Exploring gaps in cancer care using a systems safety perspective

Gaps in the continuity of care may appear as losses of information or momentum or as interruptions in the delivery of care. To systematically improve patient safety, we need to know more about how gaps in the continuity of health care are identified and mitigated. This study seeks to describe healthcare professionals' understanding of how they anticipate, detect and handle gaps in cancer care. Ten focus-group interviews and two individual interviews were conducted with a total of 34 cancer-care professionals (physicians, nurses, managers and administrators) from three counties in mid-Sweden. Various specialties in cancer care were covered: primary care, in-hospital care, palliative care, advanced home care, and children's care. Interviews were analyzed inductively using qualitative content analysis. The results show that patient safety in cancer care is dependent on a resilient organization that is capable of anticipation, monitoring, adapting and learning at all levels of care. The professionals anticipated gaps in situations where contacts between healthcare providers were limited and when they were faced by time or resource constraints. The extent to which gaps could be managed by professionals at the sharp end was largely determined by their ability to adapt to complex and unexpected situations in their daily work. The management of gaps was perceived differently by managers and clinicians, however. The study also indicates that the continuity of care could be improved by patients' participation in decisions about treatments and care plans, and by a mutual responsibility for the transfer of information and knowledge across professional boundaries. These results are discussed from a resilience engineering perspective, and they emphasize the management's responsibility to address gaps identified in the system. Designing resilient healthcare organizations enables professionals at the sharp end to prevent human error or mitigate its consequences.