Improving the Safety of Dispensing

In a nutshell: It is recognised that the dispensing error rate in community pharmacy is low.

However it could be even lower. 

As part of our work to improve patient safety, the Yorkshire & Humber Academic Health Sciences Network’s Improvement Academy led 7 community Pharmacy teams and 2 dispensing practice teams in a 20-week improvement programme to reduce dispensing errors. The programme focused on ‘near misses’ and taught the teams how to apply ‘human factors’ thinking. The programme was successful, showing improvements in the rate of near misses, improved safety culture, and has been well received by the participating teams.

The Challenge

Having worked with a small number of teams, the challenge is to scale up this innovative and effective approach to a larger number of pharmacies and dispensing practices. There are over 1500 pharmacies and dispensing practices in Yorkshire & Humber.


What we are doing about it.

We want to work with pharmacy chains, representative organisations and professional bodies to make the resources we used in this programme accessible to a much wider audience.

We have made some of these resources available here:

Watch our webinar on Mental Workload from Dr Hannah Family


Our templates for embedding Human Factors into Significant Event Audit can be found here:

Yorkshire Contributory Factors Framework diagram Download and checklist Download.

We used this SBAR  template to make communication safer

You can learn about the methods we used to improve safety from our Improvement Academy Quality Improvement Training and download our template PDSA Cycle 

Our pharmacies used the following measure to track the safety of dispensing,

The number of prescription items identified at the ‘final check’ which required referral back into the dispensing process for whatever reason (near misses) as a proportion of the number of items dispensed that day.

These charts can be used to track how changes in the pharmacy affect the safety of dispensing using this measure:

                                                            Near misses

                                                        Daily item count

Run chart template (including weekends) Download and Run chart template (excluding weekends) Download.


Our future plans.

We will be seeking expressions of interest to work with us on developing the tools for wider use.

If you are interested contact Tony Jamieson.

Patient Voice

The AHSN Improvement Academy is using an innovative method of capturing the 'voice of patients' in improving the safety of their healthcare. Read about the PRASE (Patient Reporting and Action for a Safe Environment) tool here.