On 8/12/2011, a patient was admitted to a medical center for post-operative care after a right thyroid lobectomy.
The patient presented with multiple risk factors for coronary artery disease, including obesity and tobacco use. She had a prolonged and difficult time with extubation after the surgery and complained of shortness of breath.
An internist was consulted for medical management. The internist diagnosed the patient with questionable and mild pulmonary edema. The internist’s plan of care for the patient was to admit her to the hospital, obtain ventilation/perfusion (V/Q) scan, perform cardiology and deep vein thrombosis evaluations, and perform peptic ulcer disease prophylaxis. The internist did not order telemetry monitoring for the patient.
On 8/12/2011, the patient was found slumped over the left side of her hospital bed and unresponsive. Staff initiated resuscitative efforts but they were unsuccessful and the patient expired.
The Board judged the internists conduct to be below the minimum standard of competence given that he failed to order telemetry monitoring for her upon her admission to the medical center.
The Board ordered that the internist pay a fine of $5,000 against his license and pay reimbursement costs for the case for a minimum of $2,378.85 and not to exceed $4,378.85. The Board also ordered that the internist complete five hours of continuing medical education in “Risk Management” and complete a one hour lecture/seminar on “Risk Management.”
Date: November 2017
Specialty: Internal Medicine
Symptom: Shortness of Breath
Diagnosis: Pulmonary Disease
Medical Error: Failure to properly monitor patient
Significant Outcome: Death
Case Rating: 1
Link to Original Case File: Download PDF
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