| Summary: | **Background:** When patients transition from an inpatient hospital stay to a skilled nursing facility (SNF), the information that is sent with them is essential to proper care in the facility. **Methods:** Records of hospital-to-SNF transfer were reviewed for opportunities for improvement in providing accurate or complete information. SNF staff were asked about their experiences caring for these patients and the effects that the inadequate documentation had on the patient’s medical care. **Results:** Four cases were identified that exhibit key errors that make the transition from the inpatient setting to the SNF setting difficult and potentially unsafe for patients and providers. These included: (1) inaccurate medication reconciliation on discharge, (2) incomplete medication instructions on discharge, (3) lack of information about the inpatient course and diagnoses and (4) missing instructions for follow-up care and procedures. **Conclusions:** Education for hospital-based providers has the potential to decrease the risks associated with transitioning patients from inpatient to SNF care settings. Structural and systemic changes could reduce the role of human error in this process and decrease the time requirements on overburdened hospital staff.
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