This systematic review of 38 published studies identified communication failures in all phases of surgical care, including intraoperatively and during postoperative care. Such breakdowns in information transfer, particularly during handoffs, have been linked to adverse events in prior studies. A number of interventions have been proposed to address this issue, including standardized checklists—which were remarkably successful at reducing postoperative complications in a classic study—and incorporation of handoff techniques from other industries. An AHRQ WebM&M commentary discusses the disastrous consequences of an intraoperative communication breakdown.