Talk to Me! The Importance of Face-to-Face Communication at Shift Change


In 2016, retail pharmacists in the United States dispensed more than 4.4 billion prescriptions from 58,000 retail locations. What happens at change of shift in these pharmacies, and how can we improve?

Community pharmacies are busy places. In 2016, retail pharmacists in the United States dispensed more than 4.4 billion prescriptions from 58,000 retail locations. What happens at change of shift in these pharmacies, and how can we improve?

That's the question that researchers from the Madison School of Pharmacy at the University of Wisconsin in Madison, Wisconsin tried to answer. Their study, published in the Journal of Patient Safety, indicates that pharmacists need to improve their communication strategies. Community pharmacies experience communication problems similar to other health care locations.

These researchers looked at 2 types of handoffs. The first, synchronous handoff, occurred when pharmacists met with each other and transferred information at change of shift. The second, asynchronous handoff, occurred when pharmacists exchanged information at different times. This included leaving notes on paper or in computer software, or leaving voice messages.

Previous research indicates that communication failure accounted for 71% of sentinel events (serious or life-threatening errors) related to medication errors. The lack of data describing handoffs and community pharmacy suggested that this was an area ripe for research.

The researchers screened 543 community pharmacists, and 82% of these participants returned questionnaires. Half of respondents practiced in national chain or box store pharmacies.

Approximately half of responding pharmacists reported that they received inadequate information at shift change, and distractions and interruptions caused much information to be lost or forgotten. Poor handoff quality correlated positively with high workload, interruptions and distractions, and 24-hour service. These pharmacists indicated that poor handoff increased their workload, creating duplicative and unnecessary work, as well as the possibility of error.

Close to 40% of responding pharmacists indicated that their technologic support was unable to create seamless transfer at shift change. Their software simply was unable to transfer handoff information.

Pharmacists associated poor handoff with conflicts among the staff and outside health care providers. They cited patient dissatisfaction when they had to wait for prescriptions at least 25% of the time.

One startling finding was that pharmacists generally would explore every other possible source of information before calling an off-duty pharmacist to clarify handoff information. In addition, very few pharmacists reported having had any training on handoff communication.

The researchers concluded that face-to-face transfer of information was more effective. They also noted that pharmacists who knew their patients were more likely to provide positive handoff information. Pharmacy managers need to be proactive, provide education to staff to improve handoff, and examine their pharmacy software to see if it facilitates good communication.


Abebe E, Stone JA, Lester CA, et al. Quality of handoffs in community pharmacies. J Patient Saf. 2017 Apr 27. doi: 10.1097/PTS.0000000000000382. [Epub ahead of print]

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