Background: Medical practitioners tend to focus too much in certain disorders, overlooking others that can cause greater damage on the patient. A patient with no diagnosis of diabetes was admitted to hospital with a severe perianal abscess, sepsis and diabetic ketoacidosis. He was followed up by several doctors, including endocrine, but they never detected his diabetes.
Case report: 58 years-old man, came to the hospital with signs of gangrene of Fournier. Blood test at admission showed hyperglycemia, metabolic acidosis, signs of infection and coagulopathy. He became septic and needed three aggressive surgeries in 24h to control the source of infection. We assumed it was a diabetes debut, but checking his analytical results of last years, we found hyperglycemia since 4 years ago. These results were seen by Primary care, Digestive and Endocrinology practitioners, but they didn´t take measures to correct them.
Discussion: In medicine is common to lose the global vision of the patient. That is what we call “tunnel vision”, we tend to see just the information we are interested in, losing the rest. This attitude can drive to medical mistake and supposes a threat for the patient's safety 1. Safety culture is based on the idea that even a qualified and motivated professional can make a mistake. Every incident supposes an opportunity to learn to identify and correct them. We have used the Spanish Anesthesia and Recovery Safety Notification System to communicate this incident 2. We made the following analysis: The active error is the omission due to the tunnel vision. Some contributing factors are involved too: lack of attention, welfare pressure, fatigue and inadequate use of material (as the information obtained in blood test wasn`t handled properly) 3 The corrective measures we suggest are: 
1. Debriefing with the implied professionals. 
2. Making the case visible by Informative Service Meetings. 
3. Creating a computer alert that shows up when certain number of laboratory abnormalities are found repeatedly. 
4. Stressing the importance of safety culture
References: 
1-Helsinki declaration on patient safety. EJA.2010;27:592-97
2-Incident reporting in anaesthesiology. Best Pract Res Clin Anaesthesiol. 2011;25:207-14
3-Int J Qual Health Care 2009; 21 n1:18-26
Learning Points: Any clinical practitioner can make mistakes with consequences on the patient's health. Communicating and analyzing the incident with a Safety Notification System is the best way to avoid repeating it.

“Tunnel vision” as a possible cause of medical error. A gangrene of Fournier that should never have happened