ORIGINAL RESEARCH article
Front. Health Serv.
Sec. Patient Safety
This article is part of the Research TopicResponding to Harm with Compassion, Accountability and TransparencyView all 11 articles
Risk Factors for Unexpected Death in Patients Identified by a Communication and Resolution Program
Provisionally accepted
Pete Lodato, MPH, CPHQ, LSSGB1
Neal D Goldstein2,3
Alexandra M Mapp4
Adebayo Gbadebo4
Stephen Pearlman5,6*- 1Department of Patient Safety and Accredidation, Christiana Care Health System, Wilmington, United States
- 2Department of Epidemiology and Biostatistics, Drexel University Dornsife School of Public Health, Philadelphia, United States
- 3Department of Microbiology and Immunology, Drexel University College of Medicine, Philadelphia, United States
- 4Institute for Research on Equity and Community Health (iREACH), Christiana Care Health System, Wilmington, United States
- 5Department of Clinical Effectiveness, Christiana Care Health System, Wilmington, United States
- 6Department of Pediatrics, Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, United States
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Many patients experience unexpected harm while receiving healthcare, with a lasting impact on patients, families, and caregivers. Communication and Resolution Programs are being adopted with increased frequency, as a more systematic, transparent, and equitable approach to these unexpected outcomes. The aim of this study was to identify whether demographic factors played a role in identifying patients with unexpected death, as managed in our CRP. This nested case-controlled compared 236 patients who experienced an unanticipated death with 2360 controls who died expectedly over a 10-year period. Patients with unexpected death were more likely to be Black (AOR 2.18 95% CI 1.01-4.68), higher comorbidity burden (AOR 1.07 per additional co-morbidity, 95% OR 1.01-1.14), and a lower Relative Expected Mortality (AOR: 5.39; 95% CI: 1.76-16.55). Awareness of these demographic risk factors for unexpected mortality may lead to changes in how these patients are evaluated and treated. Communication and Resolution Programs can be used to identify the patients at the highest risk for unexpected outcomes.
Keywords: Candor, crp, Communication and Resolution, disparities, Patient Safety, SDOH, patient harm, social drivers of health
Received: 24 Sep 2025; Accepted: 07 Nov 2025.
Copyright: © 2025 Lodato, MPH, CPHQ, LSSGB, Goldstein, Mapp, Gbadebo and Pearlman. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
* Correspondence: Stephen Pearlman, spearlman@christianacare.org
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