The 2025 Emmy winner for Best Drama, The Pitt, takes viewers inside the daily chaos of an emergency department (ED), exposing cracks in the healthcare system—a major one being ED boarding. In a riveting scene, fiction meets reality when an attending physician pleads with a hospital administrator to move admitted patients “upstairs,” lamenting that those left in crowded hallways are receiving substandard care. The administrator, hands tied, replies that boarding isn’t just their hospital’s problem—it’s a nationwide crisis.
What The Pitt dramatized is the lived reality in emergency departments across the country: patients admitted to the hospital but left waiting in the ED, often for hours or even days. These patients, termed boarders, are not just a hurdle in the ED process of care but also represent one of the most pressing patient safety challenges facing emergency medicine.
As defined by the American College of Emergency Physicians, a “boarder” is one who has been admitted to a facility but remains in the ED while awaiting transfer to an inpatient or observation unit. Nursing shortages, limited access to post-acute care, and cost-cutting measures are just some of the common reasons for slowed patient throughput and increased boarding of patients. A study of academic emergency departments indicates how the nationwide crisis has surpassed pre-pandemic levels.
Why Boarding Magnifies Risk
In routine cases, each step in the process of care is vulnerable but generally manageable. During ED boarding, however, monitoring, communication, and timely handoffs are undermined. Patients linger in a limbo where responsibility between emergency physicians, consultants, and inpatient teams is blurred—creating fertile ground for lapses that later become the subject of legal scrutiny.
The Joint Commission says holding someone in the ED for more than four hours is a patient safety issue, yet hospitals are not legally required to remedy the problem. The result is a situation primed for preventable harm and, too often, malpractice allegations.
What the Malpractice Data Shows
An analysis of asserted MPL cases from Candello, a division of CRICO (the malpractice insurer for the Harvard medical community), illustrates the risks of prolonged ED stays. Between 2014 and 2023:
- Over 340 malpractice cases were linked to ED boarding, compared with nearly 4,800 cases involving ED patients who were not boarded.
- On the NAIC Severity Scale (0–9), boarded patients averaged 6.7, compared with 5.8 for non-boarded patients, which was a statistically significant difference.
- Severe outcomes, including death, were disproportionately more common among boarded patients when compared to non-boarded ED patients.
The findings suggest opportunities for improvement in how hospitals manage ED boarding while considering the many aforementioned contributors to the crisis. Strengthening communication during patient handoffs, both within ED teams and between ED and inpatient services, is critical. The data supports the use of fully standardized handoff systems, such as I-PASS. Beyond process improvements, there may also be value in rethinking staffing models: assigning a dedicated provider or team to care for ED boarders or expanding the role of consult services such as internal medicine to bridge the gap while patients await transfer. Importantly, these actions would require broader collaboration, drawing non-emergency specialties into the ED “patient safety table” to address shared responsibility.
Where Risks Can Emerge in the ED
The patient journey through the emergency department follows a series of interdependent steps. Each represents both a safeguard for patient safety and a potential point of breakdown. Candello’s taxonomy assigns specific codes to each step in the ED process of care. This structured framework transforms a complex clinical flow into an analyzable sequence, making it possible to spot patterns across cases. The framework works as follows:
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Recognition and Arrival
The process begins when the patient identifies a health problem and seeks emergency care. Delays here are usually outside the ED’s control, but downstream timing still matters.
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Initial Assessment
Providers gather a history and perform a physical exam. Early impressions can steer care in the right direction—or, if rushed or incomplete, can be a catalyst for future errors.
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Ongoing Monitoring
As patients wait (often for hours, sometimes days, when boarding), their clinical status must be reassessed. This step is notoriously vulnerable in crowded EDs, where subtle deterioration can be missed. Practical constraints, such as a limited ability to perform cardiac telemetry monitoring when a patient is in the hallway, may also come into play. Newer technologies, such as early warning systems, can integrate data, such as vital signs and laboratory values, and send an alert when there is an increased risk of clinical deterioration.
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Diagnostics: Orders, Tests, and Interpretation
The cycle of ordering, performing, interpreting, and transmitting results requires multiple handoffs. Miscommunication or delays are common contributors to malpractice allegations, especially if abnormal results don’t reach the provider promptly. Diffusion of clinical responsibility for acting on test results is a risk when the transition from the ED to the inpatient team is prolonged or ambiguous.
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Consultation Management
Specialty input is often needed. When consultants are delayed—or when recommendations are lost in translation—the care plan may stall.
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Discharge Planning
For patients deemed stable to leave, clear and appropriate instructions are crucial. Gaps in documenting risk, providing follow-up, or ensuring that the patient understands the plan can all be liability triggers.
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Post-Discharge and Adherence
Even after leaving the ED, the safety net depends on follow-up arrangements and whether the patient adheres to instructions. Poorly coordinated transitions are frequent sources of malpractice claims.
In the malpractice analysis, ongoing monitoring emerged as the highest-risk stage for boarded patients. Failures to reconcile symptoms, test results, and changing conditions were common, especially when communication between ED and non-ED clinicians broke down.
Boarded patients also faced higher risks in diagnostic testing and post-discharge follow-up compared with non-boarded patients. In short, the very delays and diffusion of responsibility inherent to boarding create fertile ground for error.
A Key Caveat
Dr. Adam Schaffer, Senior Clinical Analytics Specialist of CRICO’s Patient Safety Department, who conducted the analysis, emphasizes a key limitation: the comparison group. “The comparison group used (ED patients who were not boarded) included many individuals who were never admitted to the hospital. By definition, however, all ED boarders were admitted patients. This creates an uneven comparison, as admission inherently selects for patients with more complex or severe conditions.”
Opportunities for Improvement
Despite its limitations, the analysis highlights several opportunities for hospitals to reduce harm tied to ED boarding when resources allow:
- Strengthen communication during handoffs. Standardized systems, such as I-PASS, can reduce missteps when responsibility shifts between clinicians.
- Dedicate staff to boarded patients. Assigning a specific provider or team helps ensure patients in hallways do not fall through the cracks. Clinicians dedicated to caring for ED boarders have been shown in studies to improve follow-up on lab tests and decrease length of stay.
- Expand the role of consult services. Consultant care from an internal medicine team or other specialties can help bridge gaps while patients await transfer.
- Promote shared accountability. Non-ED specialties should be included in ED safety planning, since patient outcomes depend on collective responsibility.
These steps require resources and collaboration. Process tweaks alone will not solve the systemic shortages driving the crisis, but they can mitigate harm in the meantime. Innovative approaches to increasing our capacity for providing inpatient level of care, such as home hospital programs, may be part of the answer.
The Bigger Picture
With widespread federal budget cuts to healthcare programs and insurance access, patients’ reliance on the ED is only expected to grow, as these critical facilities will be the only place many people can receive care and not be denied access if they can’t afford to pay.
The malpractice data underscores what frontline clinicians already know: Patients caught in this limbo face higher risks of severe harm. The question is whether hospitals, policymakers, and payers will treat ED boarding as the urgent safety issue it has become, rather than as an unavoidable inconvenience.