It’s a moment when clear and specific communication is so imperative. And yet somehow crucial details are slipping through the cracks as hospital staffs change shifts across America.

As one team of physicians leaves and is replaced by another group, important briefings are typically held to transfer, or “hand-off” vital information regarding a patient’s current condition. However, a new study just published in the journal Pediatrics indicates that not only is the most significant information often lost in the hand-off, apparently some physicians also mistakenly think that what they are communicating is clearly understood.

The study analyzed communications between first-year pediatric residents at a major children’s hospital in Chicago as interns ended an overnight shift and spent fifteen minutes sharing information about hospitalized patients with the resident relieving them in a designated conference room. Researchers then asked both groups of interns to identify what they understood to be the most important information conveyed during the hand-off about each patient.

Surprisingly, what was noted to be the most vital information by the outgoing intern was not effectively communicated to the incoming intern sixty percent of the time. Critical details, like why a patient was on a particular drug or under what circumstances the primary care physician should be contacted were lost in the transition. Furthermore, even with these miscommunications, interns in both groups consistently rated the quality of their communication as very successful.

The researchers noted that even with a designated quiet area, vital information was lost. Their recommendations? Improved training, and continued attention to factors like physician fatigue that could play a role in the problem.