{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,29]],"date-time":"2026-08-29T03:18:43Z","timestamp":1787973523311,"version":"build-2784847793"},"reference-count":14,"publisher":"American Society of Clinical Oncology (ASCO)","issue":"12","content-domain":{"domain":["ascopubs.org"],"crossmark-restriction":true},"short-container-title":["JCO Oncology Practice"],"published-print":{"date-parts":[[2022,12]]},"abstract":"<jats:p> This is the first case of Cancer Morbidity, Mortality, and Improvement Rounds, a series of articles intended to explore the unique safety risks experienced by oncology patients through the lens of quality improvement, systems and human factors engineering, and cognitive psychology. This case highlights how multiple overlapping factors contributed to a delay in diagnosing disseminated tuberculosis in a patient with lung cancer. The discussion focuses on the ways that cognitive biases contributed to the delayed diagnosis in a patient who, with the benefit of hindsight, exhibited several signs and symptoms suggesting tuberculosis. <\/jats:p><jats:p> Cancer Morbidity, Mortality, and Improvement Rounds is a series of articles intended to explore the unique safety risks experienced by oncology patients through the lens of quality improvement, systems and human factors engineering, and cognitive psychology. For purposes of clarity, each case focuses on a single theme, although, as is true for all medical incidents, there are almost always multiple, overlapping, contributing factors. The quality improvement paradigm used here, which focuses on root cause analyses and opportunities to improve care delivery systems, was previously outlined in this journal. <jats:sup>1<\/jats:sup> <\/jats:p>","DOI":"10.1200\/op.22.00145","type":"journal-article","created":{"date-parts":[[2022,9,1]],"date-time":"2022-09-01T20:01:13Z","timestamp":1662062473000},"page":"833-839","update-policy":"https:\/\/doi.org\/10.1200\/crossmark","source":"Crossref","is-referenced-by-count":4,"title":["A Perfect Storm Averted: Flawed Systems, a Dropped Ball, and Cognitive Biases Delay a Critical Diagnosis"],"prefix":"10.1200","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0709-2270","authenticated-orcid":false,"given":"Thomas J.","family":"Roberts","sequence":"first","affiliation":[{"name":"Dana-Farber Cancer Institute, Boston, MA"},{"name":"Massachusetts General Hospital, Boston, MA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3078-4155","authenticated-orcid":false,"given":"Maclean C.","family":"Sellars","sequence":"additional","affiliation":[{"name":"Dana-Farber Cancer Institute, Boston, MA"},{"name":"Massachusetts General Hospital, Boston, MA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jacob M.","family":"Sands","sequence":"additional","affiliation":[{"name":"Dana-Farber Cancer Institute, Boston, MA"},{"name":"Harvard Medical School, Boston, MA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8634-5891","authenticated-orcid":false,"given":"Joseph O.","family":"Jacobson","sequence":"additional","affiliation":[{"name":"Dana-Farber Cancer Institute, Boston, MA"},{"name":"Harvard Medical School, Boston, MA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"233","reference":[{"key":"b1","doi-asserted-by":"publisher","DOI":"10.1200\/JOP.2014.003566"},{"key":"b2","doi-asserted-by":"publisher","DOI":"10.1016\/S1470-2045(17)30679-4"},{"key":"b3","doi-asserted-by":"publisher","DOI":"10.1097\/ACM.0000000000001421"},{"key":"b4","doi-asserted-by":"publisher","DOI":"10.1177\/0272989X14547740"},{"key":"b5","doi-asserted-by":"publisher","DOI":"10.1001\/jama.2010.1276"},{"key":"b6","doi-asserted-by":"publisher","DOI":"10.1515\/dx-2017-0012"},{"key":"b7","doi-asserted-by":"publisher","DOI":"10.1377\/hlthaff.2009.0513"},{"key":"b8","volume-title":"To Err Is Human: Building a Safer Health System","author":"Institute of Medicine (US) Committee on Quality of Health Care in America","year":"2000"},{"key":"b9","volume-title":"Improving Diagnosis in Health Care","author":"Committee on Diagnostic Error in Health Care, Board on Health Care Services, Institute of Medicine, The National Academies of Sciences, Engineering, and Medicine","year":"2015"},{"key":"b10","doi-asserted-by":"publisher","DOI":"10.1136\/bmjqs-2013-002627"},{"key":"b11","doi-asserted-by":"publisher","DOI":"10.1097\/ACM.0000000000002518"},{"key":"b12","volume-title":"The Hierarchy of Intervention Effectiveness","year":"2015"},{"key":"b13","volume-title":"RCA2: Improving Root Cause Analyses and Actions to Prevent Harm","year":"2015"},{"key":"b14","doi-asserted-by":"publisher","DOI":"10.1007\/s13187-010-0107-9"}],"container-title":["JCO Oncology Practice"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/ascopubs.org\/doi\/pdfdirect\/10.1200\/OP.22.00145","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2022,12,12]],"date-time":"2022-12-12T23:01:29Z","timestamp":1670886089000},"score":1,"resource":{"primary":{"URL":"https:\/\/ascopubs.org\/doi\/10.1200\/OP.22.00145"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,12]]},"references-count":14,"journal-issue":{"issue":"12","published-print":{"date-parts":[[2022,12]]}},"alternative-id":["10.1200\/OP.22.00145"],"URL":"https:\/\/doi.org\/10.1200\/op.22.00145","relation":{},"ISSN":["2688-1527","2688-1535"],"issn-type":[{"value":"2688-1527","type":"print"},{"value":"2688-1535","type":"electronic"}],"subject":[],"published":{"date-parts":[[2022,12]]},"assertion":[{"value":"2022-03-01","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2022-04-19","order":1,"name":"revised","label":"Revised","group":{"name":"publication_history","label":"Publication History"}},{"value":"2022-06-09","order":2,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2022-09-01","order":3,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}]}}