“We have all thoroughly enjoyed the TAPS events and have learnt a great deal with regards to near misses, our business in general, customer safety/satisfaction and about ourselves (our ways of thinking and working). These informative workshops have provided us with invaluable insight, which in turn has led us all to change our ways of working in order to provide better care for our customers.”
Faheem and team at Asda Pharmacy, Morley

Overview

The PharmTAPSacy TAPS (Training and Action for Patient Safety) programme supports community pharmacies to reduce dispensing errors.

Independent economic analysis showed that the Pharmacy TAPS programme is a highly cost-effective programme, well below the NICE cost-effectiveness threshold of £20,000 per QALY.

On average, for every pharmacy involved in the Pharmacy TAPS programme, £22.54 of avoidable costs associated with patient harm were released to the NHS for every 1000 prescription items dispensed.  Over 1bn prescription items are dispensed in the community annually.

Following the first wave of pharmacies, Yorkshire and Humber AHSN has partnered with Community Pharmacy West Yorkshire and two national pharmacy chains – Lloyds Pharmacy and Well Pharmacy – to demonstrate how the intervention can be delivered at scale. A brief intervention package was delivered to 92 pharmacies and has been shown to have sustained change over 12 months. A second wave of 19 pharmacies are currently scaling up the full Pharmacy TAPS programme.

Challenge/ problem identified

Dispensing medicines in community pharmacy is a process which is required to be highly reliable. The pharmacy team must combine clinical, technical and non-technical skills in order to accurately supply medicines which are safe and effective for patients.  Research estimates that up to 3.32% of dispensed items include an error (James et al., 2009). Although this level of accuracy could be considered to be very high, errors can have serious consequences for patients and for the responsible pharmacists.

One billion prescriptions are dispensed in the 12,000 plus community pharmacies in England. This would be 33 million dispensing errors; 11 million errors are thought to be moderately severe (with an estimated primary care cost of £500m). 330,000 errors are severe (with an associated secondary care cost of up to  £990m)

Reducing the error rate by 1/3 would reduce the NHS deficit by approximately £500m across England.

Actions taken

Yorkshire & Humber AHSN’s Improvement Academy (IA) developed a 20-week quality improvement programme for patient safety within community pharmacies. It uses a “Training and Action for Patient Safety (TAPS)” methodology similar to a ‘breakthrough collaborative’ but distinguished by the underpinning Human Factors training. A core delivery team supported participants and was important in maintaining momentum throughout. The first wave of Pharmacy TAPS was delivered in eight teams.

For wave 2, Yorkshire & Humber AHSN partnered with Community Pharmacy West Yorkshire to deliver four education sessions. 92 pharmacy teams attended a 1.5 hour interactive session to share the learning from the first wave.

For wave 3, Yorkshire & Humber AHSN is partnering with Well and Lloyds Pharmacy groups to scale up the programme. Yorkshire & Humber AHSN, West Midlands AHSN and the Innovation Agency NWC are supporting Well and Lloyds to facilitate the TAPS programme in 19 pharmacies in three regions.

Impacts/ outcomes

The pharmacy teams in wave 1 maintained run-charts of their near-miss errors per 100 dispensed items. Statistically significant improvements in near-miss error rate was seen in six out of eight teams. These represent improvements in error rate from between four and 10 near misses per 1000 dispensed items down to one or less.Pharmacy TAPS

Independent Economic analysis showed that the first wave of the Pharmacy TAPS programme demonstrated an Incremental Cost Effectiveness Ratio (ICER) of £1647 per Quality Adjusted Life Year (QALY) and, as such, is a highly cost-effective programme, well below the NICE cost effectiveness threshold of £20,000 per QALY.

On average for every pharmacy involved in the Pharmacy TAPS programme, £22.54 of avoidable costs associated with patient harm were released to the NHS for every 1000 prescription items dispensed. Over 1bn prescription items are dispensed in the community every year.

In wave 2, out of 184 attendees at the training sessions, 95 committed to positive changes as a result of attending the training. The steps taken included:

  • Applying the learning given to practice
  • Using the Situation Background Assessment Recommendation (SBAR) communication tool
  • Recording errors and feedback to the team
  • Analysing and evaluating errors
  • Devising and implementing an audit system
  • Improving near miss reporting

95% of participants ‘strongly agree’ or ‘agree’ that the course provided them with practical advice and skills.Independent evaluation of wave 2 by Huddersfield University demonstrated that,12 months after the education sessions, 32% of responding participants believed the number of errors had been reduced after the tools and techniques taught had been implemented. Only 5% thought errors had increased. 85% of the responders stated that the education provided skills and techniques that they had successfully implemented within the last 12 months demonstrating the utility of the Pharmacy TAPS programme.

Independent evaluation of wave 2 by Huddersfield University demonstrated that,12 months after the education sessions, 32% of responding participants believed the number of errors had been reduced after the tools and techniques taught had been implemented. Only 5% thought errors had increased. 85% of the responders stated that the education provided skills and techniques that they had successfully implemented within the last 12 months demonstrating the utility of the Pharmacy TAPS programme.

“I would strongly recommend this course to anyone who is interested in the area of patient safety, or for those who need to be made more aware of it.”
James Denning at Well Pharmacy, St Lukes

Plans for the future

Wave 3 of Pharmacy TAPS is being prepared for delivery at a national scale in three phases:

  • Co-design between Yorkshire & Humber AHSN, Well and Lloyds Pharmacy of a programme that could be delivered by the pharmacy chains’ staff. This is complete.
  • Testing the suitability of Pharmacy TAPS for delivery by pharmacy chains. This is underway. Yorkshire & Humber AHSN, West Midlands AHSN and Innovation Agency NWC are working on this.

Production and hosting of an education package and tools that can be rolled out on a national scale. Pfizer has awarded a grant to support delivery of this package.

Which national clinical or policy priorities does this example address?

  • Patient safety.
  • Unplanned care.

Start and end dates

  • Preparation and Design Oct 2014
  • Wave 1 March 15 to July 15
  • Wave 2 November 2015
  • Evaluation Wave 1 complete Sept 2016
  • Evaluation Wave 2 complete April 2017
  • Wave 3 April 2017 to March 2018

Contact for help and advice

Project contact for further information
Tony Jamieson
Medicines Safety Improvement Lead
E:Tony.jamieson@yhahsn.com
T: 07880 388 232

Media contact for further information
Esme Crabtree
Public Relations Officer
E: Esme.crabtree@yhahsn.com
T: 01924 664728

Find out more

Videos and supporting information from wave 1:

From wave 2:
YHAHSN_TAPS graphic
YHAHSM TAPS PROJECT POSTER
See also: http://www.improvementacademy.org/patient-safety/improving-the-safety-of-dispensing.html