Handoffs represent a vulnerable time for patients when lapses in communication may adversely impact safety. Prior research has shown that medication errors occur frequently among patients transferred from ICU to non-ICU locations within the same hospital. In this qualitative study, physicians reviewed transfer notes and handoff documents for 50 patients transferred from a pediatric ICU to a medical unit. They found clinically relevant differences between the handoff and transfer note documentation in 42% of the transfers and conclude that such discrepancies are both common and place patient safety at risk. A previous WebM&M commentary described an adverse event related to a patient handoff.