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 ORIGINAL ARTICLE
Learning From Lawsuits: Using Malpractice Claims Data to
Develop Care Transitions Planning Tools
Alicia I. Arbaje, MD, MPH,*†‡ Nicole E. Werner, PhD,‡§|| Eileen M. Kasda, MHS,¶
Albert W. Wu, MD, MPH,#**†† Charles F.S. Locke, MD,**‡‡ Hanan Aboumatar, MD, MPH,§§||||¶¶##
Lori A. Paine, RN, MS,¶¶ Bruce Leff, MD,****††† Richard O. Davis, PhD,‡‡‡
and Romsai Boonyasai, MD, MPH§§¶¶##§§§
Objectives: Our understanding of care transitions from hospital to home
is incomplete. Malpractice claims are an important and underused data
source to understand such transitions. We used malpractice claims data to
(1) evaluate safety risks during care transitions and (2) help develop care
transitions planning tools and pilot test their ability to evaluate care transi-
tions from the hospital to home.
Methods: Closed malpractice claims were analyzed for 230 adult patients
discharged from 4 hospital sites. Stakeholders participated in 2 structured
From the *Division of Geriatric Medicine and Gerontology, Johns Hopkins
University School of Medicine; †Department of Clinical Investigation, Johns
Hopkins University Bloomberg School of Public Health; and ‡Center for Inno-
vative Care in Aging, Johns Hopkins University School of Nursing; §Division
of Geriatric Medicine and Gerontology, Johns Hopkins University School of
Medicine; ||Department of Industrial and Systems Engineering, University of
Wisconsin-Madison, Madison, Wisconsin. ¶Patient Safety, The Johns Hopkins
Hospital, Johns Hopkins Health System; #Epidemiology, International Health,
Johns Hopkins Bloomberg School of Public Health; **Departments of Medi-
cine and Surgery, Johns Hopkins University School of Medicine; ††Carey Busi-
ness School; ‡‡Utilization/Clinical Resource Management, Johns Hopkins
Medicine; §§Division of General Internal Medicine, Johns Hopkins University
School of Medicine; ||||Department of Health, Behavior, and Society, Johns
Hopkins University Bloomberg School of Public Health; ¶¶Johns Hopkins
Armstrong Institute for Safety and Quality; ##Welch Center for Prevention, Ep-
idemiology and Clinical Research, Johns Hopkins University; ***Department
of Health Policy and Management, Johns Hopkins University Bloomberg
School of Public Health; †††Department of Community and Public Health,
Johns Hopkins University School of Nursing; ‡‡‡Sibley Memorial Hospital,
Johns Hopkins Medicine; and §§§John Hopkins Center to Eliminate Cardiovas-
cular Health Disparities, Baltimore, Maryland.
Correspondence: Alicia I. Arbaje MD, MPH, Division of Geriatric Medicine
and Gerontology, Johns Hopkins University School of Medicine, Mason
F. Lord Bldg, Center Tower, 5200 Eastern Ave, 7th Floor, Baltimore, MD
21224 (e‐mail: aarbaje@jhmi.edu).
This study was supported by funding from the Agency for Healthcare Research
and Quality (R21 HS019519-01).
A.I.A. and N.E.W. currently receive grant support from the following sources:
the National Patient Safety Foundation, the Agency for Healthcare
Research and Quality, and the Center for Innovative Care in Aging at the
Johns Hopkins School of Nursing.
A.W.W. is a consultant to BMS, Genentech, Otsuka, and Pfizer and has an
educational grant from the PhRMA Foundation. He is a member of the
National Quality Forum Patient Safety Standing Committee. He is
supported by grants and contracts from the Agency for Healthcare Research
and Quality, the Patient Centered Outcomes Research Institute, the National
Institutes of Health, and AIG Corporation. He receives royalties from the
Joint Commission for his book The Value of Close Calls in Improving
Patient Safety. The financial interests of A.W.W. have been reviewed by the
Johns Hopkins University in accordance with its institutional policies.
H.A. currently receives grant support from the following sources: the National
Institutes of Health, the Patient Centered Outcomes Research Institute, and
the Gordon and Betty Moore Foundation.
R.B. currently receives grant or contract support from the following sources: the
Agency for Healthcare Research and Quality, the National Institutes of Health,
the Patient Centered Outcomes Research Institute, and the American Medical
Association for research related to improving quality of care and reducing
health care–related disparities; and the Center for Medicare and Medicaid
Services for implementation of a health systems innovation program.
Supplemental digital contents are available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions
of this article on the journal's Web site (www.journalpatientsafety.com).
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Patient Saf • Volume 00, Number 00, Month 2015
Copyright © 2016 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
focus groups to review concerns. This led to the development of 2 care
transitions planning tools—one for patients/caregivers and one for frontline
care providers. Both were tested for feasibility on 53 patient discharges.
Results: Qualitative analysis yielded 33 risk factors corresponding to hos-
pital work system elements, care transitions processes, and care outcomes.
Providers reported that the tool was easy to use and did not adversely affect
workflow. Patients reported that the tool was acceptable in terms of length
and response burden. Patients were often still waiting for information at the
time they applied the tool.
Conclusions: Malpractice claims provided insights that enriched our un-
derstanding of suboptimal care transitions and guided the development of care
transitions planning tools. Pilot testing suggested that the tools would be fea-
sible for use with minor adjustment. The malpractice data can complement
other approaches to characterize systems failures threatening patient safety.
Key Words: care transitions, discharge planning, patient safety,
malpractice claims, dashboard, measure development
(J Patient Saf 2015;00: 00–00)
D espite more than 2 decades of efforts to improve patient
safety, care transitions in health care remain a point of in-
creased risk in patient care. Care transitions refer to the movement
of patients from one provider or health care setting to another,1
such as from the hospital to a skilled nursing facility. The
hospital-to-home transition represents a key hazard point for
lapses in coordination and communication, which serve as impor-
tant drivers of adverse outcomes and malpractice claims. Effective
care transitions require thorough and precise coordination and
communication of information among health care providers, pa-
tients, and caregivers. All of the individuals involved may fail to
execute tasks successfully during care transitions,2,3 which can
lead to adverse health events, unplanned hospital readmission,
poor patient and family satisfaction, and malpractice claims.3–11
Malpractice Claims as a Data Source for
Improving Care Transitions
Despite substantial research in the area of care transitions, re-
admission rates continue to be high, adverse events associated
with care transitions remain an issue, and patients are often dis-
satisfied with the quality of their care.4,12 Many of the adverse
outcomes associated with suboptimal care transitions go unrec-
ognized by the hospital system in part because several occur after
hospital discharge. It falls upon other actors within the system—
post–acute care sites, home health agencies, primary care pro-
viders, patients, and caregivers—to recognize and “pick up the
pieces.” A number of models have been developed to improve
transitions from hospital to home.13–18 However, the best prac-
tices by which to improve care transitions are not clear in part be-
cause intervention efforts are often disease13,14,18–21 or setting
specific15,21,22 and vary widely. In addition, previous studies of
suboptimal care transitions have used epidemiologic methods to
identify clinical risk factors. Less is known about system-level
www.journalpatientsafety.com 1
Arbaje et al
risk factors, such as care processes within a hospital, which con-
tribute to suboptimal care transitions.23,24 This suggests that there
is a gap in our approach for how to improve transitions.
Medical malpractice claims are a potentially rich source of
information about suboptimal care transitions. Malpractice claims
related to suboptimal care transitions represent egregious mishaps
and/or marked patient dissatisfaction, and claims can provide im-
portant information regarding underlying system-level risk fac-
tors. Many claims involve sentinel events, from which the health
system can learn about how to improve health care quality and re-
duce future risk of liability—an opportunity to “make medical er-
rors into medical treasures.”25 Malpractice claims analyses have
made important contributions to patient safety in other areas of
health care,26–30 and claims analyses offer strengths for evaluating
the quality of care transitions: (1) claims integrate documentation
from both formal legal inquiries and confidential internal investi-
gations, and claims can provide detailed descriptions of care, in-
cluding information that is not always available in medical
records26,27,30; (2) claims are likely to have information regarding
an entire episode of care that spans across care settings and time.
Combining malpractice claims with clinical documentation
and reports of adverse events can inform the development of a
conceptual model to guide the development of new care transi-
tions planning tools. New tools are needed because current tools
to measure and improve care transition quality31–33 are incomplete
and do not typically provide real-time feedback. Thus, the objec-
tives of this study were to (1) evaluate safety risks during care tran-
sitions that have led to malpractice claims and (2) use the claims to
help develop care transitions planning tools and to pilot test their
ability to evaluate care transitions from the hospital to home.
METHODS
Overview
We undertook a multistep process to achieve the stated objec-
tives. First, we conducted a content analysis of malpractice claims
and used the results to inform the development of a conceptual
model of safety risks during care transitions associated with mal-
practice claims. Then, we conducted structured focus groups in
which participants rated elements of the conceptual model and
used the results to create 2 care transitions planning tools—one
to be used by patients/caregivers and one for frontline care pro-
viders. Finally, we conducted initial feasibility testing of the tools.
This study was approved by a Johns Hopkins School of Medicine
Institutional Review Board.
Content Analysis of Malpractice Claims
Related to Care Transitions
We developed a process to extract and analyze malpractice
claims related to care transitions. Summaries of closed malprac-
tice claim files for the past 10 years involving patients 18 years
and older were obtained from the institution's malpractice insur-
ance carrier (MCIC Vermont). A multidisciplinary research team
of patient safety experts, health services researchers, primary care
and hospital-based providers, and administrative leaders devel-
oped a case definition that was used by 9 expert reviewers to re-
view these claims for relevance to care transitions. A transition-
of-care event was defined as follows: (1) an event occurring after
discharge from an acute care facility in our health system and
(2) an event clearly involving the suboptimal transfer of equip-
ment (dentures, hearing aids, glasses, prosthetics, assistive de-
vices, and others), knowable information (diagnoses, test results,
complications), or components of the management plan at the
time of discharge (aftercare, monitoring, follow-up). The claims
2 www.journalpatientsafety.com
Copyright © 2016 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
J Patient Saf • Volume 00, Number 00, Month 2015
that achieved 75% or more interreviewer agreement and deemed
likely to involve a suboptimal care transition were selected for full
review of the litigation record and associated documents (medical
records, patient complaint documents, risk management files, and
incident event documents from patient safety reporting systems).
Closed malpractice claims were analyzed for patients
18 years and older, hospitalized and discharged from 4 hospital
sites affiliated with an academic medical center (n = 230). Two
of the 4 hospitals were teaching hospitals. One hospital had ap-
proximately 1000 licensed beds, and the other 3 had between
200 and 400 licensed beds each. All claims were opened between
January 1, 2000, and December 31, 2009, and included an adverse
event that occurred after discharge from the hospital. To protect
confidentiality and privilege, claims were redacted of sensitive
or identifying information before analysis (e.g., financial informa-
tion, details of legal strategy).
A qualitative approach was used to extract a broad set of risk
factors related to a suboptimal care transition from the malpractice
data. We defined risk factor to be any attribute or characteristic at
the patient or system level that was present in our review of cases
and that could potentially increase the likelihood of a suboptimal
care transition (i.e., care that was not safe and/or did not meet the
patient's or informal caregiver's expectations). First, 3 investiga-
tors (A.I.A., E.M.K., and R.T.B.) reviewed a subsample of cases
to develop a preliminary coding template based on concepts
emerging from the review.34 The coding template was reviewed
by the entire multidisciplinary research team and refined for use
in subsequent case reviews. Resulting coding changes were ap-
plied retroactively to all previously coded cases. All of the cases
were reviewed independently by at least 2 investigators, and differ-
ences were reconciled by consensus. The qualitative research soft-
ware, ATLAS.ti, was used to facilitate data analysis (ATLAS.ti
Scientific Software Development, Berlin, Germany).
Development of Care Transitions Planning Tools
Through Focus Group Ratings of Elements of
Conceptual Model
Risk factors within the conceptual model were rated and pri-
oritized for inclusion in the tools through a series of 2 structured
focus groups with key stakeholders. The care transitions planning
Tool Development Group (TDG) consisted of inpatient physi-
cians, ambulatory physicians, patient safety officers, and senior
health system executives in safety and quality. The steps com-
pleted by TDG members were as follows: (1) conducted a series
of facilitated discussions to prioritize the conceptual domains in
terms of importance to improving patient safety during care
transitions and reducing risk for litigation associated with hos-
pital discharge processes; (2) proposed a list of candidate mea-
sures for monitoring the quality of care transitions planning; and
(3) narrowed the list of proposed measures and assembled them
into 2 brief survey instruments that served as care transitions
planning tools, one intended for use with frontline inpatient
care providers and another intended for patients and their
families/caregivers at hospital discharge (see online supplement,
http://links.lww.com/JPS/A32).
Feasibility Testing of Care Transitions
Planning Tool
Feasibility testing of the tools was conducted on 53 patient
discharges from an inpatient general medical nursing unit during
a 2-week period. To test the feasibility of applying the tools in op-
erational settings, we recruited staff from a 17-bed inpatient gen-
eral medical patient care unit at one of the hospital sites, which
was already engaged in process improvement efforts to improve
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Patient Saf • Volume 00, Number 00, Month 2015
care transitions at the time of discharge. This unit was chosen be-
cause of the presence of institutional champions and strong staff
awareness of the importance of improving care transition quality.
This allowed for frank feedback that facilitated feasibility testing.
Each morning, except for weekends and holidays, physi-
cians, nurses, social workers, and other hospital staff on this unit
participated in a 90-minute “multidisciplinary rounds,” (MDRs)
led by the unit's nurse case manager and attended by the unit's so-
cial worker, utilization nurse, pharmacist, dietician, physical and
occupational therapists, and each patient's nurse and hospitalist
physician. The purposes of this meeting were to (1) review each
patient's care plan daily, (2) promote early discharge planning,
and (3) identify and address issues that might arise after hospital
discharge. Typically, unit staff spent less than 5 minutes discussing
each patient.
To identify potential barriers to administering the tools, pro-
ject investigators attended MDRs to observe hospital workers
using the frontline provider tool and separately interviewed dis-
charged patients and their caregivers to obtain responses to the pa-
tient tool independent of those obtained by unit nurses. The
investigators observed MDR workflow and patient-nurse interac-
tions for usability concerns related to the tools and recorded inde-
pendent responses to the provider and patient tools. Differences
between responses recorded by hospital unit staff and those re-
corded by project investigators were compiled and discussed with
the unit case manager afterward.
The frontline provider tool was administered for each patient
who was planned for discharge during the hospital unit's MDR
(n = 19). The provider tool was integrated into the MDR workflow
by enlisting the unit case manager to verbally administer the tool
to the all MDR attendees as a group whenever a patient was iden-
tified as planned-for-discharge that day. The unit case manager
recorded the responses of the group as a whole. Unit nurses admin-
istered and completed the patient tool at the time of discharge when
they provided patient/family education (n = 53). Data were col-
lected on paper and later submitted to the project investigators.
RESULTS
Content Analysis of Malpractice Claims
Related to Care Transitions
The content analysis of claims yielded 33 risk factors to sub-
optimal care transitions corresponding to domains of the hospital
work system, care transitions processes, and outcomes of care.
Table 1 represents a list of these factors and their definitions.
For each litigation claim, we reviewed the associated medical re-
cords, patient complaint documents, risk management files, and
incident event reporting documents from patient safety reporting
systems. The factors in Table 1 from the claims analysis repre-
sented a distinct set of factors related to suboptimal care transi-
tions, revealing little overlap across the different reporting
methods (litigation claims, patient relations reports, and patient
safety reporting systems).
Care Transitions Planning Tool Through Focus
Group Ratings of Elements
With the use a series of 3 structured rating exercises, the
TDG converted the risk factors into 2 care transitions planning
tools. The frontline provider tool is an 8-item instrument designed
for administration during hospital multidisciplinary discharge
rounds before hospital discharge. It is intended to identify con-
cerns of frontline, inpatient care providers. The patient tool is a
4-item instrument intended for administration to patients and their
families/caregivers immediately before hospital discharge. The
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2016 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Improving Transitions by Learning from Lawsuits
purpose of these tools is to be used as both (1) an intervention
to raise awareness of care transition planning issues in real time
(as the patient is being discharged) and (2) a measure for monitor-
ing the quality of care transition planning. Copies of both instru-
ments are included in the Appendix (Supplemental Digital Content,
http://links.lww.com/JPS/A36).
Feasibility Testing of Care Transitions
Planning Tools
Feasibility testing yielded several insights. Hospital case
managers who administered the provider tool reported that the in-
struments were easy to use and did not affect the flow of multidis-
ciplinary rounds. However, case managers noted that it was
important to actively seek responses from all participants, as some
later reported that members of the multidisciplinary team did not
raise certain issues out of concern it would delay rounding. Pro-
viders also expressed concern about identifying and documenting
problems on the anticipated discharge day, as many issues they
identified (e.g., chronic substance abuse or absence of social sup-
port at home) were problems that they were unable to address di-
rectly. If the care team had concerns about patients' readiness for
discharge (e.g., patient needing additional tests, consultations, or
education before discharge), the team at times did not know dur-
ing morning rounds if the issue had been addressed. The use of
the tool prompted team members to communicate about these is-
sues before discharge and act upon unresolved issues.
Patients who received the patient tool reported that the instru-
ment was acceptable in terms of length and response burden. The
primary concern identified during feasibility testing of the tools is
that patients and their caregivers often were still waiting for infor-
mation (e.g., about postdischarge appointments or about test re-
sults) at the time they encountered the tool. When they did have
the information, patients specifically reported that the care plan
seemed appropriate.
DISCUSSION
We used malpractice claims to guide the development of care
transitions planning tools. The pair of tools captured the experi-
ences of health care providers, patients, and families, to identify
which patients are at risk for safety problems after they leave the
hospital. The purpose of these tools was to be used as both
(1) an intervention to raise awareness of care transition planning
issues in real time (as the patient is being discharged) and (2) as
a measure for monitoring the quality of care transition planning.
Implementation of these instruments in an initial pilot study
yielded lessons about feasibility and further modifications.
The results of this study were important because they led to a
novel approach to combine claims data and clinical data for use
in patient safety analyses and to the development of new tools to
aid in hospital discharge. There were several important lessons
learned from this study. First, in analyzing the claims, we found
little overlap among litigation claims, patient relations reports,
and patient safety reporting systems. This suggests that the exam-
ination of claims helped to identify a unique set of risk factors for
suboptimal care transitions. Second, these risk factors corresponded
to not only patient-specific clinical factors but also factors related to
the hospital work system, care transitions processes, and outcomes
of care. This suggests, as others have,23,24 that broader targets po-
tentially can be helpful in care transitions planning. Broader tar-
gets identified in this work include identifying the following
situations: patients whose expectations have not been met; pa-
tients who required additional interventions by others (family,
friends, network) to meet their needs; patients experiencing an ad-
verse event; patients with unsuccessful attempts to access health
www.journalpatientsafety.com 3
Arbaje et al
TABLE 1. Risk Factors to Suboptimal Care Transitions and Definitions Resulting From Qualitative Analysis
Risk Factors Related to
Suboptimal Transitions
Additional interventions by others
Adverse event—diagnostic error
Adverse event—medication error
Adverse event—procedure
Adverse event or complication
Breach of confidentiality
Care fragmentation
Complaint to staff, patient relations,
risk management
Complicated medical history
Complication—nosocomial infection
Concern—health-related goals not met
Concern—lack of apology
Concern—not understanding
follow-up or self-care plan
Concern—premature discharge
Concern—suboptimal care
Concern—undue suffering, lost
productivity, costs
Confirmation in medical record
Delay—care or follow-up
Delay—notification of
important information
Frequent encounters with health care
system after discharge
Harassment by billing office
Lack of documentation
On high-risk medications
Previous experience with
adverse events
Prolonged length of stay or recovery
Special status
Suboptimal communication—across
care settings
Suboptimal communication—among
providers
Suboptimal communication—discharge
or follow-up plan
Suboptimal
communication—findings/test results
Suboptimal communication—lack of
adequate informed consent
Unresolved medical issues/symptoms
Unsuccessful attempts to access care
care in the organization; or providers experiencing difficulty coor-
dinating or communicating about care plans. These broader
targets highlight the importance of providing feedback to and
4 www.journalpatientsafety.com
Copyright © 2016 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
J Patient Saf • Volume 00, Number 00, Month 2015
Definition of Risk Factor
Person received additional interventions/advocacy from others (e.g., family, friends, caregiver,
personal connections) to get needs met.
An error in diagnosis occurred.
An error related to medications occurred (e.g., error in administration or choice of medication).
An error related to a procedure occurred.
Person experienced an adverse event or complication during hospitalization or after discharge.
Please use this code if the other more specific “adverse event” codes are not applicable. Please
also specify what type of adverse event or complication occurred.
Breach of confidentiality of personal health information.
Care fragmented across providers or settings. Examples may include person receiving conflicting
information from multiple sources, providers unaware of what other providers are doing, or lack
of unified source of information.
Person made a complaint to staff, patient relations office, or risk management before
claim being filed.
Person has a complicated medical history that is contributing to their risk of adverse events.
Person experienced or is concerned about the acquisition of a nosocomial infection.
Person felt that their health-related goals were not met (e.g., did not experience expected recovery,
did not receive explanation for symptoms).
Person concerned that they have not received an adequate apology for harm done.
Person did not understand follow-up or self-care plan (e.g., type of monitoring needed, medication
management, additional tests/procedures, follow-up appointments).
Person concerned that discharge occurred too soon.
Person concerned about the delivery of suboptimal or substandard care.
Person concerned about adverse event or complication resulted in undue suffering, lost
productivity, high costs.
Notation in medical record that confirms a statement made elsewhere in the claims file.
A delay in care or follow-up occurred.
A delay in notification of important information occurred (e.g., test results, diagnoses).
Person has experienced frequent encounters with the health care system after discharge. This may
include visits to the emergency department, other outpatient/postacute sites of care (clinics,
rehabilitation, skilled nursing facilities), or to the hospital.
Continued requests to the patient to pay outstanding bills.
There was a lack of documentation describing needed information.
Person is on medications that require frequent monitoring or changes in dose. Examples may
include blood thinners (warfarin), diuretics (furosemide), psychiatric medications.
Person has personally experienced an adverse event or has witnessed another experience an
adverse event (e.g., family, friends, colleagues) before hospitalization.
Person has experienced a hospitalization or recovery that has taken longer than anticipated.
Patient works in health care, law, or is connected to our healthcare institution
There was suboptimal communication across sites of care (e.g., emergency department, hospital,
skilled nursing facility, rehabilitation facility, home health care agency, ambulatory clinic).
There was suboptimal communication among health care providers (e.g., nurses, consultants,
primary care physicians, discharge planners, home health care nurses).
There was suboptimal communication about the discharge or follow-up plan (e.g., medications,
durable medical equipment, monitoring, appointments, services needed).
There was suboptimal communication about findings or test results.
There was suboptimal communication about anticipated complications of a treatment or procedure.
Person has medical issues or symptoms that are unresolved (i.e., no definitive explanation for cause
or still ongoing).
Person tried to access care (e.g., request to speak to health care professional, request for
appointment) but was unsuccessful.
soliciting feedback from patients and informal caregivers as well
as “sending” and “receiving” health care providers before, during,
and after the care transition. Third, the collection of real-time
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Patient Saf • Volume 00, Number 00, Month 2015
information using our care transitions planning tools identified
potential suboptimal care during transitions at a point well before
a claim might be filed. Feasibility testing of these tools yielded
several insights that will shape further development of the care
transitions planning tools.
Our study had some limitations. Claim files represent highly
selected cases from which it can be difficult to generalize. They
may also be subject to hindsight bias and other biases.35 However,
claims file analysis also has some strengths relative to other
methods, most prominently its ability to detect latent errors as well
as including information from several different perspectives.36
Given the high rates of rehospitalizations and postdischarge ad-
verse events that have been reported previously, our examination
of malpractice claims and associated documents likely under-
estimated the prevalence of care transitions issues in our organiza-
tion. One reason for this may be that certain kinds of failures, such
as suboptimal care transitions, are reported through mechanisms
other than the legal system. Moreover, many suboptimal care tran-
sitions are likely not reported at all because robust mechanisms for
reporting are often not in place after discharge, a time when many
care transition deficiencies are detected. This suggests that using
hospital documentation systems to comprehensively examine sub-
optimal care transitions will require combining and integrating
multiple sources of event reporting. The processes developed for
this project may also be used to examine other kinds of nonstruc-
tured administrative documents, such as patient complaints.
Suboptimal care transitions represent a broad concept in health
care delivery. Many patients and providers may not identify sub-
optimal care during transitions as readily as they might identify
other suboptimal outcomes that arise in care delivery, such as
postprocedure wound infections, for example. Moreover, some
risk factors identified in our study may seem more obviously re-
lated to care transitions than others, yet the common theme is that
the risk factors were identified in care transitions-related claims
and can contribute to patient harm. In other words, although the
presence of an individual risk factor in isolation may not necessar-
ily lead to a malpractice claim, several risk factors taken together
could lead to harm and a subsequent claim. It is also important
to note that the underrecognition of suboptimal care transitions
may also stem in part from a lack of a standardized classification
system for malpractice claims. Malpractice insurers and health care
organizations can further modify the criteria used in this study to
identify claims related to suboptimal care transitions for quality im-
provement purposes.
Potential Usefulness of the Care Transitions
Planning Tools
There are several areas of potential usefulness for the care
transitions planning tools developed in this study. First, the pau-
city of practical measures for monitoring suboptimal care transi-
tions processes poses a barrier to effectively addressing safety
risks during care transitions. The care transitions planning tools
developed by this project add to the few tools available to clinical
teams, hospital executives, and other health care leaders.23,37
Second, the tools could be used to provide real-time feedback
regarding care transitions processes. Providing real-time feedback
to health care providers is a critical step in improving patient
safety and ensuring sustainability of improvement efforts.38–41
In health care settings, the critical nature of real-time feedback
has been demonstrated in areas of service improvement, reduction
of bloodstream infections, and operating room safety, among
others.39,42–45 Particularly relevant to care transitions, real-time
feedback was the most important driver of error reduction during
care transitions within a hospital in a recent study.46 Providing
real-time feedback would allow organizations to develop and
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2016 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Improving Transitions by Learning from Lawsuits
implement action plans and build “recovery scenarios”23 to ad-
dress challenges identified by the tools.
Third, the care transitions planning tools provide information
from multiple perspectives. A consensus document by the U.S. Na-
tional Transitions of Care Coalition47 outlines 3 perspectives from
which information needs to be obtained to fully address optimal care
coordination and transitions: (1) patient/family, (2) health care profes-
sional, and (3) health care system.31 The tools complement existing
measures examining care transitions and incorporate the 3 perspec-
tives outlined by U.S. National Transitions of Care Coalition. Next
steps for this effort will be to revise the tools and administration pro-
cedures based on lessons learned from feasibility testing, retesting
the revised tools, and further dissemination of these instruments
as part of efforts to improve care transitions planning processes.
Finally, lower-than-expected case identification in malprac-
tice claims and limited overlap between claims documents and
those from patient relations, patient safety, and risk management
sources suggest the need to not rely on one source of information
and instead combine multiple sources of event reporting when
studying suboptimal care transitions. The process developed for
this study may be applied to any of these nonstructured records.
CONCLUSIONS
Care transitions represent a point of heightened risk in the care
of patients and an opportunity to prevent harm. Strategies to iden-
tify increased risks of suboptimal care during transitions may
complement efforts to reduce readmissions, lower health care costs,
and decrease patient adverse events. The conceptual model devel-
oped in this study can be used to complement other approaches to
characterize and monitor systems failures during care transitions
at hospital discharge. This study confirmed observations that noted
a need for practical measures for monitoring care transitions pro-
cesses within health care organizations. The care transitions plan-
ning tools developed during this project promise to add to the
limited number of tools currently available to health care leaders.
Evaluating and synthesizing concerns drawn from malpractice
claims provided insights that enrich our understanding of subopti-
mal care transitions and the development of care transitions plan-
ning tools. Pilot testing of the tools suggests that they would be
feasible for use with minor adjustment. The malpractice data ap-
proach can be used to complement other approaches to character-
ize systems failures threatening patient safety.
ACKNOWLEDGMENTS
The authors acknowledge the contributions of Lauree
Barreca and Margaret Garrett, senior counsel for Johns Hopkins
Medicine; Michelle Goldfarb, former director, Loss Prevention &
Patient Safety, MCIC Vermont, for providing this study with access
to the litigation documents used in this study; Renee Demski, se-
nior director, Quality Improvement, The Johns Hopkins Hospital
and Johns Hopkins Health System; Margaret Neely, case manager
at Johns Hopkins Hospital; and Modupe Savage, nurse manager
at Johns Hopkins Hospital for their support with the implementa-
tion and feasibility testing of the patient and provider tools.
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