“…To illustrate, 80% of severe medical errors were attributed to miscommunication during handoffs (Joint Commission, 2012b). Specifically, poor communication during handoffs can lead to delayed and missed diagnoses (Lorincz et al, 2011), litigation and malpractice claims (Gandhi et al, 2006; Singh, Thomas, Petersen, & Studdert, 2007), omitted patient information (Devlin, Kozij, Kiss, Richardson, & Wong, 2014), diagnostic testing errors (Murphy, Singh, & Berlin, 2014), treatment delays (Horwitz, Moin, Krumholz, Wang, & Bradley, 2008), patient harm (Arora, Johnson, Lovinger, Humphrey, & Meltzer, 2005; Kitch et al, 2008; Saleem, Paulus, Vassiliou, & Parsons, 2015), and mortality (American Thoracic Society, 2016). Despite handoffs being vulnerable to communication breakdowns, they are an essential, frequent part of routine medical care.…”