Care Fragmentation, Faulty Communication, and Documentation Lapses Derail a Treatment Plan

Abstract

This is the second Cancer Morbidity, Mortality, and Improvement Rounds, a series of articles intended to explore the unique safety risks experienced by oncology patients through the lens of quality improvement, systems and human factors engineering, and cognitive psychology. This case describes the care of a patient who was diagnosed with locally advanced lung cancer during the COVID-19 pandemic; it highlights how gaps in communication and care coordination caused the patient to receive care that did not reflect the consensus of his multidisciplinary team. The discussion highlights the importance of multidisciplinary care, particularly for patients with stage III non–small-cell lung cancer, discusses factors that led to communication gaps, and examines how we should assign accountability across dispersed health care systems. Cancer Morbidity, Mortality, and Improvement Rounds is a series of articles intended to explore the unique safety risks experienced by oncology patients through the lens of quality improvement, systems and human factors engineering, and cognitive psychology. For purposes of clarity, each case focuses on a single theme, although, as is true for all medical incidents, there are almost always multiple, overlapping, contributing factors. The quality improvement paradigm used here, which focuses on root cause analyses and opportunities to improve care delivery systems, was previously outlined in this journal.

Teams, Teaming, and Complex Systems in Cancer Care

“…Research has found that there is a premium on coordination with the core member(s) of a team 27 and among core team representatives in more complex MTS arrangements, such as AYA multidisciplinary teams (Wolfson), 28 main and community affiliate sites in the same health care system (Roberts). 29,30 Mechanisms such as the interoperability of health information technology 31 and dedicated program coordinators with integrated screening tools have shown promise (Fleege), 32 whereas the colocation of multidisciplinary care versus serial care (Majumdar, Smeltzer) 33,34 and other structural arrangements (O'Malley) 35 have yielded mixed results.…”

Technology Supports to Cancer Care Teams: Promises and Pitfalls

“…Roberts et al 4 report a compelling case study that highlights the pitfalls of over-reliance on technology to support cancer care teams. The case highlights how increased reliance on technology tools and virtual communication methods has suppressed mainstays of high-quality cancer care, including interdisciplinary tumor boards, role clarification, team sensemaking, 5 and closed-loop communication.…”