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Understanding how Community Pharmacists complete tasks in practice

30 Jan

community pharmacists sorting meds_banner

by Ahmed Ashour, PhD Fellow in the NIHR Greater Manchester PSTRC

The World Health Organization set its 3rd Global Patient Safety Challenge in 2017 to reduce severe avoidable medication-related harm by 50%, globally in five years (1). This led researchers to publish a new report investigating how often medication errors happen and the cost to the NHS in England (2). This renewed the focus on reducing errors and particularly errors occurring within primary care. Internationally, and specifically within the UK, the majority of healthcare interactions will occur with a primary care healthcare professional. One of the ways medication errors can be reduced is by using the scientific discipline of Human Factors and Ergonomics, which uses a number of tools to help reduce human error.

Human Factors and Ergonomics (HFE) aims to understand how individuals are affected by and affect factors around them, and the consequences of their actions. One of the tools used by Human Factors experts is Hierarchical Task Analysis (HTA). HTAs presents the sub-tasks involved in completing a task in a step-by-step form, accompanied by plans that describe the order and context in which the sub-tasks take place (3).

Within community pharmacy practice, pharmacies are required to have in place procedures describing how they should deal with the sale and supply of medicines and for specific services related to patients (4). However, it has been reported that under certain circumstances these Standard Operating Procedures (SOPs) are not always followed (5).

Ahmed Ashour’s PhD will aim to identify and develop the non-technical skills that community pharmacists require in practice. He will use the HTA tool to describe the tasks community pharmacists complete in practice. As part of the work of the Community Pharmacy Patient Safety Collaborative, which was set up by the NIHR Greater Manchester Patient Safety Translational Research Centre (GM PSTRC), participants were trained by a process expert in how to conduct an HTA before being asked to prepare an HTA for a specific task. These HTAs were then discussed in a focus group consisting of between 5 and 7 community pharmacists. Participants were encouraged to share the differences in how they completed the sub-tasks. The HTAs will be used as a basis for observations in community pharmacies. Differences will be documented and an analysis between the HTAs produced by the focus groups and those observed in practice, will be conducted.

There are a number of error-predicting tools that can be applied to HTAs to identify potential errors ahead of time and suggest solutions. One such tool is the Systematic Human Error Reduction and Prediction Approach (SHERPA), which is a method used to identify potential failures. The SHERPA tool can be used to design tasks in a way that minimises the possibility of potentially serious errors. By applying such methods to tasks that community pharmacists do, more specific training can be developed which will help to reduce the number of errors that occur.

Error prediction is not the only use for HTAs. HTAs provide an accurate description of how tasks are completed in practice, which can help to better understand the skills required to complete the tasks. It can also be used as a basis for discussing best practice and sharing information on the barriers to effectiveness. By producing this collection of HTAs, an important resource will be available to HFE researchers and others, to improve how tasks are carried out within community pharmacy.

The validated HTAs will also be published online for use by researchers. If you would like to get involved or for more information, you can contact Ahmed Ashour.

1.       https://www.who.int/patientsafety/medication-safety/medication-without-harm-brochure/en/

2.       Elliot R, Camacho E, Campbell F, Jankovic D, Martyn M, Kaltenthaler E, Wong R, Sculpher M, Faria R. Prevalence and economic burden of medication errors in the NHS in England. Rapid evidence synthesis and economic analysis of the prevalence and burden of medication error in the UK. 2018.

3.       Stanton N. Hierarchical task analysis: Developments, applications, and extensions. Applied Ergonomics. 2006;37(1): 55-79, ISSN 0003-6870, https://doi.org/10.1016/j.apergo.2005.06.003.

4.       Royal Pharmaceutical Society. Developing and implementing standard operating procedures for dispensing, 2007:1–13.

5.       Thomas C, Phipps D, Ashcroft D. When procedures meet practice in community pharmacies: qualitative insights from pharmacists and pharmacy support staff. BMJ Open. 2016.

A new career in patient safety…thanks to the Community Pharmacy Patient Safety Collaborative!

13 Nov

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by David Mehdizadeh

Joining the Community Pharmacy Patient Safety Collaborative for me was to gain new insights and new experience in healthcare. I have always had a passion for improving systems and reducing errors, and this collaborative within the NIHR Greater Manchester PSTRC allowed me to take this one step further. This project certainly took me out of my comfort zone as a community pharmacist, and I relished the opportunity to explore and gain new skills!

Meeting regularly with fellow community pharmacists, and researchers within the Greater Manchester PSTRC at The University of Manchester was a rewarding and unique experience. As healthcare professionals, we all have a responsibility of caring for patients safely, and therefore it was refreshing that we could spend protected time solely on patient safety within our practice. This involved learning elements of “improvement science” for improving work systems, sharing and discussing real life patient safety incidents and reflecting on our experiences, all within a non-judgmental and supportive environment.

One of my highlights was being trained up to develop “safety cases” for our individual pharmacies; identifying problem areas which could lead to patient safety incidents and subsequently targeting areas for improvement. Members of my pharmacy team were really supportive of this, and identified areas for improvement in our dispensing of high risk opioid products. This led to higher quality dispensing in this area, but ultimately changed the culture amongst the team, and encouraged the team to prioritise patient safety, and continually reflect on their practice. This was a real success for our pharmacy, and changed the safety culture for the better.

I would highly recommend other community pharmacists and technicians to get involved with the Community Pharmacy Patient Safety Collaborative. You never know what doors this could open for you!

For me, it gave me a platform to explore patient safety further, and to re-evaluate my career goals. This led to me pursue a career in patient safety, and in October 2018 I will be commencing a full-time NIHR PhD studentship at the University of Bradford (in partnership with the NIHR Yorkshire and Humber PSTRC), with the title “Digital Decision Support for Safer Prescribing.” My experience in the collaborative was instrumental in developing a strong application for this PhD programme, and I am grateful to the team at the Greater Manchester PSTRC for providing me with this opportunity.

NHS 70: celebrating pharmacy and looking to the future

2 Aug
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Members and organisers of the Pharmacy Collaborative l-r: James Hind, Edward Teggart, Melinda Lyons, Lauren Worrall

by Lauren Worrall and Melinda Lyons

This year, to celebrate 70 years of the NHS, the Local Professional Network for Pharmacy in Greater Manchester held a conference to recognise how pharmacy professionals had contributed to the NHS and looking forward to how pharmacists expect their role to change to serve the needs of the NHS in the future. The conference involved exploring current issues impacting on pharmacy practice. As part of this, the NIHR Greater Manchester PSTRC Community Pharmacy Patient Safety Collaborative gave a workshop in Manchester on their continuing research into improving patient safety.

Co-chaired by Lauren Worrall and Melinda Lyons from the PSTRC, previous translational research was presented demonstrating how some techniques used in high hazard industries could be applied to pharmacy practice.  These included looking at errors, as well as trying to manage distractions and interruptions. There was also insight from the pharmacy collaborative members on how involvement in the research has influenced their practice and provided them with new approaches to improve patient safety in their pharmacy teams.  Collaborative member Edward Teggart presented his approach to managing error risk in practice and James Hind presented his award winning work on managing distractions.

To get the audience of pharmacists really engaged and learn about risk management decision making, the delegates took part in a team game where their risk management decisions could result in them maintaining lucrative service contracts or going bankrupt in the blink of an eye!

The workshop concluded with a question and answer session which led to a lively discussion about safety in practice. The delegates shared the issues that impact upon their work on a day-to-day basis.  In the relatively unexplored area of risk management research in community pharmacy, questions were posed about the potential avenues and future direction of their research. Whilst everyone agreed that patient safety is critical to their practice, there was also agreement that it is often difficult to share good ideas and learning. The concept of the community pharmacy collaborative was something that all agreed enhanced patient safety and could be used in other geographical areas.

How was it for you? Reflections on involvement

3 May

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This edition’s reflection comes from Lauren Worrall, a pharmacist who is involved in the NIHR Greater Manchester PSTRC Community Pharmacy Patient Safety Collaborative.

Lauren, why did you become involved in the Greater Manchester Community Pharmacy Patient Safety Collaborative?

My motivation to join the collaborative was to receive training on different skills and techniques to improve patient safety within my own practice area.  Furthermore I wanted to explore the world of research within pharmacy.

How do you think the Greater Manchester PSTRC benefitted from your involvement – what difference do you feel that you made?

As a group we devise potential ways to improve practice and develop various interventions.  As an individual I can then go out and test the efficacy of the interventions in pharmacy practice settings. My experience in community pharmacy allows me to positively contribute to the work of the collaborative.

Personally and professionally, how do you feel you benefitted from your involvement?

Getting involved with the group has allowed me to work with other pharmacists and safety experts to reflect upon and improve my own practice. It has also afforded me a better knowledge of what is involved in research.

Would you recommend becoming involved in research to other healthcare professionals? If so, why?

Participating in research allows you to be creative and explore innovative methods in whichever healthcare setting you are working in. If you are interested in improving your practice and that of others then I would highly recommend getting involved.

Pharmacists working towards safety improvements

3 May

CP Patient Safety Collaborative image

The Greater Manchester PSTRC’s Community Pharmacy Patient Safety Collaborative was set up by the PSTRC to encourage a mutually-beneficial dialogue between community pharmacy workers and researchers, and ultimately to improve patient safety.

The PSTRC’s Medication Safety team shares their knowledge on best practice in patient safety and risk management techniques with the Collaborative and in turn, the Collaborative shares their experiences and insights of practical day-to-day pharmacy practice with the PSTRC.

The group of 9 pharmacists are employed in a range of pharmacies from small independents to large chains, and they meet on a monthly basis. Sessions involve teaching of safety concepts and risk management techniques, sharing of experiences and discussions on the issues currently impacting on the safety of work in pharmacies. Outside of the sessions, the Collaborative engages in research-based activities – such as audits, or applying the taught risk management techniques to their own practice – with a view to sharing their insights within the group.

Pharmacists have seen real-world benefit through their involvement in the Collaborative:

  • James Hind, Community Pharmacist, says:  “I developed the idea of label that could be attached to the dispensing bag. I wanted something that could be used as a quick check (have we got the right patient; did we tell them what their medication was for, and are they confident that they know how to use it).”
  • Tomasz Niebudek, Community Pharmacist, says: “The tool that, in my opinion, had the biggest impact on my practice was PRIMO (Proactive Risk Monitoring for Organisational Learning). This was a questionnaire given to all staff members in my team to find out what affects their ability to dispense accurately. I have very carefully analysed all the data from those questionnaires and shared my conclusions with my whole team during a staff meeting. We have straight away implemented changes to our practice.”

You can read more about the Community Pharmacy Patient Safety Collaborative in our blog series.

Patient Safety in Community Pharmacy: the importance of teamwork

19 Oct

by Tomasz Niebudek, Pharmacist

Tomasz Niebudek_CROP_blog pic_Oct17

My name is Tomasz Niebudek. I work as a community pharmacist in the Salford area. Last year at the end of May our Superintendent Pharmacist forwarded to me an e-mail asking if anybody would be interested in taking part in a project at The University of Manchester. In a nutshell, the aim of the project was to improve safety in community pharmacy. I expressed my interest in participating, thinking that this would be an interesting challenge, that would allow me to reflect on and improve safety in my pharmacy and across the whole company.

One of the key things that I learnt by joining the collaborative is that we should look, not only at reactive ways of analysing errors, but also use proactive methods  to prevent errors from occurring before they’ve happened. The tool that, in my opinion, had the biggest impact on my practice was PRIMO (Proactive Risk Monitoring for Organisational Learning). This was basically a questionnaire given to all staff members in my team to find out what affects their ability to dispense accurately. This led to many interesting observations and reflections. It was encouraging to see that staff members who are usually quiet during the staff meetings had very strong views on certain matters. Some team members identified a problem and were able to provide a solution to it almost immediately. It was so motivating to see that they care about safety and it was also interesting to discover that my staff members have observed issues that I have never picked up on. I have very carefully analysed all the data from those questionnaires and shared my conclusions with my whole team during a staff meeting. We have straight away implemented changes to our practice. As you all know, change within organisations can be met with resistance by staff. However, the fact that the ideas were generated by the staff themselves made a huge difference (a positive one, of course). Doing that questionnaire made me realise that staff need to be fully onboard when safety is being considered.

I now encourage all staff in my branch to report near misses and dispensing errors, as previously, this was a task only/usually undertaken by myself. We work together to think of ideas to improve practice and safety in the pharmacy. Initially, I was worried that some staff might have the attitude that “this is not my problem”, which is an approach that I think is partially to blame for errors in primary care. However, I’ve learned that if you respect your team for the valuable input they can have in improving practice, and work with them to achieve this aim, it pays back.

Big thanks to The University of Manchester researchers in helping us to look at safety from a different perspective.

The purpose of the Community Pharmacy Patient Safety Collaborative is to work as a group exchanging ideas and sharing experiences. The same approach must be used on an individual pharmacy level- pharmacists can only improve the safety of their patients with his or her team on board.

Community Pharmacy Patient Safety Collaborative: Safety Initiatives

14 Jun

Chui Cheung photo

My name is Chui Cheung, working as a community pharmacist in Wigan, Lancashire.  I joined the NIHR Greater Manchester PSTRC Community Pharmacy Patient Safety Collaborative Study with the University of Manchester in November 2015.  Looking back, it was curiosity that led to my participation and I was worried how I would handle the research projects.  Nevertheless, the title of patient safety attracted me to find out more.

Patient safety is at the centre of our everyday tasks whether we are pharmacists, technicians, dispensers, medicine counter assistants or other members of the team. Whatever we do in the course of our work, we must do it safely.

At the start of the first year project, there were 8 to 10 pharmacists with a range of different working backgrounds and age groups.  We attended a full day session every 4 to 6 weeks at the University.  We were relieved to discuss openly and share our experience on patient safety.  The aim was to build a safety case using our working environment and team resources.  My project centred on dispensing safety: ‘Are we dispensing safely?’ and later on was refined to a quantitative safety incident claim.

We were introduced to specific tools: Hierarchial Task Analysis (HTA), Failure Mode and Effect Analysis (FMEA), System Human Error Reduction & Production Approach (SHERPA) to help our analysis of the safety profile. Our team broke down the complex dispensing tasks into smaller working steps or processes systematically. On a practical application, the Proactive Risk Monitoring (PRIMO) questionnaire was helpful to use as a team to identify various patient safety risk factors.  We then made risk assessments of the dispensing processes through the SHERPA and used Plan, Do, Study, Act (PDSA) cycles to evaluate improvement.

The whole team began to monitor and record near misses and dispensing incidents on a more conscious level than before and made voluntary changes towards an open, no-blame working culture. The goal of safer dispensing became a number one priority all the times.  The team’s brainstorming revealed many common triggers or events of ‘the vulnerable moment’ during the dispensing processes.  Several checking procedures were used as checker reminders.

The pooled data of errors showed high times of errors, typical error categories and even the common medicines.  Individually, we were able to find out when and how we perform best and made aware of the pitfalls.  We discovered that we were prone to errors particularly when we were ‘expected’ to have ultra-quick dispensing.  Through a member’s suggestion and our dispenser’s effort, we now display a shop poster giving a summary of ‘the way we prepare your medicines’ and give customers opportunities to read through the additional copies whenever there is a queue forming.  It works really well and the feedback is positive too.  The team and customers seem happier.

In year 2 of the project, we came across analytical tools (Faulty Tree Analysis, Bowtie diagram) to look at our safety claim.  We continued to expand our safety interests and used a more sophisticated reporting form called  ‘Incident Investigation Form’ which covers error description, the factors causing the error, the risk category, course of the event and improvement plans.   We have since modified the form for in-house use.  The bundle of safety data showed how we had been dispensing safely or otherwise.  As a result, we implemented a couple of measures (such as safety shelf reminders, Top 20 common error medicines list) to help us improve on a regular basis.  The data is also useful in staff appraisal.

Moreover, we felt fortunate to have the ready-made patient safety data for Quality Payment application.  My experience in the patient safety collaborative has been overwhelmingly good and positive.  I wouldn’t have known about these analytical methods and thought about the improvement plans if I hadn’t been part of the study group.

I recommend that any pharmacy team who is interested should come along for a taster session to see if this is right for you.