Found 20 Results Sorted by Case Date
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Virginia – Rheumatology – Questionable Diagnoses Of Multiple Infectious Disease With Respective Questionable Antibiotic Regimes



A rheumatologist diagnosed a patient with reactive arthritis/spondyloarthropathy.  The patient was HLA B27, erythrocyte sedimentation rate, and C-reactive protein negative.  According to the Board, these findings would make this diagnosis less likely, although they would not exclude it.  The Board stated that the clinical presentation and lack of radiographic findings such as sacroiliitis were not suggestive of chronic reactive arthritis.

The rheumatologist’s medical record for the patient dated in August 2003 diagnosed the patient with systemic vasculitis.  The rheumatologist admitted she mistakenly used the term systemic vasculitis instead of systemic lupus erythematosus.

In February 2005, the rheumatologist diagnosed the patient with calcium pyrophosphate dihydrate disease/pseudogout and prescribed colchicine to treat the condition.  The basis of the diagnosis remained unclear to the Board.

Medical records did not include any radiographic documentation of chondrocalcinosis or synovial fluid crystal analysis.  The rheumatologist testified that the patient refused to submit to synovial fluid crystal analysis, but there was no documentation of such refusal.

In October 2003, the rheumatologist diagnosed the patient with Lyme disease.  The medical records did not note any erythema migrans, arthritis of the large weight-bearing joints, carditis, Bell’s palsy, acute radiculopathy, or lymphocytic meningitis.

After initial lab tests (Western blot and ELISA) were negative, the rheumatologist ordered repeat tests on approximately sixteen occasions.  Each result was negative.  On approximately nine occasions, the rheumatologist ordered polymerase chain reaction (“PCR”) tests on urine.  This test is not approved by the U.S. Food and Drug Administration to diagnose Lyme disease.  The rheumatologist testified that she was not aware the urine PCR test had a low diagnostic yield for Lyme disease.

From 11/6/2003 to 2/13/2004 and 7/28/2006 to 11/2/2006, the rheumatologist treated the patient with long-term antibiotic therapy (ceftriaxone).  This treatment increased the risk of infection from the PICC line and antibiotic-associated side effects.  The Board’s infectious disease expert testified that the patient derived no clinical benefit from the antibiotics.

In May 2003, the rheumatologist diagnosed the patient with salmonella without any positive cultures of blood, stool, or urine to support the diagnosis.  Although the patient had multiple positive serologic screens for salmonella, the Board noted that such tests would not distinguish between past and present infection.  The rheumatologist ordered such tests on approximately nine occasions.

The rheumatologist treated her with ciprofloxacin from 5/5/2004 to 10/18/2004 without any evidence of active salmonella infection.

In January 2004, the rheumatologist treated the patient for babesiosis and/or reactive arthritis secondary to babesiosis without positive identification of the parasite on thin blood smears and in the absence of a history of tick exposure or blood transfusion.  In addition, the patient did not have any fever, evidence of hemolytic anemia, or thrombocytopenia.  The rheumatologist testified that these diagnostic criteria referred to acute babesiosis and not chronic babesiosis.  The Board noted that there was no convincing evidence that the patient suffered from chronic babesiosis.

The rheumatologist diagnosed the patient with babesiosis based on a positive Babesia microti PCR on one occasion, a positive Babesia microti IgG on two occasions, and a persistently positive WA1 IgG.  However, on multiple occasions, the patient had negative Babesia microti PCR results, raising the issue of a false positive or contaminated specimen.  In addition, serologic tests are unable to distinguish past from current infection.  The rheumatologist failed to refer the patient to an infectious disease specialist who would be more familiar with the reliability and significance of such tests.  The rheumatologist felt that she would be able to manage the patient on her own and did not believe she needed to refer the patient to an infectious disease specialist.  The rheumatologist testified that the patient refused to see other medical specialists, although there was no evidence in the medical record to support this claim.

After ordering an initial blood test for Babesia antibodies, the rheumatologist ordered repeat tests on approximately seventeen occasions, although the patient never had positive identification of the parasite on thin blood smears and was not at risk to being exposed to Babesia while under the rheumatologist’s care.

Even if the diagnosis of babesiosis had been correct, the rheumatologist incorrectly treated the patient with antibiotics.  Standard treatment for babesiosis lasts 7-10 days, unless continued parasitemia on blood smears is documented.  The rheumatologist treated the patient with several regimens of Biaxin lasting several months each, 2 regimens of atovaquone lasting several months each, two months of Ketek, around 5 months of clindamycin, and 2 regimens of azithromycin each lasting a month.

On 10/13/2003, the rheumatologist diagnosed the patient with “candida yeast infection of stool/gut” based on a single stool culture in the absence of clinical evidence.  The rheumatologist treated the patient with fluconazole for a year (10/13/2003-10/18/2004).

The Board concluded that the rheumatologist’s care of the patient fell below the standard of care given excessive use of antibiotics for multiple conditions diagnosed without corroborating evidence.  She failed to evaluate the patient for more common diagnoses of non-infectious cognitive impairment.  A tick-borne disease expert testified on behalf of the rheumatologist.  It was concluded that his testimony was not sufficient enough to refute the Commonwealth’s expert testimony.

A reprimand was issued by the Board.  The rheumatologist was ordered to complete 6 hours of continuing medical education in antimicrobial stewardship and 6 hours in cognitive impairment.

State: Virginia


Date: February 2015


Specialty: Rheumatology


Symptom: N/A


Diagnosis: Infectious Disease


Medical Error: Improper medication management, Diagnostic error, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Family Medicine – Provera And Ortho Tri-Cyclen For Amenorrhea And Abnormal Vaginal Bleeding In A Patient With A History Of Polycystic Ovarian Syndrome



A family practitioner had been a patient’s physician since 2009.  On 4/11/2012, at the age of 26, the patient presented with amenorrhea.  The patient’s last menstrual period of 2/24/2012 was reportedly normal.  At an interview with Board personnel on 4/17/2012, the family practitioner stated that the patient had a history of polycystic ovarian syndrome (PCOS).  No symptoms of pregnancy were reported on 4/11/2012.  A urinary pregnancy test was read as negative in the office.  The genito-urinary exam was reported as normal.  The family practitioner prescribed medroxyprogesterone (Provera) 10 mg daily for 10 days, but instructed the patient not to begin for a week and to stop if menstrual bleeding resumed.

The patient returned on 5/4/2012 complaining of heavy bleeding.  Although the patient was only spotting at the time of the visit, no pelvic exam was performed “due to the bleeding.”  No tests were ordered or performed.  The family practitioner prescribed Ortho Tri-Cyclen as a treatment for the bleeding.  On 5/5/2012, the patient went to the emergency department due to nausea and vomiting with continued vaginal bleeding.  The patient was diagnosed as pregnant at 9 weeks and 6 days by a quantitative HCG test and pelvic ultrasound.  The patient was given prescriptions for Zofran, albuterol, Pepcid, and a nebulizer for her symptoms.  Obstetric lab results ordered by an obstetrician and gynecologist were identified as within normal limits except for an elevated thyroid stimulating hormone of 63 (upper limit of normal around 4).  The patient was started on thyroid supplements along with her prenatal vitamins on 5/11/2012.  On 5/7/2012, the ultrasound dated the pregnancy at 6 weeks and 1 day, which changed the estimated date of delivery from 12/1/2012 to 12/30/2012.

On 7/3/2012, a follow-up ultrasound found a normal intrauterine pregnancy at 14 weeks and 1 day.  The patient presented to the emergency department on 7/20/2012 complaining of bleeding in pregnancy.  The diagnosis was a threatened abortion at 16 weeks.  On 7/21/2012, the patient was admitted with oligohydramnios with an intrauterine pregnancy at 16 weeks.  Fetal heart tones were reported at 140 BPM.  Since the patient was diagnosed with premature rupture of membranes, the patient was treated with misoprostol.  Soon thereafter, she spontaneously passed the fetus and placenta.  The standard of care dictates a thorough evaluation of abnormal uterine bleeding through a history, physical, and appropriate lab work.  Pregnancy must be excluded, and a pelvic examination and/or ultrasound are required.

The family practitioner saw the patient for follow-up amenorrhea treated with Provera.  Although the patient complained of heavy bleeding, the patient was only spotting at the time of her visit. Pregnancy was not excluded by testing or examination.  A pelvic exam was noted as not done due to vaginal bleeding.  The etiology/physiology of the bleeding was assumed, but not evaluated.  Ortho Tri-Cyclen, a tri-phasic oral contraceptive, was prescribed.  This class of oral contraceptive pills is not an ideal choice for the treatment of bleeding problems due to their low and fluctuating levels of estrogen.  The follow-up care and treatment of the patient for abnormal uterine bleeding was a simple departure from the standard of care.

The standard of care is to document complaints and/or symptoms, objective findings, the assessment of the physician, tests performed and/or ordered, and a detailed treatment plan for each patient encounter.  The above should be readily interpretable.  The family practitioner employed a standardized pre-printed history and physical form.  The form was organic and contained, for example, checkboxes for the exam.  The only entries were brief and illegible notations were scribbled in the right margin.  A pelvic exam was described as normal with no description of the pelvic organs or any findings.  The issue of illegibility was so pronounced that it was necessary for the 4/11/2012 and 5/4/2012 encounters to be retyped from the notes in order for them to be reviewed by Medical Board personnel.  The incomplete and illegible documentation was a simple departure from the standard of care.

The Medical Board of California judged that the family practitioner’s conduct was grossly negligent in the care and treatment of the patient because she failed to conduct a pelvic exam, exclude pregnancy as the cause of bleeding, as well as having illegible documentation.

For this case and others, the Medical Board of California placed the family practitioner on probation for 3 years and ordered that she complete a medical record-keeping course, an education course (at least 20 hours for 5 years), a prescribing practices course, 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.

State: California


Date: February 2015


Specialty: Family Medicine, Internal Medicine


Symptom: Abnormal Vaginal Bleeding, Nausea Or Vomiting


Diagnosis: Obstetrical Complication, Gynecological Disease


Medical Error: Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Improper medication management, Lack of proper documentation


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



California – Family Medicine – Improper Management Of Benzodiazepines Among Other Medications And Lack Of Proper Documentation



A 42-year-old male visited the office of a family practitioner on 6/9/2010.  The patient was seen a total of 10 times after that initial visit with the last office visit on 8/8/2012.  During this time frame, the patient received 21 prescriptions for Xanax, 23 prescriptions for Ambien, 4 prescriptions for Valium, and 1 prescription for Restoril.

At the initial office visit on 6/9/2010, the patient complained of hemorrhoids.  An anoscopy revealed “mild internal hemorrhoids.”  The family practitioner’s records said a rectal exam was “within normal limits.”  At the subject interview, the family practitioner had difficulty explaining whether the patient had a bleeding hemorrhoid or a fissure.  The patient also said he had testicular pain.  At the subject interview, the family practitioner claimed that she had examined the patient’s testicles, but this alleged examination was not recorded.

At the 11/11/2010 visit, the family practitioner felt that the patient had potential cardiac disease, sufficient enough to order a stress test and give nitroglycerin and aspirin.  In the subject interview, the family practitioner stated that the patient had a “little bit of arrhythmia.”  As stated by the Board, “this was not the language of art in medicine.  It was less than any meaningful expression.”  In the interview, she stated “[the patient] was getting the chest pain and pressure.”  These symptoms were not noted in the medical records.  There were no cardiac descriptions, either positive or negative.  The family practitioner stated that she ordered a Holter monitor, but there was no notation of that order in the medical records.  Finally, there was neither a Holter monitor nor a stress test report in the chart.

In the family practitioner’s records of a 3/22/2012 visit, the chief complaint was listed as cough.  The family practitioner wrote bronchitis as the diagnosis.  “Respiratory” was checked with no findings noted on the chart.  In the subject interview, the family practitioner claimed to recall (16 months after the fact) that the patient had “bronchial breath sounds.”

The standard of care in prescribing medicines is to give the minimum dose adequate for treatment for the appropriate and shortest necessary time frame.  The patient was maintained chronically, i.e., during the entire period he was a patient, on benzodiazepines (mostly Xanax) and zolpidem.  The dosage of Xanax was started at 0.25 mg a day and increased to 0.25 twice per day.  Zolpidem remained stable at 10 mg.  This was not an excessive dose, but this duration and consistency of two years with no attempt to wean the patient off of their use was below the standard of care.  There was no comment in the chart regarding the efficacy of those drugs.  The patient was advised to see a therapist.  There was no evidence this was done, and no further discussion of the matter appeared in the chart.

The Medical Board of California judged that the family practitioner’s conduct was grossly negligent in the care and treatment of the patient because she didn’t attempt to wean the patient off of the drugs and kept the patient on the drugs for too long.

For this case and others, the Medical Board of California placed the family practitioner on probation for 3 years and ordered that she complete a medical record-keeping course, an education course (at least 20 hours for 5 years), a prescribing practices course, 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.

State: California


Date: February 2015


Specialty: Family Medicine, Internal Medicine


Symptom: Pelvic/Groin Pain, Cough, Chest Pain


Diagnosis: N/A


Medical Error: Improper medication management, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Family Medicine – Improper Documentation And Prescribing Practices Of Lexapro And Norco



A 42-year-old female was seen by a family practitioner on 3/14/2006.  On that date, the family practitioner started her on Lexapro.  According to the family practitioner’s records, the patient had periodic “complete physicals.”  However, the family practitioner’s records of those examinations did not record any history and never recorded a review of systems.  A complete physical from 7/24/2008 noted “abnormal uterine bleeding” without descriptors.  The family practitioner prescribed Norco to the patient beginning on 4/10/2009.  The family practitioner first noted this prescription in the chart on a page related to an office visit of 10/18/2010.  The family practitioner’s notes referred to “low back and pelvic pain”, but no significant history or examination.  On 6/16/2011, the patient had a complete physical without history, review of systems, or notation of medications.

The 2/20/2012 office visit notes said that the patient was to see pain management and to get physical therapy and an x-ray, but the family practitioner continued Norco.  The 7/12/2012 office visit notes stated, “continues low back pain.”  The initial Norco prescription dated from 7/16/2009.  The family practitioner’s initial chart note of low back pain dated from 10/18/2010.  At this time, the patient had been receiving Norco for 3 years without proper work-up or diagnosis.  The family practitioner noted in the chart, “Hasn’t seen pain management specialist so advised needs decrease-dose Norco has to tuff it.”  “Needs to get to PT.”  Starting no later than 3/15/2010, the family practitioner prescribed progressively higher amounts of Norco, starting with 30 tablets per month and ending with 120 for an unknown condition that was never truly studied or diagnosed.

The standard of care mandates adequate and complete medical records.  The purpose of a medical record was to allow that physician or any subsequent physician to understand the current condition and situation of the patient at a subsequent date.  The standard of care mandated follow up of a prescription of antidepressant drugs concerning their efficiency and side effects as well as dose and any changes.  The patient was prescribed Lexapro.  Her chart has no notation regarding dose, efficacy, or side effects of Lexapro.  An observer cannot ascertain if the patient continued on it or if or when this drug was discontinued.  One cannot determine the dose from the family practitioner’s chart.  This represented practice below the standard of care, a simple departure.

The Medical Board of California judged that the family practitioner’s conduct was grossly negligent in the care and treatment of the patient because she failed to maintain adequate and complete medical records and prescribed drugs without assessing efficiency, side effects, and dosage.

For this case and others, the Medical Board of California placed the family practitioner on probation for 3 years and ordered that he complete a medical record-keeping course, an education course (at least 20 hours for 5 years), a prescribing practices course, 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.

State: California


Date: February 2015


Specialty: Family Medicine, Internal Medicine


Symptom: Back Pain


Diagnosis: N/A


Medical Error: Improper medication management, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Family Medicine – Elevated PSA And Urinary Problems Diagnosed As Benign Prostatic Hyperplasia



In 2006, a 56-year-old male became a patient of a family practitioner.  The last visit with the family practitioner was 11/28/2011.  In the interim, there were about 15 office visits with the family practitioner and at least four at the same clinic with other physicians.  On 8/14/2009, the patient was seen in urgent care by Physician A with a complaint of urinary frequency and diabetes mellitus.  Labs were ordered, including prostate specific antigen (PSA), and labs were drawn.  On 8/17/2009, the PSA results came back as 9.78 NG, the upper limit normal per the lab was 4 NG.  On 8/18/2009, the patient had an appointment with the family practitioner specifically to  “follow labs.”  Lab reports were printed by the urgent care at 8:01 a.m., but were apparently not seen by the family practitioner before or during the appointment.

On 9/29/2009, the patient had another appointment with the family practitioner.  The family practitioner again did not recognize or note the elevated PSA.  On 11/10/2009, the family practitioner saw the full report of the lab test from 8/17/2009.  The family practitioner noted the elevated PSA, and he requested a routine urological consult.  Subsequently, the urological consult appointment was canceled by the patient.  The family practitioner did not inquire regarding the results of the urology consultation.  Digital Rectal Examinations and follow-up PSA were not noted in the chart as offered, discussed, or performed.

On 12/21/2009, the family practitioner treated the patient and worked with a medical student.  The medical student interviewed the patient.  After the medical student came out of the examination, he discussed the case with the family practitioner.  The impression noted on the record included benign prostatic hyperplasia.  This impression was made without first or concurrently ruling out prostatic cancer.  The family practitioner provided a Flomax sample to the patient.  There was no documentation of the rationale behind providing the Flomax sample.  No digital rectal examination was performed on that day.

On 2/22/2010, a diagnosis of benign prostatic hyperplasia was made.  A chart note indicated that the patient “stopped Flomax, still taking Avodart. Has urinary urgency somewhat helped by Avodart.”  On 4/27/2010, the family practitioner treated the patient.  The diagnosis of benign prostatic hyperplasia was continued by the family practitioner.  He did not recognize the elevated PSA.  The family practitioner also did not repeat a follow-up PSA or digital rectal examination.  The family practitioner didn’t ask the patient if he had seen the urologist.

On 5/28/2010, the family practitioner treated the patient.  On 10/26/2010, he treated the patient, and blood tests were ordered for a comprehensive metabolic panel and a hemoglobin A1c.  No follow-up PSA test was ordered.  On 12/27/2010, 3/28/3011, 5/3/2011, and 9/27/2011, the family practitioner treated the patient.  On 9/30/2011, the family practitioner ordered a PSA test.  On 10/3/2011, the patient had lab work performed, and the patient’s PSA was elevated to 13.52 NG.  On 11/28/2011, the patient had his last visit with the family practitioner.  There was no mention of an abnormal PSA or urology referral.  On 12/2/2011, a “Referral Center Fact Sheet” was faxed.  It stated: “Patient with PSA 13.52 would like evaluation for biopsy.”  On 12/30/2011, a transrectal biopsy revealed prostate cancer bilaterally, Gleason score 7, extending into left seminal vesicle, Gleason 6.  The patient was ultimately treated with hormonal therapy ablation and external beam radiation.

The Medical Board of California judged that the family practitioner’s conduct departed from the standard of care and was grossly negligent in the care and treatment of the patient because he failed to follow up on an abnormal PSA test, had no information regarding a urology consult, failed to order follow-up PSAs from August 2009 until September 2011, failed to perform or offer a digital rectal examination, failed to note if he offered the patient a digital rectal examination or explained a digital rectal examination to the patient, and diagnosed the patient with benign prostatic hyperplasia instead of prostate cancer despite lower urinary tract symptoms.

The Medical Board of California issues a public reprimand and ordered that the family practitioner complete a medical record-keeping course, prescribing practices course, patient communication course, and an education course (at least 40 hours) equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California


Date: February 2015


Specialty: Family Medicine, Urology


Symptom: Urinary Problems


Diagnosis: Prostate Cancer


Medical Error: Diagnostic error, Failure to order appropriate diagnostic test, Referral failure to hospital or specialist, Failure of communication with patient or patient relations, Failure to follow up, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Family Medicine – Improper Evaluation Practices For A Patient Injected With Toradol And Prescribed Vicodin For Back Pain



A 24-year-old male saw a family practitioner at his first and only office visit on 9/30/2010.  The patient’s chief complaint was “middle of back pain” for one week.  The patient’s general appearance was checked on the family practitioner’s records as within normal limits, and his records also stated “mild to moderate pain.”  In his notes, the family practitioner stated that the patient was in “severe pain” or he was in “excruciating pain,” 8 on a scale of 10, and stated that a girl brought the patient in saying “he cannot walk.”  The family practitioner also claimed that a Toradol injection was given, but the family practitioner didn’t record this treatment.  The patient was prescribed 30 tablets of Vicodin ES because he stated it “worked better in past.”  Subsequently, the patient had 11 refills of 30 tablets each, some as frequent as at one- to two-week intervals.

The standard of care mandates an adequate and appropriate history and physical examination.  This must include mechanism and/or history of injury as well as duration of symptoms.  Pertinent negatives may be necessary.  The family practitioner’s history and physical gave little information to anyone reviewing medical records.  This represented medical practice below the standard of care and was a simple departure.  The standard of care mandates adequate and complete medical records.  The purpose of a medical record was to allow that physician or any subsequent physician to understand the instant condition and situation of the patient at a subsequent date.  The family practitioner’s failure to note the administration of Toradol in the medical record was below the standard of care.

The Medical Board of California judged that the family practitioner’s conduct was grossly negligent in the care and treatment of the patient because she failed to take an adequate history and physical examination.

For this case and others, the Medical Board of California placed the family practitioner on probation for 3 years and ordered that she complete a medical record-keeping course, an education course (at least 20 hours for 5 years), a prescribing practices course, 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.

State: California


Date: February 2015


Specialty: Family Medicine, Internal Medicine


Symptom: Back Pain


Diagnosis: N/A


Medical Error: Failure to examine or evaluate patient properly, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



North Carolina – General Surgery – Failure To Timely Address A Postoperative Complication



On 11/27/2009, a 58-year-old male with hypertension and diffuse arthritis presented to a general surgeon for a laparoscopic cholecystectomy operation due to a history of cholecystitis and cholelithiasis.  After the operation, the patient was admitted to the hospital given persistent abdominal pain in the left lower quadrant and an elevated temperature.

In the morning on 11/28/2009, the general surgeon ordered a CT scan and blood work.  The CT scan could not be performed given the patient’s pain and agitation.  The general surgeon ordered antibiotics and postponed the CT scan.

On 11/28/2009, the general surgeon re-examined the patient and noted that his temperature and heart rate were normal and his pain had decreased.  After this examination, the general surgeon elected to postpone the CT scan.

At 3:40 a.m. on 11/29/2009, the patient was noted to be unresponsive, and significant drainage was noted at the umbilical incision site.  Cardiopulmonary resuscitation was initiated.  The patient was intubated and transferred to the intensive care unit.  The general surgeon was called.  He arrived at 5:00 a.m., placed a central line and a nasogastric tube, opened the patient’s incision site, and suctioned a significant amount of abdominal fluid from the patient.

The general surgeon believed that attempts should be made to stabilize the patient first prior to taking the patient back to the operating room.  The patient was hypotensive and had a pH of 7.1.  The general surgeon did not believe the patient would survive surgery if taken prior to stabilization.

Despite efforts at stabilization, the patient continued a steady clinical deterioration throughout 11/29/2009, resulting in multi-system failure, acidosis, and a code at 9:10 p.m.

The patient was then transferred to a higher level care center and died at 6:37 a.m. on 11/30/2009.

An autopsy was performed that indicated that the patient died from an acute purulent peritonitis secondary to microperforation of the small bowel.

In March 2014, the Board received information regarding a medical malpractice lawsuit settlement payment with regard to the care provided by the general surgeon to the patient.

The Board sent the patient’s medical records to an independent medical expert, who explained that the standard of care requires that operative complications be diagnosed and treated in a timely and proficient manner.

The medical expert opined that the standard of care required taking the patient back to the operating room for surgery in the early morning hours of 11/29/2009, when the patient required resuscitation and a significant drainage was noted at the umbilical incision site.  The patient likely had a fistula created by an unrecognized injury to his intestine from the original operation.

The Board judged the general surgeon’s conduct to be below the minimum standard of competence given failure to recognize a complication from the surgery and address it in a timely manner.

The Board ordered the general surgeon to be reprimanded.

State: North Carolina


Date: February 2015


Specialty: General Surgery


Symptom: Abdominal Pain


Diagnosis: Acute Abdomen


Medical Error: Procedural error, Delay in proper treatment, Diagnostic error, Improper treatment


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



North Carolina – Pediatrics – Pale, Dusky Appearance Of Neonate After Several Failed Attempts By Vacuum Extraction And Subsequent Delivery By Cesarean Section



The Board received notice of a medical malpractice payment made on behalf of a pediatrician.

On 04/03/2009, an obstetrician delivered a newborn by Cesarian section after several failed attempts using vacuum extraction.  A pediatrician assumed care of the newborn in the hospital nursery after delivery.

The newborn presented with respiratory distress and an initial blood pressure of 42/21.  He was described as having a pale and dusky appearance with normal oxygen saturation levels between 90 to 100%, which suggested poor perfusion, anemia, or both.  A cord blood gas reading showed moderate mixed acidosis and a base deficit of -16.8.

The newborn’s condition rapidly deteriorated.  Resuscitation was attempted.  The newborn was transferred to a neonatal intensive care unit at a tertiary hospital where he died after arrival secondary to subgaleal hemorrhage caused by failed vacuum delivery.

The Board believed the pediatrician’s conduct to be below the minimum standard of competence given failure to closely monitor the newborn, obtain additional blood gas testing, obtain additional blood pressure readings, and assess serial hemoglobin and hematocrit levels.  Despite repeated documentation by the nursing staff of the child’s pale and dusky appearance, no additional interventions were taken, such as obtaining IV access, intubation, and mobilization to a tertiary care neonatal support team to assess with an earlier transport.

The Board ordered pediatrician to take 10 hours of CME in neonatal care and to obtain recertification in Pediatric Advanced Life Support and Neonatal Advanced Life Support within six months.  The Board issued a public letter of concern and reported the letter the Federation of State Medical Boards and the National Practitioner Data Bank.

State: North Carolina


Date: February 2015


Specialty: Pediatrics


Symptom: Bleeding


Diagnosis: Hemorrhage


Medical Error: Diagnostic error


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



Virginia – Physician Assistant – Numerous Attempts At Placing Central Line



On 3/6/2013, physician assistant did not document consent obtained from a 52-year-old female regarding subclavian central line placement.  The patient reported to the Department of Health Professions that the physician assistant stuck her clavicle area 17 times but was never able to successfully insert the central line.  She cried out in pain at one point and asked the physician assistant to stop the procedure, but he “ignored” her.  The physician assistant admitted that he made 5-6 unsuccessful sticks in the patient’s clavicular area while attempting to cannulate the subclavian vein, but denied that the patient asked him to stop the procedure. The patient submitted an undated photograph of a clavicular area that showed at least 10 needle insertion marks.

The Board stated that the physician assistant failed to maintain an accurate and complete patient record for the patient.  The physician assistant admitted that he failed to document information regarding the unsuccessful attempts to insert the central line.  The Board ordered a reprimand for the physician assistant and ordered that he submit evidence of continuing medical education in the subject of ethics for physician assistants.

State: Virginia


Date: February 2015


Specialty: Physician Assistant


Symptom: N/A


Diagnosis: N/A


Medical Error: Procedural error, Ethics violation, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Obstetrics – Pregnant Patient With TSH Of 0.10 MIU/L



On 1/9/2013, a 25-year-old female patient began her first pregnancy care at a medical center where she was examined by a physician.  The patient was in her first trimester of pregnancy.  The patient weighed 154 pounds.  The physician ordered laboratory analysis of the patient’s thyroid stimulating hormone (TSH) blood level.

On 2/1/2013, a sample of the patient’s blood was collected for TSH analysis.

On 2/5/2013, the TSH level result was reported low at 0.10 MIU/L with a first trimester reference range of 0.26-2.66 MIU/L.

On 2/7/2013, the patient returned to the medical center for obstetric follow-up and complained that she could not hold down food.  The patient weighed 150 pounds.  An obstetrician evaluated the patient.

The medical records document that on 1/22/2013 the patient had been prescribed Zofran 8 mg, with instructions to take one tablet every eight hours for fifteen days.  Zofran is the brand name for ondansetron, an anti-emetic used during pregnancy for treatment of morning sickness, nausea, and vomiting.

On 2/7/2013, the medical records document that the patient would be traveling for three months.

The obstetrician prescribed Phenergan suppositories to the patient.  Phenergan is the brand name for promethazine, an antihistamine with antiemetic properties used during pregnancy to treat morning sickness, nausea, and vomiting.

On 2/7/2013, the medical centers records documented the patient’s low TSH test result from 2/1/2013.  The obstetrician failed to recognize the significance of the patient’s complaints and TSH test results.  The obstetrician did not order additional tests to evaluate the patient’s low TSH at any time during his care of the patient.  The obstetrician did not inform the patient of her low TSH result at any time during his care of the patient.  The obstetrician instructed the patient to return as needed.  The obstetrician did not plan close follow-up of the patient’s complaints of weight loss.  The obstetrician did not refer the patient to a specialist for evaluation of her low TSH.

Following her 2/7/2013 visit with the obstetrician, the patient was diagnosed with and began treatment for hyperthyroidism while visiting Iran.

The Board judged the obstetrician’s conduct to be below the minimum standard of competence given his failure to recognize the significance of the patient’s symptoms and test results, advise the patient of her low TSH, order laboratory analysis of T3 and T4 blood levels, plan close monitoring of the patient’s symptoms and thyroid hormone levels to prevent a delay in diagnosis of hyperthyroidism, diagnose the patient’s hyperthyroidism, or refer the patient to an endocrinologist for evaluation.

The Board ordered that the obstetrician pay a fine of $5,000 against his license and pay reimbursement costs for the case for a minimum of $3,076.77 and not to exceed $5,076.77.  The Board also ordered that the obstetrician complete a medical records course in “Quality Medical Record Keeping for Health Care Professionals” and complete five hours of continuing medical education in “Risk Management.”  The Board ordered that the obstetrician complete one hour lecture/seminar on prenatal screening, including screening for hyperthyroidism.

State: Florida


Date: February 2015


Specialty: Obstetrics, Endocrinology


Symptom: Weight Loss


Diagnosis: Endocrine Disease


Medical Error: Diagnostic error, Referral failure to hospital or specialist, Failure of communication with patient or patient relations, Failure to follow up, Failure to properly monitor patient


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



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