Prior research has found that the transfer of patients from the emergency department (ED) to inpatient wards can be a source of errors. This survey of ED and hospitalist staff at an academic medical center solicited examples of adverse events associated with the ED–inpatient transition. The examples cited revealed many root causes, ranging from lack of a standardized signout process to environmental factors (such as ED overcrowding) and failure to assign responsibility (eg, when an admitted patient is "boarded" in the ED while awaiting a floor bed). The study authors provide suggestions for system improvements to prevent and ameliorate adverse events associated with this care transition.