Diagnostic errors don’t always look dramatic at first. Often they start with something that feels routine—an urgent care visit, a primary care appointment, a specialty referral, or test results that don’t get integrated into the next decision.
In the San Marino area, we frequently see issues tied to:
- Care transitions across providers: patients see clinicians in one system and follow up in another, and key information doesn’t travel cleanly.
- Time pressure and high patient volume: busy practices and imaging centers can miss abnormal findings or delay communication.
- Delayed follow-up on abnormal results: labs or imaging come back “borderline,” then the next step never gets scheduled—or gets scheduled too late.
- Automated tools treated like final answers: clinical decision support or AI-assisted documentation can influence triage, risk scoring, or what gets flagged for review.
The result is the same: the patient continues to worsen while the care team is working from an incomplete or incorrect clinical picture.


