Unexpected Return Visits To Emergency Department: A Healthcare Quality Management Challenge

Objective: The aim of the study was to assess the unexpected return visits (URV) rate attributed to emergency physicians (EP) diagnostic or therapeutic errors.Methods: Retrospective review was conducted based on electronic medical records (EMR) database of an emergency department with an annual attendance of 460,000 patient visits. The EMR tracked any revisit within 48 h of discharge from ED. Two teams of three EP reviewed EMR for each identified URV independently. The cases were categorized as Category-1: URV clearly unrelated to EP quality of care; Category-2: URV attributable to EP quality of care; or Category-3: uncategorizable into either of the above. The results were presented as proportions with 95% CI for categorical outcomes and kappa (kappa) testing was utilized as an indicator of the inter-group agreement.Results: Total URV was 1753 with a URV rate of 5.1% (95% CI, 4.8-5.3) of the monthly census (34,649). The n of category-2 URVs were 615 (1.7%, 95% CI 1.6-1.9%) during the study month. Out of total URVs, 575 were registered as left without being seen (LWBS) on the initial visit. None of the URV patients died within a month from index visit, and none of the LWBS were admitted to the ICU. The kappa calculation for the two groups agreement was .94 (95% CI 0.93-0.96).Conclusion: We found URVs were frequently due to factors that were exceedingly unlikely due to physician care quality on the initial ED visit. Study also found that there was nearly perfect agreement between independent groups of physicians tasked to categorized URVs, supporting the use of single physician review to do the task in resource limited setting.