A perfect storm averted: flawed systems, a dropped ball, and cognitive biases delay a critical diagnosis.
Roberts TJ, Sellars MC, Sands JM, et al. A perfect storm averted: flawed systems, a dropped ball, and cognitive biases delay a critical diagnosis. JCO Oncol Pract. 2022;18(12):833-839. doi:10.1200/op.22.00145.
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.