This study addresses issues associated with sign-out reports occurring during shift changes in the pediatric intensive care unit of a large metropolitan hospital. The issues include the need for organizing our knowledge concerning the types of errors that providers are susceptible to during the sign-out process, the roles of personality, experience, and cultural factors, particularly as they may affect the incoming provider's inquisitiveness, and the potential impact on patient care of various different methods of performing sign-outs. We observed eight outgoing nurses and four residents who gave sign-out reports, and conducted eight semi-structured interviews with nurses, residents, nurse managers, and attending physicians. The results revealed important and intricate relationships among many of the variables that were investigated and suggested a number of interventions that might improve the sign-out process. Overall, our data on shift change sign-outs in an acute care setting confirmed the resiliency of health care providers and their capability for managing patient care under extremely demanding conditions.