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An Outpatient “Zebra”
Berkowitz L. AHRQ WebM&M [serial online]. January 2006.
Over several weeks, a man with left foot pain and numbness is evaluated by numerous doctors, each resident and attending pair offering a different incorrect diagnosis until the patient's fourth visit.
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Commentary
Target Audience
Physicians
Facility and Group Administrators
Clinical Area
Medicine
Safety Target
Clinical Misdiagnosis
Discontinuities, Gaps, and Hand-Off Problems
Error Types
Cognitive Errors ("Mistakes")
Latent Errors
Approach to Improving Safety
Practice Guidelines
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