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A payment of $775,000 had been made on the gastroenterologist’s behalf to settle a civil malpractice action brought against him by a patient.

It was alleged the gastroenterologist failed to follow-up on pathology results that revealed cancer after he had performed a colonoscopy on the patient, which led to a delay in the diagnosis of colorectal cancer.

On 8/12/2009, a 55-year-old woman presented to a gastroenterologist with complaints of abdominal pain and rectal bleeding.  The patient’s medical history revealed a family history of colon cancer.  The gastroenterologist recommended that the patient have a diagnostic colonoscopy to evaluate her persistent rectal symptoms.

On 9/17/2009, the gastroenterologist performed a colonoscopy on the patient.  During the procedure, the gastroenterologist identified internal hemorrhoids associated with a sessile polyp in the mid-rectum.  The gastroenterologist removed the polyp and submitted the specimen for pathologic analysis.  The patient was discharged from the hospital on 9/17/2009.

On 9/18/2009, pathology diagnosed the polyp to be a moderately differentiated adenocarcinoma arising within a tubular adenoma.  On 10/6/2009, the gastroenterologist entered a progress note in the patient’s hospital chart directly documenting the finding of adenocarcinoma made in the pathology report.  Despite entering that chart note, the gastroenterologist never advised the patient of the finding of adenocarcinoma that had been made.

The gastroenterologist thereafter had no further contact with the patient until he saw her in his office on 8/23/2010, approximately eleven months after the colonoscopy had been performed.  At that visit, the gastroenterologist diagnosed the patient with hemorrhoids and prescribed steroid suppositories; however, he once again failed to inform her of the finding of cancer that had been made following the September 2009 colonoscopy.  Additionally, the gastroenterologist did not then recommend that the patient schedule a repeat colonoscopy.

The patient ultimately had a repeat colonoscopy performed by another physician on 4/27/2011.  Following that procedure, she was found to have an invasive carcinoma of the mid-rectum, and she commenced receiving treatment for colon cancer.

When appearing before the panel, the gastroenterologist testified that he was aware of the pathology findings that had been made following the colonoscopy but did not specifically advise the patient of those findings because he considered the pathology findings to be “benign.”  The gastroenterologist further testified that he was confident that he had removed the entirety of the rectal polyp at the time of the colonoscopy.  The gastroenterologist maintains that, after completing the colonoscopy, he advised the patient that she would need to see him again in “about” a year, but there is no documentation in either the gastroenterologist’s medical record or the hospital chart which memorializes respondent’s having advised the patient to have a repeat colonoscopy within one year.  Further, although the gastroenterologist entered a note in the patient’s hospital chart on 10/6/2009 documenting the pathology findings, he failed to record the pathology findings in his office medical record, and he failed to obtain and/or maintain a copy of the pathology report in his office record.

The Board judged the gastroenterologist’s conduct to have fallen below the standard of care given failure to document that he advised the patient to have a repeat colonoscopy performed within one year of the date on which the original colonoscopy was performed and failure to have documented the pathology findings of adenocarcinoma in his office record.

The Board assessed a fine against the gastroenterologist with stipulations to complete courses in medical record keeping and medical ethics.

State: New Jersey

Date: March 3017

Specialty: Gastroenterology

Symptom: Blood in Stool, Abdominal Pain

Diagnosis: Colon Cancer

Medical Error: Failure to follow up, Failure of communication with patient or patient relations, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 3

Link to Original Case File: Download PDF

A 9-year-old girl was referred by her pediatrician to a child neurologist for headaches.  The child neurologist first saw the patient on 9/10/2009. The patient’s mother stated that the patient’s headaches started in 7/20/2009.  The patient had no episodes of loss of consciousness of any type. The child neurologist’s review of systems revealed headaches, neck pain, and back pain.  The child neurologist noted headaches following a viral infection in July 2009 described as constant tension and pressure with nausea, photophobia, and difficulty concentration.  The child neurologist’s diagnosis was childhood migraine and prescribed 10 mg amitriptyline. The child neurologist ordered an MRI to rule out neoplasm and aneurysms. The child neurologist also ordered an EEG, which was not indicated for headaches.

On 9/18/2009, the EEG was performed.  The technician described the EEG with “sharp and slow waves.” On 9/30/2009, the child neurologist saw the patient for an office visit.  The child neurologist read the EEG as showing “generalized polyspike and wave which was synchronous bilaterally over both hemispheres which is highly suggestive of a generalized seizure disorder.”  The child neurologist stopped the amitriptyline 10 mg she prescribed at the last visit because of “seizures on EEG.” She ordered a neurosurgery consult and planned a separate meeting with the mother.

The child neurologist next saw the patient on 11/4/2009.  The child neurologist prescribed Depakote at 250 b.i.d. The patient’s Depakote level was at 72.  The patient reported no seizures or auras, but the child neurologist in her diagnosis documented “seizures, breakthrough.”  The child neurologist ordered a second video EEG with computer analysis without medical indication. The EEG was performed on 11/25/2009.  The technician report showed no abnormality. The child neurologist’s report was of generalized polyspike and slow waves bilaterally, “highly suggestive of generalized epilepsy,” with localized slowing in the left temporal area.

On 2/11/2010, the child neurologist saw the patient for a follow-up visit.  The chief complaint was learning difficulty. The Depakote level was 53. The patient denied experiencing any auras and/or any seizures.  On the next visit, on 5/11/2010, the patient still did not report any auras or seizures. The child neurologist’s diagnoses were generalized epilepsy, childhood headaches, adverse effect of medication, and learning disability.  The child neurologist ordered a third video EEG with computer analysis to rule out seizures and BAER (brainstem auditory evoked response) to rule out hearing loss, despite no medical indication. The video EEG was performed on 6/28/2010 and was normal.  On 7/12/2010, the child neurologist saw the patient for a follow-up visit. The patient denied having headaches and seizures. The child neurologist ordered a 72-hour ambulatory EEG despite the normal EEG.

The child neurologist next saw the patient on 1/19/2011 for a follow-up visit.  The patient’s mother complained that the patient’s math and history test results were still low.  The patient had no witnessed seizures and was tolerating Keppra well. Despite the negative findings, the child neurologist diagnosed “seizures, breakthrough, rule out.”  The child neurologist ordered another video EEG. At this point in time, the 72-hour video EEG she previous ordered on 7/12/2010 had not been performed.

On 2/18/2011, a 72-hour ambulatory EEG was performed.  The child neurologist’s last visit with the patient was on 3/14/2011.  On the last visit, the child neurologist noted that the 72-hour ambulatory EEG was normal.  She discontinued Keppra. She diagnosed the patient with “arachnoid cyst, middle cranial fossa; generalized epilepsy; learning disability; and adverse effect of medication given correctly.”

The Medical Board of California judged that the child neurologist’s conduct departed from the standard of care because she ordered 3 video EEGs and an ambulatory EEG without medical indication, ordered a BAER with no medical indication, misdiagnosed epilepsy on a patient with no medical history of seizures of any type, and made diagnoses of breaththrough seizures with no basis, contrary to her own findings that were no auras or seizures reported.

The Medical Board of California placed the child neurologist on probation and ordered the child neurologist to complete a medical record keeping course, a professionalism program (ethics course), an education course (at least 40 hours per year for each year of probation), and a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.  The child neurologist was assigned a practice monitor and was prohibited from supervising physician assistants and advanced practice nurses.

State: California

Date: January 2018

Specialty: Neurology, Pediatrics

Symptom: Headache, Nausea Or Vomiting, Back Pain, Head/Neck Pain

Diagnosis: N/A

Medical Error: Unnecessary or excessive diagnostic tests, False positive

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

A 14-year-old girl was referred by her pediatrician to a child neurologist for seizures.  The child neurologist first saw the patient on 8/10/2009. The patient’s first seizure occurred at age 10, early morning on 2/21/2006, and a second episode occurred in the early morning sometimes around December 2008.  At the time the patient saw the child neurologist, her medication included Klonopin 0.5 mg p.m., Depakote at 750 b.i.d., and Vistaril 10 mg p.m. The patient’s MRI on October 2008 was normal. The patient’s EEG performed on October 2007 noted 3-13 seizures.  The child neurologist’s assessment was “juvenile myoclonic epilepsy; rule out adverse effect of med correctly given; insomnia unspecified; depressive disorder; and cafe au lait spots x 2.” The child neurologist ordered a video EEG “to rule out any epileptogenic foci.”

On 8/12/2009, the video EEG was performed.  The technician reported sharp and slow waves left F3-C3.  The child neurologist read it as normal. A BAER was performed on the same day even though it was not ordered by the child neurologist.  The BAER was not indicated, and the referring diagnosis for the BAER was not in the record and was used only for billing.

The child neurologist next saw the patient on 8/21/2009 for a follow-up visit.  The child neurologist noted that the patient was tolerating Depakote well. The Depakote level was 101.  The child neurologist diagnosed breakthrough seizures despite the fact that no seizures were reported. The child neurologist added Topamax Sprinkles 25 mg to increase to 50 mg b.i.d.  She stopped the Klonopin and Vistaril.

On 11/2/2009, the child neurologist saw the patient for a follow-up visit.  She noted that patient was gaining weight with Topamax and wanted to stop Depakote, though it was well tolerated.  The patient had no seizures and no myoclonic jerks. The child neurologist ordered another video EEG without medical indication.  The result of the second video EEG was normal. The child neurologist’s reading of the video EEG followed a template and was the same with all of her video EG reports except for the first paragraph regarding time of sleep, wake, and meals.

The child neurologist next saw the patient on 5/3/2010.  The patient reported no auras or seizures. The child neurologist noted under past medical history that the patient had suicidal thoughts.  The child neurologist did not address this issue during this visit. The child neurologist continued Topamax 50 mg b.i.d., even though there was a note of memory problems.  The child neurologist reduced Depakote to 500 b.i.d. She ordered labs and a 4-day ambulatory EEG without any medical indication. The 2 previous video EEGs were normal, and the patient did not have any seizures.  The patient underwent a third video EEG on this visit, which was not ordered nor medically indicated.

On 6/8/2010, the child neurologist saw the patient for a follow-up visit.  The patient was taken off Topamax. Her memory improved, but her headaches recurred.  The child neurologist diagnosed migraines without asking sufficient questions to make that diagnosis.  She added amitriptyline 10 mg, Imitrex 100 mg, and continued Depakote 500 b.i.d.

The 4-day ambulatory EEG ordered on 5/3/2010 was performed on 7/6/2010.  It was completed despite the fact that the patient just underwent a third video EEG on 5/3/2010.  There was no medical indication for the 3 previous EEGs and the 4-day ambulatory EEG. The 4-day ambulatory EEG was read as normal.

On 8/23/2010, the child neurologist saw the patient for 2 back-to-back seizures that occurred on 8/11/2010.  The patient was taken to the emergency room with a history of early morning twitching since the seizures. The child neurologist’s assessment was breakthrough seizures.  The child neurologist added Lamictal 100 mg b.i.d. and raised Depakote from 500 mg b.i.d. to 1000 mg b.i.d. The child neurologist failed to recognize that on 7/29/2010, the patient was having myoclonic jerks, which were described as twitches.  The patient had been on 750 mg b.i.d. with a level of 100 and had been seizure free for 2 years. The child neurologist failed to recognize the important interaction between Lamictal and Depakote. The child neurologist failed to consider that it was very likely that the patient had toxic levels of both Depakote and Lamictal.  The child neurologist did not check the patient’s blood levels. The child neurologist ordered another video EEG and another ambulatory EEG. The video EEG was performed on September 2010 and was normal. The child neurologist used the same template on her report.

The child neurologist next saw the patient on 11/4/2010.  The patient was unable to sleep, had difficulties with coordination and balance, was forgetful; all symptoms consistent with medication toxicity.  The child neurologist failed to recognize it as such. The patient was on Depakote 500 mg b.i.d. and Lamictal 100 mg b.i.d. Suicidal ideation was noted in the child neurologist’s previous notes, but the child neurologist failed to address this issue.  The child neurologist added Prozac 20 mg, which had a black box warning for suicidal ideation.

The Medical Board of California judged that the child neurologist’s conduct departed from the standard of care because she ordered 4-5 video EEGs and an ambulatory EEG without medical indication, ordered a BAER with no medical indication, lacked knowledge and/or did not consider the important interaction between Depakote and Lamictal.  The child neurologist diagnosed migraines without establishing diagnostic criteria, diagnosed circadian sleep disorder without asking any questions regarding symptoms and adding the polysomnogram report in the chart, and prescribed Prozac to patient with a history of suicidal thoughts despite the black box warning.

For this case and others, the Medical Board of California placed the child neurologist on probation and ordered the child neurologist to complete a medical record keeping course, a professionalism program (ethics course), an education course (at least 40 hours per year for each year of probation), and a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.  The child neurologist was assigned a practice monitor and was prohibited from supervising physician assistants and advanced practice nurses.

State: California

Date: January 2018

Specialty: Neurology, Pediatrics

Symptom: Headache

Diagnosis: Neurological Disease, Drug Overdose, Side Effects, or Withdrawal, Psychiatric Disorder

Medical Error: Improper medication management, Diagnostic error, Failure to examine or evaluate patient properly, Unnecessary or excessive diagnostic tests

Significant Outcome: N/A

Case Rating: 3

Link to Original Case File: Download PDF

A 56-year-old female was referred by her primary care physician to a neurologist.  The patient’s primary care physician noted neck pain and numbness of the upper extremities, left greater than right, present for 1 year.  Her medications were lisinopril 5 mg daily, Lyrica 50 mg 3 times daily, Flexeril 10 mg 3 times daily, Mobic 15 mg daily, and Nexium 40 mg daily.  Her primary care physician noted that she had lumbar laminectomy for disk herniation in the past for low back pain and tingling of the left leg. He also noted that the MRI of her cervical spine was abnormal and requested a neurological evaluation.  It revealed an abnormal signal intensity C2-3 affecting posterior columns with the radiologist’s comment of “could account for arm numbness and tingling.” The x-ray of her cervical spine performed on 11/5/2012 ordered by her primary care physician showed moderate degenerative changes.  The x-ray of her lumbar spine performed on 2/23/2012 showed similar findings.

The neurologist first saw the patient on 12/10/2012 for the abnormal cervical spine MRI.  The patient’s complaints were “neck pain; left neck and arm numb; right arm and right knee; losing urine; and generalized weakness on the left.”  The patient also complained that she “also feels ‘dead’ hips down, [d]izzy spells several times, no energy, difficult to concentrate.” The neurologist noted the “neuro exam essentially normal.”  The neurologist’s diagnoses were demyelinating disease; paresthesias of face and her extremities, vertigo, and memory loss. The neurologist ordered the following tests: EMG/NCV lower extremities, though later she also did upper extremities; MRI of the brain; neuromuscular junction tests with EMG; BAER with vestibular testing; VEP; EEG, overnight; and EEG awake and sleep with digital analysis 95957.

The upper extremity EMG/NCV study was performed on 1/3/2013.  She tested 4 motor nerves, 5 sensory nerves, and F waves. The neurologist tested every muscle, which was present in the upper extremities.  The results of the study were normal.

The electrodiagnostic study of the lower extremities were performed on 1/10/2013.  The neurologist tested 4 motor nerves, 6 sensory nerves, 2 H reflexes, bilateral F waves of the motor nerves.  She did a needle EMG of all muscles in the lower extremities and paraspinal muscles. The results of the study were normal.

There was a report of a video-monitored EEG utilizing a 32-channel digital EEG system manufactured by Cadwell.  This test was performed on 12/26/2012. The report stated that the technician performed hyperventilation, but the patient reported she did not, and that the patient was videotaped, though the patient reported she was not.  It was read as normal.

The ambulatory EEG was performed on 2/5/2013 to 2/6/2013.  In the report, it was termed a 2-day ambulatory EEG despite lasting only 1 day.  The neurologist prepared the report. The report contained a printout of 1 page. It was timed 6:21 a.m., and it contained widespread artifacts lasting 10 seconds.  This was the exact time that the patient reported she stood in front of her microwaves. The neurologist read this as “Isolated sharp waves were noted in the frontal left hemispheric area. The isolated sharp waves may be epileptogenic in nature.”  The visual and brainstem auditory evoked potentials were normal.

On 2/26/2013, the neurologist saw the patient for a follow-up visit.  The test results were available to the neurologist at the visit. The neurologist noted that the EEG for the patient was normal for both awake and drowsy.  The neurologist also noted that the 2-day EEG, which lasted only 1 day and the MRI of the brain showed a corpus callosum lesion. Her assessment and plan contained the same diagnoses as the first visit of 12/10/2012, and she failed to consider new information that should have changed her initial diagnoses.

The neurologist did not diagnose seizures in the assessment and plan, but she prescribed Depakote.  The neurologist discussed with the patient that she met criteria for relapsing and remitting Multiple Sclerosis with an acute exacerbation.  The neurologist also noted that the patient had pain with neck movement, which was sharp and went to the toes. She believed that the symptom was consistent with the finding of the ambulatory EEG and thus started the patient on Depakote 500 mg b.i.d.  The neurologist failed to recognize Lhermitte’s sign, consistent with the myelopathy. The neurologist ordered laboratory studies for Lyme disease, lupus, and lumbar puncture. She ordered monitoring labs for Depakote, CBC, and liver function tests to be done before the next visit.

The MRI of the brain the neurologist referred to in the 2/26/2013 follow-up visit was performed at the neurologist’s request on 12/28/2012.  The report indicated 20 FLAIR hyperintensities and a possible tiny corpus callosum lesion. The neurologist concluded it was consistent with multiple sclerosis.  The 12/28/2012 report contained a comparison to a previous MRI of the brain performed on 7/1/2007. The radiologist thought the new MRI showed abnormalities “probably very slightly more numerous” than the 2007 MRI.  He further considered the appearance to be nonspecific, and the tiny lesion in the corpus callosum was considered possible.

The 2007 MRI was requested by another physician.  It was read as showing “a few nonspecific scattered punctate of unlikely clinical significance.”  Multiple sclerosis was not raised as a possible cause. Referring diagnosis was “recent vertigo and left-sided dizziness.”  The neurologist failed to question the patient on symptoms that occurred in 2007.

On 3/12/2013, the patient was seen in the emergency room for nausea and vomiting.  She was diagnosed with Depakote toxicity with a level of 108. She was told to stop the medication.  She was scheduled for the lumbar puncture the following day and was told to keep that appointment. The day following the lumbar puncture, she developed symptoms consistent with a postspinal headache.  She was seen by the neurologist in her office on the same day and diagnosed with Depakote toxicity. At this point, the neurologist erroneously believed that the patient had “definite” multiple sclerosis.  She also erroneously believed that “the patient wrongfully assumed” Depakote caused her symptoms and believed that they were from the lumbar puncture.

The neurologist next saw the patient on 3/26/2013 for an office visit.  The neurologist noted that the patient had a postspinal headache. She noted that the spinal fluid was negative for oligoclonal bands, but incorrectly thought the IgG synthesis was abnormal.  She incorrectly diagnosed “primary stabbing headache” despite her earlier entry of postspinal headache.

In a subsequent interview with a Medical Board investigator, the neurologist was questioned as to why she did not take a history of previous symptoms, such as optic neuritis, that help to establish a diagnosis of multiple sclerosis.  She was questioned if the examination was normal and why she did not check the “saddle” area for sensory loss, and she reported, “Why should I check the saddle area?” There were no “incontinence of stools.” When asked if she would have documented Lhermitte’s symptom or sign if present, she answered yes.  She obtained a history of symptoms consistent with Lhermitte’s, but did not recognize it as such. Memory loss was given as a diagnosis, but when asked how it was based, she could not recall. When asked to explain the reasons that each test was ordered, she responded that the EMG was based on symptoms, the neuromuscular test was based on the possibility of myasthenia gravis causing general weakness, the BAER and VEP as part of the multiple sclerosis work-up, and the EEG to rule out seizures as the cause of numbness and weakness.  She stated video monitoring on EEG was standard practice. Hearing loss was her reason for performing the BAER, but no hearing loss or visual disturbance was documented. She stated that the 2007 MRI showed infratentorial and supratentorial lesions whereas there was no mention of an infratentorial lesion in the radiology report. She ordered the EMG of the upper extremities to “rule out any other diseases” and stated “EMG is part of differential diagnosis,” and the indication she believed was numbness and tingling in the hands. When asked why she did 24 upper extremity and 6 cervical paraspinal muscles on EMG, she stated she wanted to make sure there was “no polyradiculopathy,” but she admitted there were no findings to suggest that diagnosis.  Further, she believed that numbness and tingling and incontinence would indicate polyradiculopathy. When questioned regarding indications for EMG of the lower extremities, she stated back problems, numbness right arm and right knee, and feeling the hips on down were “dead.” In the lower extremities, she tested 12 different muscles and 6 paraspinal muscles. She was then questioned about what were the indications for the EEG, and she believed they were generalized weakness, dizzy spells, no energy to work, and difficulty focusing. She was questioned as to why the first EEG was not sufficient. She stated that on 2/26/2013 visit, she had findings of generalized seizure disorder, but this was not the wording in the EEG report nor was it in her letter to the Board.  She was not aware that a microwave can cause artifacts. Regarding indication for Depakote, her answer was because of the EEG and numbness and tingling. She thought it would be trial and error to see if it would help. She thought that the patient’s symptom of “neck killing her” would be consistent with a multiple sclerosis plaque. When asked why she ordered Lyme disease and lupus blood tests, she stated that they were “on my mind.”

The Medical Board of California judged that the neurologist’s conduct departed from the standard of care because she failed to recognize symptoms and findings on the MRI of a partial transverse cervical myelopathy, ordered an EMG for the upper and lower extremities, video EEG, and ambulatory EEG without medical indication, conducted an excessive number of nerve tests for any diagnosis, misdiagnosed epilepsy, lacked knowledge in reading EEGs, and had no knowledge and/or did not consider the important interaction between Depakote and the patient’s other medications.  The neurologist also lacked knowledge in several fundamental areas.  She failed to recognize symptoms of a partial transverse cervical myelopathy and Lhermitte’s symptoms even though it was described to her by the patient.  She did not recognize or, if she did, did not reflect in her records that almost all of the patient’s symptoms were caused by the cervical myelopathy. The neurologist erroneously believed that a multiple sclerosis plaque could cause severe neck pain and that IgG synthesis could indicate active or inactive multiple sclerosis.  She diagnosed multiple sclerosis on the basis of the McDonald criteria, and she included the original report, but she gave no information in her records how those criteria fit the patient. She failed to question the patient for previous symptoms, which might establish an initial exacerbation of multiple sclerosis. The neurologist was aware that the patient had an MRI in 2007 and did not question the patient regarding her symptoms at that time.  She ordered laboratory studies for possible Lyme disease or “lupus” and a monophasic cervical myelopathy despite the fact that it was exceedingly unlikely to be caused by any of those disorders. She failed to consider alternative causes for the patient’s presentation, specifically B12 deficiency or adrenomyeloneuropathy.

For this case and others, the Medical Board of California placed the neurologist on probation and ordered the neurologist to complete a medical record keeping course, a professionalism program (ethics course), an education course (at least 40 hours per year for each year of probation), and a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.  The neurologist was assigned a practice monitor and was prohibited from supervising physician assistants and advanced practice nurses.

State: California

Date: January 2018

Specialty: Neurology

Symptom: Head/Neck Pain, Dizziness, Headache, Nausea Or Vomiting, Numbness, Urinary Problems, Weakness/Fatigue

Diagnosis: Spinal Injury Or Disorder, Drug Overdose, Side Effects, or Withdrawal

Medical Error: Diagnostic error, Failure to examine or evaluate patient properly, Unnecessary or excessive diagnostic tests, Improper medication management

Significant Outcome: N/A

Case Rating: 4

Link to Original Case File: Download PDF

A 43-year-old male was referred by his primary care physician to a neurologist for multiple medical issues, including obesity, chronic post-operative pain following lumbar spine surgery, major depressive disorder, familial tremor, shoulder pain, excessive daytime sleepiness, congestive heart failure, and peripheral neuropathy.  The patient had been on Norco and was switched to Tramadol. The dose of Tramadol was 100 mg 4 times a day. Other medications were trazodone 100 mg h.s., zolpidem 10 mg h.s., HCTZ 25 mg, Lasix 40 mg, Flomax 0.5 mg, and topiramate 100 mg twice daily.

On 3/27/2014, the neurologist saw the patient for an office visit.  The patient complained of symptoms of foot pain, burning, and restless leg syndrome (RLS) symptoms.  The neurologist diagnosed neuropathic pain, RLS, obesity, carpal tunnel syndrome, low back pain, and tremor.  She planned to do B12 and ferritin levels, and she recommended an EMG/NCV of both upper and lower extremities.  The neurologist noted a normal neurological examination. Despite the normal neurological examination, the neurologist failed to keep adequate documentation to establish her multiple diagnoses.  She coded the visit as a level 5 new patient evaluation. The neurologist failed to document her 14-point review of systems and other required examinations to substantiate level 5 billing.

During a subsequent interview with the Medical Board, the neurologist initially stated that she had no recollection of the patient.  Her medical report timed the office visit at 9:15, and the encounter ended at 11:11 a.m., approximately 2 hours. She stated that she spent 40 minutes with him.  She could not account for the other time. She stated that “the rest was not me” and that she did not know what the time was “in between.” The patient claimed that she asked him only to stand and to try to stand on his heels and to squeeze her fingers.  When asked why she ordered the EMG, she answered, “For neuropathy versus radiculopathy versus carpal tunnel syndrome could have CDIP.” She did not know what a Controlled Substance Utilization Review and Evaluation System (CURES) report was.

The Medical Board of California judged that the neurologist’s conduct departed from the standard of care because she failed to keep accurate, timely, complete medical records to support her diagnoses, coded and billed for level 5 services not substantiated in her records, and was not aware of CURES reports and did not utilize it in her practice.

For this case and others, the Medical Board of California placed the neurologist on probation and ordered the neurologist to complete a medical record keeping course, a professionalism program (ethics course), an education course (at least 40 hours per year for each year of probation), and a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.  The neurologist was assigned a practice monitor and was prohibited from supervising physician assistants and advanced practice nurses.

State: California

Date: January 2018

Specialty: Neurology

Symptom: Extremity Pain, Back Pain, Joint Pain, Psychiatric Symptoms

Diagnosis: Neurological Disease

Medical Error: Lack of proper documentation, Procedural error

Significant Outcome: N/A

Case Rating: 1

Link to Original Case File: Download PDF

A 49-year-old female presented to a general surgeon for a colonoscopy.  During the colonoscopy the general surgeon documented a 25mm polyp in the patient’s descending colon.  Due to its size, the general surgeon was only able to partially resect the polyp.  He placed a hemostatic clip to prevent bleeding and tattooed the area.

The patient was subsequently referred to the general surgeon for surgical resection of the left colon.

On 7/15/2015, the patient presented to the general surgeon for a preoperative history and physical.  On 7/15/2015, the general surgeon documented that a doctor incompletely resected a polyp in the patient’s colon, and identified the planned procedure as a right colectomy.

On 7/20/2016, the patient presented to the general surgeon at a community hospital.  On 7/20/2016, the general surgeon performed a right colectomy of the patient’s ascending colon.

The Board judged that the general surgeon’s conduct to be below the minimum standard of competence given that he performed a wrong-site procedure when he performed a right colectomy of the patient’s ascending colon instead of a left colectomy of her descending colon.

The Board ordered the general surgeon to pay a fine of $4,015.23.  The general surgeon was ordered to complete five hours of continuing medical education in “Risk Management.”  Also, the Board ordered that the general surgeon present a one hour lecture/seminar on wrong site and/or wrong procedures to medical staff at an approved medical facility.

State: Florida

Date: December 2017

Specialty: General Surgery

Symptom: N/A

Diagnosis: Gastrointestinal Disease

Medical Error: Wrong site procedure

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

On 6/26/2015, a patient presented to an interventional radiologist’s outpatient clinic for a left lower extremity arteriogram and intervention for a thrombosed left lower extremity bypass graft, originally placed in 2007.  The patient had an extensive medical history including a renal transplant, diabetes, right leg amputation, and multiple revascularization procedures, including prior thrombectomies of the left lower extremity graft.

The patient reportedly had pain both at rest and with activity, and had a cold left leg prior to and immediately before the procedure.  In order to improve blood flow in the patient’s left leg, the interventional radiologist performed an arteriogram, angioplasty, tPA administration, atherectomy, and stent placement within the left lower extremity, including an attempt to revascularize the native superficial femoral artery.

Images show an initially thrombosed femoral artery to popliteal bypass graft and deep femoral artery.  Further images show balloons inflated in various parts of the graft and native arteries.  Final images show flow through a patent common femoral artery (CFA), bypass graft, and peroneal and anterior tibial arteries.  The deep femoral artery appeared occluded shortly beyond its origin.

After the procedure, a nurse noted the patient’s foot was cold.  The interventional radiologist also assessed the patient post-procedure and found the foot to be cold, both two (2) and four (4) hours post-procedure.  The interventional radiologist recommended to the patient that she travel to the emergency department of a university hospital.

The patient was then driven by her companion two hours to the emergency department, where she was assessed by an ED physician and a vascular surgeon.  She was taken to the operating room where she underwent surgery, which included a left leg above-the-knee amputation and a deep femoral artery thrombectomy.

The Board stated that the standard of care for an interventional radiologist when performing an intervention is to recognize complications and to take appropriate steps to manage them.  Although the patient’s foot was reportedly cold and painful immediately post-procedure, it can take some time for the foot to warm, and pain could be caused by reperfusion.  However, it is clear that two to four hours after the procedure, the interventional radiologist recognized that the patient’s leg had not improved and was worsening and that further care was needed.  Thus, when it became clear to the interventional radiologist that the foot was not improving, he recommended that the patient seek more treatment.

The records of the interventional radiologist’s care of the patient were inadequate in that they do not state whether the patient’s clinical status post-procedure was worse than before the procedure.  A post-procedure pulse examination was lacking which would have helped in determining the patient’s clinical status.

The patient reported to the ED physician that the pain began after the procedure and steadily worsened, which indicates that the patient rethrombosed her bypass graft and deep femoral artery (source of collateral flow) immediately.  This event should have been recognized by the interventional radiologist.

However, the interventional radiologist’s documentation for this patient was inadequate and sparse.  The medical records lacked documentation of the change in the patient’s status post-procedure, the discussion with the patient leading up to the discharge from his center, and the patient’s disposition.  The interventional radiologist discharged the patient to her own care directly from his clinic instead of calling Emergency Medical Services (EMS), which indicates that the interventional radiologist failed to recognize the gravity of what was occurring.

His conduct did not ensure that the patient would be attended continuously until definitive treatment was given.  The patient arrived at the emergency department at approximately 8:00 p.m., two hours after the patient was discharged from the interventional radiologist’s clinic.

Had the process of discharge and transfer occurred earlier, it is possible that the outcome could have been different.  The interventional radiologist failed to communicate with the ED physician ahead of the patient’s arrival.  The interventional radiologist gave the patient a CD of the procedure, a copy of the medical records, and his phone number, as an attempt of communicating with the emergency department personnel regarding the events that occurred at the interventional radiologist’s clinic.

However, the interventional radiologist failed to telephone the ED physicians at the emergency department to give a verbal report on the patient and to provide a more informative transition and preparation for continued care.  In expecting the practitioners at the emergency department to call the interventional radiologist to gain more information, the interventional radiologist improperly sought to shift his responsibility to provide needed information about the patient to the staff at the emergency department.

The interventional radiologist failed to maintain documentation regarding the change in the patient’s status post-procedure, the discussion leading up to the discharge from his center, and the patient’s disposition.  He stated that he was not sure if he documented these events, and if he did, he sent them with the patient.  Documentation sent with the patient has since been lost.  Documentation of a change in the patient’s clinical status was lacking.  The medical records lacked documentation of what was discussed regarding the patient’s disposition and where she was told to go for further care.

The Board judged the interventional radiologist’s conduct to have fallen below the standard of care for the following reasons:

1) The interventional radiologist failed to offer to transport the patient by ambulance or EMS services to ensure that she would be attended continuously until definitive treatment was given. His failure to do so indicates that he failed to understand the gravity of the situation which was occurring.

2) The interventional radiologist failed to adequately communicate with the emergency department, to call ahead of time to inform them that the patient was in transit, and to inform them of the circumstances.

3) The interventional radiologist failed to maintain adequate and accurate records.

The Board issued a public reprimand.

State: California

Date: December 2017

Specialty: Interventional Radiology, Vascular Surgery

Symptom: Extremity Pain

Diagnosis: Acute Ischemic Limb, Post-operative/Operative Complication

Medical Error: Diagnostic error, Delay in proper treatment, Underestimation of likelihood or severity, Failure of communication with other providers, Lack of proper documentation

Significant Outcome: Permanent Loss Of Functional Status Or Organ

Case Rating: 3

Link to Original Case File: Download PDF

On 10/19/2011 at 5:23 p.m., a 35-year-old male presented to the emergency department at a hospital with a chief complaint of abdominal pain and vomiting, which started approximately five hours before he presented to the hospital.

The patient was admitted to the hospital under the service of an intensivist and was notified of his arrival and condition at 5:35 p.m.

Between the hours of 5:50 p.m. and 7:22 p.m. the intensivist gave verbal orders of Dilaudid and ketorolac to the patient’s nurse.

At 9:20 p.m., the intensivist gave telephonic orders to the patient’s nurse, to place him on his home BIPAP mask.

On 10/20/2011, at 3:15 a.m. a rapid response was called due to an acute change in the patient’s respiratory status.

During the rapid response, an arterial blood gas (“ABG”) was drawn that revealed critical metabolic acidosis.

The intensivist never presented to the emergency room to assess the patient when he demonstrated medically dangerous/life-threatening signs at 3:15 a.m. or any time thereafter.

The intensivist never attended to the patient when his clinical situation was from an unknown cause and when a clear treatment plan had not been determined.

From 3:43 a.m. to 4:15 a.m., the critical care practitioner was contacted approximately five times with information on the patient’s medically unstable and deteriorating condition.

At 3:45 a.m., the patient became short of breath, restless, diaphoretic, and seizure episodes followed.  He was then transported to an intensive care unit.

At 5:25 a.m., a second rapid response was called due to a further decline in the patient’s health.  The rapid response turned into a code blue.

The patient underwent a cardiopulmonary arrest, and the code team was unable to resuscitate him.

On 10/20/2011, the patient expired at 6:25 am.

The autopsy results were consistent with acute hemorrhagic pancreatitis with diffuse pancreatic necrosis.

The Medical Board of Florida judged the intensivist’s conduct to be below the minimal standard of competence given that he failed to presented to the emergency room to assess the patient when the patient demonstrated medically dangerous/life-threatening signs on 10/20/2011 at 3:15 a.m.

The Medical Board of Florida issued a letter of concern against the critical care practitioner’s license.  The Medical Board of Florida ordered that he pay a fine of $7,500 against his license and pay reimbursement costs for the case at a minimum of $4,503.10 and not to exceed $6,503.10.  The Medical Board of Florida ordered that the critical care practitioner complete ten hours of continuing medical education in the area of critical care medicine and complete five hours of continuing medical education in “risk management.”

State: Florida

Date: December 2017

Specialty: Critical Care Medicine, Emergency Medicine, Pulmonology

Symptom: Abdominal Pain, Nausea Or Vomiting

Diagnosis: Gastrointestinal Disease

Medical Error: Failure to properly monitor patient

Significant Outcome: Death

Case Rating: 4

Link to Original Case File: Download PDF

On 4/15/2015, a 48-year-old female presented to the Mayo Clinic for an assessment regarding cancer treatment.

The patient presented with a history of a palpable rectal mass and bloody stool.  The patient presented to an oncologist after undergoing a colonoscopy and after a CT scan at Borland Grover Clinic revealed tumors suspicious for metastases.

The Borland Grover Clinic took a biopsy of the affected area.  Initial pathology indicated suspicion for adenocarcinoma.  Borland Grover clinic sent the sample to Cleveland Clinic for confirmation.  Cleveland Clinic returned a diagnosis of endometriosis, not cancer.

The oncologist did not obtain the pathology reports from Borland Grover Clinic or Cleveland Clinic.  The oncologist diagnosed the patient with rectal cancer with possible spread to the liver, lungs, and mediastinum.  The oncologist ordered an endobronchoscopic ultrasound (EBUS). The patient’s EBUS showed some concern for cancer, but the pathologist deemed the results of the EBUS insufficient for a definitive cancer diagnosis.

Despite not having a pathologic diagnosis of cancer, from May to July 2015, the oncologist ordered the patient receive a port placement and three chemotherapy treatments.

Due to continuing rectal pain, on 7/6/2015, the oncologist referred the patient to a colorectal surgeon.  As part of his review, the colorectal surgeon obtained the patient’s pathologic results from Borland Grover Clinic and Cleveland Clinic, which showed that the patient had endometriosis and not cancer.

On 7/16/2015, a Mayo Clinic pathologist reviewed the patient’s previous biopsy sample and came to a final diagnosis of endometriosis.  On 9/3/2015, two doctors performed a procedure to remove the endometrioma.

The Board judged that the oncologist’s conduct to be below the minimum standard of competence given her failure to obtain a pathologic diagnosis of cancer prior to initiating cancer treatment for the patient.

The Board ordered the oncologist have her license revoked, pay an administrative fine, and have remedial education.

State: Florida

Date: December 2017

Specialty: Oncology, Internal Medicine

Symptom: Blood in Stool, Mass (Breast Mass, Lump, etc.)

Diagnosis: Gynecological Disease

Medical Error: Diagnostic error

Significant Outcome: N/A

Case Rating: 4

Link to Original Case File: Download PDF

On 11/15/2013, a patient complained of chest pain radiating to his neck, throat, and across his back.  The patient stated the onset of the pain was noted to be one hour prior to his arrival at the hospital while he was screwing something into the wall, and that the pain was exacerbated by movement.

An ED physician performed an initial EKG, labs, and a chest x-ray on the patient.

The ED physician initially treated the patient with nitroglycerin and a GI cocktail, and subsequently with diazepam, morphine, Toradol, and Dilaudid.

The ED physician’s final assessment of the patient noted that the patient was still complaining of left side neck pain and “trap pain.”

The ED physician discharged the patient with a diagnosis of “musculoskeletal chest pain” and prescribed naproxen, Norco, and diazepam, along with instructions to follow up with him in three to five days.

The patient returned to the hospital the following day in cardiac arrest and expired on 11/16/2013.

The Medical Board of Florida judged the ED physician’s conduct to be below the minimal standard of competence given that he failed to perform a CT of the patient’s chest to evaluate for aortic dissection.  He also failed to adequately document bilateral pulses and/or blood pressures in the patient.  He failed to pursue other etiologies of the patient’s reported pain.  The ED physician failed to admit the patient for further observation.

It was requested that the Medical Board of Florida order one or more of the following penalties for the ED physician: permanent revocation or suspension of his license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Medical Board of Florida deemed appropriate.

State: Florida

Date: December 2017

Specialty: Emergency Medicine

Symptom: Chest Pain, Back Pain, Chest Pain, Head/Neck Pain

Diagnosis: Aneurysm

Medical Error: Failure to order appropriate diagnostic test, Delay in proper treatment, Failure to examine or evaluate patient properly, Lack of proper documentation

Significant Outcome: Death

Case Rating: 4

Link to Original Case File: Download PDF