This study evaluated factors that jeopardize safe decision-making using ethnographic observation and interviews. Using a high-paced emergency department (ED) setting, investigators discovered that interruptions occurred nearly every 10 minutes for attending physicians. Observed gaps in communication resulted from poor information flow complicated by inherent multitasking, shift changes, and other activities such as documentation time and utilization of computer resources. The authors present typical workflow patterns in the ED and provide a summary of interview responses to illustrate the taxing nature of cognitive overload facing the studied clinicians. They conclude that carefully designed technology can minimize the effect that interruptions and handoffs have on patient safety.