A 70-year-old man, without documented past psychiatric history, was placed on an involuntary hold as a danger to others for grave disability because of his belief that his neighbors were shocking him with low-voltage electricity. The patient had been seen for many years through a local HMO and his records indicated no psychiatric or medical disorders other than a remote GI bleed. A friend of the patient's reported the patient had believed for the past five to seven years that the shockers had been after him. In the two weeks prior to hospitalization, the patient reported they had somehow upped the current. At a local ER, the patient had normal labs and physical examination, with a confirming non-focal neurologic exam on admission to the psychiatric inpatient unit. The patient used a walker for ambulation because of pain. He was diagnosed as psychosis NOS, not otherwise specified, with a note in the plan to defer starting antipsychotic medications and rule out medical etiologies for his acute symptoms. The treating team began low-dose haloperidol. On the first day of hospitalization, the patient complained that he couldn't move because he was shocked by something in his room. Although he felt paralyzed, he was able to lift both legs off the bed and move his toes. On day two, he was incontinent of urine. He was placed on an extended involuntary hold on day three. By day four, he reported continued difficulty moving, continued incontinence of urine, decreased sensation below the waist, and constipation. Neurology was then consulted. They found his history and findings on exam to be concerning for spinal cord pathology of advanced severity. They ordered an MRI of the spine, which demonstrated an infiltrating mass between T8 and T10 with well-preserved disc space, thought most likely to be either lymphoma or metastasis. Brain metastases were also present. The patient was transferred to the inpatient medical unit for CT-guided biopsy and other indicated procedures. The consensus was that the patient's prognosis was not affected by the several-day delay. His neurological status improved after radiation treatment for his cord compression, but the mistake could have resulted in permanent loss of neurological function. His neurological status improved after radiation treatment for his cord compression, but the mistake could have resulted in permanent loss of neurological function. 1. The mistake of neglecting the medical risks associated with older age. 2. The mistake of ascribing all symptoms to a chronic psychiatric disorder. 3. The mistake of medical clearance. 4. The mistake of neglecting a patient's symptom reports. Take-home points. Be aware that diagnostic error leads to greater mortality than other error. Utilize standard approaches to diagnosis. Ensure teams and team leaders are open to disagreement. Use near misses to assess teamwork. See patients as team members.

70-year-old man

involuntary hold

psychosis

spinal cord pathology

diagnostic errors