Background: Diagnostic error may occur in up to 5% of all adult hospitalizations, leading to prolonged length of stay, higher cost, and significant morbidity and mortality. Improving diagnostic safety requires measurement, analysis, and learning accelerated by dissemination. While safety is at the forefront of hospital priorities, organizational readiness to address diagnostic safety lacks consistent deployment [...]

Case Presentation: A 48 year-old woman with a past medical history of prediabetes presented with a one-week history of confusion, cough, and fever. She was lethargic with slurred speech on admission and intubated for airway protection in the Emergency Department. A few hours after admission to the intensive care unit (ICU), her respiratory PCR returned [...]