Identifying and Reducing Complications After Emergency Room Discharge

 Justification for taking prompt action

According to a July 2016 report in Health Affairs by researchers at the University of California, San Francisco, there was a 48% reduction in adult mortality rates in U.S. ERs between 1997 and 2011. The researchers noted this trend likely has many causes, related to advances in palliative, prehospital, and emergency care. Such progress should now be supplemented by a well-structured initiative to identify and reduce complications and deaths after patients are discharged from the ER (Kanzaria, Probst, & Hsia, 2016).

An effective program benefits patients while improving community health status and lowering ER visits and hospital admissions due to preventable adverse outcomes. Concurrently, the number of potential lawsuits and the costs of insurance should both be decreased. It is not uncommon for medical malpractice cases to result from unidentified problems in the ER associated with the miscommunication of critical results involving the laboratory and radiology, the provision of inadequate discharge instructions, and the premature release of suicidal and other patients.

CEOs and chief medical officers, as well as directors of emergency medicine, patient safety, quality assurance, and risk management, should enthusiastically support this initiative (Hofmann and Yates 2015).  Given the cost/benefit advantages, the indefensible financial and nonfinancial consequences of not taking action are too high.


Paul Hofmann is president of the Hofmann Healthcare Group in Moraga, California. For the past 20 years, he has devoted a majority of his time to assisting hospitals and health systems with accelerating their performance improvement efforts and writing, speaking, and consulting on ethical issues in healthcare. He served previously as executive director of Emory University Hospital and director of Stanford University Hospital and Clinics. Dr. Hofmann co-founded Operation Access and the Alliance for Global Clinical Training. His Bachelor of Science, Master of Public Health, and Doctor of Public Health degrees are from the University of California, Berkeley.


James Bagian is the director of the Center for Healthcare Engineering and Patient Safety and is a professor in the Department of Anesthesiology and College of Engineering at the University of Michigan. Previously, he served as the first and founding director of the VA National Center for Patient Safety and as the VA’s first chief patient safety officer. In addition to numerous other positions, he is the chair of The Joint Commission’s Patient Safety Advisory Group and board member of the National Patient Safety Foundation. Dr. Bagian holds a bachelor’s degree in mechanical engineering from Drexel University and a doctorate in medicine from Thomas Jefferson University.




American Hospital Association (2016). [Data on volume of U.S. emergency room patients]. AHA Annual Survey Database™. Unpublished data.

Bagian, J. P. (2005). Patient safety: What is really at issue? Frontiers of Health Service Management, 22(1), 3–16.

Bagian, J. P., Lee, C., Gosbee, J., DeRosier, J., Stalhandske, E., Eldridge, N. … Burkhardt, M. (2001). Developing and deploying a patient safety program in a large health care delivery system: You can’t fix what you don’t know about. Journal of Quality Improvement, 27, 522–532.

Bagian, J., Lee, C. and Cole, J. (1999). A method for prioritizing safety-related actions. In A. Scheffler & L. A. Zipperer (Eds.), Enhancing patient safety and reducing errors in health care (pp. 176–185). Chicago, IL: National Patient Safety Foundation, 1999.

Burke, R. E., Whitfield, E. A., Hittle, D., Min, S. J., Levy, C., Prochazka, A. V. … Ginde, A. A. (2016). Hospital readmission from post-acute care facilities: Risk factors, timing, and outcomes. Journal of Post-Acute and Long Term Care Medicine, 27, 249–255.

Hofmann, P. B. (1986). The importance of asking the extra why. California Medicine, 7(7), 29.

Hofmann, P. B., & Yates, G. R. (2015, September 21). The one trait that consistently high-performing health systems and hospitals share. Hospitals & Health Networks Daily. Retrieved from

Kanzaria, H. K., Probst, M. A., & Hsia, R. Y. (2016). Emergency department death rates dropped by nearly 50 percent, 1997–2011. Health Affairs, 35(7), 1303–1308.

Minemyer, P. (2016, October 21). New York hospitals take aim at ER ‘super users.’ FierceHealthcare. Retrieved from

National Patient Safety Foundation (2015). RCA2: Improving root cause analyses and actions to prevent harm. Retrieved from

Nguyen, O. K., Makam, A. N., Clark, C., Zhang, S., Xie, B., Velasco, F. … Halm, E. A. (2016). Vital signs are still vital: Instability on discharge and the risk of post-discharge adverse outcomes. Journal of General Internal Medicine. doi:1007/s11606-016-3826-8.

Rau, J. (2016, May 2). Hospital discharges: It’s one of the most dangerous periods for patients. Kaiser Health News. Retrieved from

Salber, P. (2015, May 16). Are You Better, Same, or Worse? Your ER Wants to Know. HIMSS 2015. Retrieved from