Send to

Choose Destination
Res Social Adm Pharm. 2014 Jan-Feb;10(1):195-203. doi: 10.1016/j.sapharm.2013.04.009. Epub 2013 May 9.

Exploring information chaos in community pharmacy handoffs.

Author information

School of Pharmacy, University of Wisconsin - Madison, 2513 Rennebohm Hall, 777 Highland Ave., Madison, WI 53705, USA. Electronic address:



A handoff is the process of conveying necessary information in order to transfer primary responsibility for providing safe and effective drug therapy to a patient from one community pharmacist to another, typically during a shift change. The handoff information conveyed in pharmacies has been shown to be unstructured and variable, leading to pharmacist stress and frustration, prescription delays, and medication errors.


The purpose of this study was to describe and categorize the information hazards present in handoffs in community pharmacies.


A qualitative research approach was used to elicit the subjective experiences of community pharmacists. Community pharmacists who float or work in busy community pharmacies were recruited and participated in a face to face semi-structured interview. Using a systematic content data analysis, the study identified five categories of information hazards that can lead to information chaos, a framework grounded in human factors and ergonomics.


Information hazards including erroneous information and information overload, underload, scatter, and conflict, are experienced routinely by community pharmacists during handoff communication and can result in information chaos. The consequences of information chaos include increased mental workload, which can precipitate problematic prescriptions "falling between the cracks." This can ultimately impact patient care and pharmacist quality of working life.


The results suggest that handoffs in community pharmacies result in information hazards. These information hazards can distract pharmacists from their primary work of assessing prescriptions and educating their patients. Further research on how handoffs are conducted can produce information on how hazards in the system can be eliminated.


Community pharmacy; Handoffs; Human factors; Medication safety

[Indexed for MEDLINE]
Free PMC Article

Supplemental Content

Full text links

Icon for Elsevier Science Icon for PubMed Central
Loading ...
Support Center