On 11/17/2011, a 56-year-old female underwent a colonoscopy performed by a gastroenterologist. The patient had undergone a bone marrow transplant for chronic lymphocytic leukemia. After the procedure, the patient complained of nausea, vomiting, and epigastric pain. An endoscopy was performed the prior day to rule out graft versus host disease or cytomegalovirus infection and the colonoscopy was a part of that procedure.
The gastroenterologist performed the coloscopy to the terminal ileum. The patient was sedated with midazolam 8 mg IV, fentanyl 175 micrograms IV, and diphenhydramine 50 mg IV in divided doses as the patient exhibited any signs of discomfort. Biopsies and cultures were obtained and submitted for evaluation. Pathology results indicated apoptosis of the ileum and right colon, but negative findings for CMV.
During the course of the colonoscopic procedure, full sedation was not achieved. The patient became drowsy, but she became fully awake during the procedure more than once, complained of pain, and asked that the procedure be stopped. The gastroenterologist continued and completed the procedure despite the patient’s urgent requests.
The Board issued a public reprimand against the gastroenterologist. Stipulations included continuing medical education in the topics of pre-operative patient evaluation, informed consent, sedation, and medical record keeping.
Date: May 2017
Medical Error: Procedural error
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
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