“…We observed disposition decision-making to involve the patient, care partners, and a variety of ED and consulting clinicians. The involvement of these multiple roles across time and, in some cases, across work systems, required intentional communication, coordination, and collaboration, which could indicate some level of teaming (Salas et al, 2008;Werner et al, 2020). The combination of work system elements we identified are likely to contribute to high mental workload for ED clinicians, which has been associated with poor decision quality (Shanafelt et al, 2002;Weigl et al, 2016).…”