Unpacking the Black Box: How the CHAT Study Turned Discharge Confusion into Patient Confidence

Why discharge medication communication matters

Hospital discharge is a high‑risk moment for patients. New prescriptions, changed doses, time pressure, and fragmented handovers can leave people unclear about what to take, when to take it, and who to call when something goes wrong. That uncertainty is not trivial: it can translate into medication errors, adverse events, and avoidable re-presentations.

A ‘black box’ worth opening

In the IJQHC Seminar Series panel discussion, Professor Reece Hinchcliff (Deputy Editor, International Journal for Quality in Health Care; ISQua) framed a question many quality and safety researchers recognise: complex real‑world studies look elegant on paper, but what did it take to actually deliver them inside busy health systems?

This session set out to unpack that black box by spotlighting the Reizenstein Award-winning paper, “Co‑design of an intervention to improve patient participation in discharge medication communication,” and letting the team tell the story behind the study.

Unpacking the Black Box: How the CHAT Study Turned Discharge Confusion into Patient Confidence

Nourhan Kawtharani

Nourhan, a quality and safety coordinator with eight years of experience in ambulatory healthcare in Lebanon, aims to deepen her understanding of the systemic and holistic approach to healthcare through this fellowship.

She aims to identify gaps and develop tailored interventions that address specific contexts rather than applying general solutions. Engaging with diverse professionals and perspectives during this educational journey will expand the application of these concepts across different cultural settings.

Nourhan emphasizes the importance of promoting a culture of continuous learning and improvement within healthcare institutions, considering it a vital leadership responsibility to integrate quality and safety initiatives into the organizational culture.

Nourhan's commitment to patient safety and quality management includes sourcing practical resources and transforming insights into actionable knowledge to drive continued progress in healthcare practices and outcomes.

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Elom Otchi

Elom is passionate about improving quality of care and patient safety outcomes.

In view of this, he has had the opportunity to work in various capacities with various organisations including AfIHQSA, WHO, UNICEF and others undertaking research, supporting the development of national quality policies and strategies, facilitating the establishment of quality governance systems across all the levels of the health sector and building capacity of national and sub-national quality leads/teams to institutionalize the practice of quality and patient safety across the continent.

He has also worked extensively across all levels of care in the health sector of Ghana, including leading the Quality & Patient Safety program in its largest teaching hospital.

I would like to use this Fellowship as a learning platform and an opportunity to acquire the requisite knowledge, skills and competencies to complement ongoing efforts by like-minded individuals and organizations to continuously advance improve the quality and patient safety in Ghana and the continent.

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Stephen Taiye Balogun

Stephen is a Senior Programme Officer at the Institute of Human Virology in Nigeria as well as Country Representative for Health Information for All (HIFA).

Stephen plans to use this opportunity to maximise his impact by championing the cause of patient safety and quality in Nigeria and across Africa.

Stephen says "Quality and safety is a major wheel through which universal healthcare coverage can be achieved. The goal is to be a bridge in the gap between the International Quality Improvement and Patient Safety community and my country to ensure rapid spread, adoption, implementation and practice."

We are looking forward to working with both Stephen and our 2020 winner Rhoda Kalondu over the next year.

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Dr Rhoda Kalondu

Rhoda is the Head of the Patient Safety Unit at Kenyatta Hospital in Nairobi and wants to use this Fellowship to learn how to establish a culture of safety and develop systems for assessment and analysis at her institution, and more widely. As well as this, Rhoda intends to develop and execute an intervention to improve patient safety in Kenyatta National Hospital.

It is one thing to institute measures and processes for improvement, but quite another to change the culture of an environment. Rhoda's ambition to lead others in this change inspired the panel.

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Dr Subhrojyoti Bhowmick

I am an MBBS graduate from Calcutta University with a Gold Medal in Gynecology & Obstetrics.

I have completed M.D in Pharmacology from IPGME& R, Kolkata and have over 12 years of experience in the field of Clinical Research, Pharmacovigilance and Medication management in Hospitals.

I have completed certification in Clinical Research Administration & Project Management from Stanford University, USA and in Patient Safety from Johns Hopkins University, USA.

I am an Assessor for National Accreditation Board for Hospitals & Health care providers (NABH), India assessing hospitals for medication safety and clinical quality standards and NABH Assessor for Ethics Committee Accreditation program in India as well.

I serve as the Chairperson, Institutional Ethics Committee of Health Point Hospital, Kolkata and am associated with 2 other Hospital ethics committees as a member.

I finished my Fellowship in Healthcare Quality from the International Society of Quality in Healthcare (ISQua) from Ireland in 2017.

I have published several research articles and have also authored a chapter on “Regulations governing Clinical Trial” in the book “Fundamentals of Clinical Trial & Research”.

I am a peer reviewer for prestigious international journals like the British Journal of Clinical Pharmacology, CNS Drugs and Drug Safety case reports.

I am the recipient of the UK Seth Oration Award for Best Clinical Pharmacology paper by the Indian Pharmacological Society in 2009 and the “Most promising Healthcare professional in Patient Safety in India” award by the Asian African Chamber of Commerce and Industry in October 2018.

Recently in April 2019, I received the Young Quality Achiever award by Consortium of Accredited Healthcare Organizations (CAHO), India for 2019 for my work in the field of medication safety and clinical research.

I have a keen interest in teaching and am visiting adjunct faculty of Pharmacology at KMC, Mangalore, India and for Healthcare technology at MAKAUT, Kolkata, India.

I was associated with Stanford University School of Medicine, in the USA as a Senior Clinical Research Associate from 2015 to 2017 and have certification in Biostatistics, Evidence-based Medicine and Medical Writing from Stanford University.

Currently, I am working as the Clinical Director of Academics, Medical Quality and Clinical Research at Peerless Hospital and B K Roy Research Centre, Kolkata.

I am very happy and thrilled to receive the prestigious ISQua Lucian Leape Patient safety Fellowship Award for 2019 and I look forward to honing my skills further in the field of healthcare quality and patient safety through my experiences during this fellowship.

I sincerely believe that successful completion of this fellowship will help me evolve as a more confident Patient safety leader in India who in turn can provide significant inputs on policy changes through NABH for the Indian healthcare system.

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