2 Training is available from DD&P Training Services

DD&P Training Services also offer learning workshops for experienced dispensers
and technicians

For more information about our courses please visit our website:
www.ddandptraining.co.uk

Or e-mail us: [email protected]

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Standard Operating Procedures – Dispensing

Receiving Prescriptions

Purpose

To ensure a high standard of customer service and the safe, secure, and efficient
handling of prescriptions received at the dispensary.

Scope

The procedure covers the receipt of NHS and private prescriptions presented at the
dispensary.

Procedure / Process

1. Greet patient
2. Confirm patient details – name, address, age/date of birth. Clarify incomplete
details if necessary
3. Advise patient if medicine is cheaper to buy OTC (if a P or GSL medicine)**
4. Check availability of stock – consult a dispenser if necessary
5. Advise approximate waiting time if appropriate
6. Pass prescription to dispensary staff

Responsibility

All dispensary staff are involved in this procedure.

Review Procedure

This procedure will be reviewed following:

• Changes in the law affecting dispensing
• Changes in DDA or other guidelines affecting the dispensing process
• Change of staff.
• Any adverse dispensing incident.
• In the absence of any of the above, this procedure will be reviewed 12
months after the date shown on the first page

Known Risks

None

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Standard Operating Procedures – Dispensing

Pharmaceutical assessment

Purpose

To ensure that all prescriptions dispensed are safe, clinically appropriate, legally
valid, and cost-effective.

Scope

The procedure covers the assessment of all NHS and private prescriptions.

Procedure / Process

1. Check for legal validity, eg. that the prescription has been signed and dated
(for “walk-in” prescriptions), that it is in date and, if it is for a controlled drug,
that it complies with the requirements of the Misuse of Drugs Regulations
2. Check for forgeries
3. Check for disallowed items prescribed on NHS prescription forms
4. Check for compliance with Health Centre formulary
5. Appropriateness of drug in relation to patient’s condition and other
parameters such as age, pregnancy/breastfeeding status, previous treatment,
etc
6. Appropriateness of dosage form
7. Appropriateness of dose
8. Appropriateness of route of administration
9. Check for therapeutic duplication
10. Check for contraindications
11. Check for drug/drug, drug/disease interactions
12. Assessment of possible side-effects and risks of adverse reactions
13. Assessment of compliance or inappropriate use/misuse

Responsibility

Dispensing doctor. Steps 1 to 4 and step 13 may be delegated to any dispenser.

Review Procedure

This procedure will be reviewed following:

• Changes in the law affecting dispensing
• Changes in DDA or other guidelines affecting the dispensing process
• Change of staff
• Any adverse dispensing incident
• In the absence of any of the above, this procedure will be reviewed 12
months after the date shown on the first page

Known Risks

1. New or unfamiliar drugs

2. Drugs with similar names
3. Drugs capable of causing most harm to patients if given inappropriately. Eg.
Methotrexate, anticoagulants, hypoglycaemics
4. Patient on other medicines of which the doctor is unaware
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Standard Operating Procedures – Dispensing

Assembling and labelling prescriptions

Purpose

To ensure the safe and effective assembly and labelling of prescribed items.

Scope

The procedure covers the labelling and assembly of all prescriptions with the
exception of those requiring extemporaneous preparation and those requiring a
special order (see appendices). It does not cover emergency supply of POMs at
the request of a doctor, nurse, or patient.

Procedure / Process

Labelling:
1. Check whether the prescription has been received electronically or manually.
If it is an electronic prescription, labels should be generated in accordance
with the dispensing software procedures, then go to step 6
2. For manual prescriptions, check if the patient is registered on the practice’s
dispensing software system. If yes, then add the prescribed items to the
patient’s record and produce labels in accordance with dispensing software
procedures.
3. Calculate the correct quantity to be dispensed if the prescriber has used the
number of days treatment box
4. If the labelling system warns of drug interactions, incorrect dosage, etc. then
refer the matter to the doctor (see SOP on pharmaceutical assessment)
5. Endorse prescription
6. Record any interventions if not already done so under the “Interventions and
Problem Solving” SOP
7. Ensure wording on labels is correct and in plain English, making any
necessary amendments
8. Place prescription(s) and label(s) in a dispensing tray and place in the
appropriate area, ready for assembly

Assembly:
1. Check that relevant protective clothing, such as a clean overall, is worn where
appropriate and that hands have been washed
2. Read the prescription (NOT the label) and select the correct product. Pay
particular attention to medicines with similar names which may be in close
proximity, eg amlodipine, amiloride
3. For oral dose forms, pay particular attention to ensuring the correct strength
has been selected
4. For oral forms, check that the correct formulation has been selected – SR,
EC, LA etc. are all different
5. For topical preparations, pay particular attention to ensuring that the correct
formulation has been selected (cream vs. ointment, eye drops vs. eye
ointment, etc.)
6. Check the expiry date on the product. Pay particular attention to eye drops
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7. If opening an oral liquid medicine, write the date of opening on the bottle
8. Select the correct number of calendar/patient packs OR
9. Select the appropriate bulk pack and count out the correct number of dosage
units using a triangle, a capsule counter, or if appropriate, an electronic tablet
counter
10. Do not touch or handle medicines while counting, particularly those that can
cause sensitisation, eg cytotoxics, finasteride
11. If insufficient quantity is in stock, refer to the “Owings” procedure
12. If using patient packs, check that all the packs are full and do not contain half
strips or loose tablets. If the box contains loose strips or tablets, check these
correspond with what is supposed to be in the box
13. If necessary, transfer the medicine to another container, using child resistant
closures (CRC) when appropriate
14. If transfer to another container is necessary, check whether this compromises
stability or expiry
15. If the patient has requested non-CRCs, ensure that plain tops are used and
annotate the prescription accordingly
16. Check that the label corresponds with what has been prescribed and attach it
to the assembled item, initialling the “dispensed by” box
17. Ensure the pack contains the relevant patient information leaflet (PIL) if
appropriate
18. Check that the assembled item matches the prescription and that the label
matches the prescription
19. If dispensing from bulk packs, keep the dispensed item with the bulk pack
until the whole prescription has been checked for accuracy
20. Repeat the assembly procedure until all items on the prescription form have
been dispensed
21. Leave the assembled and labelled items, together with the stock pots or
empty containers, in the prescription tray and transfer to the checking area for
checking by the relevant person
22. For items with special storage requirements (e.g. fridge items, CDs), consider
placing them in a separate area so that they will be checked and returned to
the appropriate storage area as soon as possible
23. Re-order stock,
24. If the prescription is private, calculate the price to be paid and annotate the
prescription form accordingly

Responsibility

All dispensers

Review Procedure

This procedure will be reviewed following:

• Changes in the law affecting dispensing
• Changes in DDA or other guidelines affecting the dispensing process
• Change of staff.
• Any adverse dispensing incident.
• In the absence of any of the above, this procedure will be reviewed 12
months after the date shown on the first page

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Known Risks

1. Unfamiliar products
2. Unfamiliar names, eg rINNs (dosulepin is the rINN for dothiepin)
3. Assembling items from labels, not from prescriptions
4. Similar packaging
5. Products with similar names, eg co-amilozide, co-amilofruse
6. Not marking half-full boxes
7. Distractions
8. Quieter periods. Research shows that fewer errors occur when the
dispensary is busy
9. Working long hours without a break

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Appendix 1

Prescriptions requiring extemporaneous preparation

1. Follow the SOP for the “Labelling of Prescriptions”. Ensure the label contains
a batch number and expiry date, and that a duplicate label is produced
2. Inform the patient of the likely waiting time
3. Extemporaneous preparations should be prepared in a separate area of the
dispensary
4. Use the “Extemporaneous Preparation” book to calculate the ingredients and
quantities required, and the method of manufacture. Order any ingredients
needed, and any containers, etc.
5. Ensure that the doctor checks all ingredients, quantities, and methods of
manufacture, and that the batch numbers and expiry dates are noted in the
record
6. The label affixed to the completed product should contain both a batch
number, which refers to the appropriate page of the record book, and an
expiry date. A duplicate label should be attached to the relevant page of the
book
7. The “dispensed by” box should be annotated by the dispenser responsible for
manufacturing the product
8. The prescription can now be subjected to the usual checking procedures

Appendix 2

Prescriptions requiring a special order

1. Follow the SOP for the “Labelling of Prescriptions”, ensuring a duplicate

label is produced
2. Inform patient of the likely waiting time
3. Order the “special” item from the appropriate supplier,
4. Make an entry in the “Special Order Record Book” detailing the date, the
item ordered, the expected date of delivery, and the order reference
number
5. Upon receipt of the “special item”, affix the duplicate label to the
manufacturing record supplied with the product and file the record in the
“Extemporaneous Preparation” book
6. Affix a dispensing label to the product, ensuring batch number and expiry
dates are not obscured, and sign the “dispensed by” box
7. The prescription can now be subjected to the usual checking procedures

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Standard Operating Procedures – Dispensing

Accuracy checking

Purpose

To ensure that dispensed prescriptions have been assembled and labelled

accurately before being transferred to the patient.

Scope

The procedure covers the way in which prescriptions that have been dispensed
(assembled and labelled) are checked for accuracy. It covers all prescriptions except
those which have to be dispensed into monitored dosage systems.

Procedure / Process

1. Keep distractions and interruptions to a minimum

2. Read the prescription through once, including details of patient name as well
as drug name, strength, and quantity
3. Check each item individually in the order it appears on the prescription before
moving on to the next

Check the product:

1. Read the drug name on either the bulk stock pack or the patient pack and
check that this matches what is written on the prescription
2. Check that the product strength correlates with that on the prescription. Be
careful with units, eg mg (milligrams) and mcg (micrograms)
3. If using multiple patient packs, check that all packs are the same medication
and the same strength
4. Check that the correct form has been dispensed (cream vs. ointment etc.)
5. If using bulk packs, carry out a quick visual check on the contents of the bulk
pack and the contents of the container to ensure they match
6. If using patient/calendar packs, open all unsealed packs checking that the
contents are correct, the number of strips present in each pack is correct, and
that there are no loose blisters or tablets
7. Check that the pack contains the relevant PIL or, for medicines dispensed
from bulk packs, that a leaflet is supplied; these can be downloaded from the
internet.
8. Check that the correct quantity has been given (the correct number of patient
packs or a quick visual check of the container)
9. For controlled drugs, double-check and count the number of dosage units
dispensed
10. Check the expiry date on each patient pack or on the bulk pack

Check the label:

1. Check the label against the prescription (not against what has been
dispensed) to ensure that it contains the correct patient name, correct
medication name, correct strength, quantity, and dosage form
2. Check that the dose and usage instructions on the label correspond with the
prescription
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3. Check that the correct BNF warnings appear on the label

4. If dispensing more than one item, check that the labels on the items have not
been transposed

Complete the checks:

1. When the accuracy check is complete, initial the “checked by” box on the
dispensing label
2. If any of the above steps reveals that an error has been made, this must be
brought to the attention of the dispenser concerned. Errors should be
recorded, and any trends should be brought to the attention of the doctor in
charge.
3. Count the number of items on the prescription and then count the
corresponding number of dispensed items (not packs) into an appropriately
sized bag
4. Check that you have not included any stock containers in the bag
5. If the dispensed items have special storage requirements, eg items needing
refrigeration or controlled drugs, ensure that the prescription form is
annotated accordingly
6. Ensure that 5ml spoons, oral syringes, etc. are included if necessary
7. Attach any owing labels or other notes if necessary
8. Attach the prescription to the bag
9. Hand the dispensed items to the patient in accordance with the “Transfer to
Patient” procedure OR
10. If the patient is collecting the prescription at a later time, store the dispensed
items in the appropriate collection area, ensuring that any items which have
special storage conditions are stored in the appropriate area

Responsibility

Repeat prescriptions requiring remote delivery may be checked by the Dispensary

Manager after any problems have been satisfactorily solved.

Review Procedure

This procedure will be reviewed following:

• Changes in the law affecting dispensing
• Changes in DDA or other guidelines affecting the dispensing process
• Change of staff
• Any adverse dispensing incident
• In the absence of any of the above, this procedure will be reviewed 12
months after the date shown on the first page

Known Risks

• Distractions or interruptions
• Working long hours without a break
• Quieter periods (research shows that fewer errors occur when the dispensary
is busy)
• Illness/lack of focus/personal problems
• Over-reliance on accuracy of person who dispensed the medication
• Self-checking

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• New staff, locums, etc.

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Standard Operating Procedures – Dispensing

Interventions & problem solving

Purpose

To ensure that interventions are dealt with appropriately and promptly, and that
patience confidence in the prescriber is maintained.

Scope

The procedure covers interventions and problem solving for all NHS and private
prescriptions.

Procedure / Process

1. Consult patient as he or she may be able to help solve the problem

2. Inform patient, if present, without causing undue alarm, that there may be
a delay in dispensing the prescription
3. Inform patient, if present, if a prescribed item is likely to take some time to
obtain, e.g. long-term out-of-stocks, special orders
4. Check dispensary reference sources
5. Contact external reference sources for advice or information if necessary,
e.g. manufacturer’s medical information department.
6. Contact prescriber and discuss the problem
7. If prescriber cannot be contacted, refer problem to prescriber’s deputy
8. Come to an agreement with prescriber on action to be taken (if the matter
cannot be solved by the dispensary team)
9. Record details of intervention and outcome

Responsibility

Dispensing doctor. All steps may be delegated to any dispenser.

Review Procedure

This procedure will be reviewed following:

• Changes in the law affecting dispensing
• Changes in DDA or other guidelines affecting the dispensing process
• Change of staff.
• Any adverse dispensing incident.
• In the absence of any of the above, this procedure will be reviewed 12
months after the date shown on the first page

Known Risks

1. problems presenting during busy periods

2. problems not followed up or progressed

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Standard Operating Procedures – Dispensing

Transferring dispensed items to patients

Purpose

To ensure that patients receive the dispensed items intended for them and with
sufficient information to enable them to use the items effectively.

Scope

The procedure covers the transfer of all dispensed prescriptions to patients and their
representatives.

Procedure / Process

If patient/representative has called back to collect a dispensed prescription:

1. Greet patient/representative
2. Check whether person present is the patient or a representative
3. Ask the patient/representative for the patient’s full name and address (not just
surname)
4. Locate the correct bag.
• Items which the doctor wishes to give out personally are identified by
a note on the prescription
• Prescriptions solely for controlled drugs are located on ………………..
Prescriptions which contain a controlled drug plus other items are
annotated “CD”. The controlled drugs are stored in the controlled drug
cabinet, located in the dispensary
• Items which need to be refrigerated are stored in the refrigerator,
located in the dispensary. Prescriptions solely for fridge items are
located on ……………….. Prescriptions which contain a fridge item(s)
plus other items are annotated “fridge”
• Large/bulky items are stored on the dispensary shelving adjacent to
……………………………
• Items which were initially dispensed more than 1 month ago are
disbanded and a record made on the EMIS system
5. Cross-check patient name and address against the attached prescription
6. Follow any special instructions on the bag (eg notes concerning use or
availability of a product)

If patient/representative has been waiting for the prescription:

1. Call out patient name when items have been checked and are ready
2. Ensure that those with hearing difficulties are made aware that the
prescription is ready
3. Ask the patient/representative for the patient’s full name and address (not just
surname)
4. Check whether patient can open packaging (eg bottles with CRCs, blisters,
etc.)

If patient has not previously used the item(s):

1. It may be inappropriate to counsel representatives on a medicine’s indications
– remember to maintain patient confidentiality at all times
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2. Within the limits of your competence, explain how the items should be
used/taken and any major unwanted effects/interactions (eg warnings on
drowsiness, alcohol interactions, take with food, complete the course, etc.)
3. Explain fully any complicated dosage regimes (eg reducing courses, etc.)
4. Refer patients who require elastic hosiery or truss fitting to the local pharmacy
or practice nurse.
5. Where appropriate and/or necessary, demonstrate the use of inhalers or
other devices or refer to Christine Westwood.
6. Ask the patient/representative whether they have any further questions about
the items or if they would like to speak to the doctor
7. At any stage, if necessary, refer to the doctor or other member of the
dispensary team

If the patient has had the item(s) in the past:

1. Point out your telephone number and advise the patient to contact the doctor
if they have any further queries

For all prescriptions:

1. Ensure the reverse of the prescription has been completed,
the declaration signed, and the correct number of charges
collected where appropriate
2. If evidence of exemption is not presented, place a cross in
the Pharmacy Use Only box on the reverse of the
prescription
3. If the prescription has been paid for, or contains a
contraceptive alone, the form should be annotated
accordingly
4. If not all items can be supplied, explain the procedure for
collecting owings and advise on approximate delivery time
5. Place the prescription form in the appropriate basket for
filing.
6. Ensure that appropriate records have been made (eg
prescription register, CD register

Responsibility

All dispensary staff are potentially involved in this procedure. Dispensers must
ensure that all prescriptions containing CDs and fridge items are annotated
accordingly. Counter assistants must ensure that these items are passed on to the
patients/representatives, along with any notes or messages.

Review Procedure

This procedure will be reviewed following:

• Changes in the law affecting dispensing
• Changes in DDA or other guidelines affecting the dispensing process
• Change of staff
• Any adverse dispensing incident
• In the absence of any of the above, this procedure will be reviewed 12
months after the date shown on the first page

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Known Risks

• New staff
• Patients with commonly occurring surnames
• Patients with the same name living at the same address (e.g. father and
son)
• Patients collecting more than one prescription
• Third-party (e.g. nurse, carer) or patient representative collection
• Patients with sensory disabilities
• Patients with language or literacy problems
• Patients who are too busy for counselling
• Items stored in unusual locations (e.g. fridge, CD cabinet, bulky items)
• Prescriptions that have been dispensed into more than one bag
• Prescriptions for different patients that need to be collected together

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All dispensary staff must read the standard operating procedures and sign below to
say that they understand and will comply with the standard operating procedures

Name Position held Signature Date

Prepared by : DD&P Training Services Ltd

Edited by: ………………………………

Effective from : ……………………………

Version no. : 1

Date of preparation : May 2007

Date of review:

Signature:

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