The PRIDE Learning Network aims to educate clinicians and spread awareness through a repository of diagnostic error case studies.

Cases studied by PRIDE published on AHRQ’s WebM&M:

Anemia and Delayed Colon Cancer Diagnosis

An elderly man had iron deficiency anemia with progressively falling hemoglobin levels for nearly 2 years. Although during that time he underwent an upper endoscopy, capsule endoscopy, and repeat upper endoscopy and received multiple infusions of iron and blood, his primary physician maintained that he didn't need a repeat colonoscopy despite his anemia because his previous colonoscopy was negative. The patient ultimately presented to the emergency department with a bowel obstruction, was diagnosed with colon cancer, and underwent surgery to resect the mass.
Read about this case on AHRQ WebM&M

Endometriosis: A Common and Commonly Missed and Delayed Diagnosis

A 15-year-old girl developed disabling menstrual cramps and heavy bleeding at the onset of her first menstrual period. She went to a gynecologist, who attributed the symptoms to "bad periods" and started her on an oral contraceptive pill. In the ensuing years she experienced severe abdominal cramps, bloating, nausea and diarrhea, and sought care from another gynecologist, her primary care provider and a gastroenterology specialist. She was variously diagnosed with Irritable Bowel Syndrome with Diarrhea and "tortuous bowel." After experiencing “sharp” right-sided abdominal pain she was admitted for an emergency appendectomy by a general surgeon. At her postoperative appointment, the surgeon informed her that the procedure was prolonged due to endometriosis lesions close to the appendix. The surgeon said these lesions caused the appendix to become infected, and referred her to a gynecologist. The patient experienced delays in treatment due to medical insurance coverage issues and often intolerable medication side effects. Ultimately, the patient underwent a diagnostic laparoscopy to confirm endometriosis via biopsy, and definitive surgery: laparoscopic wide-field excision of the endometriosis, which was performed 12 years after her symptoms started.
Read about this case on AHRQ WebM&M

Renal Failure Due to Benign Prostatic Hyperplasia

Referred to urology for a 5-year history of progressive urinary frequency, nocturnal urination, and difficulty initiating a stream, a man had been reluctant to seek care for his symptoms because his father had a "miserable" experience with treatment for the same condition. A physician assistant saw him at that first visit and ordered a PSA test (despite the patient's expressed views against PSA testing) and cystoscopy (without explaining why it was needed), and urged the patient to self-catheterize (without any instructions on how to do so). The patient elected not to follow up with the tests because of this negative interaction. Ten weeks later, he sought care from a nurse practitioner at his primary care provider's office where his blood pressure and creatinine levels were found to be markedly elevated, 2L of urine were drained via catheter, and he was admitted to the hospital for renal failure.
Read about this case on AHRQ WebM&M

Spinal Epidural Abscess

A woman with a history of prior spine surgery presented to the emergency department with progressive low back pain. An MRI scan of T11–S1 showed lumbar degenerative joint disease and a small L5–S1 disc herniation. She was referred for physical therapy and prescribed muscle relaxant, non-steroidal anti-inflammatories, and pain relievers. Ten days later, she presented to a community hospital with fever, inability to walk, and numbness from the waist down. Her white blood cell count was greater than 30,000 and she was found to be in acute renal and liver failure. She was transferred to a neurosurgery service at an academic hospital when an MRI revealed a T6–T10 thoracic epidural abscess.
Read about this case on AHRQ WebM&M