Don’t Drop the Ball: Safer Handoffs in Community Pharmacy

A patients hands a prescription to a pharmacy professional.

Comprehensive, accessible, timely, and correct communication is key to providing safe and effective healthcare. Many studies have identified poor communication as a primary contributing factor to patient harm especially during the transfer of care between providers. Studies of these transfers or ‘handoffs’ in healthcare have shown that there is an increased risk of patient harm when patients are cared for by multiple providers or providers that are unfamiliar with their care[1].

In community pharmacy, prescriptions may be managed by several different pharmacy technicians, assistants, or pharmacists at various prescription stages during a shared shift, at shift change or the next day. When a prescription handoff in community pharmacy happens under chaotic or haphazard conditions, there is not only a risk of patient harm, but also an increase in stress and workload, and a decrease in efficiency.

In “Exploring Information Chaos in Community Pharmacy Handoffs,” Michelle Chui and Jamie Stone use a human factors engineering (HFE) concept called the ‘information chaos framework’ to look at how communication impacts pharmacy workflow. The information chaos framework explores the relationship between information problems or hazards in a pharmacy, and the pharmacist’s ability to provide safe, accurate, and timely care to their patients. 

They identify five key information/communication hazards that pharmacy teams can fall into during prescription handoff:

  1. Information overload: There is so much information that the pharmacy professional has a difficult time understanding what data is relevant.
  2. Information underload: Needed information is missing. For example, there is no indication who originally managed the prescription, what work has already been completed, if a prescriber was contacted for verification, etc. Pharmacy professionals often repeat work under these conditions.
  3. Information scatter: Needed information is in multiple places throughout the pharmacy. For example, unresolved prescriptions are located throughout the pharmacy. Sometimes multiple unfilled prescriptions for the same patient are in different locations around the pharmacy. When this happens, pharmacy professionals are interrupted and distracted.
  4. Information conflict: Pharmacy professional is unable to determine which conflicting information is correct. For instance, if a patient believes they were prescribed a medication that is different from the prescription they were given.
  5. Erroneous information: Information is incorrect because of a mistake in the patient profile or because a patient has given one of their healthcare providers incorrect information.

There are often multiple information/communication hazards occurring at once which adds to the workload and stress pharmacy professionals experience in their day-to-day work. Under these conditions people tend to get ‘tunnel vision’ that narrows their focus because their brains cannot manage additional cues or solutions. This puts people at greater risk of decision errors because they miss things they would normally notice.

How can community pharmacies improve prescription handoff and reduce information chaos?

It is imperative that community pharmacy teams reduce information chaos to decrease stress, workload, and patient safety risk. Structured communication, delivered verbally and in writing, is a widely recognized way to perform a handoff more safely.

In an Australian study of prescription handoff in community pharmacies, pharmacists identified some key information that should be included in prescription handoffs:

  • A description of the problem being handed off. For example, ‘medication dose seems inappropriate.’
  • A description of the current status of the problem. For instance, ‘I am waiting for a call back from the clinic about the medication dose.’
  • An outline of the information that is still needed and what the next steps should be taken to resolve the problem.

Your pharmacy could consider using a widely accepted structured communication tool such as SBAR (Situation, Background, Assessment, and Recommendation) to standardize prescription handoffs.

S = Situation (a concise statement of the problem)

B = Background (brief statement of information about the situation)

A = Assessment (analysis of the viable option – what you found or think)

R = Recommendation (recommended action – what you want to see happen)

The Joint Commission provides the following example of a verbal handoff[2]:

Situation: ‘Ms. Lee has multiple prescriptions of warfarin in her home and she is unclear as to which ones she is supposed to take.’

Background: Provide clear, relevant background information that relates to the situation. In the example above, you should consider including the patient’s diagnosis, the prescribing physicians, and the dates and dosages of the medications.

Assessment: A statement of your professional conclusion. “Ms. Lee had her INR test done 2 days ago, so the dose may be changing depending on the results.”

Recommendation: What do you need to happen next? For example, ‘Please clarify which is the correct dose of warfarin for Ms. Lee to take and which physician will be responsible for managing her anticoagulant therapy?’

It is equally as important to structure written communication to standardize and centralize information about prescription handoffs. Your team could find a way to leverage your pharmacy’s computer software or use a paper system such as the Community Pharmacy SBAR Communication Tool. Using this form of written communication ensures other staff members not present at the onset of the situation can clearly and easily understand what the issue is and what still needs to be done.

Most importantly, your team should choose a structured form of communication that works for your specific situation and your team must be adequately trained on the method you choose. While research has identified haphazard communication as a contributing factor to medication incidents, there has not been any attempt to identify a ‘gold standard’ of structured communication to prevent medication incidents.



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