Patients leaving the operating room undergo a complex transition of care, first to the recovery room and subsequently to the intensive care unit or ward. Prior research has identified patient safety problems during this handoff, perhaps related to a lack of standardized handoff procedures. In this study, researchers used direct observation of interactions between anesthesiologists and recovery room nurses to assess the quality of handoffs and potential problems. Although handoffs were not standardized, observers noted many informal conventions about the information transmitted during the handoff, and suggested that these elements be incorporated into formal handoff procedures. A prior study used methods developed in auto racing to develop a handoff protocol for patients admitted to the intensive care unit after surgery.