Introduction: Emergency Department (ED) return visits leading to admission (RVs) are a well-recognized quality metric that can potentially signal gaps in patient care. Routine capture, investigation and monitoring of monthly ED RVs provides a better understanding of patient and visit- level factors associated with a return, which can then inform system-level quality improvement (QI) opportunities. The objective of this study is to develop a sustainable database that routinely tracks and analyzes pediatric ED RVs in a large Canadian children’s hospital to understand recurring themes and inform QI initiatives. Methods: Using a computerized record system, all 72-hour RVs are collected and reviewed for patient and visit-level variables. Clinicians receive monthly notification of their RVs and assist with completing root cause analyses. Ongoing cumulative analyses using descriptive statistics and t-test analysis are reviewed to identity trends and predictors of RVs. Targeted solutions are sought to address system-level themes through educational, quality, safety and administrative avenues. Results: The RV database contains almost three years of data analyzing approximately 1,500 cases, equaling 0.75% of our annual ED patient volumes. RVs have higher acuity scores on both their index and return visit (P=0.001) and children under 12 months of age have significantly higher rates of return (24% vs 16%, P<0.001). A consultation service was involved during 31% of the index ED visits, with the top three consultants being Hematology/Oncology (23%), General Surgery (12%), and Neurology (8%). The root cause of the majority of RVs were related to disease progression (65%), while 8% were call-backs for positive blood cultures or discrepant results, and 6% were categorized as a misdiagnoses. Completed quality improvement initiatives to date include the ED Sickle Cell Optimization Program, the Culture Follow-up and Escalation Algorithm, and the Young Infant Fever Pathway and Order Set. Conclusion: Routine monitoring and investigation of ED RVs provides a proactive approach to seeking improvement opportunities. With a better understanding of specific patient and visit-level factors associated with RVs, future system-level quality improvement initiatives can be targeted.