{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,8,28]],"date-time":"2025-08-28T12:43:03Z","timestamp":1756384983825,"version":"3.44.0"},"reference-count":10,"publisher":"BMJ","content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Case Reports"],"accepted":{"date-parts":[[2015,2,20]]},"abstract":"<jats:p>A low-grade sebaceous carcinoma was excised from a 55-year-old woman's neck. At follow-up, 11\u2005months later, a recent diagnosis of mucinous adenocarcinoma of the colon and history of clear cell endometrial carcinoma were identified. A strong family history of bowel cancer suggested Muir-Torre syndrome. Unexpectedly, hereditary non-polyposis colorectal cancer had previously been genetically confirmed; the results were found loosely filed in the paper chart. The patient had not informed us about her diagnosis; having discussed the case with other physicians she felt the diagnosis would be common knowledge. In 1999, US National Institute of Medicine estimated that preventable medical error resulted in the deaths of 44\u201398\u2005000 people yearly in US hospitals. Four categories of medical error, including diagnosis, treatment, preventive and \u2018other\u2019 were described, while the reasoning processes that result in these errors are outlined by Reason <jats:italic>et al<\/jats:italic>. We utilise this rare case to illustrate these important concepts.<\/jats:p>","DOI":"10.1136\/bcr-2014-206959","type":"journal-article","created":{"date-parts":[[2015,3,20]],"date-time":"2015-03-20T13:20:20Z","timestamp":1426857620000},"page":"bcr2014206959","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":1,"title":["Diagnostic error: what Muir-Torre syndrome has taught us"],"prefix":"10.1136","volume":"2015","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-0107-4488","authenticated-orcid":false,"given":"Dmitri","family":"Wall","sequence":"first","affiliation":[{"name":"Department of Dermatology, University Hospital Limerick, Limerick, Ireland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Caitriona Bridget","family":"Hackett","sequence":"additional","affiliation":[{"name":"Department of Dermatology, University Hospital Limerick, Limerick, Ireland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Vourneen","family":"Healy","sequence":"additional","affiliation":[{"name":"Department of Pathology, University Hospital Limerick, Limerick, Ireland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Bart","family":"Ramsay","sequence":"additional","affiliation":[{"name":"Department of Dermatology, University Hospital Limerick, Limerick, Ireland"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2015,3,20]]},"reference":[{"key":"2025082805083212000_2015.mar20_1.bcr2014206959.1","doi-asserted-by":"publisher","DOI":"10.1136\/ewjm.172.6.393"},{"key":"2025082805083212000_2015.mar20_1.bcr2014206959.2","doi-asserted-by":"publisher","DOI":"10.1111\/j.1468-3083.2012.04539.x"},{"key":"2025082805083212000_2015.mar20_1.bcr2014206959.3","doi-asserted-by":"publisher","DOI":"10.1016\/j.jaad.2010.08.003"},{"key":"2025082805083212000_2015.mar20_1.bcr2014206959.4","unstructured":"International Society for Gastrointestinal Hereditary Tumours. 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