When you arrived at the unit today and listened to the change of shift report, you heard about a patient named Jane W. According to the tape-recorded signout, Jane:“is a 57-year-old woman with abdominal pain and vomiting. She has pain medications ordered p.r.n. [as needed].” During your shift, Jane does not request pain medications. Near the end of your shift, however, you get a call from Jane’s daughter. Distraught, she asks why nobody is treating her mother’s pain. When you explain that Jane has not requested any pain medications, her daughter exclaims, “But she’s had a stroke! She can’t use the call light! What kind of place are you running over there?” How might the transition between providers ("hand-over") have contributed to this situation? You had no opportunity for verbal repeat back. You weren’t paying close attention to the information you were being given. The handoff was hard to understand.The handoff was too brief and failed to include important information.