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Making Transitions of Care Safe - Pat Croskerry Summary by: Pat Croskerry It is now well recognized that transferring the care of a patient from one caregiver to another is a vulnerable point in a patient’s care and a potential threat to patient safety. There may be many intra-disciplinary and inter-disciplinary transition points in the ED during an individual patient’s care. The process requires that each participant communicates well with others to establish an accurate shared mental representation of the important issues. To minimize transition failures, the process should be trained and standardized, recognized as a multi-professional activity, defined by who should be present, where and when it should occur, and have an end-point that is a clear plan for the ongoing care of the patient. The reliability, consistency, and efficacy of the transition should be a hallmark of departmental culture. Training should be provided in how the process works and how it fails. The broad distinction between the transfer