Unscheduled returns to the emergency department: an outcome of medical errors?

Abstract

Background: The causes of unscheduled returns to the emergency department (ED) within 72 hours of discharge are unclear. A study was undertaken to identify factors associated with this quality care indicator.

Methods: 250 cases and 250 controls from the ED were prospectively studied. Outcomes measured were unscheduled returns, post-ED destination, and patient dissatisfaction. Possible medical errors (in diagnosis, treatment, prognosis or patient information) and errors in follow up care were identified. Other factors examined included chief complaint at presentation, discharge diagnosis, level of triage, category of treating physician, observation or not, application of emergency treatment, ancillary studies, accessibility to ED, ED time band or work shift, day of the week, past medical history, and demographic data (age, sex, educational level and economic status).

Results: The main factor associated with unscheduled returns was error in prognosis (odds ratio 18.62, 95% CI 9.60 to 36.09). Advanced age and a chief complaint of dyspnoea were also associated with unscheduled returns and with admission to hospital. Post-ED destination worsened by 0.61 (95% CI 0.33 to 0.90) with diagnostic errors and by 0.60 (95% CI 0.30 to 0.90) with errors in follow up care. Patient dissatisfaction increased by 0.68 (95% CI 0.55 to 0.80) with information errors, by 0.63 (95% CI 0.17 to 1.09) with errors in follow up care, and by 0.52 (95% CI 0.09 to 0.94) with diagnostic errors.

Conclusion: Unscheduled returns are associated with medical errors in prognosis, treatment, follow up care, and information. A worse post-ED destination is associated with these medical errors and patient factors (dyspnoea and advanced age). Patient dissatisfaction is associated with medical errors, level of triage or care zone, patient educational level and ED time work shift. Most of these factors are modifiable.