In May, 2008, 75-year-old Jim Workman, a retired Air Force colonel, entered an emergency room at a Department of Veterans Affairs (VA) hospital in Biloxi, Miss., complaining of shortness of breath, coughing and fever.

A chest X-ray was ordered, and the radiologist discovered a two-centimeter mass in Workman’s lung. He didn’t tell Workman directly but noted the finding, and recommended an immediate follow-up in an electronically signed note sent to Workman’s primary care doctor at VA.

But that doctor never bothered to look at the note, nor the X-ray. Nearly two years later, Workman was diagnosed with lung cancer. He died in January 2011.

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