The institution of duty hour limitations for housestaff has led to fundamental changes in the structure of patient care at teaching hospitals. This study used direct observation of surgical teams, focus groups with surgery residents and staff, and an Internet-based survey to characterize current practices for information transfer and communication (ITC) between physicians and determine how suboptimal ITC may lead to adverse events. Four domains of ITC that contribute to adverse events were identified, including blurring of provider responsibility and decreased familiarity with individual patients. The focus group data were combined with a literature review to establish best practices for ITC at both the individual physician and institutional levels. An Agency for Healthcare Research and Quality (AHRQ) WebM&M commentary discussed the inherent challenges of inter-physician communication when multiple care teams are involved.