Steps to Misdiagnosis: Dissecting an Emergency Visit

Despite the common sense that we learn from our mistakes, an error is an unwelcome event when we deal with patients. Diagnostic error is common, costly, and the leading cause of malpractice litigation. Yet, errors occur occasionally in a lifetime of practice, and the consequences of these faults are significant for patients and physicians. If someone would have told me that I would miss a brain tumor in my first years of practice, in a patient presenting to my care with several cranial nerve signs, I would not have believed it. Here is how it happened.