Human factors engineering aims to optimize performance by examining the relationship between individuals and the system within which they work. This field of study has long been used to improve the safety of industries like manufacturing and aviation, and it has more recently been applied to health care. This study used human factors approaches to conduct observations, surveys, interviews, and focus groups about handoffs, specifically for postsurgical patients transferred from the operating room to the intensive care unit. The investigators identified flaws in handoff practices; then they designed a standardized handoff process to address these vulnerabilities. The redesigned handoff did not take more time than prior handoffs but did demonstrate better participant satisfaction. The authors suggest that their human factors-based improvement approach could be applied to other patient safety processes. A past PSNet interview discussed the application of human factors to health care.