Mitigating pathogenesis for target discovery and disease subtyping.

Treatments ideally mitigate pathogenesis, or the detrimental effects of the root causes of disease. However, existing definitions of treatment effect fail to account for pathogenic mechanism. We therefore introduce the Treated Root causal Effects (TRE) metric which measures the ability of a treatment to modify root causal effects. We leverage TREs to automatically identify treatment targets and cluster patients who respond similarly to treatment. The proposed algorithm learns a partially linear causal model to extract the root causal effects of each variable and then estimates TREs for target discovery and downstream subtyping. We maintain interpretability even without assuming an invertible structural equation model. Experiments across a range of datasets corroborate the generality of the proposed approach.

Investigation of annual trucks fatal accidents in El Hajeb province of Morocco using TRIZ-Ishikawa diagram.

A stretch of road in the province of EL HAJEB, located in the central-south region of Morocco, is classified among the roadways experiencing an accumulation of fatal traffic accidents, with a particular involvement of freight transport vehicles. Investigation reports elaborated for these fatal accidents specify that these accidents occurred when drivers lost control of their vehicles due to brake system failures, resulting in multiple fatalities. However, these investigation reports did not provide root causes of this phenomena. Scientific research efforts in this field are directed toward preventive solutions and proposing a comprehensive analytical approach. This study aims to elucidate the mechanisms behind these specific accident phenomena on the identified stretch in the city of EL HAJEB. To achieve the study's objective and identify the triggering or contributing factors of these failures, we employed a novel approach combining the TRIZ and Ishikawa tools. This is a systematic methodology for analyzing potential causes of accidents, allowing us to clarify the intricacies of the specific phenomena leading to accidents while systematizing the analysis process, thus contributing to enhancing the effectiveness of investigative teams. This article contributes to introducing a new analytical tool in the field of accident analysis.

Data exploration on the factors associated with cost overrun on social housing projects in Trinidad and Tobago.

This data article explores the factors that contribute to cost overrun on public sector projects within Trinidad and Tobago. The data was obtained through literature research, and structured questionnaires, designed using open-ended questions and the Likert scale. The responses were gathered from project actors and decision-makers within the public and private construction industry, mainly, project managers, contractors, engineers, architects, and consultants. The dataset was analysed using frequency, simple percentage, mean, risk impact, and fuzzy logic via the fuzzy synthetic evaluation method (FSE). The significance of the analysed data is to determine the critical root causes of cost overrun which affect public sector infrastructure development projects (PSIDPs), from being completed on time and within budget. The dataset is most useful to project and construction management professionals and academia, to provide additional insight into the understanding of the leading factors associated with cost overrun and the critical group in which they occur (political factors). Such understanding can encourage greater decisions under uncertainty and complexity, thus accounting for and reducing cost overrun on public sector projects.

The quality of drugs and drug products - Always guaranteed?

To ensure the efficacy, safety, and quality of drugs, several national and international guidelines and regulatory requirements exist. The most important international regulatory framework for quality is the collection of the guidelines ICH Q1-Q14 (International Council for Harmonization of Technical Requirements for Pharmaceuticals for Human Use), which form the basis for the development and approval of medicinal products. Additionally, international and national pharmacopoeias and national regulatory authorities like Food and Drug Administration (FDA) and European Directory for the Quality of Medicines and HealthCare (EDQM) have to be considered during the lifecycle of a drug. Further, regular updates and optimization of processes and methods together with periodic audits and inspections of the manufacturing plants help to ensure compliance with the complex regulatory requirements for medicinal products. Although the pharmaceutical world seems to be very well regulated and controlled, several drug recalls per year have to be announced and conducted to remove defect products from the market and protect the patient from any potential health risk. This review article provides an overview of the most common reasons for such recalls presenting several historical and current cases with a detailed discussion of root causes. A specific focus lies on quality issues like drug degradation, impurity and nitrosamine contamination, lack of drug stability, occurrence and transformation of polymorphs, contamination with particulates and foreign matters, amongst others. The role of APIs, excipients and packaging will be discussed as well as the analytical challenges to detect, control and mitigate such quality issues. A final chapter will discuss the current situation and an outlook on emerging topics and future challenges for drug quality.

Forensic investigations of disasters: Past achievements and new directions.

In the 2020s, understanding disaster risk requires a strong and clear recognition of values and goals that influence the use of political and economic power and social authority to guide growth and development. This configuration of values, goals, power and authority may also lead to concrete drivers of risk at any one time. Building on previous disaster risk frameworks and experiences from practice, since 2010, the 'Forensic Investigations of Disasters (FORIN)' approach has been developed to support transdisciplinary research on the transformational pathways societies may follow to recognise and address root causes and drivers of disaster risk. This article explores and assesses the achievements and failures of the FORIN approach. It also focuses on shedding light upon key requirements for new approaches and understandings of disaster risk research. The new requirements stem not only from the uncompleted ambitions of FORIN and the forensic approach but also from dramatic and ongoing transformational changes characterised by climate change, the coronavirus disease 2019 (COVID-19) pandemic and the threat of global international confrontation, among other potential crises, both those that can be identified and those not yet identified or unknown. Contribution: Disasters associated with extreme natural events cannot be treated in isolation. A comprehensive "all risks" or "all disasters" approach is essential for a global transformation, which could lead to a better world order. To achieve this, an Intergovernmental Panel for Disaster Risk is suggested to assess risk science periodically and work towards sustainability, human rights, and accountability, within a development and human security frame and on a systemic basis and integrated perspective.

Prevalence, causes and contexts of childhood overweight and obesity in the Pacific region: a scoping review.

Background: Non-communicable diseases (NCDs) are a major threat to health and development and account for 75% of deaths in the Pacific Islands Countries and Territories (PICTs). Childhood obesity has been identified as a main risk factor for NCDs later in life. This review compiled overweight and obesity (OWOB) prevalence (anthropometric data) for children aged six to 12 years old living in the Pacific region and identified possible related causes. Methods: We conducted a systematic search using PubMed, Google Scholar and ScienceDirect for articles published between January 1980 and August 2022. We also searched for technical reports from Ministries of Health. Guided by the eligibility criteria, two authors independently read the selected articles and reports to extract and summarise relevant information related to overweight and obesity. Results: We selected 25 articles, two worldwide analyses of population-based studies and four national reports. Information revealed that childhood OWOB prevalence reached 55% in some PICTs. This review also indicated that age, gender and ethnicity were linked to children's weight status, while dietary practices, sleep time and level of physical activity played a role in OWOB development, as well as the living environment (socio-economic status and food availability), parenting practices and education level. Conclusion: This review highlighted that anthropometric data are limited and that comparisons are difficult due to the paucity of surveys and non-standardized methodology. Main causes of overweight and obesity are attributed to individual characteristics of children and behavioural patterns, children's socio-economic environment, parenting practices and educational level. Reinforcement of surveillance with standardised tools and metrics adapted to the Pacific region is crucial and further research is warranted to better understand root causes of childhood OWOB in the Pacific islands. More robust and standardized anthropometric data would enable improvements in national strategies, multisectoral responses and innovative interventions to prevent and control NCDs.

In the Pacific region, populations have gained faster access to modern lifestyles in the past few decades, causing fundamental changes in the way people move about and eat (including food choices, physical activity, and sedentary time) and a dramatic increase in noncommunicable diseases. This is mainly the case in young generations since they are particularly exposed to an environment that can drive to overweight and obesity. This scoping review aims to summarize the prevalence and known causes of overweight and obesity for children aged six to 12 years old living in the Pacific region and identified possible related factors. This work highlighted that causes of overweight and obesity are mainly attributed to individual characteristics of children and behavioural patterns, children's socio-economic environment, parenting practices and educational level.

Root-cause Analysis of 762 Danish Post-colonoscopy Colorectal Cancer Patients.

BACKGROUND & AIMS: The term post-colonoscopy colorectal cancer (PCCRC) refers to colorectal cancer (CRC) diagnosed after a negative colonoscopy. Using the root-cause algorithm proposed by the World Endoscopy Organization, we aimed to investigate plausible explanations for PCCRCs and potential changes in plausible explanations for PCCRCs over time in a Danish Region. METHODS: During 1995 to 2021, we used national health registries and electronic medical records in the Central Denmark Region to identify PCCRC cases, defined as CRCs recorded within 6 to 48 months after a colonoscopy. We then applied the World Endoscopy Organization algorithm to categorize explanations for PCCRC as follows: (A) possible missed lesion, prior examination adequate; (B) possible missed lesion, prior examination inadequate; (C) detected lesion, not resected; or (D) likely incomplete resection of previously identified lesion. PCCRCs were identified before (1995-2013) and after (2014-2021) implementation of nationwide fecal immunochemical test-based CRC screening and quality indicators for colonoscopy. RESULTS: We identified 762 PCCRCs, 53.5% among males and 57% among individuals ≥70 years. Forty-five percent were located in the proximal colon. We identified 616 (80.8%; 95% confidence interval [CI], 74.6%-87.5%) category A PCCRCs; 36 (4.7%; 95% CI, 3.3%-6.5%) category B PCCRCs; 26 (3.4%; 95% CI, 2.2%-4.9%) category C PCCRCs; and 84 (11%; 95% CI, 8.8%-13.6%) category D PCCRCs. Similar patterns were observed during the early (1995-2013) and late (2014-2021) study periods. CONCLUSIONS: Most PCCRCs originate from possible missed lesions and incompletely resected lesions during the complete study period. These findings indicate the importance of quality assurance of colonoscopy procedures and polypectomy techniques.

Consequence modeling and root cause analysis (RCA) of the real explosion of a methane pressure vessel in a gas refinery.

Background: The present study aimed to consequence modeling and root cause analysis of the real explosion of a methane pressure vessel in separation unit of a gas refinery in Iran. Method: ology: This study was performed in a gas refinery in the south of Iran. The studied scenario was the actual scenario that occurred in the studied pressure vessel. Modeling of possible consequences was performed using PHAST 7.2 software. Also, the root causes analysis of the accident was performed using experts' brainstorming. Results: At radii of 15 and 45 m, the radiation level reaches 12.5 and 4 kW/m2, respectively. In the late explosion worst-case, the vapor cloud explodes after reaching a distance of 20 m from the pressure vessel. At radii of 20 m, 25 m, and 150 m from the center of the explosion, the pressure reaches 0.2068, 0.1379, and 0.02068 bar, respectively. In the Early Explosion Overpressure, the acceptable pressure is obtained at a distance of 193 m. Moreover, in the Early Explosion Overpressure radiation, at radii of 28 m, 38 m, and 193 m, the pressure reaches 0.2068, 0.1379, and 0.02068 bar, respectively. Conclusion: The findings revealed that creating an appropriate risk management algorithm with a focus on consequence modeling can be an effective step towards reducing losses in the process industry. This results can create a novel insight in comparing the two reactive and proactive approaches and also reveal the effectiveness of consequence modeling in reducing the severity of risks.

Regulatory Experiences with Root Causes and Risk Factors for Nitrosamine Impurities in Pharmaceuticals.

N-Nitrosamines (also referred to as nitrosamines) are a class of substances, many of which are highly potent mutagenic agents which have been classified as probable human carcinogens. Nitrosamine impurities have been a concern within the pharmaceutical industry and by regulatory authorities worldwide since June 2018, when regulators were informed of the presence of N-nitrosodimethylamine (NDMA) in the angiotensin-II receptor blocker (ARB) medicine, valsartan.  Since that time, regulatory authorities have collaborated to share information and knowledge on issues related to nitrosamines with a goal of promoting convergence on technical issues and reducing and mitigating patient exposure to harmful nitrosamine impurities in human drug products. This paper shares current scientific information from a quality perspective on risk factors and potential root causes for nitrosamine impurities, as well as recommendations for risk mitigation and control strategies.

Cause-responsibility analysis of occupational accidents in an automotive company.

The aim of this study was to determine the root causes of accidents and the responsibility rates of the parties involved in those accidents. For this purpose, 20 important accidents of an automotive company were selected and the root causes, the parties involved in the accidents and the respective responsibility rates were determined by 10 experts based on dividing into 11 Tripod Beta basic risk factors and using occupational accident tree analysis (OATA) and occupational accident component analysis (OACA) techniques. The results revealed that among the defects in the management system, the organizational system's defects had the greatest impact on the occurrence of occupational accidents. By modifying about half of the basic risk factors, 80% of occupational accidents can be controlled. Also, by focusing on monitoring and design units, the company's accidents can be reduced by up to 50%.

Participatory design of a sleep intervention with correctional supervisors using a root causes approach.

BACKGROUND: After a Design Team (DT) conducted a workforce health assessment of correctional supervisors, they selected sleep as an intervention priority, given its numerous health and work consequences. Existing workplace sleep interventions are designed with little worker input, but participatory solutions that incorporate workers' lived experiences and root causes of poor sleep may be more relevant, appropriate, and acceptable to end-users, resulting in better uptake. METHODS: The DT met bi-monthly to complete the Intervention Design and Analysis Scorecard (IDEAS) tool to brainstorm interventions that address root causes of poor sleep, and evaluate, rank, and select interventions for implementation. We conducted a qualitative review of meeting notes and worksheets from each IDEAS step, and present our findings on root causes and prioritized solutions. RESULTS: The DT consisted of two university researchers and seven members of a correctional supervisors' union, with 5-9 participants attending each meeting. IDEAS Steps 1-5 were completed in eight meetings over six months. Root causes of poor sleep included mind/body and environmental disruptions, and insufficient time. Three solutions were proposed: training on sleep hygiene, meditation, and sleep debt management; a sleep-tracking smartphone app; and a shared overtime policy based on splitting one 8-hour shift between two supervisors. CONCLUSIONS: This is the first known application of IDEAS to address sleep, and targeting root causes may result in more efficacious interventions for sleep improvement. Moreover, because IDEAS guides DTs in selecting solutions with the greatest perceived health benefits, reach, cost-effectiveness, and feasibility, it may result in more successful implementation.

Acute occupational exposures reported to the Dutch Poisons Information Center: a prospective study on the root causes of incidents at the workplace.

BACKGROUND: Hazardous substances at the workplace can cause a wide variety of occupational incidents. This study aimed to investigate the nature and circumstances of acute occupational intoxications reported to the Dutch Poisons Information Center. METHODS: During a one-year prospective study, data on the circumstances and causes of the incident, the exposure(s) and clinical course, were collected by a telephone survey with victims of an acute occupational intoxication. RESULTS: We interviewed 310 patients. Most incidents occurred in industry (25%), building and installation industry (14%) and agriculture (10%). Patients were often exposed via multiple routes. Inhalation was the most common route of exposure (62%), followed by ocular (40%) and dermal contact (33%). Acids and alkalis were often involved. Exposure often occurred during cleaning activities (33%). The main root causes of these accidents were: technical factors such as damaged packaging (24%) and defective apparatus (10%), organizational factors such as lack of work instructions (44%) and poor communication or planning (31%), and personal factors such as disregarding work instructions (13%), not (adequately) using personal protective equipment (12%) and personal circumstances (50%) such as inaccuracy, time pressure or fatigue. The majority of the patients only reported mild health effects and recovered quickly (77% within 1 week). CONCLUSIONS: Poison Center data on occupational exposures provide an additional source of knowledge and an important basis for poisoning prevention strategies related to hazardous substances at the workplace. These data are useful in deciding which risk mitigation measures are most needed in preventing future workplace injuries.

Modern slavery and labor exploitation during the COVID-19 pandemic: a conceptual model.

BACKGROUND: Modern slavery is a complex global health problem that includes forced labor exploitation. An ecological systems perspective is needed to understand how contextual upstream and midstream factors contribute to labor exploitation, and how disruptive societal challenges, such as infectious disease pandemics, may exacerbate established pathways leading to exploitation. Accumulation of familial and societal risk factors likely heightens vulnerability; for instance, economic precarity for an individual interacts with poor livelihood options and lack of social welfare supports increasing their likelihood of accepting exploitative labor. However, few frameworks exist that account for the accumulation of and interdependence between risk factors at different levels and across contexts. OBJECTIVE: Using an ecological systems framework, we review literature on the pathways leading to labor exploitation, with the aim of developing a conceptual model grounded in existing research. Next, we discuss how pathways in this conceptual model are likely exacerbated by the COVID-19 pandemic. This conceptual model can guide future research to detect modifiable factors and strategic points of intervention. METHODS: A critical review of research articles and gray literature was performed with a primary focus on sub-Saharan Africa. The review utilized various scholarly databases to identify perspectives from multiple disciplines and to more fully account for complex processes linked to labor exploitation. RESULTS: A conceptual model of these pathways was developed that emphasizes established determinants and risk factors for labor exploitation in sub-Saharan Africa. The model highlights how the COVID-19 pandemic may have exacerbated these pathways. CONCLUSIONS: Future studies should carefully examine the direct and indirect pathways, accumulation of and interactions between factors, and specific external and personal stressors. Interdisciplinary research on multilevel interventions is needed to guide solutions to prevent the persistent problem of labor exploitation.

Modern Cause and Effect Model by Factors of Root Cause for Accident Prevention in Small to Medium Sized Enterprises.

BACKGROUND: Factors related to root causes can cause commonly occurring accidents such as falls, slips, and jammed injuries. An important means of reducing the frequency of occupational accidents in small- to medium-sized enterprises (SMSEs) of South Korea is to perform intensity analysis of the root cause factors for accident prevention in the cause and effect model like decision models, epidemiological models, system models, human factors models, LCU (life change unit) models, and the domino theory. Especially intensity analysis in a robot system and smart technology as Industry 4.0 is very important in order to minimize the occupational accidents and fatal accident because of the complexity of accident factors. METHODS: We have developed the modern cause and effect model that includes factors of root cause through statistical testing to minimize commonly occurring accidents and fatal accidents in SMSEs of South Korea and systematically proposed educational policies for accident prevention. RESULTS: As a result, the consciousness factors among factors of root cause such as unconsciousness, disregard, ignorance, recklessness, and misjudgment had strong relationships with occupational accidents in South Korean SMSEs. CONCLUSION: We conclude that the educational policies necessary for minimizing these consciousness factors include continuous training procedures followed by periodic hands-on experience, along with perceptual and cognitive education related to occupational health and safety.

Análisis causal integrado en la radiosinoviortesis y el tratamiento mielosupresor de la policitemia vera / Integrated causal analysis in radiosynoviorthesis and the myelosupressor treatment of polycythemia vera

Introducción: Con la matriz de riesgo se identifican las medidas de control relevantes. El análisis de modos y efectos de fallo posterga definir la efectividad de las medidas correctivas. El uso de uno solo de estos métodos limita el alcance al evaluar los riesgos y la toma de decisiones. Objetivos: Determinar la contribución individual de las causas básicas de fallo en el riesgo radiológico de la radiosinoviortesis y el tratamiento mielosupresor de la policitemia vera, a partir del modelo de la matriz y los reportes. Métodos: Se adaptó el análisis de la gestión de la calidad en radioterapia a las prácticas en estudio y la selección individual de las causas básicas más contribuyentes al riesgo radiológico. La base internacional de incidentes aportó las causas que completaron el listado de las derivadas de la aplicación del principio de Pareto. Resultados: Los subprocesos más contribuyentes al riesgo fueron, por orden de importancia, la administración del radiofármaco, su preparación y la prescripción clínica. Para estos se identificaron las etapas, modos de fallo y sus causas más importantes. Existieron causas que contribuyeron a varios modos de fallo. El incumplimiento de procedimientos, protocolos o prácticas, la falta de entrenamiento del personal y la fatiga del personal son las causas de los riesgos identificados. Conclusiones: Se caracterizó la efectividad de las medidas correctivas de las causas más contribuyentes, las que se adicionan a las derivadas de la matriz, en el plan de mejora en la radiosinoviortesis y el tratamiento mielosupresor de la policitemia vera en Cuba(AU)

Introduction: The risk matrix identifies the relevant control measures. Failure modes and effects analysis postpones defining the effectiveness of corrective measures. Using just one of these methods limits the scope when assessing risks and making decisions. Objectives: To determine the individual contribution of the basic causes of failure in the radiological risk of radiosynoviorthesis and the myelosupressor treatment of polycythemia vera, based on the matrix model and the reports. Methods: The analysis of quality management in radiotherapy was adapted to the practices under study and the individual selection of the basic causes most contributing to radiological risk. The international incident base provided the causes that completed the list of those derived from the application of the Pareto principle. Results: The sub-processes that contributed the most to risk were, in order of importance, the administration of the radiopharmaceutical, its preparation and the clinical prescription. For these, the most important, stages, failure modes and their causes were identified. There were causes that contributed to various failure modes. Non-compliance with procedures, protocols or practices, lack of staff training and staff fatigue are the causes of the identified risks. Conclusions: The effectiveness of the corrective measures of the most contributing causes, which are added to those derived from the matrix, was characterized in the improvement plan in radiosynoviorthesis and myelosupressor treatment of polycythemia vera in Cuba(AU)

Anastomotic Leak: Toward an Understanding of Its Root Causes.

BACKGROUND: When an anastomotic leak is discussed at a typical surgical morbidity and mortality conference, it is often presented as a due to an error in surgical technique involving ischemia, tension, or device failure. Here we assert that without direct visual analysis of the leak site and its tissue histology, an ex post facto claim that an anastomotic leak is due to an error in surgical technique remains speculative. METHODS: The arguments and rationale used to conclude that an anastomotic leak is due to an error in surgical technique are critically reviewed and assessed for their validity. RESULTS: No case series or literature exists in which a root cause analysis has been carried out with visual and tissue level evidence to determine the root cause(s) of an anastomotic leak. CONCLUSIONS: At the individual case level, declaring that an anastomotic leak is due to an error in surgical technique without clear and compelling evidence either visually and/or at the tissue level to substantiate such a claim remains speculative.

Zeroing in on the root cause of the clots in a blood bag: Reinforcing improvement in blood collection practices.

Blood clots in the packed red blood cell [PRBC] unit can sometimes go unrecognized and could eventually give rise to flow problems while administering the same. We herein report our observation of a moderately elongated threadlike clot in a PRBC unit prepared from a whole blood donated by a young Indian male donor. The PRBC unit was returned to us from the ward by the nursing staff citing "flow issues". In fact, this warranted the initiation of root-cause analysis of the entire event led by two faculty members, one post-graduate student and the technical supervisor at our blood centre.

Health Care Cybersecurity Challenges and Solutions Under the Climate of COVID-19: Scoping Review.

BACKGROUND: COVID-19 has challenged the resilience of the health care information system, which has affected our ability to achieve the global goal of health and well-being. The pandemic has resulted in a number of recent cyberattacks on hospitals, pharmaceutical companies, the US Department of Health and Human Services, the World Health Organization and its partners, and others. OBJECTIVE: The aim of this review was to identify key cybersecurity challenges, solutions adapted by the health sector, and areas of improvement needed to counteract the recent increases in cyberattacks (eg, phishing campaigns and ransomware attacks), which have been used by attackers to exploit vulnerabilities in technology and people introduced through changes to working practices in response to the COVID-19 pandemic. METHODS: A scoping review was conducted by searching two major scientific databases (PubMed and Scopus) using the search formula "(covid OR healthcare) AND cybersecurity." Reports, news articles, and industry white papers were also included if they were related directly to previously published works, or if they were the only available sources at the time of writing. Only articles in English published in the last decade were included (ie, 2011-2020) in order to focus on current issues, challenges, and solutions. RESULTS: We identified 9 main challenges in cybersecurity, 11 key solutions that health care organizations adapted to address these challenges, and 4 key areas that need to be strengthened in terms of cybersecurity capacity in the health sector. We also found that the most prominent and significant methods of cyberattacks that occurred during the pandemic were related to phishing, ransomware, distributed denial-of-service attacks, and malware. CONCLUSIONS: This scoping review identified the most impactful methods of cyberattacks that targeted the health sector during the COVID-19 pandemic, as well as the challenges in cybersecurity, solutions, and areas in need of improvement. We provided useful insights to the health sector on cybersecurity issues during the COVID-19 pandemic as well as other epidemics or pandemics that may materialize in the future.

Root causes of deaths by suicide among patients under the care of a mental health trust: thematic analysis.

AIMS AND METHOD: This study explored the root causes of deaths by suicide among patients under the care of a mental health trust. Thematic analysis was carried out to identify themes from the serious incident reports for patients between 1 January 2017 and 31 July 2018. RESULTS: In total, 48 cases were reviewed. Three main themes emerged from this study: patient-, professional- and organisation-related factors. The majority of the deaths were caused by patient-related factors, particularly exacerbation of the patient's mental health condition. CLINICAL IMPLICATIONS: This study provides insight into perceived causes of death by suicide among mental health patients. It is hoped that this will, in turn, influence the manner in which decisions, policies and resource allocation are carried out to further prevent and reduce the incidence of suicide, particularly among mental health patients.

Unplanned return presentations of older patients to the emergency department: a root cause analysis.

BACKGROUND: In line with demographic changes, there is an increase in ED presentations and unplanned return presentations by older patients (≥70 years). It is important to know why these patients return to the ED shortly after their initial presentation. Therefore, the aim of this study was to provide insight into the root causes and potential preventability of unplanned return presentations (URP) to the ED within 30 days for older patients. METHODS: A prospective observational study was conducted from February 2018 to November 2018 in an academic hospital in Amsterdam. We included 83 patients, aged 70 years and older, with an URP to the ED within 30 days of the initial ED presentation. Patients, GPs and doctors at the ED were interviewed by trained interviewers and basic administrative data were collected in order to conduct a root cause analysis using the PRISMA-method. RESULTS: One hundred fifty-one root causes were identified and almost half (49%) of them were disease-related. Fifty-two percent of the patients returned to the ED within 7 days after the initial presentation. In 77% of the patients the URP was related to the initial presentation. Patients judged 17% of the URPs as potentially preventable, while doctors at the ED judged 25% and GPs 23% of the URPs as potentially preventable. In none of the cases, there was an overall agreement from all three perspectives on the judgement that an URP was potentially preventable. CONCLUSION: Disease-related factors were most often identified for an URP and half of the patients returned to the ED within 7 days. The majority of the URPs was judged as not preventable. However, an URP should trigger healthcare workers to focus on the patient's process of care and their needs and to anticipate on potential progression of disease. Future research should assess whether this may prevent that patients have to return to the ED.