In the setting of an existing litigious environment and using the opportunity to learn from errors to improve care, this retrospective analysis examined patient claims from an institution’s risk managers to determine contributing factors. In the majority of cases, investigators identified at least one preventable factor, with communication failures serving as the most common factor associated with adverse events. Results include breakdown of the specific factors and adverse events analyzed, including a graphic example of the process used to tabulate findings. The authors suggest that this method for analysis provides important opportunities for quality improvement efforts, and continued collaboration among providers, risk managers, and institutional leadership will lead to greater research and improved patient safety from this important resource.