Death of a 29-Year-Old Male from Undifferentiated Sepsis

Table 1

RCA for death of 29-year-old male from disseminated tuberculosis.

Problem	Patient died of undiagnosed disseminated tuberculosis
Why?	Tuberculosis not on differential diagnosis
Why?	Cognitive bias during diagnosis		Lack of awareness of infliximab use and associated adverse effects
Why?	No interspecialty case conference	No tool used to prevent bias during diagnosis	No centralized medication listing across hospitals	No red-flagging for high-risk medications	Incomplete handover between physicians during transfers
Why?				Incomplete medication postmarketing surveillance