Document Type

Journal Article

Publication Date



The Open Urology & Nephrology Journal


Volume 6

Inclusive Pages



Diagnostic Error; Diagnostic Process; Delayed Diagnosis


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.


Reproduced with permission of Bentham Science Publishers, Open Urology & Nephrology Journal.

Creative Commons License

Creative Commons License
This work is licensed under a Creative Commons Attribution-Noncommercial 3.0 License

Peer Reviewed


Open Access