Learning From Lawsuits: Using Malpractice Claims ...

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 transitions 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 Innovative 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 Medicine and Surgery, Johns Hopkins University School of Medicine; ††Carey Business 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, Epidemiology 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 Cardiovascular 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: [email protected]). 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

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 hospital 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 understanding of suboptimal care transitions and guided the development of care transitions planning tools. Pilot testing suggested that the tools would be feasible 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)

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espite more than 2 decades of efforts to improve patient safety, care transitions in health care remain a point of increased 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 important drivers of adverse outcomes and malpractice claims. Effective care transitions require thorough and precise coordination and communication of information among health care providers, patients, 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, readmission rates continue to be high, adverse events associated with care transitions remain an issue, and patients are often dissatisfied with the quality of their care.4,12 Many of the adverse outcomes associated with suboptimal care transitions go unrecognized 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 providers, 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 practices by which to improve care transitions are not clear in part because 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

Copyright © 2016 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

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risk factors, such as care processes within a hospital, which contribute 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 important information regarding underlying system-level risk factors. Many claims involve sentinel events, from which the health system can learn about how to improve health care quality and reduce future risk of liability—an opportunity to “make medical errors 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 investigations, and claims can provide detailed descriptions of care, including 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 transitions 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 objectives of this study were to (1) evaluate safety risks during care transitions 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 objectives. 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 malpractice 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 providers. 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 malpractice claim files for the past 10 years involving patients 18 years and older were obtained from the institution's malpractice insurance carrier (MCIC Vermont). A multidisciplinary research team of patient safety experts, health services researchers, primary care and hospital-based providers, and administrative leaders developed a case definition that was used by 9 expert reviewers to review these claims for relevance to care transitions. A transitionof-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 equipment (dentures, hearing aids, glasses, prosthetics, assistive devices, 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

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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 approximately 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 information, 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 investigators (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 applied retroactively to all previously coded cases. All of the cases were reviewed independently by at least 2 investigators, and differences were reconciled by consensus. The qualitative research software, 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 prioritized 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 physicians, ambulatory physicians, patient safety officers, and senior health system executives in safety and quality. The steps completed 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 hospital discharge processes; (2) proposed a list of candidate measures 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 operational settings, we recruited staff from a 17-bed inpatient general 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.



care transitions at the time of discharge. This unit was chosen because 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, physicians, 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 social 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, project investigators attended MDRs to observe hospital workers using the frontline provider tool and separately interviewed discharged patients and their caregivers to obtain responses to the patient tool independent of those obtained by unit nurses. The investigators observed MDR workflow and patient-nurse interactions for usability concerns related to the tools and recorded independent responses to the provider and patient tools. Differences between responses recorded by hospital unit staff and those recorded 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 identified as planned-for-discharge that day. The unit case manager recorded the responses of the group as a whole. Unit nurses administered and completed the patient tool at the time of discharge when they provided patient/family education (n = 53). Data were collected 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 suboptimal 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 records, 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 represented a distinct set of factors related to suboptimal care transitions, 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 concerns 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.

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 monitoring the quality of care transition planning. Copies of both instruments 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 instruments were easy to use and did not affect the flow of multidisciplinary 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. Providers 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 support at home) were problems that they were unable to address directly. 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 during morning rounds if the issue had been addressed. The use of the tool prompted team members to communicate about these issues before discharge and act upon unresolved issues. Patients who received the patient tool reported that the instrument 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 information (e.g., about postdischarge appointments or about test results) 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 experiences 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 examination 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 potentially can be helpful in care transitions planning. Broader targets identified in this work include identifying the following situations: patients whose expectations have not been met; patients who required additional interventions by others (family, friends, network) to meet their needs; patients experiencing an adverse event; patients with unsuccessful attempts to access health www.journalpatientsafety.com


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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

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.

care in the organization; or providers experiencing difficulty coordinating or communicating about care plans. These broader targets highlight the importance of providing feedback to and

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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.



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 adverse events that have been reported previously, our examination of malpractice claims and associated documents likely underestimated the prevalence of care transitions issues in our organization. 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 transitions 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 suboptimal 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 nonstructured administrative documents, such as patient complaints. Suboptimal care transitions represent a broad concept in health care delivery. Many patients and providers may not identify suboptimal 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 related 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 necessarily 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 improvement 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 paucity of practical measures for monitoring suboptimal care transitions 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.

Improving Transitions by Learning from Lawsuits

implement action plans and build “recovery scenarios”23 to address challenges identified by the tools. Third, the care transitions planning tools provide information from multiple perspectives. A consensus document by the U.S. National 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 professional, and (3) health care system.31 The tools complement existing measures examining care transitions and incorporate the 3 perspectives outlined by U.S. National Transitions of Care Coalition. Next steps for this effort will be to revise the tools and administration procedures 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 malpractice 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 identify 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 developed 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 processes within health care organizations. The care transitions planning 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 suboptimal care transitions and the development of care transitions planning tools. Pilot testing of the tools suggests that they would be feasible for use with minor adjustment. The malpractice data approach can be used to complement other approaches to characterize 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, senior 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 implementation and feasibility testing of the patient and provider tools. REFERENCES 1. Coleman EA, Boult C; American Geriatrics Society Health Care Systems Committee. Improving the quality of transitional care for persons with complex care needs. J Am Geriatr Soc. 2003;51:556–557. 2. Anderson G, Herbert R, Zeffiro T, et al. Partnership for Solutions: Better Lives for People with Chronic Conditions. 2004. Available at: http://www.partnershipforsolutions.org/. Accessed September 8, 2015. 3. Benioff MR, Lazowski ED. Revolutionizing Health Care through Information Technology: Report to the President. Washington, DC:



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