This case involves a woman in her thirties with a family history of breast cancer who was referred to a regional cancer center by her primary care physician after he detected a lump in her breast. While under the care of physicians at the medical center, the woman underwent a number of imaging studies, including a mammogram and an ultrasound, both of which were read as normal. As a result, she was cleared of a cancer diagnosis and was released without follow up. Some months later, the woman was seen by another doctor, who again ordered imaging studies after feeling a number of lumps in her breast. The patient was seen by a different oncologist, who informed the patient that the imaging performed by the original oncologist had been administered incorrectly, and the results had been misinterpreted. By the time the patient’s cancer was successfully detected, her tumor had more than doubled in size, requiring a double mastectomy as well as multiple rounds of chemotherapy to treat.