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

Thomas J Roberts; Maclean C Sellars; Jacob M Sands; Joseph Jacobson

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

Available at

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

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

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

September 28, 2022

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

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

October 26, 2022

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

June 1, 2016

Miscarriage treatment-related morbidities and adverse events in hospitals, ambulatory surgery centers, and office-based settings.

December 16, 2020

Cognitive and implicit biases in nurses' judgment and decision-making: a scoping review.

July 13, 2022

Toward the development of the perfect medical team: critical components for adaptation.

March 17, 2021

Bracing for the storm: one health care system's planning for the COVID-19 surge.

November 11, 2020

Fast does not imply flawed: analyzing emergency physician productivity and medical errors.

December 14, 2022

Clinician-identified problems and solutions for delayed diagnosis in primary care: a PRIORITIZE study.

October 5, 2016

The fusion of incident learning and failure mode and effects analysis for data-driven patient safety improvements.

March 17, 2021

Multilevel factors associated with time to biopsy after abnormal screening mammography results by race and ethnicity.

July 6, 2022

Universal protection: operationalizing infection prevention guidance in the COVID-19 era.

May 12, 2021

Racial and ethnic differences in emergency department pain management of children with fractures.

April 22, 2020

Systems-level factors affecting registered nurses during care of women in labor experiencing clinical deterioration.

April 20, 2022

A partially structured postoperative handoff protocol improves communication in 2 mixed surgical intensive care units: findings from the Handoffs and Transitions in Critical Care (HATRICC) prospective cohort study.

February 6, 2019

The perfect storm: exam of a medical error and factors contributing to its possible escalation.

June 23, 2021

A systems approach to morbidity and mortality conference.

July 28, 2010

Flexibilization of science, cognitive biases, and the COVID-19 pandemic.

September 23, 2020

Development of a core drug list towards improving prescribing education and reducing errors in the UK.

March 2, 2011

Clinical reasoning in dire times- analysis of cognitive biases in clinical cases during the COVID-19 pandemic.

February 23, 2022

Safety considerations for IMRT.

August 10, 2011

Critical care clinicians' experiences of patient safety during the COVID-19 pandemic.

November 30, 2022

A pause in pediatrics: implementation of a pediatric diagnostic time-out.

September 14, 2022

Racial disparities in diagnostic delay among women with breast cancer.

August 18, 2021

We're all in this together: how COVID-19 revealed the co-construction of mindful organising and organisational reliability.

February 9, 2022

Association of diagnostic stewardship for blood cultures in critically ill children with culture rates, antibiotic use, and patient outcomes: results of the Bright STAR Collaborative.

May 18, 2022

Education initiatives in cognitive debiasing to improve diagnostic accuracy in student providers: a scoping review.

November 11, 2020

Diagnosis of physical and mental health conditions in primary care during the COVID-19 pandemic: a retrospective cohort study.

October 21, 2020

Effects of state opioid prescribing laws on use of opioid and other pain treatments among commercially insured U.S. adults.

March 30, 2022

Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions.

August 4, 2021

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

June 1, 2022

Association of provider specialty with abortion-related morbidity and adverse events among patients having procedural and medication abortions.

August 10, 2022

A blinded, prospective study of error detection during physician chart rounds in radiation oncology.

October 14, 2020

Making communication and resolution programmes mission critical in healthcare organisations.

November 11, 2020

Optimizing Pediatric Patient Safety in the Emergency Care Setting.

October 19, 2022

Structural racism and the COVID-19 experience in the United States.

July 7, 2021

Analysis of lawsuits related to diagnostic errors from point-of-care ultrasound in internal medicine, paediatrics, family medicine and critical care in the USA.

June 24, 2020

Diagnostic error experiences of patients and families with limited English-language health literacy or disadvantaged socioeconomic position in a cross-sectional US population-based survey.

February 16, 2022

Gender biases and diagnostic delay in inflammatory bowel disease: multicenter observational study.

February 15, 2023

Characteristics of critical incident reporting systems in primary care: an international survey.

January 19, 2022

The Critical Care Safety Study: the incidence and nature of adverse events and serious medical errors in intensive care.

August 24, 2005

Transparency, public reporting, and a culture of change to quality and safety in cardiac surgery.

November 9, 2022

Restructuring of a general surgery residency program in an epicenter of the coronavirus disease 2019 pandemic: lessons from New York City.

July 29, 2020

Filling a gap in safety metrics: development of a patient-centred framework to identify and categorise patient-reported breakdowns related to the diagnostic process in ambulatory care.

October 27, 2021

Measures and measurement of high-performance work systems in health care settings: propositions for improvement.

February 9, 2011

Post-operative mortality, missed care and nurse staffing in nine countries: a cross-sectional study.

September 13, 2017

Effectiveness of pharmacist intervention to reduce medication errors and health-care resources utilization after transitions of care: a meta-analysis of randomized controlled trials.

July 19, 2017

Improving transfusion safety in the operating room with a barcode scanning system designed specifically for the surgical environment and existing electronic medical record systems: an interrupted time series analysis.

September 9, 2020

Missing the near miss: recognizing valuable learning opportunities in radiation oncology.

December 16, 2020

Association of patient and family reports of hospital safety climate with language proficiency in the US.

June 29, 2022

Cognitive biases in surgery: systematic review.

March 1, 2023

Early diagnosis of cancer: systems approach to support clinicians in primary care.

April 5, 2023

Adverse events in infants less than 6 months of age after ambulatory surgery and diagnostic imaging requiring anesthesia.

August 10, 2022

Effect of genetic diagnosis on patients with previously undiagnosed disease.

November 7, 2018

Automated identification of diagnostic labelling errors in medicine.

June 8, 2022

The source of purchased medications and its impact on medication mistakes and hospitalizations.

March 16, 2022

Health disparities: impact of health disparities and treatment decision-making biases on cancer adverse effects among black cancer survivors.

November 10, 2021

Interdisciplinary Quality Improvement Conference: using a revised morbidity and mortality format to focus on systems-based patient safety issues in a VA hospital: design and outcomes.

November 12, 2014

What can we learn from in-depth analysis of human errors resulting in diagnostic errors in the emergency department: an analysis of serious adverse event reports.

May 18, 2022

A randomized trial of a multifactorial strategy to prevent serious fall injuries.

July 29, 2020

The efficacy of mindful practice in improving diagnosis in healthcare: a systematic review and evidence synthesis.

October 13, 2021

The e-Autopsy/e-Biopsy: a systematic chart review to increase safety and diagnostic accuracy.

October 26, 2022

Interprofessional clinical event debriefing-does it make a difference? Attitudes of emergency department care providers to INFO clinical event debriefings.

December 7, 2022

Impact of interoperability of smart infusion pumps and an electronic medical record in critical care.

September 23, 2020

A retrospective audit of postoperative days alive and out of hospital, including before and after implementation of the WHO surgical safety checklist.

February 2, 2022

Oncology pharmacist-led medication reconciliation among cancer patients initiating chemotherapy.

July 29, 2020

Pursuit of "endpoint diagnoses" as a cognitive forcing strategy to avoid premature diagnostic closure.

December 21, 2022

Patient identification of diagnostic safety blindspots and participation in "good catches" through shared visit notes.

January 18, 2023

Patient and hospital characteristics associated with delayed diagnosis of appendicitis.

February 1, 2023

Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016

March 3, 2017

Improving diagnosis: adding context to cognition.

September 7, 2022

Toward safer opioid prescribing in HIV care (TOWER): a mixed-methods, cluster-randomized trial.

June 22, 2022

Urgent referrals from primary care to dermatology for lesions suspicious for skin cancer: patterns, outcomes, and need for systems improvement.

December 7, 2022

Identifying safe care processes when GPs work in or alongside emergency departments: a realist evaluation.

December 15, 2021

Healthcare failure mode and effect analysis in the chemotherapy preparation process.

November 17, 2021

Frailty, gaps in care coordination, and preventable adverse events.

July 6, 2022

Lessons learned from a systems approach to engaging patients and families in patient safety transformation.

February 12, 2020

Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study.

November 16, 2022

Implementation of safeguards to improve patient safety in chemotherapy.

September 20, 2017

Evaluation of feedback modalities and preferences regarding feedback on decision-making in a pediatric emergency department.

July 6, 2022

ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing-2019.

September 30, 2020

ASHP National Survey of Pharmacy Practice in Hospital Settings: clinical services and workforce-2021.

October 19, 2022

Missed nursing care in the critical care unit, before and during the COVID-19 pandemic: a comparative cross-sectional study.

June 22, 2022

Eliminating explicit and implicit biases in health care: evidence and research needs.

February 23, 2022

Use of a structured approach and virtual simulation practice to improve diagnostic reasoning.

February 23, 2022

Racial bias in pulse oximetry measurement.

December 20, 2020

Care coordination strategies and barriers during medication safety incidents: a qualitative, cognitive task analysis.

March 10, 2021

Medication use and cognitive impairment among residents of aged care facilities.

June 23, 2021

Partnering with patients and families living with chronic conditions to coproduce diagnostic safety through OurDX: a previsit online engagement tool.

February 15, 2023

US emergency department visits for acute harms from over-the-counter cough and cold medications, 2017-2019.

December 15, 2021

Personality traits and traumatic outcome symptoms in registered nurses in the aftermath of a patient safety incident.

July 22, 2020

Human factors analysis of latent safety threats in a pediatric critical care unit.

May 18, 2022

Related Resources

Deficiencies in Quality Management Processes and Delays in the Communication of Test Results and Follow-Up Care at the Phoenix VA Health Care System in Arizona.

November 29, 2023

WebM&M Cases

Delay in Malignancy Diagnosis Reflects Systemic Failures

October 31, 2023

Intraoperative communications between pathologists and surgeons: do we understand each other?

September 6, 2023

Implementation of medication reconciliation in outpatient cancer care.

August 9, 2023

Burden of serious harms from diagnostic error in the USA.

July 28, 2023

Association of polypharmacy and potential drug-drug interactions with adverse treatment outcomes in older adults with advanced cancer.

July 19, 2023

What causes delays in diagnosing blood cancers? A rapid review of the evidence.

July 5, 2023

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

Delays in care during the COVID-19 pandemic in the Veterans Health Administration.

May 3, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Making polypharmacy safer for children with medical complexity.

April 5, 2023

"We're not taken seriously": describing the experiences of perceived discrimination in medical settings for Black women.

March 22, 2023

WebM&M Cases

Delayed Diagnosis of Mesenteric Ischemia

August 31, 2022

Translating electronic health record-based patient safety algorithms from research to clinical practice at multiple sites.

August 3, 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

Collaborative case review: a systems-based approach to patient safety event investigation and analysis.

March 30, 2022

Patient Safety Primers

Coronavirus Disease 2019 (COVID-19) and Diagnostic Error

January 11, 2022

Bringing the clinical laboratory into the strategy to advance diagnostic excellence.

September 22, 2021

Errors in breast imaging: how to reduce errors and promote a safety environment.

July 7, 2021

Missing diagnoses during the COVID-19 pandemic: a year in review.

June 23, 2021

Cancer diagnoses delayed among prisoners in Washington state.

May 26, 2021

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

Clinical and financial implications of second-opinion surgical pathology review.

April 7, 2021

Rapid-cycle improvement during the COVID-19 pandemic: using safety reports to inform incident command.

October 7, 2020

Effect of delays in the 2-week-wait cancer referral pathway during the COVID-19 pandemic on cancer survival in the UK: a modelling study.

August 19, 2020

Missed breast cancer: effects of subconscious bias and lesion characteristics.

August 5, 2020

COVID-19: making the right diagnosis.

August 5, 2020

Planning for a pandemic: mitigating risk to radiation therapy service delivery in the COVID-19 era.

July 22, 2020

Global oncology pharmacy response to COVID-19 pandemic: medication access and safety.

June 10, 2020

See More About The Topic

Ambulatory Clinic or Office

Health Care Providers

Medical Oncology

Infectious Diseases

Diagnostic Test Interpretation Error

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

Coronavirus Disease 2019 (COVID-19) and Diagnostic Error

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

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

Coronavirus Disease 2019 (COVID-19) and Diagnostic Error

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