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Misdiagnosis can perpetuate over a long period and delay a correct course of treatment. This news feature shares an example of depression misdiagnosis that masked the true problem of a neurological tumor manifesting in what was seen and treated as a psychological condition. 

Physicians have unique perspectives when exposed to health care delivery problems as patients themselves or as caregivers. This news story shares the author’s frustrations with the system of care observed during an overnight visit at the bedside of her daughter awaiting an emergency appendectomy. Her experience underscored the value of patients and families engaging in the safety of actions clinicians take when providing care. 

Uncertainty, misinformation, management gaps, and rapid escalation undermine crisis response effectiveness. This article illustrates system, leadership, and process failures that contributed to harms associated with the COVID-19 pandemic. 

Implicit and explicit biases affect many facets of the health care delivery system. This story shares African-American patient experiences with bias that reduced the safety of maternity care. 

The reluctance of patients to seek routine health care services due to the COVID-19 pandemic is a recognized concern. This article shares data that illustrates the potential public health impact of this unreceived care over time.

The COVID-19 pandemic has reduced patient use of primary, preventive, chronic and cancer care. This article discusses how reductions in cancer diagnosis may represent a worrying trend that has the potential to reduce patient safety in this vulnerable patient population.

Diagnosis in women is complicated by cultural norms, lack of research on medical conditions affecting women, and implicit bias. The article outlines conditions that are likely to be misdiagnosed in women such as heart disease and breast cancer. The author shares strategies for women to engage in the process to improve diagnostic accuracy.  

Unconscious biases affecting health care decisions elevate the potential for harm. This news story discusses how experience and implicit biases can impact physician decision-making. The use of decision support is one strategy highlighted to redirect heuristics and other cognitive biases to minimize their impact on treatment.   

Maternal morbidity and perinatal harm can be exacerbated due to implicit bias. This story discusses a case of an American Indian/Alaska Native mother and infants whose deaths may have been preventable had her concerns been more effectively addressed. The situation illustrates conditions in the broader indigenous peoples’ community that indicate a lack of respect and patient-centeredness as factors contributing to poor care.

Infants are particularly vulnerable to patient safety errors. This article shares preliminary findings of a government investigation into infant deaths at a National Health Service Trust hospital. Initial insights discussed include the lack of a safety culture at the Trust Hospital facilitating the persistence of the problems.

Patient suicide is considered a sentinel event. This feature shares an examination of approximately 100 preventable deaths in the State of California over a decade. An examination of the case records identified breakdowns in care processes such as lack of training, low staffing and human error.

Unconscious assumptions and biases are known contributors to poor decision-making. This news story discusses racial and gender bias as common factors that reduce the accuracy and effectiveness of the diagnostic process.

Diagnostic errors occur due to a variety of factors. This magazine article reports on the persistent misdiagnosis and ineffective treatment of Lyme disease, including how lack of a standardized test for the disease and bias affect diagnosis and treatment of this condition.

Clinicians are often reluctant to report impaired or incompetent colleagues. This newspaper article discusses how a Veterans Affairs system pathologist with substance addiction continued to misdiagnose patients despite performance concerns raised by colleagues.

The slow adoption of improvement innovations is a persistent challenge to high-quality and safe patient care. This newspaper article raises concerns about how common treatments are recommended despite insufficient evidence regarding their effectiveness and provides examples of how this problem can result in harm, such as the previous physician belief that opioids were not addictive. Reassessment of science can improve safety and reduce the unintended consequences of ineffective treatments.

Implicit biases can affect communication, diagnosis, and treatment decisions. This news article reports the experience of a neurologist and the biases that negatively influenced her health care, such as lack of respect for women presenting with functional symptoms and premature closure.

Artificial intelligence (AI) and advanced computing technologies can enhance clinical decision-making. Exploring the strengths and weaknesses of artificial intelligence, this news article cautions against the wide deployment of AI until robust evaluation and implementation strategies are in place to enhance system reliability. A recent PSNet perspective discussed emerging safety issues in the use of artificial intelligence.

Efforts to reduce misuse of prescription opioids must draw from public health and behavioral strategies to be successful. This news article reports on an analysis of surgical pain management practice changes used in 43 hospitals in response to prescription guidelines.