This article presents a complex clinical scenario based on actual communication breakdowns that led to a sentinel event. Basic communication theory that underlies clinical interactions and the tenets of health care economic evaluation are reviewed. The process of the handoff as it relates to clinical interactions is discussed and the weaknesses in communication arising from handoff failures in the operative and critical care environments are examined. The discussion follows by looking at the influences of current medical culture, emerging technology, and changing care environments and their impact on communication behaviors and resultant effect on patient outcomes. A detailed cost analysis of the charges incurred for both standard and escalated care required for the case is followed by a discussion of the economic basis for improving clinical communication and patient safety using the SBAR tool.