Reforms that limited duty hours for resident physicians stimulated efforts to enhance the safety of patient handoffs, and innovative approaches to improving safety have drawn on methods from other industries (including automobile racing). However, this systematic review of nursing and physician handoffs found little high-quality research on the effectiveness of specific handoff methods. Although use of standardized handoff sheets appeared to improve the quality of handoffs, the authors were unable to find evidence linking any handoff interventions to better patient outcomes. A case of poor handoff communication that led to an avoidable surgical procedure is discussed in this AHRQ WebM&M commentary.