Transitions of care, also referred to as handoffs or handovers, involve complex communication between health care providers and have been recognized as a potential source of medical errors. In fact, The Joint Commission has estimated that 80 percent of serious medical errors involve failures in communication between caregivers.1,2  Perioperative handoffs can be especially risky, as they take place in noisy, chaotic environments (e.g., the O.R., PACU and the ICU), with the need to provide uninterrupted patient care.

Attention to reducing the risks associated with perioperative handoffs has recently increased. In September 2017, the Anesthesia Patient Safety Foundation sponsored a one-day conference exploring the topic of perioperative handoffs, with the intent to produce consensus statements regarding best practices for handoff processes, education and implementation. In addition to a growing literature examining interventions to improve handoffs...

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