A 57-year old man presenting with frequent and painful urination and negative initial urinalysis for infection was given a diagnosis of benign prostate hypertrophy, which was never revised by subsequent providers. Instead, the patient continued to be treated for urinary retention and pain. A potent NSAID, Toradol (ketorolac), was included in his regimen. One day prior to his demise, the patient was diagnosed with prostatic abscess and admitted for treatment with intravenous antibiotics. However the patient died on hospital day one from massive GI bleeding. Autopsy revealed an underlying peptic ulcer.
This case shines a light on diagnostic error: missed, wrong, or delayed diagnosis. It also uncovers the multifaceted nature of diagnostic errors and highlights the importance of system- related interventions, in particular, better communication between health care providers. Based on malpractice claims data, diagnostic error is the most frequent and costly of all medical mistakes, yet it remains one of the least studied areas of patient safety. While the field has some barriers to study, many opportunities exist for impact in the field of diagnostic errors
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.