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TRANSFERS OF PATIENT CARE FROM ONE PHYSICIAN to another (handoffs) are ubiquitous in health care. 1 Two recent developments have focused increased attention on physician handoffs: the emergence of the hospitalist field2 and the restriction of resident duty hours by the Accreditation Council on Graduate Medical Education. Handoffs are often accompanied by communication failures, which can lead to medical errors and harm. 3, 4 This potential for harm has prompted interventions to improve patient safety, 5 many of which were adapted from industries with high-risk transitions such as nuclear power and aviation. 6 At the same time, the Institute of Medicine has recommended enhanced training for residents regarding handoffs and the Joint Commission has mandated a standardized approach to handoff communications.

Research, to date, has addressed transitions necessitated by patient transfer to a …