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Overlooked Risk in Cancer Care: Failure of Medical Reconciliation.

Niharika Dixit^1,2, Jessica D McGuire³, Therese M Mulvey³

¹University of California San Francisco, San Francisco, CA.

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|June 24, 2025

Summary

Medication reconciliation errors in cancer care can harm patients. This case study highlights communication gaps and proposes system improvements to prevent medication management mistakes in oncology.

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Area of Science:

Oncology
Patient Safety
Healthcare Systems

Background:

Medication reconciliation is vital for safe oncology care.
Medication management errors can negatively impact patient outcomes.
Effective cancer care necessitates interdisciplinary collaboration.

Purpose of the Study:

To examine a patient case compromised by communication failures and assumptions in care coordination.
To identify systems-based improvements for medication management in oncology.

Main Methods:

Case study analysis.
Review of patient's medical course.
Identification of communication breakdowns and knowledge assumptions.

Main Results:

A patient's care was negatively affected by assumptions about their knowledge and inefficient interdisciplinary communication.
Specific instances of medication management errors were identified.

Conclusions:

Systems-based improvements are needed to enhance communication and prevent errors in oncology medication reconciliation.
Addressing assumptions about patient knowledge is crucial for safe and effective cancer care coordination.