The first published discussions of anesthesia handoffs began several decades ago.1–3 That work highlighted both the risks and potential benefits of handoffs, using observational approaches to develop a portrait of some of the critical aspects of exchanging anesthesia personnel. More than 40 yr later, many more studies have examined the link between anesthesia handoffs and adverse patient outcomes.4 Only a few have studied interventions to address whether standardizing handoffs can improve patient outcomes as Saha and Segal describe in this issue of Anesthesiology.5 The report by Saha and Segal should be a call-to-action for all anesthesia professionals to conduct a deliberate, structured process for every instance in which responsibility for care of a patient is permanently transferred from one clinician or team to another.
The evidence supporting the relationship between unstructured anesthesia handoffs and harm is compelling but mixed. Most relevant studies demonstrate a robust association...
