Background: Communication has been cited as the most common root cause in sentinel events, with failed patient care handoffs contributing to an estimated 80% of serious preventable adverse events. Handoffs to sub-acute care such as nursing homes are at particularly high risk for communication breakdown given high patient complexity and comorbidity. Our healthcare system includes [...]

Background: Hospitalized medical patients transitioning to new house staff at the end of an inpatient resident rotation are associated with an increased risk of mortality as compared with patients not exposed to such handoffs, yet no data exist on improvement strategies targeting this transition. Given the frequency with which residents rotate service, a transition in [...]

Background: Communication breakdown plays a part in the majority of adverse events in healthcare. Physician to physician handoffs are particularly prone to communication errors, yet have been shown to be more complete when systematized according to a standardized bundle. However,  the degree to which individual elements of this bundle, including written versus verbal handoffs, contribute [...]