Boots Pharmacy, Kirkstall

In a nutshell: Boots Pharmacy has made a statistically significant improvement in their near miss rate by testing small changes within their dispensary through a 20 week programme with the Improvement Academy.

The team wanted to reduce the number of near misses occurring daily in their dispensing processes. They process mapped the whole journey of the prescription from receipt in the dispensary, to the patient being handed their medication. They identified that the layout of medication on the shelves, and around the pharmacy was a major cause of near misses. They also decided to look into methods to minimise distractions at the workstation and focus on analysing any contributing factors to the near misses occurring on a daily basis.

What they did

  1. Utilised internal PIFS (Pharmacist Information Forms) to their full potential
  2. Re-stocked the shelves alphabetically and separated drug strengths with clear dividers. The team also ensured medication was ‘face-up’ and any split medication boxes were at the front of the shelf
  3. Checked date of medication on a weekly-basis discarding any medicine which was due to expire
  4. Dispensers swapped roles to minimise ‘auto-pilot’
  5. Pharmacist encouraged the use of controlled drug label alerts and to prompt staff to take necessary precautions

What happened/impact?

This run chart illustrates the various small changed tested by Boots Pharmacy during the 20 week programme. There is a statistically significant level of improvement (8 days in a row below the previous median average value) from week 11 onwards. The team implemented various small changes in the dispensary and this proved successful as the rate of near misses occurring reduced and remained this way during the 20 week programme. We are proud of the hard work this pharmacy put into the layout of the whole dispensary and are thrilled to have been able to celebrate the success of their achievement with them.