Tip of the Week: Mitigating ‘Information Chaos’ During Prescription Handoffs


Variability in prescrption handoffs might make the difference between a patient who is adherent or not.

The things we might take for granted during routine pharmacy operations contribute greatly to the quality of care delivery and to patient outcomes. One example is the mere handoff of prescriptions to patients. Variability in handoffs might make the difference between a patient who is adherent or not.

Chui and Stone examine a concept called information chaos, which occurs during prescription handoffs.1 They state that a significant number of prescriptions are dispensed from high-volume pharmacies with multiple pharmacists working in a single location, including a growing number of part-time or floating/relief pharmacists who may have a limited relationship with or knowledge of the patient, personally.

Thus, one pharmacist may accept a prescription, another may verify its accuracy, while yet another may counsel the patient. When there is a problem such as missing or confusing information about the prescription, that problem must be addressed by the pharmacist prior to the medication being dispensed.

The authors add that handoffs frequently occur in a haphazard fashion. Given the frequency of these potentially chaotic events, and lapses and errors in communication, handoffs have been identified as a key area for improvement in reducing medical errors and patient harm.

Consequences of information chaos can increase one’s mental workload, which can precipitate problematic prescriptions “falling between the cracks.” This can ultimately impact patient care and pharmacist quality of work life.

The resultant information hazards can distract pharmacists from their primary work of assessing prescriptions and educating patients. To that end, we are reminded of some momentous research demonstrating the results of a simple workflow redesign that had the same pharmacy personnel receiving and handing off the prescription, while other personnel prepared the medication and contributed to other operational functions.2

This relatively simply redesign helped ensure that patients receive counseling and mitigated the prospects of information chaos.

Pharmacy managers have to consider workflow in a number of contexts. One is to facilitate communication and lessen chaos, while also clarifying the roles of pharmacy personnel in general and on each particular shift. This reduces their confusion and improves their satisfaction while also minimizing risks and maximizing patient safety.

Additional information about operations management and ensuring quality in pharmacy operations can be found in Pharmacy Management: Essentials for All Practice Settings, 5e.


  • Chui MA, Stone JA. Exploring information chaos in community pharmacy handoffs. Res Social Adm Pharm. 2014;10:195-203.
  • Schommer JC, Wiederholt JB. A field investigation of participant and environment effects on pharmacist-patient communication in community pharmacies. Med Care. 1995;33:567-584.

About the Author

Shane P. Desselle, RPh, PhD, FAPhA, is professor of Social/Behavioral Pharmacy at Touro University California.

Related Videos
Semaglutide Ozempic injection control blood sugar levels | Image Credit: myskin - stock.adobe.com
Image credit: motortion | stock.adobe.com - Young depressed woman talking to lady psychologist during session, mental health
Image credit:  JPC-PROD | stock.adobe.com - Choosing method of contraception : Birth control pills, an injection syringe, condom, IUD-method, on grey
Semaglutide Ozempic injection control blood sugar levels | Image Credit: myskin - stock.adobe.com
Health care provider examining MRI images of patient with multiple sclerosis -- Image credit: New Africa | stock.adobe.com
© 2024 MJH Life Sciences

All rights reserved.