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

Area of Science:

• Oncology
• Healthcare Quality Improvement
• Patient Safety

Background:

• The COVID-19 pandemic introduced unique challenges to healthcare delivery.
• Oncology patients face specific safety risks that require careful management.
• Effective communication and care coordination are vital for complex cancer treatment.

Purpose of the Study:

• To analyze a case of locally advanced lung cancer diagnosed during the pandemic.
• To identify how communication and care coordination failures impacted patient care.
• To explore systems for assigning accountability in dispersed healthcare settings.

Main Methods:

• Case study analysis of a patient with locally advanced lung cancer.
• Application of quality improvement principles, including root cause analysis.
• Examination through the lenses of systems engineering, human factors, and cognitive psychology.

Main Results:

• Gaps in communication and care coordination led to deviations from the multidisciplinary team's consensus care plan.
• The case highlights vulnerabilities in patient safety during public health crises.
• Failures in care coordination were linked to communication breakdowns.

Conclusions:

• Multidisciplinary care is essential for optimal management of stage III non-small-cell lung cancer.
• Addressing communication gaps and clarifying accountability are critical for improving patient safety in oncology.
• Systems-level improvements are needed to prevent future care coordination failures.