Exploring the preventable causes of unplanned readmissions using root cause analysis: Coordination of care is the weakest link

Published:January 13, 2016DOI:


      • PRISMA-analysis is a suitable method to perform in-depth analysis of readmissions.
      • This study provides a structured analysis of root causes for unplanned readmissions.
      • Half of the readmissions studied were considered to be potentially preventable.
      • Healthcare worker coordination failures were mostly responsible.



      Unplanned readmissions within 30 days are a common phenomenon in everyday practice and lead to increasing costs. Although many studies aiming to analyze the probable causes leading to unplanned readmissions have been performed, an in depth-study analyzing the human (healthcare worker)-, organizational-, technical-, disease- and patient-related causes leading to readmission is still missing.


      The primary objective of this study was to identify human-, organizational-, technical-, disease- and patient-related causes which contribute to acute readmission within 30 days after discharge using a Root-Cause Analysis Tool called PRISMA-medical.
      The secondary objective was to evaluate how many of these readmissions were deemed potentially preventable, and to assess which factors contributed to these preventable readmissions in comparison to non-preventable readmissions.


      Cross-sectional retrospective record study.


      An academic medical center in Amsterdam, The Netherlands.


      Fifty patients aged 18 years and older discharged from an internal medicine department and acutely readmitted within 30 days after discharge.

      Main outcome measures

      Root causes of preventable and unpreventable readmissions.


      Most root causes for readmission were disease-related (46%), followed by human (healthcare worker)- (33%) and patient- (15%) related root causes. Half of the readmissions studied were considered to be potentially preventable. Preventable readmissions predominantly had human-related (coordination) failures.

      Conclusion and relevance

      Our study suggests that improving human-related (coordinating) factors contributing to a readmission can potentially decrease the number of preventable readmissions.


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