A perfect storm averted: flawed systems, a dropped ball, and cognitive biases delay a critical diagnosis. | PSNet

Provide Feedback |

Register

Commentary

A perfect storm averted: flawed systems, a dropped ball, and cognitive biases delay a critical diagnosis.

November 2, 2022

Roberts TJ, Sellars MC, Sands JM, et al. JCO Oncol Pract. 2022;18(12):833-839.

View more articles from the same authors.

Missed diagnosis of infectious diseases can have serious consequences for patient safety. This article describes a delayed diagnosis of disseminated tuberculosis in a patient with lung cancer and discusses the how cognitive biases and systems failures contributed to the diagnostic error.

PubMed citation

Related Resources From the Same Author(s)

The randomized AMBORA trial: impact of pharmacological/pharmaceutical care on medication safety and patient-reported outcomes during treatment with new oral anticancer agents.

April 21, 2021

Impact of the COVID-19 pandemic on cancer care: a global collaborative study.

November 11, 2020

Description of the role of pharmacist independent double checks during cognitive order verification of outpatient parenteral anti-cancer therapy.

March 24, 2021

How to mitigate the effects of cognitive biases during patient safety incident investigations.

September 28, 2022

Preventing and mitigating radiology system failures: a guide to disaster planning.

February 2, 2022

Scaling-up a pharmacist-led information technology intervention (PINCER) to reduce hazardous prescribing in general practices: multiple interrupted time series study.

January 11, 2023

Complexity and challenges of the clinical diagnosis and management of Long COVID.

November 30, 2022

Perceived patient safety culture in a critical care transport program.

July 31, 2013

Handshake antimicrobial stewardship as a model to recognize and prevent diagnostic errors.

September 8, 2021

Chemotherapy errors: a call for a standardized approach to measurement and reporting.

June 1, 2016

View More

Related Resources

WebM&M Cases

Critical Echocardiogram Result Lost to Follow-up.

June 14, 2023

Diagnostic errors in musculoskeletal oncology and possible mitigation strategies.

May 24, 2023

Making polypharmacy safer for children with medical complexity.

April 5, 2023

Patient Safety Primers

Coronavirus Disease 2019 (COVID-19) and Diagnostic Error

January 11, 2022

ISMP medication error report analysis.

June 16, 2019

ISMP medication error report analysis.

June 16, 2019

WebM&M Cases

Failed Interpretation of Screening Tool: Delayed Treatment

September 1, 2017

ISMP medication error report analysis.

December 30, 2014

WebM&M Cases

A Seasonal Care Transition Failure

July 1, 2011

WebM&M Cases

Hospital Admission Due to High-Dose Methotrexate Drug Interaction

January 1, 2009

View More

See More About The Topic

Ambulatory Clinic or Office

Health Care Providers

Medical Oncology

Infectious Diseases

Diagnostic Test Interpretation Error

To sign up for updates or to access your subscriber preferences, please enter your email address below.

5600 Fishers Lane
Rockville, MD 20857
Telephone: (301) 427-1364