Unstable patients have the priority to ED rooms. Typically, this means less critical boarded patients are often placed in hallways to make more ED rooms available for patients while they wait for admission to an inpatient unit. This setting subjects boarded patients to a disruptive and unpredictable environment. There are also inherent structural differences between the care provided to boarded patients compared to the care in inpatient units. First, emergency physicians (EPs) and nurses lack the proper skill set to manage boarded patients. Care in the ED focuses more on stabilization, disposition, and preliminary diagnosis than on inpatient observation and management (Hockberger, et al., 2005). Second, new patients act as a distraction and are higher priority for ED staff compared to boarded patients. This level of distraction increases potentially dangerous handoffs between EPs as compared to an inpatient service setting. According to the Institute of Medicine’s safety publication, To Err Is Human: Building a Safer Health System, emergency departments (EDs) are susceptible to “high error rates with serious consequences” (Havens & Boroughs, 2006). These structural differences may explain why boarded patients could experience compromised quality of…