Pharmacy Handoff Study



Community-based pharmacists are confronted with problems in information sharing during handoffs. As their computer systems provide little support in this process, informal handoffs (e.g. hand-written notes) become widely used. Issues such as poor handwriting and insufficient information come up everyday. As a result, errors, delays in medication distribution, and system-wide disorganization occurs.


To build a more efficient way to exchange information between shifts of pharmaceutical staff.


  1. What are the facilitators and barriers to the handoff process in the pharmacy work system?

  2. How could the barriers be addressed by a supporting interface?


Observations with informal interviews; contextual design.


Models of facilitators and barriers to the handoff process;

A prototype of Handoff Helper (iPad App).

Observations & Insights

  • Information needs to be shared during pharmacist handoff are complex

  • There lacks a standardized way of sharing information

  • Many barriers including time pressure, fatigue and limited working memory can further hamper this process





  • 40+ years old

  • Community pharmacist

  • Works three-and-a half 8-hour days a week

  • Enjoy interacting with customers, and sometimes goes out of his way to help customers of need

  • Somehow tech savvy but tired of the pharmacy computer system


  • 22 years old

  • Pharmacy technician

  • Works five 8-hour days a week (full-time)

  • Has very limited amount of knowledge of medications, so have to work under the supervision of the pharmacist




Metaphor analysis


User Environment design

The chart below shows the UE design - the purposes, functions, objects on each page as well as the links between pages:


Paper prototypes


Final prototype



How the Final Design Solves our Central Findings:

  • The electronic-based handoff solves the poor handwriting issue

  • Ipad follows workflow: employees moving around a lot

  • All handoffs are located in one place

  • Handoffs are assigned to work roles

  • Standardizing handoff