Common Factors | Fall 2022

HEAL- Four Core Services

Spotlighting cases that benefit from Constellation’s HEAL services

Early communication following a harm event preserves the physician–patient relationship

Two physicians miss an abnormal Pap smear report that results in an eight-month delay in diagnosis of cervical cancer.

Facts of the case
A 44-year-old woman was examined by her gynecologist for an annual exam and Pap smear. Three weeks earlier, she had been examined for complaints of abdominal pain and nausea. The gynecologist noted cervical bleeding and a polyp during the annual exam. Her Pap smear results returned, indicating abnormal cells. She was instructed to return in 6-12 months for a repeat Pap smear.
She returned to see another gynecologist in the same group six months later with complaints of heavy vaginal bleeding. The gynecologist did not do a pelvic exam nor a follow-up Pap smear, and did not comment on the previous abnormal Pap smear result in his exam note. He discontinued her birth control (but did not document as to why) and prescribed naproxen.
Two months later, she was examined by a family physician for ongoing vaginal bleeding and concern about a vaginal infection. This physician performed a vaginal exam, noted heavy cervical bleeding and ordered an ultrasound. The ultrasound report noted a hyper vascular anterior myometrium. The physician referred her to another gynecologist, who noted a friable mass on the cervix with tissue sloughing during the exam. He sent a biopsy of the tissue to pathology and also did a Pap smear. The gynecologist told the woman that the mass was highly suspicious for cervical cancer and referred her to an oncologist. The pathology report indicated invasive poorly differentiated adenocarcinoma. The oncologist noted that the tumor was too large for surgery and ordered radiation plus chemotherapy. The woman contacted the gynecology clinic that originally examined her and told them about her cervical cancer diagnosis. The gynecology clinic then reported the eight-month delay in diagnosis to Constellation, and a HEAL case was opened.

HEAL positive impact
Because the clinic reported the event
to Constellation as soon as they were
made aware of the delay in diagnosis,
Constellation’s early intervention team was able to provide communication assistance and support to the involved gynecologists as they prepared to talk to the woman, apologize and explain
what had happened to cause the delay in diagnosis.
One of Constellation’s early intervention team members contacted the patient to discuss her ongoing care, prognosis and medical bills. Conversations continued throughout the investigation, which included an expert standard of care review. The woman was assured that she would be kept informed during the review of the care and about findings of the investigation. Once the expert review was completed— indicating the standard of care was not met—discussions were initiated with the woman about her medical bills, prognosis and future care needs.
The HEAL case was closed with a payment to the woman on behalf of the gynecologists and their clinic nine months after the clinic reported the harm event.

Risk and safety perspective
The medical experts who reviewed the case stated the standard of care for this category of abnormal Pap smear was to do a colposcopy and rule out cancer. The gynecologists who initially examined her agreed that they missed two opportunities to make an earlier diagnosis. The experts opined that an earlier diagnosis and treatment would have improved her outcome.
Communicating after a harm event
After a harm event, patients, residents and families need immediate, accurate and empathetic communication. Proactive communication that occurs after a harm event should be transparent, with those involved taking responsibility. Such an approach is consistent with ethical and professional responsibilities, and this level of openness fosters continued trust between patients and their health care team.
Research shows that poor or no communication following a harm event can lead to long-lasting loss of trust in the health care system and health care avoidance.1 Julia Prentice et al. at the Betsy Lehman Center for Patient Safety found “substantial persisting emotional harm, healthcare avoidance and loss of trust in healthcare” among patients and family members who self-reported an experience with a medical error. This loss of trust can impact a health care organization’s brand reputation and market share, and health care avoidance can cause worsening patient outcomes.
Opening an honest dialogue with patients after a harm event has multiple benefits: maintaining trust, giving care teams peace of mind, and helping bring about resolution, which may or may not include compensation. The honest and transparent approach of early intervention in the handling of this harm event through Constellation’s HEAL program helped this patient maintain her relationship with the gynecologists and her trust in the health care system. She remains a patient of the gynecology clinic and continues to receive medical treatment for her cancer diagnosis.

Mitigating future harm events: The HEAL Prepare Toolkit
Our HEAL Prepare Toolkit will help assess your team’s readiness to respond to harm events like this one, and then help you get to best practices. Start your journey by taking the HEAL Assessment. Then the Action Plan will guide you through the Toolkit’s four units: 1) Culture, 2) Event Response, 3) Communicating After Harm Events and 4) Moving Forward.

Sign in to to access the HEAL Prepare Toolkit found in Risk Resources.

1. Prentice JC, Bell SK, Thomas EJ, et al. Association of open communication and the emotional and behavioral impact of medical error on patients and families: state-wide cross-sectional survey. BMJ Quality & Safety. 2020;29:883- 894.

Presenter Lori Atkinson

Content Manager and Patient Safety Expert