This case describes a 13-year-old girl who presented to several health care providers with typical symptoms, physical signs, and early laboratory findings suggestive of adrenal insufficiency (AI) yet the diagnosis was delayed for several months due to diagnostic biases. After she suffered a sudden cardiac arrest during a visit to her local emergency department and was airlifted to a tertiary care facility, she was found to be in adrenal crisis secondary to Addison’s disease.

Minoritized patients continue to experience disproportionately high rates of maternal morbidity and mortality. This hospital developed a health-equity checklist to identify if bias and/or social determinants of health played a role in preventable adverse events.

The cases described in this WebM&M reflect fragmented care with lapses in coordination and communication as well as failure to appropriately address medication discrepancies. These two cases involve duplicate therapy errors, which have the potential to cause serious adverse drug events.

A 71-year-old man presented to his physician with rectal bleeding and pain, which was attributed to radiation proctitis following therapy for adenocarcinoma of the prostate. He subsequently developed a potentially life-threatening complication of sepsis while awaiting follow up care for a spontaneous rectal perforation. The commentary addresses the importance of early identification and timely intervention in the event of treatment failure and the post-discharge follow-up programs to improve care coordination and communication during transitions of care.