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Background

Communication errors are a contributing cause of approximately two-thirds of sentinel events, 3 over half of which involve handoff failures. 4 In health care, the magnitude of the patient safety epidemic first became widely recognized with the publication of To Err Is Human in 1999, which concluded that medical errors cause up to 98 000 preventable deaths annually in the United States. 5 Subsequently, calls for action emerged from the federal government and many private and professional organizations, including the recommendation that principles from High Reliability Organizations (HROs) be applied to the health care system.