Well Pharmacy (TAPS)

In a nutshell: St Luke’s pharmacy tested many small changes during the 20 week programme which resulted in a statistically significant reduction in the near misses occurring in their dispensary.

The team wanted to reduce the number of near misses occuring daily in their dispensing processes. They process mapped the journey of the prescription from recepit of it in the pharmacy, to the medicines being handed out to the customer. They identified that as a team, they work well together. However the layout of the dispensary with an open-view layout and close proximity to colleagues created created many distractions and thus increased the level of near misses. Repetitive tasks were also perceived to increase the error rate.

What they did

  1. Changed the dispensary layout by moving the two dispensing stations further apart from each other, to avoid prescriptions and medication getting mixed up.
  2. Addressed communication issues within the team as general communication caused distractions and often led to near near misses occuring.
  3. Minimised multi-tasking i.e. if dispensing medication, this would be their only focus, however if the dispenser had to break away mid-task, they would begin the dispensing process from the start.
  4. Changed the reporting system so that dispensors recorded their own near misses.
  5. Introduced self-assessment of dispensed medication prior to the final check.

What happened/impact



This run chart illustrates the progress made by St Luke’s Pharmacy. There is a step change between week 4 and week 8. This occurred because the principal pharmacist was on annual leave and near miss recording was not completed. There is a statistically significant level of improvement from 17 onwards. This reflects an impressive level of improvement in the level of near misses occuring in the pharmacy illustrating how testing of small changes over time can result in visible improvement.

This pharmacy did exceptionally well, in spite of the pharmacist having to leave part way through to cover maternity leave at another branch, they continued with the programme. The team's dedication and commitment was invaluable.