Despite the well-documented prevalence of adverse events after hospital discharge and a growing policy focus on preventing readmissions, the factors leading to poor care transitions are not well understood. This qualitative study from Spain used in-depth interviews with patients, hospital staff, and primary care providers to better define the mechanisms by which adverse events and readmissions occur. The investigators found that discharge processes are often haphazard and a major source of frustration for hospital providers, and that patients often shoulder the burden of communicating clinical information to their primary care providers, which leaves those with limited health literacy particularly vulnerable to errors. These findings mirror and expand upon prior research. This study is part of a large, multi-national effort to improve the quality of patient handovers.