Example project: Safer medication handover
General Hospital — Nursing Directorate · Dr. Elena Petrou · Clinical Pharmacist · Healthcare / clinical
This is a fully answered example session, read only. Use it to see what a good answer to each question looks like.
Project & goal
Give this project a short name.
Safer medication handover on every shift
What change would you like this project to achieve? Make it measurable — a number and a date.
Medication reconciliation completed correctly and on time rises from 48% to 90% across all wards by the end of Q3.
What do you see that tells you there is a problem?
Anticoagulants stopped during a stay and never restarted at discharge. Pharmacy calls doctors several times a day to fix doses.
Is there data we could use as a baseline — audits, surveys, incident reports, system data?
Quarterly audit, March: reconciliation compliance 39-48% overall, 66% in one ward. The same audit can be repeated after training.
How will you know the goal has been achieved?
Audit compliance stays above 90% for two consecutive quarters and pharmacy correction calls drop by half.
What are the benefits of this project to the organisation?
1. Fewer medication incidents. 2. Less pharmacy rework. 3. Shorter discharge delays. 4. Better accreditation scores. 5. More confident nursing handovers.
How business critical is this project?
Very critical
Who exactly will change what they do?
Ward nurses and junior doctors who complete handover and discharge documentation.
What has already been tried to bring about this change, and what happened?
A 40-slide policy presentation in the annual mandatory training day; incident numbers stayed the same.
What happens if nothing changes?
Preventable medication errors, longer stays, repeated pharmacy interventions and accreditation findings.
Performance gap
What is the current level of performance? Describe what people actually do today.
Handover is done verbally and the medication chart is updated later, so changes made during the shift are lost.
How is this measured today?
Quarterly medication reconciliation audit and the incident reporting system.
What is the desired level of performance? What should they be able to do without asking anyone?
Every handover uses the chart in hand, and every stopped medication is documented with a restart decision.
Why don't they do it today? Is it knowledge, skill, tools, time, or the environment?
Time pressure at shift change, no single agreed handover format, and uncertainty about who owns the restart decision.
What are the effects of the problem right now?
Missed restarts, duplicated doses, pharmacy phone calls, and delayed discharges.
Actions & tasks
Hand over each patient with the medication chart in hand, naming every stopped drug
What makes this hard to do right? Shift change happens while call bells are ringing and relatives are waiting.
What mistakes do people make? Saying 'nothing changed' without checking the chart for stopped doses.
What would help them do it? A two-minute handover template pinned at the nurses' station.
Record a restart decision for every medication stopped during the stay
Call the pharmacist when a dose looks inconsistent with the discharge letter
Audience
Which job roles need this training?
Ward nurses, charge nurses and junior doctors on medical and surgical wards.
Roughly how many people per year, and where are they?
About 320 clinical staff across 9 wards.
What experience level are we designing for?
Mixed audience
What do they already know or do well on this topic?
All have clinical training; experience with the reconciliation form ranges from daily use to almost none.
What are their computer skills and language needs?
Comfortable with the ward system, but rarely use e-learning on a computer.
Where and when will they realistically do the course, and how much time do they have?
On the ward, on a shared tablet or phone, in short 5-10 minute breaks.
How often should people repeat it?
Annually
Evaluation
What improvement do you expect — by what percentage, and by when?
Reconciliation compliance from 48% to 90% by the end of Q3.
If one person has learned this and another hasn't, how would you tell just by watching them work?
The prepared nurse hands over with the chart in hand and states each stopped drug and its restart plan; the other gives a verbal summary and the change is never recorded.
A year from now, which metric would you look at to say the problem is solved?
Fewer medication incidents on the ward dashboard, pharmacy calls halved, and audit scores stable above target.
Logistics & materials
Is there a deadline or launch date?
Before the Q3 audit cycle
What budget is allocated for this course?
Internal budget, approx. €10,000
Which devices will learners use?
Mobile devices
What should the course include?
Real-life scenarios, Practice quizzes, Video
Which of these materials already exist? We'll use them as references, not as the course itself.
Policy documents and standards, Guidelines, Existing training material
Where will the course be hosted, and are there technical constraints we should know about?
320 licences, renewed with the annual mandatory training cycle.
Who should we contact with follow-up questions? Name, role, email and phone.
Dr. Elena Petrou, Clinical Pharmacist — e.petrou@example.org / +30 210 000 0000