Case Presentation: A 90-year-old-male with history of hypertension, coronary artery disease and chronic lymphocytic lymphoma presented with shortness of breath that had been getting worse over the previous few weeks, particularly at night and with lying down. He also reported increased cough and worsening leg swelling. In the ED, he was hypoxic (84% on room [...]

Case Presentation: A 29-year-old man with a history of mood disorder was admitted with acute encephalopathy after friends had requested a welfare check. The patient was found to have nonsensical speech, delusions of alien interaction and possible gait ataxia without other signs of focal neurological deficits. Vitals were within normal limits; no other significant physical [...]

Background: The COVID-19 pandemic required physicians to care for a new disease with uncertain and evolving characteristics while also adhering to physical and social distancing practices, and under conditions of extreme duress – all factors likely to lead to missed or delayed diagnoses among patients admitted ‘under investigation’ for COVID-19. Methods: We carried out a [...]

Case Presentation: A 68-year-old man with a history of cryptogenic cirrhosis and hepatocellular carcinoma status post liver transplant with donor positive for cytomegalovirus (CMV), and recent treated CMV reactivation, was transferred from a nearby hospital with acute hypoxic respiratory failure requiring intubation secondary to Pneumocystis jirovecii pneumonia (PJP) identified on bronchoalveolar lavage. He was treated [...]

Case Presentation: A 59 year old woman with presumed systemic lupus erythematosus (SLE) was admitted to hospital medicine for severe pancytopenia (WBC 1.3 x109/L, hemoglobin 9.2g/dL, platelet 14×109/L). She had an extensive diagnostic work-up with rheumatology and hematology without a definitive diagnosis; rheumatology questioned her prior SLE diagnosis. Imaging showed diffuse lymphadenopathy and splenomegaly. Three [...]

Background: Diagnostic errors (DE), defined as missed opportunities to make a correct or timely diagnosis based on the available evidence, are a critical but understudied cause of patient harm. While previous efforts have focused on examining the incidence and factors contributing to DEs in ambulatory and emergency room settings, fewer studies have examined incidence of [...]

Background: Diagnostic errors (DEs), or the failure to accurately identify or provide timely explanations of a patient’s health problem, are a significant source of patient harm. DEs occur in up to 23% of adult inpatients who transfer to intensive care units (ICU) or die. Few studies have examined how clinician team composition impacts DE risk. [...]

Background: Medical misadventure, defined as unintended harm caused during medical care or procedures, is an increasingly significant concern in patient safety and healthcare quality. Recent decades have seen heightened awareness and reporting of such incidents globally, including in the United States. This study quantifies trends in medical misadventure-related mortality and morbidity by examining regional disparities [...]

Background: Diagnostic errors (DE) are common in patients who die or go to the ICU and are caused by gaps in diagnostic processes. Few data describe whether this observation holds true among patients with sepsis, a disease that progresses quickly and requires a range of clinical information to diagnose correctly. The objective of our study [...]

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 [...]