Abstract Transitions of care are critical periods when NICU patients are at risk for miscommunication leading to patient harm. This quality improvement project aimed to decrease post-operative hand-off-related failures and improve communication in a level IV NICU. The Vermont Oxford Network transitions of care framework was used to develop a safe surgical hand-off definition; (1) all team members present, (2) a structured hand-off format utilized, and (3) an environment conducive for hand-off.
