Although seminal studies have documented persistent problems in care transitions, including readmissions and adverse events after discharge, understanding of the basic mechanisms of these problems remains incomplete. This Dutch study examines the hospital discharge process through a clinical microsystems approach, using detailed interviews with patients, nurses, hospital physicians, and primary care physicians to construct a 360-degree view of the factors contributing to effective and ineffective transitions. The major theme that emerged was a lack of consistent information transfer across settings, implying the need for both technological solutions and increased personal contact between hospital-based and outpatient clinicians. This study is part of a special theme issue of BMJ Quality and Safety dedicated to the issue of care transitions.