Meagan M Ladell

INTRODUCTION Despite countless hours and attempts to improve safety in health care, we recognize a frustrating lack of progress to actualize a safer health care system. Nurses, doctors, pharmacists, and others often dedicate their time and effort outside of their clinical appointments to improve both patient care and the system within which they work.

The patient is a 21-day-old infant presenting to a paediatric emergency department with respiratory distress. The patient was primarily seen by a rotating trainee with limited paediatric experience. The trainee was at the end of their shift during which they saw multiple young children with viral bronchiolitis. The patient’s father, who had limited English proficiency, reported that a sibling was also sick.

Diagnostic errors Patient safety Human factors Diagnostic error: the problem Failures in the diagnostic process are thought to affect at least 15% of patient encounters, cause 34% of adverse events in hospitals, are a leading cause in major malpractice claims and payouts and are recognised as a top priority in patient safety research.1–3 The National Academies of Science, Engineering and Medicine defines diagnostic error as a failure to establish an accurate and timely explanation of a...