In Marin County, many residents cycle through different care settings: primary care, urgent care, emergency departments, imaging centers, and specialist follow-ups. Misdiagnosis risk can increase when:
- Handoffs get fragmented (records don’t arrive quickly or at all between facilities)
- Abnormal results aren’t communicated clearly or are routed into the wrong workflow
- Follow-up depends on patient action (and symptoms worsen before appointments)
- Imaging and lab results are interpreted under time pressure—then documented imperfectly
- Automated tools influence triage or documentation without the clinician adequately reconciling outputs with the patient’s actual presentation
A key question is not just “what diagnosis was made later,” but what the care team did with the information available at the time—and whether the process met California standards for timely, reasonable medical decision-making.


