Previous Work

Medicines Safety


In a nutshell: The Improvement Academy will be working with community pharmacies, hospitals, care homes and CCGs across the region to reduce dispensing errors in pharmacy services, reduce prescribing errors in General Practice and improve medicines safety at transitions of care.

The Challenge

The delivery of healthcare is by its nature complex and error prone. The largest study to date of the prevalence of prescribing and drug monitoring errors in general practises in the United Kingdom found an error in 4.9% of prescriptions with 1 in 550 prescriptions having an error that was considered severe.

What did we do?

As part of the Yorkshire & Humber Patient Safety Collaborative, we established communities of improvement that used locally pioneered approaches to support teams to improve medicines safety through the application of human factors theory and quality improvement methods.

Our initial work was focussed on ‘avoiding dispensing errors in community pharmacies’ by applying human factors to the dispensing of medicines.  

We trained CCG staff GPs and Practice Nurses to support the roll out of enhanced significant event audit for medication errors in general practice. We produced a range of resources to improve the effectiveness of Significant Event Audit which could be used in conjunction with our Quality Improvement training. The Resources can be found here.

Participants in our Communities of Improvement were supported to access and apply a range of tools and resources, including:

Our Future Plans

Future phases of the medicines safety programme will focus on scaling-up the achievements of the first cohort of teams in the safer dispensing community of improvement and supporting CCGs to utilise the tools for Significant Event Audit.

Our plans also include a project focussing on keeping patients safe during transition of care. This project will look at how primary and community teams can work together to improve medicines safety for patients transferring into care homes.

To register interest in participating in one of these programmes please contact Tony Jamieson.

Further Information

Y&H AHSN Medicines Optimisation Programme

National Reporting and Learning System

Communities of Practice

Training & Action for Patient Safety (TAPS)

Medicines optimisation

Medicines Optimisation Dashboard

Clinical Human Factors Group

Health Foundation – human factors training

Safety in doses