Neurosurgery: Communications and System Failure Leading to Diagnostic Error (Claims Corner CME)


Failures of systems often prevent physicians from making timely diagnoses. Failures may result when needed equipment isn’t available or when access to a patient is difficult System failures may result when there is a lack of coordination of appropriate care among providers, or when poor communication among providers leads to missed and delayed diagnoses. Other factors that can cloud timely decision making include provider’s biases based on incomplete information or assumptions. This neurosurgery case explores a number of factors that contributed to the patient’s outcome but are not unique to this claim.

Course ID #: TDE 200717.0 Issue Date: 03/16/2020 Expiration Date: 03/16/2023


After completing this activity, learners will be able to:

  • Describe common mistakes that prevent reaching a timely diagnosis

  • Reflect on how their decision-making process may impact reaching a timely and accurate diagnosis

  • Identify when communication and interactions with other providers restricts decisions related to diagnosing, treating or coordinating care for your patients


No individual in a position to control or influence the content of this activity has reported relevant financial relationships with commercial interests. No commercial support was provided for this activity.


The information and guidelines contained in this activity are generalized and may not apply to all practice situations. We recommend that legal advice be obtained from a qualified attorney for specific application to your practice. The information is intended for educational purposes and should be used as a reference guide only.

Course Developers

Susan Shepard, MSN, MA, RN, CPHRM, Senior Director, Patient Safety and Risk Management Education, Department of Patient Safety and Risk Management, The Doctors Company

Shelley Rizzo, MSN, RN, CLNC, CPHRM, CPPS, Senior Patient Safety Risk Manager, Department of Patient Safety and Risk Management, The Doctors Company.

Leslie J. Castaneda, BSN, RN, Healthcare Quality & Risk Consultant, The Doctors Company

Julie Hopkins, MA, MBA, Senior Director, Continuing Professional Education, The Doctors Company

Continuing Education Credit

The Doctors Company is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical educational activities for physicians.

The Doctors Company designates this activity for a maximum of 0.50 AMA PRA Category 1 Credit™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Complies with State Requirements

Please SEE the Federation of State Medical Boards overview of Continuing Medical Education requirements by State. 

Technical Requirements

The activity is best experienced using the most current browser: Firefox, Chrome, or Microsoft Edge. Internet Explorer is not supported on this platform. All activities featuring audio must have a speaker. To view graphic images and references that appear in separate "pop-up" windows, JavaScript and session cookies must be enabled on your computer. Adobe Acrobat Reader may be required for certain activities.

Contact Us

If you have questions, contact or call 800.421.2368, extension 1243.


Visit our Resource document for this program