Behavioral health patients present unique challenges in their care that can contribute to unintended harm. The analysis examines a delayed diagnosis, referral, and treatment of skin cancer that contributed to the death of a patient. Suggestions for improvement included conducting a root cause analysis to identify systemic problems, use of photography to track skin lesion progression, and implementation of a warm handoff process to improve staff communication.

Structural racism and implicit biases can lead to poor quality of care and adverse outcomes among Black women. This article describes the experience of a Black OB/GYN patient whose concerns about abdominal pain during her pregnancy were not thoroughly evaluated; clinicians also missed risk factors placing her at risk of spontaneous preterm birth.

Women have been affected by implicit bias that undermines the safety of their care and trust in the medical system. This book shares the history anchoring the mindsets driving ineffective care for women and a discussion of the author’s long-term lupus misdiagnosis.

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.

Implicit biases are known to impact effective diagnosis. This story highlights how dismissed concerns resulted in a delay in cancer diagnosis that contributed to the death of a young woman. 

Missed or delayed diagnosis in maternal care can result in serious harm to both the mother and the child. This report analyzes a delayed diagnosis ectopic pregnancy incident and found that referral and discharge missteps contributed to the error.