What happens during a vaccination audit

This article originally appeared on AJP.

A Sydney pharmacist who recently underwent a vaccination audit with just 48 hours’ notice shares what she learnt from the experience … and how to prepare

Last month, NSW Health announced that it would be undertaking quality assurance audits to monitor pharmacist compliance with the NSW Pharmacist Vaccination Standards.

Adele Tahan, a community pharmacy proprietor from Sydney, said one of her pharmacists received a call from the NSW Ministry of Health on the morning of Wednesday 26 August.

It was an auditor informing her that Adore Compounding Pharmacy Rozelle had been randomly selected to undergo a vaccination audit, to occur that Friday 28 August.

The auditor emailed a copy of the authority from the state health minister through the pharmaceutical regulatory unit. Pharmacies are given 48 hours’ notice prior to the audit and the vaccinating pharmacist needs to be free for at least 60 minutes.

“At first, I thought it was a bit insane to be carrying out vaccination audit during a pandemic,” Ms Tahan told AJP.

“It’s at a time when the Federal Department of Health has provided community pharmacy with $25 million to carry our home deliveries to the most vulnerable, immunocompromised, and elderly in our communities to ensure their safety.

“Meanwhile, the state ministry is sending people into community pharmacies to check on their vaccination practices. I expect them to do the same to GP practices and nurses around the state.”

Ms Tahan sprang into action as she had been given just two days’ notice. She called the PSA to get a copy of their audit tool and then checked the Pharmacy Guild of Australia’s audit tool, realising that she had everything in order.

She described her audit experience in detail: “The initial step of the audit ensures that all vaccination certificates, Ahpra registration, and First Aid, CPR, and Anaphylaxis training is up to date for all pharmacist vaccinators,” said Ms Tahan.

“Secondly, the examiner checks out the room. She thought my rooms were spacious and adequate. Part of her check was making sure the rooms have sanitising stations, sharps disposal, the adrenaline dosage chart, a checklist for patients who qualify for the National Immunisation Program (NIP), pen, paper to record adrenaline injection frequency and an anaphylaxis kit in date.”

The anaphylaxis kit has to be kept in the pharmacy ready for use with adrenaline vials, needles to draw the adrenaline solution and a needle to inject along with cotton balls and plasters, she added.

It’s critical that community pharmacy has a high percentage of compliance.

“She then checked the fridge that needs to: be a vaccine fridge; have a data logger; have twice daily temperature monitoring, and; a yearly servicing history.

“Meanwhile, an online version of Strive 5 covering current guidelines for vaccine storage and the latest edition of the Australian Immunisation Handbook can be saved on your browser and accessed regularly for updates.”

The Australian Immunisation Register was next on the list and the auditor asked Ms Tahan to show her how to log on it. Once on this platform, she asked about various specifics such as checking someone’s previous vaccination history prior to administering any vaccines.

“I can see the reasoning for such requests with various vaccination, however with influenza vaccinations I don’t think it’s necessary,” said Ms Tahan.

“GuildCare NG has proven to be a valuable tool to record and submit registration to AIR. Its various sub-headings don’t allow you to proceed without making sure we have answered all questions and proved specifics. All vaccination records have to be kept for 7 years.”

The auditor also checked paper records – the accredited vaccinator is required to have their number on all paper records.

“Patients also need to stay at the pharmacy for 15 minutes post vaccination. An appropriately trained staff member has to be present when the vaccination is being conducted and the patient has to be observed during that time,” she said.

“It’s great to see all those safety net protocols in place, however, why are pharmacists being treated differently to doctors?” asked Ms Tahan.

“They get their nurses to vaccinate, patients don’t need to wait 15 minutes and doctors don’t bother recording vaccination on AIR.

“It seems that the Ministry of Health targeting pharmacists for no reason when pharmacists are one of the few professions that are taking the risk to show up and see patients. They are serving their communities, contributing to community immunity by vaccinating masses of people who have never been vaccinated before as they don’t like waiting at doctors’ rooms.

“Waiting at doctors’ rooms has been identified by the Productivity Commissioner in his 2019 annual report as costing the Australian taxpayer over a billion dollars.

“Vaccination is certainly an opportunity for the Australian Government to partner up with the profession that it will not only save it financial dollars but also productivity dollars.”

Ms Tahan provided a summary of what to prepare for with a vaccination audit:

1) Certificates

  • AHPRA registration
  • CPR, Anaphylaxis and First Aid
  • Vaccination Certificate


2) Vaccinating room 

  • Need to be spacious enough allowing patients to lie down
  • Have sharps, sanitising station, anaphylaxis kit, sharps disposal, adrenalin dosage chat, NIP requirements


3) Record keeping and recording 

  • AIR access
  • Paper records kept for 7 years
  • AIR retrieval before vaccinating
  • Australian Immunisation Handbook


4) Fridge 

  • Vaccine Fridge
  • Data logger
  • Yearly service
  • Twice daily monitoring
  • Strive 5 latest online edition


5) Human resources

  • Have an additional trained person to observe the patient post vaccination


“In the end, the auditor indicated she was satisfied by my answers, set up and deemed Adore Compounding Pharmacy compliant. I asked for a CPD certificate and she didn’t provide one! It would have been useful toward my CPD points,” said Ms Tahan.

“It’s critical that community pharmacy has a high percentage of compliance so that when the COVID-19 vaccine is available, community pharmacists who are accredited

vaccinators can assist the rest of the healthcare workers who are operating at the frontline, by vaccinating patients who don’t wish to attend medical practices.

“If any pharmacist has any question about the vaccination audit and requires assistance please contact me directly on adele@adorepharmacy.com.”

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