During an initial physical for a new 38-year-old female patient, the PCP noted a normal breast exam, and recommendations for a screening mammogram and colonoscopy due to family history of colon cancer. A mammogram was never done, although the patient returned to this physician practice a dozen times over the next several years for episodic care. Then she presented with a a self-identified lump, followed by a cancer diagnosis. Dr. Carla Ford discusses the patient safety and risk management implications.