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Washington, DC: VA Office of the Inspector General; June 28, 2022. Report No 21-03349-186.

 Cancer test communication failures can contribute to physical, emotional, and financial patient harm. This report examines missed opportunities made by multiple clinicians involved in the care of a patient with prostate cancer who then died from metastasized disease Seven recommendations are included for improving abnormal test result communication and error management at the facility.

London, UK: Parliamentary and Health Service Ombudsman; 2021. ISBN 9781528627016. 

Lack of appropriate follow up of diagnostic imaging can result in care delays, patient harm, and death. This report summarizes an investigation of 25 imaging failures in the British National Health Service (NHS). The analysis identified communication and coordination issues resulting in lack of action and reporting of unanticipated findings to properly advance care. Recommendations to improve imaging in the NHS include use of previous analyses to enhance learning from failure.

Medscape Medical News. May 12, 2021.

Delays and mistakes in health care for distinct patient populations hold improvement lessons for the broader system. This news story highlights problems in correctional system cancer diagnoses and treatment that may indicate other types of prison care delivery problems.
Hensgens RL, El Moumni M, IJpma FFA, et al. Eur J Trauma Emerg Surg. 2020;46:1367-1374.
Missed injuries and delayed diagnoses are an ongoing problem in trauma care. This cohort study conducted at a large trauma center found that inter-hospital transfer of severely injured patients increases the risk of delayed detection of injuries. For half of these patients, the new diagnoses led to a change in treatment course. These findings highlight the importance of clinician vigilance when assessing trauma patients.
Dadlez NM, Adelman J, Bundy DG, et al. Ped Qual Saf. 2020;5:e299-e305.
Diagnostic errors, including missed diagnoses of adolescent depression, elevated blood pressure, and delayed response to abnormal lab results, are common in pediatric primary care. Building upon previous work, this study used root cause analyses to identify the failure points and contributing factors to these errors. Omitted process steps included failure to screen for adolescent depression, failure to recognize and act on abnormal blood pressure values, and failure to notify families of abnormal lab results. Factors contributing most commonly to these errors were patient volume, inadequate staffing, clinic environment, electronic and written communication, and provider knowledge.