Managing medicines safely in pharmacy

Designing safe systems in pharmacy departments

Well-designed pharmacy processes are essential to minimise the risk of medication errors and to ensure patient safety. This article explores how pharmacy departments can apply best practice when designing each stage of the medicines management process. Well-designed processes can also prevent treatment delays and minimise the risk of wastage.

Pharmacy environments are complex and often busy, with staff managing multiple tasks under time pressure. Systems and processes should be designed with human factors in mind, for example reducing distractions, avoiding multitasking, and ensuring workspaces are clean, well-lit and organised. Automation and digital tools can also support safer practice by reducing reliance on memory and manual processes.  Further details can be found in our article preventing errors on the medicine journey (SPS Page).

All processes, including ordering, receipt, storage, selection, labelling and dispatch, should be underpinned by robust procedures and supported by staff training. Staff should be aware of medicines commonly associated with errors, and of working practices that increase risk.

Verification steps, such as double-checks or independent second checks may add value in certain scenarios, such as high-risk processes. Further details can be found in our article understanding when a check adds value to medication processes (SPS Page).

Standards and guidance

Refer to the Royal Pharmaceutical Society (RPS) Professional guidance on safe and secure handling of medicines when designing safe systems.

Archived National Patient Safety Agency (NPSA) design guides are widely referenced and contain valuable advice:

• Design for patient safety: A guide to the design of the dispensing environment (NPSA, 2007, NHS National Archives)
• Design for patient safety: A guide to the design of dispensed medicines (NPSA, 2007, NHS National Archives)
• Design for patient safety: Guidelines for the safe on-screen display of medication information (NPSA, 2010, NHS National Archives)

Ordering

Whether placing external orders with suppliers or internal requisitions between departments, the process must ensure the correct medicine is ordered in the correct strength, formulation, and quantity.

Ordering systems should be structured and well-designed to support safe decision making. Electronic systems offer safeguards, but only if medicines are correctly set up and differentiated within the system and inappropriate or unauthorised ordering is prevented. Manual ordering carries additional risks, particularly when sourcing alternatives during shortages or when timeframes are tight.

Examples of best ordering practice

• Design processes to set up medicines correctly in electronic ordering systems.
• Use pharmacy system order algorithms appropriately to generate orders.
• Ensure systems appropriately differentiate between similarly named medicines and unlicensed medicines.
• Define processes for manual and system-generated orders.
• Restrict permissions to prevent unauthorised ordering and implement processes to control the approval process.
• Use e-commerce systems if available to place orders with suppliers to minimise manual transposition.

Receipt

Receipt processes verify that the delivery is undamaged, and that the correct medicine, in the correct quantity, pack size, strength, formulation and presentation is received into stock. Receipt errors are usually related to failure to notice errors that have been made ‘upstream’, either by the supplier or during ordering.

Processes should be designed to support staff in effective and accurate receipt checking.

Examples of best receipt practice

• Use barcode scanning to verify product.
• Segregate receipt activities from other processes, for example storage and dispatch, to reduce distractions and support accuracy.
• Quarantine items that do not meet expected standards or require further verification.
• Follow additional local procedures for receipting unlicensed medicines.

Storage

Medicines are usually stored in pharmacy departments prior to dispensing and supply to clinical areas or patients. Storage errors are often preventable through good design, clear procedures, and consistent staff training. Storage areas should be controlled to ensure product integrity and designed to aid correct selection of products.

Examples of best storage practice

Use good housekeeping practices, for example:

• ensure storage areas are clearly organised and labelled to aid identification, for example, use location codes or alphabetical systems
• store products so that critical information is clearly visible (for example name, strength, formulation)
• implement robust stock check systems with regular stock rotation to ensure all stock remains in the right location and within its expiry date

Use segregation to reduce picking errors, for example:

• separate different formulations, routes of administration or strengths of the same product
• physically separate look-alike and sound-alike products where possible
• store diluents and fluids separately from medicines

Where possible use robotic storage solutions to reduce manual selection errors.

Store medicines at the right temperature to ensure they remain fit for purpose. Further information can be found in our article understanding why temperature management is important for medicines storage (SPS Page).

Labelling

Clinical verification plays a key role in ensuring that the information used for labelling is complete, accurate and unambiguous. Labels applied during dispensing or supply must clearly communicate essential information. They must be clear, accurate, and well-applied so that the medicine can be used safely.

Examples of best labelling practice

• Design labels for clarity using legible fonts, sufficient font size, sensible use of space and strong contrast between text and background.
• Standardise label content by using templates with consistent wording and requiring minimal manual entry.
• Integrate pharmacy systems with electronic prescribing platforms to reduce transcription errors.
• Use standard, approved, pre-set directions where possible.
• Ensure that labels are checked for accuracy and quality of print before they are applied.
• Provide instructions for application of labels, ensuring placement does not obscure critical product information.

Selection

Safe selection relies on readable, complete prescriptions or orders, well-organised storage systems, and easily identifiable medicines.

Well-designed medicines packaging and labelling can aid identification, as discussed in our article understanding design for safety in medicines packaging and labels (SPS Page), but additional safe working practices will always be needed.

Examples of best selection practice

• Ensure prescriptions are legible and complete, using electronic prescribing systems where possible.
• Store medicines appropriately, as described in the section above on storage.
• Use technology to reduce the need for manual checks including barcode scanning and robotic dispensing systems.
• Avoid practices prone to misinterpretation such as verbal orders or unapproved abbreviations.
• Ensure staff are aware of high-risk or look-alike sound-alike (LASA) medicines.
• Ensure all staff double-check their own work.
• Review processes and identify when an independent second check would add value. Further details can be found in our article understanding when a check adds value to medication processes (SPS Page).

Dispatch

Dispatch is the final step in the pharmacy supply process and must ensure that the correct medicine reaches the correct location in a safe and timely manner. The dispatch process should be clearly organised, traceable, and designed to protect medicine integrity during transit.

Examples of best dispatch practice

• Organise dispatch areas with a clear workflow to prevent mix-ups.
• Store medicines under the correct conditions before dispatch and during transport, following SPS guidance on temperature control whilst transporting medicines (SPS Page).
• Use tamper-evident packaging to prevent damage or interference during transit.
• Maintain dispatch records.
• Track delivery and receipt where appropriate, for example controlled drugs and intrathecal medicines.

Medicine returns

The return of medicines to pharmacy departments for potential re-use should only be undertaken in line with local policy. Processes for handling returns must be clearly defined, with responsibilities for decision-making and assessment of medicine integrity. Returned items should be quarantined until verified as suitable for re-use.

While returns may help reduce waste, they carry significant risks if medicines have been stored incorrectly, tampered with, or damaged while outside pharmacy control.

Supporting safe clinical use

Well-designed systems, clear procedures, and considered use of technology supports safe clinical use. Getting it right in pharmacy ensures that medicines are safe, appropriate, and ready for use when passed on to clinical teams or patients.

For more detail on managing medicines once they have left pharmacy, see the companion article managing medicines safely in clinical areas (SPS Page).