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 [...]

Background: Diagnostic error is a major threat to the safety of hospitalized patients, affecting as many as 1 in 4 patients and leading to 7% of inpatient deaths. However, diagnostic error remains difficult to identify and measure, particularly in the hospital setting, where determination of an error relies on medical record review. Measurement difficulty also [...]

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 [...]

Case Presentation: 49 year old woman with past medical history of alcoholic cirrhosis and autoimmune hemolytic anemia treated with a course of steroids and rituximab 3 months prior who presented with 3-days of nausea, nonbloody/nonbilious vomiting and diarrhea associated with dysuria, and suprapubic discomfort. Vitals notable for heart rate 129/min, BP 115/61mmHg. Labs significant for [...]