PSNet publish a case of a misdiagnosed pelvic mass in a pregnant woman with an accompanying commentary from Leiserowitz and Hedriana discussing the diagnostic errors and the systems change needed.
- Patient-related factors, cognitive errors, and systems factors are common categories of diagnostic errors, all three of which played a role in the failure to recognize that the patient in this case was in her third trimester of pregnancy and in early labor
- Communication among members of work teams is critical for avoiding perpetuation of cognitive errors
- Appropriate supervision of physician trainees is necessary to ensure high-quality patient care
- Diagnostic errors in the use obstetrical ultrasound can result from inadequate training and experience, and the lack of a systematic approach to examinations and interpretations; patient factors such as obesity can limit diagnostic detection of important findings.