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Care Fragmentation, Faulty Communication, and Documentation Lapses Derail a Treatment Plan.
Roberts, Thomas J; Bailey, Alexandra S; Tahir, Naeem; Jacobson, Joseph O.
  • Roberts TJ; Dana-Farber Cancer Institute, Boston, MA.
  • Bailey AS; Massachusetts General Hospital, Boston, MA.
  • Tahir N; Harvard Medical School, Boston, MA.
  • Jacobson JO; Dana-Farber Cancer Institute, Boston, MA.
JCO Oncol Pract ; : OP2200471, 2022 Nov 14.
Article in English | MEDLINE | ID: covidwho-2234916
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.

Full text: Available Collection: International databases Database: MEDLINE Type of study: Prognostic study Language: English Journal: JCO Oncol Pract Year: 2022 Document Type: Article Affiliation country: OP.22.00471

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Full text: Available Collection: International databases Database: MEDLINE Type of study: Prognostic study Language: English Journal: JCO Oncol Pract Year: 2022 Document Type: Article Affiliation country: OP.22.00471