8 Joint Commission International Center for Patient Safety. http://www.jcipatientsafety.org/22791/

9 Joint Commission. Root causes of sentinel events, all categories. Oakbrook, IL; 2006 http://www.jointcommission.org/NR/rdonlyres/FA465646-5F5F-4543-AC8F-E8AF6571E372/0/root_cause_se.jpg

10 Andrews C, Millar S. Don't fumble the handoff. MAG Mutual Healthcare Risk Manager 2005; 11(28): 1-2. http://www.magmutual.com/mmic/articles/2005_11_28.pdf

11 Zinn C. 14,000 preventable deaths in Australia. BMJ 1995; 310: 1487

12 Joint Commission. National Patient Safety Goal FAQs. Oakbrook, IL, 2006 http://www.jointcommission.org/NR/ rdonlyres/25E48E23-6946-43E4-916C-5E116960FD5/0/06_npsg_faq2.pdf

13 Australian Commission for Safety and Quality in Health Care. Clinical handover and patient safety literature review report. March 2005 http://www.safetyandquality.org/clinhovrlitrev.pdf

14 British Medical Association. Safe handover: safe patients-guidance on clinical handover for clinicians and managers, 2004 http://www.npsa.nhs.uk/site/media/documents/1037_Handover.pdf