She was headed to a locked psych ward. Then an ER doctor made a startling discovery.

Newspaper/Magazine Article

She was headed to a locked psych ward. Then an ER doctor made a startling discovery.

March 2, 2022

Boodman SG. Washington Post. February 12, 2022.

Misdiagnosis over a long period of time can be exacerbated by stigma and cognitive bias. This news story illustrates the problem of omissions due to potential stigma associated with patient mental health issues that contributed to a missed diagnosis. The author discusses how clinician experience led to flagging of a different testing approach to reveal a diagnosis that, once addressed, improved the patient's health.

Free full text

Related Resources From the Same Author(s)

A woman’s laborious search uncovered the probable cause of her searing abdominal pain. Getting a doctor to help was much harder.

March 3, 2021

A silent epidemic.

March 7, 2007

Not ‘just depression.’ She seemed trapped in a downward mental health spiral. The real cause was a profound shock.

February 3, 2021

Five simple steps to avoid becoming a medical mystery.

December 14, 2016

What a doctor may miss by reaching for the MRI first.

May 28, 2014

The pain of wrong site surgery.

July 6, 2011

Medical mystery: alcoholism didn’t cause man’s diabetes and cirrhosis.

June 29, 2011

Shifting the risks at night.

June 22, 2011

Anger management courses are a new tool for dealing with out-of-control doctors.

March 13, 2013

Misdiagnosis is more common than drug errors or wrong-site surgery.

May 22, 2013

Electronic medicine can send you test results quickly. But what if they're scary?

April 11, 2018

The other big drug problem: older people taking too many pills.

December 20, 2017

Medicare study finds teaching hospitals have higher risk of complications; findings disputed.

February 29, 2012

Double-booked: when surgeons operate on two patients at once.

July 26, 2017

Not quite fail-safe: computerizing isn't a panacea for dangerous drug errors, study shows.

April 3, 2005

The overlooked danger of delirium in hospitals.

June 24, 2015

Some doctors questioning whether shorter shifts for interns are endangering patients.

July 24, 2013

Two words can soothe patients who have been harmed: we're sorry.

March 29, 2017

Spikes in demand from coronavirus patients are creating shortages of asthma drugs and sedatives for ventilator patients.

April 22, 2020

From heart disease to IUDs: how doctors dismiss women’s pain.

December 21, 2022

Persisting high rates of omissions during anesthesia induction are decreased by utilization of a pre- & post-induction checklist.

February 1, 2023

Comprehensive Healthcare Inspection Summary Report: Evaluation of Mental Health in Veterans Health Administration Facilities, Fiscal Year 2020.

March 16, 2022

Are opioid infusions used inappropriately at end of life? Results from a quality/safety project.

July 20, 2022

How Veterans Affairs failed to stop a pathologist who misdiagnosed 3,000 cases.

September 11, 2019

My life was upended for 35 years by a cancer diagnosis. A doctor just told me I was misdiagnosed.

April 7, 2021

How to seek care for non-covid health issues during the pandemic, and why you shouldn’t delay.

September 29, 2021

A doctor gave me an inept diagnosis for a neurological problem. I should know: I’m a neurologist.

October 14, 2020

To eliminate bias, some seek out doctors of their own race or ethnicity.

December 22, 2021

Suspicious insulin injections, nearly a dozen deaths: inside an unfolding investigation at a VA hospital in West Virginia.

October 23, 2019

Hospital discharge: it's one of the most dangerous periods for patients.

May 11, 2016

US drug shortages threatening those whose lives depend on crucial remedies.

May 18, 2011

Rating hospitals by the stars: the feds' latest plan to measure quality is the most controversial.

June 1, 2016

A growing number of primary-care doctors are burning out. How does this affect patients?

April 9, 2014

Hospitals scramble on the front lines of drug shortages.

April 25, 2012

Hospitals tally their avoidable mistakes.

August 5, 2009

How one medical checkup can snowball into a ‘cascade’ of tests, causing more harm than good.

January 22, 2020

Your diagnosis was wrong. Could doctor bias have been a factor?

December 11, 2019

Get me out alive.

May 17, 2006

Reused devices, surgery's deadly suspects.

January 18, 2006

Teaming up to prevent 'crashes': some hospitals give patients the power to get extra help, stat.

September 19, 2007

Ambulance crew in Chicago got lost trying to find hospital.

November 7, 2007

Suicides point to gaps in treatment. Errors in psychiatric diagnoses and drugs plague strained immigration system.

May 21, 2008

Hospitals save money, but safety is questioned.

January 4, 2006

Cedars-Sinai doctors cling to pen and paper: transition to electronic medical records proves difficult.

April 3, 2005

Optimizing post-acute care patient safety: a scoping review of multifactorial fall prevention interventions for older adults.

July 13, 2022

Does standardisation improve post-operative anaesthesia handoffs? Meta-analyses on provider, patient, organisational, and handoff outcomes.

June 1, 2022

Patient Safety, Spring 2019 Final CDP Report.

March 25, 2020

Getting closer to the bull's eye: 2014–2015 Targeted Medication Safety Best Practices.

February 25, 2015

Medication errors 2023: the year in review: January through December.

March 6, 2024

Follow ISMP guidelines to safeguard the design and use of automated dispensing cabinets (ADCs).

March 4, 2009

Patient safety and quality improvement.

February 20, 2008

Survey suggests disrespectful behaviors persist in healthcare: practitioners speak up (yet again) – Parts I and II.

March 15, 2022

Inadequate Outpatient Mental Health Triage and Care of a Patient at the Chico Community-Based Outpatient Clinic in California.

March 1, 2023

Identification and Prioritization of Health IT Patient Safety Measures.

March 16, 2016

Patient Safety: Hospitals Face Challenges Implementing Evidence-Based Practices.

March 9, 2016

Recent Evidence That Health IT Improves Patient Safety: Issue Brief.

May 13, 2015

Greater Focus on Credentialing Needed to Prevent Disqualified Providers From Delivering Patient Care.

March 13, 2019

Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries.

March 19, 2014

Drug Shortages: Public Health Threat Continues, Despite Efforts to Help Ensure Product Availability.

February 19, 2014

Request for proposals for clinical quality measures to improve diagnosis.

October 6, 2022

Maternity Pre-arrival Instructions by 999 Call Handlers.

March 16, 2022

Nowhere is safe: record number of patients contracted Covid in the hospital in January.

March 2, 2022

Ensuring critical instruments and devices are appropriate for reuse.

March 2, 2022

Three new best practices in the 2022-2023 Targeted Medication Safety Best Practices for Hospitals.

February 23, 2022

Medicare penalizes dozens of hospitals it also gives five stars.

February 16, 2022

Weight-based Medication Errors in Children.

February 16, 2022

Patient Safety: HHS Has Taken Steps to Address Unsafe Injection Practices, but More Action Is Needed.

August 15, 2012

Evaluation of Registered Nurse Competency Processes in Veterans Health Administration Facilities.

June 13, 2012

VA Health Care: VA Uses Medical Injury Tort Claims Data to Assess Veterans’ Care, but Should Take Action to Ensure That These Data Are Complete.

November 9, 2011

Veterans Health Care: Veterans Health Administration Processes for Responding to Reported Adverse Events.

September 5, 2012

The justification for strike action in healthcare: a systematic critical interpretive synthesis.

April 27, 2022

Improving discharge safety in a pediatric emergency department.

October 26, 2022

Rates of surgical consultations after emergency department admission in Black and White Medicare patients.

October 26, 2022

Diagnostic trajectories in primary care at 12 months: an observational cohort study.

June 15, 2022

A blueprint for success: implementation of the Center for Medicare and Medicaid Services mandated anesthesiology oversight for procedural sedation in a large health system.

June 15, 2022

A learning health system agenda for organizational approaches to enhancing occupational well-being among clinicians.

May 25, 2022

Patient safety performance: reversing recent declines through shared profession-wide system-level solutions.

January 18, 2023

Posttraumatic growth and second victim distress resulting from medical mishaps among physicians and nurses.

January 11, 2023

Conceptual and practical challenges associated with understanding patient safety within community-based mental health services.

December 7, 2022

Achieving Excellence in Cancer Diagnosis: Proceedings of a Workshop—in Brief.

October 5, 2021 - October 6, 2021

The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff.

April 20, 2022

Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, WA.

March 30, 2022

Evaluation of Quality, Safety and Value in Veterans Health Administration Facilities, Fiscal 2021.

November 16, 2022

Artificial Intelligence in Health Care: Benefits and Challenges of Machine Learning Technologies for Medical Diagnostics.

October 26, 2022

Comprehensive Healthcare Inspection Summary Report: Evaluation of Care Coordination in Veterans Health Administration Facilities, Fiscal Year 2021.

October 12, 2022

COVID-19 in Nursing Homes: CMS Needs to Continue to Strengthen Oversight of Infection Prevention and Control.

October 12, 2022

Meeting the Moment: Addressing Barriers and Facilitating Clinical Adoption of Artificial Intelligence in Medical Diagnosis.

October 12, 2022

Opportunities to Improve Patient Safety, Advancing U.S. Innovation, and Innovation Hubs.

October 5, 2022

National Plan for Health Workforce Well-Being.

September 28, 2022

Advancing Anticoagulation Stewardship: A Playbook.

September 7, 2022

The Uneven Burden of Maternal Mortality in the U.S.

August 10, 2022

Recognizing Excellence in Diagnosis: Recommended Practices for Hospitals.

August 10, 2022

The New Electronic Health Record’s Unknown Queue Caused Multiple Events of Patient Harm.

July 27, 2022

Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate Cancer at the Hampton VA Medical Center in Virginia.

July 13, 2022

Artificial Intelligence in Health Care: The Hope, the Hype, the Promise, the Peril.

December 1, 2019

Addressing Health Worker Burnout.

June 8, 2022

Adverse Events in Hospitals: A Quarter of Medicare Patients Experienced Harm in October 2018.

May 25, 2022

Advancing Diagnostic Excellence for Older Adults: Proceedings of a Workshop in Brief.

July 21, 2022 - July 21, 2022

Lessons Learned from the COVID-19 Pandemic to Improve Diagnosis. Proceedings of a Workshop–in Brief.

May 11, 2022

Long-Term Trends of Psychotropic Drug Use in Nursing Homes.

February 1, 2023

Related Resources

Annual Perspective

Equity in Patient Safety

March 27, 2024

‘I felt like I was dying’: how women with postpartum depression fall through the cracks of U.S. health care.

July 5, 2023

AI in medicine needs to be carefully deployed to counter bias – and not entrench it.

June 21, 2023

AI may be on its way to your doctor’s office, but it’s not ready to see patients.

May 24, 2023

Death Inside Lemuel Shattuck Hospital: A Case Study on Medical Treatment for Persons with Mental Health Disabilities.

May 24, 2023

How the opioid backlash went wrong.

May 17, 2023

Medical errors kill thousands of people each year. But are hospitals getting any safer?

May 17, 2023

Non-accidental Injuries in Infants Attending the Emergency Department.

May 17, 2023

VA pauses $16B Oracle Cerner EHR deployments indefinitely to address error-ridden early rollout.

May 3, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Doctors must stop tuning out Black women. It happened to me, as a pregnant OB-GYN.

April 26, 2023

The prisoner.

March 29, 2023

Why hospitals still make serious medical errors—and how they are trying to reduce them.

March 29, 2023

Senators threaten consequences after VA confirms 4 deaths tied to computer system tested in Spokane.

March 29, 2023

Hospital ‘black boxes’ put surgical practices under the microscope.

March 29, 2023

I’m an ER doctor: here’s what I found when I asked ChatGPT to diagnose my patients.

March 22, 2023

Few hospitals are willing to bear the cost of providing psychiatric care for kids.

March 22, 2023

Feds move to rein in prior authorization, a system that harms and frustrates patients.

March 22, 2023

Using A.I. to detect breast cancer that doctors miss.

March 15, 2023

Do no unconscious harm.

March 15, 2023

NHS staff cried in safety interviews, says watchdog.

March 8, 2023

'They were his best shot. And they failed to help’: why did EMS workers neglect Tyre Nichols?

February 15, 2023

Embedded bias: how medical records sow discrimination.

October 5, 2022

When medical error becomes personal, activism becomes painful.

September 28, 2022

Charlie Bourg was on the lookout for veterans harmed by a new VA computer system. He didn’t expect to be one of them.

September 21, 2022

A California man’s ‘painful and terrifying’ road to a Monkeypox diagnosis.

August 17, 2022

Skin cancer is a risk no matter the skin tone. But it may be overlooked in people with dark skin.

August 17, 2022

The Uneven Burden of Maternal Mortality in the U.S.

August 10, 2022

Improving Diagnosis in Medicine Act of 2022.

July 20, 2022

Nurse Vaught sentenced for deadly medical error.

May 25, 2022

See More About The Topic

General Public

Medicine

Clinical Misdiagnosis

Noncognitive Errors ("Slips and Lapses")

She was headed to a locked psych ward. Then an ER doctor made a startling discovery.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

She was headed to a locked psych ward. Then an ER doctor made a startling discovery.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site