Programme Case Studies

Safer Dispensing in Community Pharmacy


The Improvement Academy TAPS (Training and Action for Patient Safety) programme helped 8 pharmacy teams in the Yorkshire and Humber region to reduce dispensing errors.

The participating teams used improvement cycles to test interventions they had designed themselves, to address safety risks associated with human factors.


  • Several teams achieved statistically significant reductions in their dispensing errors. For example Pharmacy G, by testing changes to work flow, task allocation and environment have reduced their dispensing errors from an average of 2 per month to virtually zero (see chart below) Further examples can be found here. Some teams reported that they had become more honest and open when discussing errors, developing a ‘no-blame’ culture
  • Teams came to understand the importance of measurement as a tool for improvement
  • A Community of Practice for medicines safety has been established in partnership with NHS Leadership Academy
  • Work is now underway with Health Economists to calculate the Return of Investment (ROI) of this programme


We are in discussions with one pharmacy group about scaling up the Pharmacy TAPS method across their UK branches and hope in the future to be able to make the tools necessary to embed Human Factors and Quality Improvement in community pharmacies available to all pharmacies in the UK via our website.