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Risk factors for unexpected death in patients identified by a communication and resolution program
Journal article   Open access   Peer reviewed

Risk factors for unexpected death in patients identified by a communication and resolution program

Peter Lodato, Neal D. Goldstein, Alexandra M. Mapp, Adebayo Gbadebo and Stephen A. Pearlman
Frontiers in health services, v 5, 1712574
21 Nov 2025
url
https://doi.org/10.3389/frhs.2025.1712574View
Published, Version of Record (VoR) Open

Abstract

CANDOR CRP communication and resolution disparities patient safety SDOH patient harm social drivers of health
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 2,360 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.

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Collaboration types
Domestic collaboration
Web of Science research areas
Health Care Sciences & Services
Public, Environmental & Occupational Health
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