Common Factors | Fall 2022

HEAL Review

Spotlighting cases that benefit from early intervention services

Failure to See Warning Signs
A 75-year-old woman with multiple medications and kidney disease develops kidney failure after her physician prescribes an arthritis medication he should have recognized as contraindicated.

Facts of the case A 75-year-old woman with chronic kidney disease and high blood pressure sought care for arthritic leg pain from her family physician (FP). The FP prescribed a NSAID (nonsteroidal anti-inflammatory drug) for her leg pain. He was also already prescribing an ACE (angiotensin-converting enzyme) inhibitor and a diuretic for her high blood pressure. After taking the NSAID for a year, the woman developed a gastrointestinal bleed and was hospitalized. At that time, she was also diagnosed with kidney failure. She was transferred to a tertiary hospital where dialysis was begun. The nephrologist commented that the combination of the NSAID and her blood pressure medications pushed her into kidney failure and that she will need dialysis three times a week for the rest of her life. The woman contacted the FP and complained that he improperly managed her medical treatment. She alleged that the FP failed to appreciate the risks of using NSAIDs for pain in a patient with chronic kidney disease, failed to inform her about these risks, and failed to appropriately monitor her kidney disease—all causing kidney failure.

Disposition of the case
The case was closed with a payment to the patient on behalf of the FP.

Early intervention outcome
After this harm event was reported to Constellation, we conducted a thorough case review as part of our early intervention program, HEAL. The experts who reviewed the care were critical of the FP for not recognizing that NSAIDs, diuretics and ACE inhibitors carry the risk of kidney injury, especially when they are prescribed together over an extended time. During the review, the FP acknowledged that he did not appreciate or discuss with the patient the risks and benefits of using these drugs together given her chronic kidney disease. Because Constellation was made aware of this event through early reporting, we were able to quickly conduct an expert review. The expediency with which we conducted this review helped us to determine our next steps. In this case, we made a fair offer of compensation to the patient to help all parties involved begin to heal, and we reduced the life cycle of the event. Without Constellation’s early intervention, this case could easily have escalated to a lawsuit and taken many more months or even years to resolve. Shortening the life cycle of a case alleviates clinician stress and anxiety, and lessens care team disruptions. This helps clinicians and care teams learn, move forward and get back to what matters most: providing safe, high-quality care.

Medical treatment harm events
In Constellation’s recent review of malpractice claims, medical treatment allegations were found to be second in occurrence and fourth in costs across all settings. Medical treatment allegations occur in two main categories:

  • 49% involve improper performance of a procedure.
  • 38% involve improper management of medical treatment (as illustrated in the above malpractice claim).

While the majority of these harm events involve medium-severity injuries, 15% involve high-severity harm events like permanent injury (e.g., kidney failure) or death.

The locations of these claims are split between the clinic setting (39%) and the hospital setting (39%). Within the hospital, the top locations involved in medical treatment allegations include:

  • Emergency department 28%
  • Patient room 23%
  • Special procedure areas 16%
  • Radiology/imaging 9%

When allegations of improper performance of a procedure are made, these claims typically involve routine, common procedures such as:

  • Scope procedures
  • Injections
  • Venipunctures
  • Spinal taps
  • Biopsies

Contributing factors in medical treatment claims
Contributing factors are those risk factors that contribute to the alleged harm event or filing of a claim and are amenable to risk mitigation strategies. Most harm events are the result of more than one contributing factor.
The primary contributing factors involved in medical treatment performance claims include:

  1. Technical skill or poor technique, including the occurrence of known risks of the procedure
  2. Improperly used equipment
  3. Retained items (e.g., sponges, needle tips)

The contributing factors involved in improper management of medical treatment claims include:

  • Patient assessment issues, such as failure to appreciate symptoms or delay in ordering tests
  • Improper selection of therapy to treat a condition
  • Communication breakdowns with patients and families

How Constellation can help
Unanticipated outcomes and adverse events happen. After all, clinicians and care teams are human, and even the most seasoned of them make errors. Unfortunately, these events often generate cascading ripples of hurt and cause additional harm in the absence of communication and clear steps forward. At Constellation, we’re on a mission to set the precedent for a better way forward after harm events—a way that can preserve relationships, promote communication and improve everyone’s experience. Our early intervention program, HEAL, champions this better way forward.
Constellation is prepared and ready to support our customer care teams, clinicians and health care organizations immediately following a harm event. We encourage customers to contact us as soon as possible when things don’t go as planned, so we can offer our HEAL services.
Reporting a harm event as early as possible has important benefits. Early reporting prompts immediate access to:

  • Thorough case review to provide peace of mind about the care provided
  • Communication assistance to help clinicians and care team members talk with patients, senior living residents and families after an event
  • Clinician peer support to help clinicians and care team members navigate the many landmines of a harm event, claim or lawsuit
  • Risk consultation to help improve care processes to reduce or mitigate future harm events

And when our case review findings uncover that there were no issues with the care provided, we will defend good medicine.

Ultimately, early intervention can help:

  • Enhance the trust between the patient or senior living resident, care teams and clinicians
  • Reduce the chance of claims and lawsuits
  • Reduce clinician and care team turnover
  • Uncover lessons to mitigate future events

To learn more about Constellation’s early intervention program, HEAL, and to assess your ability to respond effectively to a harm event like this one, sign in to to access the HEAL Prepare Toolkit and take the HEAL assessment.

Reducing Medical Treatment Harm Events

✓ Use simulation training to ensure technical skill and competence in performing routine procedures and using equipment.
✓ Educate patients about procedures and medication treatment regimens with material risks using a patient-centered, shared decision-making approach.
✓ Implement a triage and communication process for office teams to address symptom related patient concerns and respond appropriately.

✓ Mitigate the risk of retained items by implementing count procedures/technologies, and by reducing distractions when setting up for procedures, during procedures and at the conclusion of procedures.
✓ Provide clinical decision support tools to aid clinicians in selecting appropriate treatment for and monitoring of common medical conditions, as well as recognizing contraindications to medications.