Shelf Pharmacy (TAPS)

In a nutshell: Shelf pharmacy took part in the 20 week programme and had two statistically significant step change reductions in their near miss rate.

The team wanted to reduce the number of near misses occurring daily in the dispensing process of their pharmacy. They process mapped the journey of the prescription from receiving it, through to it being handed to the customer.

They identified that as a team, they work well together, however effective communication regarding the prescription process was an issue. The team felt that patients would arrive to collect a prescription and often staff members had to look through various shelves and paperwork to locate what stage the patients’ prescription has reached. This was very time-consuming and often led to an increase in near misses. Also as the dispensary was small, working in close proximity was also problematic therefore needed to be addressed.

What they did

  1. Refined the current I.T. system
  2. Updating ‘patient medication record’ (PMR) to provide up-to-date information on prescription status
  3. Re-arranged the reception and dispensary workspace providing dispensers more space to work in
  4. A rota was created for making blister packs for patients and the role was completed in a room above the pharmacy
  5. Organised weekly team meetings (rather than monthly) to discuss staff input at all levels from prescription submitted through to medication handed to the patient

What happened/impact?

This run chart illustrates the various inputs and small changes that have taken place throughout the 20 week programme. A statistically significant level of improvement has been noted on 25/03/2015 and a further step change occurred on 05/06/15. This illustrates a sustained reduction in near misses, which is an impressive achievement the team made during this 20 week programme.

The Improvement Academy is working closely with Shelf Pharmacy to support them with testing small changes they are making within the dispensary and are hugely impressed not only by the level of engagement from the whole team, but also the scale of the improvements that have been effected.  We look forward to sharing the success they achieve on their mission to making patient safety their top priority.

Some photos captured throughout the 20 week TAPS Programme