Abstract
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.
Similar content being viewed by others
References
Abraham J, Kannampallil TG, Patel VL (2012) Bridging gaps in handoffs: a continuity of care based approach. J Biomed Inform 45(2):240–254. doi:10.1016/j.jbi.2011.10.011
Arora VM, Johnson JK, Meltzer DO, Humphrey HJ (2008) A theoretical framework and competency-based approach to improving handoffs. Qual Saf Health Care 17(1):11–14. doi:10.1136/qshc.2006.018952
Arzy S, Brezis M, Khoury S, Simon SR, Ben-Hur T (2009) Misleading one detail: a preventable mode of diagnostic error? J Eval Clin Pract 15(5):804–806. doi:10.1111/j.1365-2753.2008.01098.x
Burnard P (1991) A method of analysing interview transcripts in qualitative research. Nurse Educ Today 11(6):461–466
Caines LC, Brockmeyer DM, Tess AV, Kim H, Kriegel G, Bates CK (2011) The revolving door of resident continuity practice: identifying gaps in transitions of care. J Gen Intern Med 26(9):995–998. doi:10.1007/s11606-011-1731-8
Cook RI, Rasmussen J (2005) “Going solid”: a model of system dynamics and consequences for patient safety. Qual Saf Health Care 14(2):130–134. doi:10.1136/qshc.2003.009530
Cook RI, Woods DD (1996) Adapting to new technology in the operating room. Hum Factors 38(4):593–613
Cook RI, Render M, Woods DD (2000) Gaps in the continuity of care and progress on patient safety. BMJ 320:791–794
Doherty C, Stavropoulou C (2012) Patients’ willingness and ability to participate actively in the reduction of clinical errors: a systematic literature review. Soc Sci Med 75:257–263. doi:10.1016/j.socscimed.2012.02.056
Edmondson AC (2004) Learning from failure in health care: frequent opportunities, pervasive barriers. Qual Saf Health Care 13(Suppl 2):3–9. doi:10.1136/qhc.13.suppl_2.ii3
Ekdahl AW, Hellstrom I, Andersson L, Friedrichsen M (2012) Too complex and time-consuming to fit in! Physicians’ experiences of elderly patients and their participation in medical decision making: a grounded theory study. BMJ open 2(3). doi:10.1136/bmjopen-2012-001063
Elo S, Kyngas H (2008) The qualitative content analysis process. J Adv Nurs 62(1):107–115. doi:10.1111/j.1365-2648.2007.04569.x
Fex A, Flensner G, Ek AC, Soderhamn O (2011a) Health-illness transition among persons using advanced medical technology at home. Scand J Caring Sci 25(2):253–261. doi:10.1111/j.1471-6712.2010.00820.x
Fex A, Flensner G, Ek AC, Soderhamn O (2011b) Living with an adult family member using advanced medical technology at home. Nurs Inq 18(4):336–347. doi:10.1111/j.1440-1800.2011.00535.x
Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW (2003) The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med 138(3):161–167
Forster AJ, Clark HD, Menard A, Dupuis N, Chernish R, Chandok N, Khan A, van Walraven C (2004) Adverse events among medical patients after discharge from hospital. Can Med Assoc J (journal de l’Association medicale canadienne) 170(3):345–349
Glouberman S, Mintzberg H (2001) Managing the care of health and the cure of disease-Part I: differentiation. Health Care Manage Rev 26(1):56–69
Gustafsson C, Asp M, Fagerberg I (2009) Reflection in night nursing: a phenomenographic study of municipal night duty registered nurses’ conceptions of reflection. J Clin Nurs 18(10):1460–1469. doi:10.1111/j.1365-2702.2008.02438.x
Haggerty JL, Reid RJ, Freeman GK, Starfield BH, Adair CE, McKendry R (2003) Continuity of care: a multidisciplinary review. BMJ 327(7425):1219–1221. doi:10.1136/bmj.327.7425.1219
Hollnagel E (2009) The ETTO principle: efficiency-thoroughness trade-off: why things that go right sometimes go wrong. Ashgate, Aldersgate
Hollnagel E, Nemeth C, Dekker S (2008) Resilience engineering perspectives. Aldershot, Hampshire, England; Ashgate, Burlington
Hollnagel E, Pariès J, Woods D, Wreathall J (2011) Resilience engineering in practice: a guidebook. Farnham, Surrey, England; Ashgate, Burlington
Krueger RA, Casey MA (2000) Focus groups. A practical guide for applied research. Sage Publications, California
Kvale S, Brinkmann S (2009) Interviews learning the craft of qualitative research interviewing. Sage, Los Angeles
Nemeth C, Cook RI, Woods DD (2004) The messy details: insights from the study of technical work in healthcare. IEEE Trans Syst Man Cybernet Part A Syst Hum 34(6):689–692
Nemeth C, Wears R, Woods DD, Hollnagel E, Cook RI (2008) Minding the gaps: creating resilience in health care. In: Henriksen K, Battles JB, Keyes MA, Grady ML (eds) Advances in patient safety: new directions and alternative approaches (vol 3: performance and tools). Agency for Healthcare Research and Quality, Rockville, MD
Oksholm T, Röstuen T, Ekstedt M (2011) It is risky and difficult to be in “the gap”. Paper presented at the 17th international qualitative health research conference, October 25–27, Vancouver, British Columbia, Canada
Patterson ES, Roth EM, Woods DD, Chow R, Gomes JO (2004) Handoff strategies in settings with high consequences for failure: lessons for health care operations. Int J Qual Health Care J Int Soc Qual Health Care/ISQua 16(2):125–132. doi:10.1093/intqhc/mzh026
Reiman T, Pietikäinen E (2010) Indicators of safety culture—selection and utilization of leading safety performance indicators. Research report, 2010:07. Strålsäkerhetsmyndigheten, Stockholm. www.stralsakerhetsmyndigheten.se
Robinson N (1999) The use of focus group methodology—with selected examples from sexual health research. J Adv Nurs 29(4):905–913
Rollenhagen C (1997) MTO—an introduction. The relationships man, technology and organization. Studentlitteratur, Lund
Schilling L, Dearing JW, Staley P, Harvey P, Fahey L, Kuruppu F (2011) Kaiser Permanente’s performance improvement system, Part 4: creating a learning organization. Jt Comm J Qual Patient Saf/Jt Comm Resour 37(12):532–543
Scott IA (2009) Errors in clinical reasoning: causes and remedial strategies. BMJ 338:b1860. doi:10.1136/bmj.b1860
SFS 2010:659, Patientsäkerhetslagen (The Swedish patient safety act)
Siemsen IM, Madsen MD, Pedersen LF, Michaelsen L, Pedersen AV, Andersen HB, Ostergaard D (2012) Factors that impact on the safety of patient handovers: an interview study. Scand J Public Health 40(5):439–448. doi:10.1177/1403494812453889
Socialstyrelsen (2011) [National Board of Health and Welfare] Lägesrapport om Hälso- och sjukvård och socialtjänst
SSMFS 2008:1. Strålsäkerhetsmyndighetens föreskrifter om säkerhet i kärntekniska anläggningar. [Radiation Safety regulations on the safety of nuclear industries.] (in Swedish)
Tandjung R, Rosemann T, Badertscher N (2011) Gaps in continuity of care at the interface between primary care and specialized care: general practitioners’ experiences and expectations. Int J General Med 4:773–778. doi:10.2147/IJGM.S25338
Uijen AA, Schers HJ, Schellevis FG, van den Bosch WJ (2012a) How unique is continuity of care? A review of continuity and related concepts. Fam Pract 29(3):264–271. doi:10.1093/fampra/cmr104
Uijen AA, Bosch M, van den Bosch WJ, Bor H, Wensing M, Schers HJ (2012b) Heart failure patients experiences with continuity of care and its relation to medication adherence: a cross-sectional study. BMC Fam Pract 13(1):86. doi:10.1186/1471-2296-13-86
Weick KE (1995) Sensemaking in organizations. Sage, Thousand Oaks
Wibe T, Ekstedt M, Helleso R, Slaughter L (2010) Why do people want a paper copy of their electronic patient record? Stud Health Technol Informa 160:676–680
Wibe T, Helleso R, Slaughter L, Ekstedt M (2011) Lay people’s experiences with reading their medical record. Soc Sci Med 72(9):1570–1573. doi:10.1016/j.socscimed.2011.03.006
Woods DD, Patterson ES, Cook RI (2006) Behind human error: taming complexity to improve patient safety. In: Caryon P (ed) Handbook of human factors and ergonomics in health care and patient safety. Lawrence-Erlbaum Press, Hillsdale, pp 459–476
Acknowledgments
This work was kindly supported by Sweden’s National Board of Health and Welfare. We would like to thank all participants in the interviews for sharing their time and experiences. We thank Kjell Bergfeldt and Lena Sharp at Radiumhemmet, Karolinska Institutet, and Katarina Eveland at the Patients’ Advisory Committee in Stockholm, for participation in the initial discussions. Thanks also to Claes Bernes for valuable editing of the manuscript.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Ekstedt, M., Ödegård, S. Exploring gaps in cancer care using a systems safety perspective. Cogn Tech Work 17, 5–13 (2015). https://doi.org/10.1007/s10111-014-0311-1
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10111-014-0311-1