We read, with great interest, the article “Best Practices for Handover Communication” by Dr. Singh-Radcliff in the March 2013 ASA NEWSLETTER. Handovers, or “handoffs,” are indeed an important yet frequently overlooked component of patient safety, especially in the perioperative setting. As Dr. Singh-Radcliff notes, handoffs between anesthesia providers and the PACU team or ICU team are critical communication exchanges that should be formalized to maximize completeness. There is, however, another perioperative handoff scenario that occurs very frequently but has drawn less attention. Specifically, we are referring to intraoperative handoffs between anesthesia providers during transitions such as shift changes.

There is very little literature addressing the practice of changing anesthesia personnel during surgery. An early study by Cooper et al. suggested that errors potentially leading to critical incidents could either be caused or prevented by a change in...

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