Found 15 Results Sorted by Case Date
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North Carolina – Nephrology – Abdominal Pain And Hypotension After Renal Biopsy



In December 2011, a nephrologist performed a renal biopsy on a patient, a 70-year-old male with a diagnosis of temporal arteritis and presumed acute tubular necrosis.  The procedure was uncomplicated and the nephrologist provided care of the patient following the procedure.

Approximately two hours after the procedure, the patient developed abdominal pain.  After receiving a call from the nursing staff, the nephrologist ordered hydromorphone 2 mg and ondansetron 4 mg for pain and nausea.  The nursing staff contacted the nephrologist two hours later to notify the nephrologist that the patient’s blood pressure had dropped.  The nephrologist ordered an ampule of intravenous naloxone and normal saline bolus for the patient.  One hour later the patient was transferred to the ICU, where he suffered a cardiopulmonary arrest, but was resuscitated.  The patient became hemodynamically unstable and, despite aggressive resuscitation, died.

The Board obtained the patient’s records and sent them to a qualified independent medical expert for review.  The independent medical expert judged the nephrologist’s conduct to be below the minimum standard of competence given failure to sufficiently appreciate the significance of post-biopsy pain; failure to recognize the significance of the patient’s drop in hemoglobin; and failure to order appropriate follow-up laboratory evaluation to assess the patient’s status when he began to complain of abdominal pain which was treated with what was thought to be an excessive dose of hydromorphone.

The Board issued a public letter of concern, which was reported to the Federation of State Medical Boards.  It was not reported to the National Practitioner Data Bank.

State: North Carolina


Date: January 2016


Specialty: Nephrology


Symptom: Abdominal Pain, Bleeding


Diagnosis: Hemorrhage, Renal Disease


Medical Error: Diagnostic error


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



California – Anesthesiology – Oxygen Saturation Levels Drop During Rhizotomies To Address Cervical Facet Syndrome



On 12/28/2011, a 41-year-old female came under an anesthesiologist’s care and treatment for monitored anesthesia care (MAC) while she was undergoing radiofrequency rhizotomies to address cervical facet syndrome involving C5-C6-C7  on the right side. The patient had a prior medical history significant for diabetes mellitus, for which she was taking Janumet.  She was taking Norco and had undergone prior rhizotomies on 4/11/2011 and 12/5/2011.

The Board notes that a rhizotomy is also referred to as radiofrequency ablation and is a procedure used to reduce pain.  An electrical current produced by a radio wave is used to heat up a small area of nerve tissue, thereby decreasing pain signals from that specific area.

On the morning of 12/28/2011, the anesthesiologist met with the patient’s surgeon, who had also performed her prior radiofrequency ablation procedures.  The surgeon advised the anesthesiologist that the patient had been difficult to sedate, resulting in movement, during the prior procedures.  The anesthesiologist interviewed the patient, reviewed her prior records, and performed a limited physical examination.  In a brief pre-anesthesia evaluation note, the anesthesiologist noted the patients diabetes, chronic pain, hypertension and suspected sleep apnea.  He did not mention the difficulty with sedation in prior rhizotomies, although it had been reported to him by the surgeon.  He listed the patient’s medications but omitted mention of her diabetes medication, Janumet.

The patient was consented for anesthesia, but on the consent form, the planned MAC sedation was not marked as the type of anesthesia.

At 11:08 a.m., the anesthesiologist began MAC sedation by administering 2 mg of midazolam and taking the patient to the operating room (OR).  The patient was positioned in the prone position on the OR table and was administered oxygen at 2L/min by nasal cannula.  Monitors were connected to measure and record blood pressure, heart rate, oxygen (O2) level and respiratory rate.

The anesthesiologist then administered 100 mcg fentanyl and 60 mg propofol in divided doses.  According to the anesthesia record, the surgical procedure began at 11:18 a.m.

When the surgeon injected local anesthesia at the rhizotomy entry points, sometime between 11:18 a.m. and 11:22 a.m., the patient complained of pain, lifted herself up on the OR table, and requested additional medication.  When reassurance failed, the anesthesiologist administered 50 mg propofol and, later, 50 mcg fentanyl.

During the procedure, the patient’s oxygen saturation (SaO2) levels began to drop.  However, the anesthesiologist was no longer doing real-time record keeping and the SaO2 values between 11:15 a.m. and 11:30 a.m. are collectively described only as “low sat.”  Although the SaO2 monitor recorded actual values during the period of time that the anesthesiologist was attending to the patient, the anesthesiologist did not retrieve that data after the procedure.  The anesthesiologist later testified that his recollection was that the SaO2 had decreased to 74 percent at the time of the second ablation.

A nurse who was present recalled the oxygen saturation descending to the 50 percentile range.  The anesthesiologist later testified that he assumed initially that the descending SaO2 levels were caused by a dislodged nasal cannula, which he repositioned between approximately 11:25 a.m. and 11:30 a.m.  As the patient’s SaO2 continued to decline, the anesthesiologist addressed the descending SaO2 by increasing the oxygen flow to 6L/min, inserting a nasopharyngeal airway, and applying jaw thrusts to resolve possible airway obstruction.  The anesthesiologist later testified that after applying the jaw thrusts, the SaO2 did not decline further.

Aware of the descending SaO2 levels, the surgeon asked the anesthesiologist whether the procedure could continue with a second ablation and the anesthesiologist answered affirmatively.  The anesthesiologist later stated that he considered reversing the patient’s sedation but did not do so as he felt it would be safer if she did not move during the procedure.  He also testified that he knew it was an option to halt the procedure but felt confident that the airway maneuvers would be adequate to reverse her airway obstruction and low oxygen saturation.

The procedure finished at approximately 11:35 a.m., at which time the patient was urgently transferred from her prone position on the OR table to a supine position on a gurney that had been brought in.  The surgeon and nurse in attendance later testified that the patient was cyanotic in appearance.  An oral airway was placed and oxygen was increased to 100%, resulting in the SaO2 rising to 99 percent.  However, she did not regain consciousness and, at approximately 12:10 p.m., the anesthesiologist administered naloxone to reverse her sedation.

By 12:40 p.m. to 1245 p.m., the patient had not regained consciousness.  The anesthesiologist and the surgeon made a decision to transfer her to a nearby hospital.  On the way to the hospital and upon arrival at the hospital, she experienced seizure activity.  Thereafter, the patient underwent extensive medical treatment.  Eventually, her condition “stabilized to one of severe motor impairment and a seizure disorder.”  She died of an accidental medication overdose at her home on 7/26/2014.

The Board judged the anesthesiologist’s conduct as having fallen below the minimum level of competence given failure to document the patient’s quantitative SaO2 levels at appropriate time intervals, failure to respond urgently to the patient’s with critically low oxygenation, and failure to keep adequate and accurate medical records of his care and treatment of the patient.

The Board issued a public reprimand with stipulations for the anesthesiologist to enroll in the Physician Assessment and Clinical Education Program offered at the University of California-San Diego School of Medicine.

State: California


Date: January 2016


Specialty: Anesthesiology


Symptom: N/A


Diagnosis: Post-operative/Operative Complication, Drug Overdose, Side Effects, or Withdrawal, Spinal Injury Or Disorder


Medical Error: Failure to properly monitor patient, Lack of proper documentation


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



Virginia – Internal Medicine – Elevated White Blood Cell Count With Immature Granulocytic Cell Population



On 10/28/2013, a patient’s laboratory results, as reviewed by an internist, indicated a markedly elevated white blood cell count and immature granulocytic cell population.  The pathologist’s blood smear review and consultation report noted immature granulocytic cell findings along with nucleated red blood cells and abnormal red blood cell morphology on smear, and suggested “full hematologic evaluation if clinically indicated.”  The internist did not order a full hematologic evaluation for the patient as recommended by the pathologist.

On 12/3/2013, the laboratory blood test results, which the internist reviewed and signed, again indicated a markedly elevated WBC and granulocytic cell population.  The internist again did not order a full hematologic evaluation for the patient.

On 5/28/2014, the patient presented to another physician who ordered laboratory results.  When the blood test results indicated a markedly increased number of white blood cells, the physician referred the patient to a hematologist-oncologist, who diagnosed the patient with a myeloproliferative neoplasm.

The internist stated that she did not order a hematologic evaluation after receiving the 10/28/2013 because she did not believe it was clinically indicated at that time.  The internist had ordered it for 12/13/2013 and reviewed the results and had planned to consider referral to a specialist based on the next lab work results.

The internist stated that she expressed concern to the patient about his white blood cell count during his 1/7/2014 office visit.  At that visit, which was a “sick visit,” the patient informed her that he was leaving the country in eight days for a three-month visit to Vietnam.  The internist stated that she urged the patient to have his blood recheck while he was away and when he was no longer ill.

The Board issued a reprimand and ordered the internist to take a continuing medical education course in the subject of interpreting complete blood count laboratory data.

State: Virginia


Date: January 2016


Specialty: Internal Medicine, Family Medicine


Symptom: N/A


Diagnosis: Hematological Disease


Medical Error: Failure to follow up


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Family Medicine – Nephrology And Urology Consults For Consistent Abdominal Pain, Back Pain, And Concern For Kidney Infection



On 1/25/2012, a 33-year-old female had her first visit with a family practitioner.  The handwritten medical record for this visit was largely illegible. The patient’s blood pressure for this visit was 153/96.  The chief complaint was listed as a one-year abscess on the patient’s right side with right-sided abdominal pressure for the past three days.  On examination, the family practitioner noted skin and abdomen as abnormal and recorded “right lower abdominal wall. Cystic swelling, 2 x 2 cm, semi-solid, non-tender, mobile,” no discharge and no induration.  The assessment was mild muscular sprain in the abdominal wall and right abdominal wall cyst, sebaceous possible. The family practitioner’s plan was to avoid manipulation of the lesion, take Keflex 500 mg q.i.d. For 14 days, use Estrace cream (vaginal cream with estrogen) t.i.d., Flexeril for muscle spasm, and topical antibiotics.  There was no detailed history taken and/or documented regarding the patient’s elevated blood pressure, and there was no management plan discussed and/or documented concerning the patient’s elevated blood pressure.

On 8/3/2013, the patient was seen in the emergency department for abdominal pain, flank pain, and fever.  The patient complained of flank pain, body aches, dizziness, and feeling weak. The patient’s blood pressure was 162/84, normal temperature, pulse 88, and pulse oximetry 100% on room air.  The patient experienced right lower quadrant discomfort when her abdomen was palpated. She was diagnosed with a urinary tract infection (UTI) with pyelonephritis (bacterium or virus infecting the kidneys) and given Keflex q.i.d. for 7 days with instructions to increase her fluid intake and check back into the emergency department if her condition did not improve in 2 days or if her pain got worse.  The clinical impression also included acute lumbar spasm with the patient being provided with a small dose of Flexeril for the muscle spasm.

On 8/16/2013, the patient was seen again in the emergency department for her complaints of back pain, headaches, muscle aches, and a rash.  The medical record for this visit referenced the emergency department visit of 8/3/2013, and noted “patient has not followed up with her primary care [and] she wants to get rechecked at this time… [and] [s]he wants a school note and a work note and a refill on pain medicine and muscle relaxer.”  The review of systems was unremarkable with the exception of “low back pain” with pain measured at 6 on a 10-point pain scale. The patient’s blood pressure for this visit was 138/92. The patient’s physical examination was unremarkable with the exception of mild tenderness of her paraspinal muscles bilaterally.  The patient was “convinced that she had a kidney infection” which was not supported by her urinalysis or other laboratory results (but could not be specifically ruled out). The medical record for this visit stated, in pertinent part, “…[the patient] was convinced that she had a kidney infection, so we checked her urinalysis and it was negative.  There was a high specific gravity at greater than 1.030, which goes with her dehydration. It was also contaminated with squamous epithelial cells, so I cannot rule out an infection, but there was no sign of an infection there.” The ED physician ultimately concluded the patient had “musculoskeletal back pain” and the diagnostic impression was low back pain, dehydration, and a skin rash, which appeared chronic.  The patient was prescribed ibuprofen 400 mg #30, 1 tablet every 6 hours as needed for pain, Soma 350 mg #20, 1 tablet every 6-8 hours as needed for musculoskeletal pain and stiffness, and tramadol hydrochloride 50 mg #20, 1 tablet every 6 hours as needed for pain (not to be taken with the Soma).

On 8/23/2013 at 2 p.m., the patient was seen by a physician assistant.  The documented history of present illness for this visit was document as “H/O [history of] enlarged [right] kidney” with symptoms reported as severe and “occur[ing] frequently” with a notation that “Patient has been to the Er where she had an abnormal CT and needs urology referral.”  The history of present illness also documented a rash, which began approximately 3 weeks ago. The blood pressure for this visit was 136/94. The patient’s overall appearance was listed as “ill appearing,” and the “abdomen” section of the medical record indicated “CVA tenderness reveals Right kidney tenderness.”  The assessment was “acquired asymmetrical kidneys” and the plan was referral to urology, continue Motrin as needed for pain, with an advisement to go to the emergency department if the patient’s condition worsened.

On 8/23/2013, the patient was seen at the emergency department at 7:30 p.m. for her complaint of right flank pain.  The medical record for this visit indicated the patient’s history of present illness, which set forth her recent emergency department visits and medications with a notation that “[s]he sees the family practitioner [and] [s]he is trying to get referred to a nephrologist, but she says she is tired of waiting, the pain is persisting, so the family practitioner sent her to a different ER tonight.”  The past medical history was listed as “Pyelonephritis, chronic back pain.” The patient’s review of systems was unremarkable and, on examination, she was noted as having blood pressure of 160/96 (later measured at 132/80). The patient’s physical exam was benign with the exception of “positive right CVA [costovertebral angle] tenderness.” A renal ultrasound showed a “small right kidney, otherwise negative.”  The medical record for this visit noted that the patient was upset that she was not seen by a nephrologist as part of her visit and that “[s]he needs to see the family practitioner Monday to get rechecked and push this referral through for Nephrology and Urology.” The clinical impression was flank pain, a chronic appearing atrophic right kidney (as shown on the ultrasound), and chronic pain. The patient was instructed to discard her tramadol and was given a prescription for Percocet and a “muscle relaxer.”

On 8/31/2013, the patient had her second visit with the family practitioner.  The history of present illness for this visit was documented as “f/u [follow up] on [right] kidney problem” and “eye discharge.”  The medical record indicated that the patient had an appointment scheduled with a nephrologist and a urologist. The patient’s blood pressure for this visit was 137/91.  The family practitioner documented benign examinations of the head, eyes, ear, nose, and throat, cardiac and respiratory, musculoskeletal, extremities, and neurological. The patient was noted as having “bilateral back pain, no deformity, no swelling.”  The family practitioners assessment was back pain and acute conjunctivitis. The family practitioner recommended artificial tears for the conjunctivitis and continue previously prescribed pain medications of the back pain. Despite the patient’s history of elevated blood pressure, there was no detailed history taken and/or documented regarding elevated blood pressure, and there was no management plan discussed and/or documented concerning the patient’s elevated blood pressure.  There also was no detailed history taken and/or documented concerning the patient’s back pain.

On 9/9/2013, the patient had her nephrology consultation with the nephrologist.  The nephrologist noted the patient’s history for intermittent back pain and right-sided flank pain after UTI diagnosed on 8/4/2013.  The family practitioner’s prior lab results were reviewed. The patient’s blood pressure was recorded at 150/80, and she was noted to not be in any acute distress.  On examination, the patient’s back was noted to have mild tenderness, there was “some costovertebral angle tenderness” and “some pain with rotation, flexion and extension of the lumbar thoracic spine”  Otherwise, the physical exam was normal. The nephrologist’s impression was mild ongoing lower back pain, which he believed was unrelated to any kidney abnormality and instead was likely musculoskeletal in nature.  The nephrologist recommended flat bed rest, taper off and then discontinue pain medications, return to work in 2 weeks, and a conditioning program for the back pain once the pain subsided.

On 9/30/2013, the patient had a urology consultation with the urologist, who noted, among other things, the patient’s history of being diagnosed with a smaller sized right kidney and an injury to the kidney from a prior auto accident.  On examination, the urologist noted no CVA tenderness and that the patient’s abdominal exam was normal. The urologist further noted the patient’s presumed pyelonephritis on the right side since August 2013 and her continued pain. The urologist prescribed Macrobid for one month (typically used to treat acute uncomplicated UTI’s) and other medication for the patient’s pain at night with a recommendation to follow up with him in one month if no significant improvement.  The clinical impression also included back pain and right flank pain.

On 1/20/2014, the patient had a urology follow up with the urologist.  The medical record for this visit indicated that the patient did not have a UTI on this visit, but was noted as having hypertension, constipation, and proteinuria.  The urologist recommended the patient’s renal etiology be evaluated by a nephrologist.

On 1/22/2014, the patient had her third visit with the family practitioner.  The history of present illness for this visit was documented as back pain, “read specialist report” (referring to the urologist’s report), and “lab/nephrology.”  The medical record for this visit documented “having atrophic unilateral kidney” and a chronic problem of “acquired asymmetrical kidneys.” The patient’s recorded blood pressure for this visit was 130/93, and her current medications were listed as tramadol and Soma.  The review of systems was normal with the exception of the patient’s complaint of back pain. The family practitioner’s physical examination of the patient was unremarkable. The musculoskeletal examination noted “normal range of motion, muscle strength, and stability in all extremities with no pain on inspect.”  The family practitioner’s assessment and plan for this visit listed low back pain to be treated with medication, patient referral to nephrology, neck pain (which was not listed in the HPI section) to be treated with medication, a neck collar, and physical therapy and occupational therapy. Despite the patient’s history of elevated blood pressure and/or hypertension, there was no detailed history taken and/or documented regarding elevated blood pressure and/or hypertension, and there was no management plan discussed and/or documented concerning the patient’s elevated blood pressure and/or hypertension.  The “medications” section of the medical record indicated a prescription for hydrochlorothiazide, which is typically used to treat hypertension. However, the medical record failed to indicate the basis for the prescription, and hypertension was not listed in the “Assessment Plan” section of the medical record. There also was no detailed history taken and/or documentation concerning the patient’s back and neck pain, and there was no focused physical examination of the patient’s back and/or neck conducted and/or adequately documented.

On 3/1/2014, the patient had her fourth visit with the family practitioner.  The history of present illness for this visit was documented as “hypertension (follow up)” and “f/u [follow up] on back pain” with the patient noted to be on medications for her hypertension.  The medical record further indicated “f/u [follow up] with chiropractor,” an MVA in November 2013, and that the patient was taking medication for pain. The patient’s blood pressure for this visit was 149/101.  The review of systems was normal with the exception of the back pain and constipation. The family practitioner’s physical examination of the patient was unremarkable. The electronic chart note for this visit did not indicate the results of any musculoskeletal examination and/or back examination.  The family practitioner’s assessment and plan for this visit was low back pain with a recommendation to continue to treat with current medications and follow up with chiropractor and physical therapy; and constipation with a recommendation for a high fiber diet and a prescription for Colace 100 mg, 1 tablet every night, as needed.  Despite the patient’s history of elevated blood pressure and/or hypertension, there as no detailed history taken and/or documented regarding elevated blood pressure and/or hypertension, and there was no management plan discussed and/or documented concerning the patient’s elevated blood pressure and/or hypertension. The “medications” section of the medical record indicated the prior prescription for hydrochlorothiazide on 1/22/2014, presumably for hypertension.  However, hypertension was not listed in the “Assessment Plan” section of the medical record. Also, there was, once again, no detailed management plan for treating the patient’s history of elevated blood pressure and/or hypertension nor any documentation of any management plan being discussed with the patient.

The Medical Board of California judged that family practitioner’s conduct departed from the standard of care because he failed to obtain and document adequate histories for the patient’s back and/or neck pain as well as elevated blood pressure and/or hypertension, conduct and document adequate physical examinations, and manage and document a clear and thorough action plan to manage the patient’s elevated blood pressure and/or hypertension.

The Medical Board of California issued a public reprimand and ordered the family practitioner to complete 40 hours of continuing medical education as a medical record-keeping course and an education course.

State: California


Date: January 2016


Specialty: Family Medicine, Internal Medicine


Symptom: Mass (Breast Mass, Lump, etc.), Constipation, Dermatological Abnormality, Rash, Dizziness, Fever, Abdominal Pain, Back Pain, Head/Neck Pain, Weakness/Fatigue


Diagnosis: Musculoskeletal Disease


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


Significant Outcome: Hospital Bounce Back


Case Rating: 1


Link to Original Case File: Download PDF



California – Anesthesiology – Lack Of Proper Indication And Physician Assistant Supervision For Transforaminal Cervical Epidural Administration



A patient was seen by a physician assistant on 6/15/2010, and the note was “cosigned” by an anesthesiologist.  The patient complained of neck pain and low back pain. There were no nerve conduction studies performed, and there were no neurologic findings of the objective type noted in the objective section of the exam.  No vital signs appeared on the “pain consult.” No loss of reflexes in any of the cervical reflex distributions (C5 or C7) were noted or described, no muscle atrophy was noted in any associated myotome, and no provocative maneuvers described.  It was unclear whether the anesthesiologist actually evaluated the patient on 6/15/2010. However, the patient was given a prescription for controlled substances under the anesthesiologist’s signature. The patient signed an opioid agreement, but left vital sections of the agreement blank, specifically the pharmacy where prescriptions were to be filled.  There was no risk evaluation and mitigation strategies described, which would include a CURES report, obtaining a urine sample for baseline consistency, or another questionnaire that might indicate an increased risk of addiction to opioids. The patient was ordered to undergo a CT scan of the cervical spine.

A CT scan of the cervical spine was performed on 6/29/2010, which revealed minimal pathologic findings.  Specifically, there was mention of mild bilateral facet disease, and the discs of the intervertebral space appeared to be relatively normal with the exception of a 2 mm protrusion at C6-7 in the left direction.  However, the radiologist report clearly stated that no nerve root appeared to be impacted. Furthermore, all the neural foramen were clear. The radiologist suggested correlation with a physical exam and an MRI.

The patient returned to the anesthesiologist’s office on 7/15/2010 and was again seen by the physician assistant.  Again, no vital signs were recorded. No urine collection was performed to check for compliance with controlled substance protocols.  It was again unclear whether the anesthesiologist actually saw the patient on 7/15/2010, because the co-signature on the report was undated.  The physician assistant decided, apparently on his own, to do a left transforaminal epidural steroid injection. However, the level-selection for the injection was confusing and appeared to have been overwritten in the notes provided.  The initial level was listed as C6-7, but there appeared to be a scribble over those numbers showing C5-6. Again, the physical exam did not demonstrate any objective findings of radiculopathy. No MRI was ordered, as suggested by the radiologist interpreting the CT scan.  No electromyographic studies were ordered to help clarify which level may be the target of a precise injection. No reference was made for potential surgical referral for the patient based on the expected diagnostic results of a precise injection. Finally, there was absolutely no discussion noted in the record with the patient regarding the extreme risks associated with the proposed procedure.

On 7/26/2010, the patient presented to the surgery center for the left transforaminal C5-6 injection.  The patient received deep sedation by the anesthesiologist’s physician partner in the operating room. The pre-procedure description stated that the patient had received up to 50-60% relief from the previously performed procedures; however, this appeared to be incorrect because this was the patient’s first procedure with the anesthesiologist.  The anesthesiologist dictated that in order to perform the procedure safely, deep sedation involving an anesthesiologist was required. The procedure was performed at the C5-6 level, and the anesthesiologist billed for an epidurogram. However, in keeping with the American Medical Association Current Procedural Terminology code description, no corresponding interpretation report for such a procedure was included.  Further, there was no mention of use of digital subtraction with the fluoroscopy unit, and no such images were presented with the supplemental records, which meant they did not exist.

Finally, the procedure was performed with a particulate steroid associated with infarction, paralysis, and death.  It should be noted that the patient, on presentation prior to the procedure, did not indicate any arm pain of any kind, but the anesthesiologist did not question either the level to be injected or whether it was appropriate to continue with the procedure based on her lack of symptoms.

A document in the file dated 8/18/2010, appeared to be a procedural visit at the surgical center.  However, there was no record of an interval evaluation of the patient, and there was no record of a pain diary being presented for review after the selective nerve root block.  The records reflected that the patient indicated that she still had neck pain but without arm pain and stated in her own writing that the previous injection made her pain worse.  However, the indication for the procedure as dictated by the anesthesiologist stated that the patient received 50-60% pain relief from a prior injection; this appeared to be boilerplate language, did not reflect what the patient actually related, and was seriously misleading. Furthermore, the patient was scheduled with the anesthesiologist’s partner for deep sedation utilizing propofol again.  The stated rationale was that the deep sedation was for the patient’s safety.

The patient was then scheduled for a bilateral intra-articular facet block from C3-C7.  The operative notes by the anesthesiologist indicated that the procedure took exactly 2 minutes.  However, not only was this a highly unusual injection series, but the time claim of 2 minutes was either physically impossible or highly dangerous.  The medical records indicated that the patient was not given a pain diary for diagnostic purposes to interpret the benefit of such an unusual injection series.

The patient follow-up on 9/27/2010 with a physician assistant then scheduled, inexplicably, yet again, for a left C5-C6 transforaminal injection.  The patient had indicated on 8/18/2010 that the similar injection performed in July 2010 made her pain worse. There was no further discussion for diagnostic purposes on whether to obtain the radiologist-recommended MRI, or to send the patient for an EMG to help clarify the expressed concern.  There was no documented neurologic change suggesting radiculopathy. The patient then followed up at the surgery center on 9/29/2010 for the scheduled left C5-6 transforaminal injection. The anesthesiologist dictated again that the previous surgery was 50-60% effective; however, previously the patient stated that her pain was worse after prior treatment.  The patient received anesthesia with propofol for this injection, with the addition of fentanyl and Versed. No indication that a pain diary was given to the patient was reflected in the records.

The patient again visited the anesthesiologist’s office on 10/21/2010 and was seen by the physician assistant, who noted in the medical records that there had been no relief from any of the cervical procedures and that the patient wished to focus on her low back.  She was referred for a CT scan of the lumbar spine without contrast, and the prescriptions for controlled substances were refilled. No objective findings, as noted on the physical examination, suggested radiculopathy or a progressive neurologic deficit.

The patient returned on 11/4/2010 and was again seen by the physician assistant and not the anesthesiologist.  The patient was diagnosed by the physician assistant with lumbar facet syndrome and was scheduled for a lumbar facet block.  The notes of 11/24/2010 suggested that the patient underwent a procedure with deep sedation in the operating room by the partner of the anesthesiologist.  Boilerplate language appeared in the records with respect to the need for this type of sedation, as well as the response to previous procedures.

In the original records provided, it appeared that the anesthesiologist himself saw the patient several times at the surgery center only, but that the physician assistant was the primary medical professional who saw the patient in the office.  No copy of the Delegation of Services agreement for this physician assistant was in the records. It was unclear if the physician assistant had the necessary training in prescriptions of controlled substances. Neither was there a formulary presented by the anesthesiologist or advanced notification and authorization for refilling of controlled substances.  In the original records, there was no date and time stamp indicating when or even if the anesthesiologist co-signed the notes for the patient. Little documentation was provided and most of the handwriting was completely illegible. There did appear to be a small scrawl by the anesthesiologist’s name, which could have been liberally interpreted as a cosignatory of the provided notes, but again, there was no date or timestamp as to when that actually occurred.  Additionally, the notes of 11/17/2011 did not appear to have any co-signature by the anesthesiologist.

The anesthesiologist’s overall treatment of the patient was grossly negligent in that he failed to obtain proper opioid treatment agreements, failed to determine if misuse was occurring, failed to monitor the physician assistant prescribing opioids, failed to perform proper examinations, and failed to determine if the opioid treatment modality was effective.  The anesthesiologist’s transforaminal cervical epidural steroid injections were unnecessary and dangerous. The decision to perform the procedure was not supported by medical evidence. The anesthesiologist’s delegation of the decision-making process for the patient to a physician assistant for facet blocks was grossly negligent. There was no evidence contained in the records that the physician assistant had the skills, training, or the competency to perform such an important function.  The anesthesiologist’s failure to properly supervise the physician assistant in the treatment and care of the patient was grossly negligent.

For this allegation and others, the Medical Board of California issued the anesthesiologist a public reprimand.

State: California


Date: January 2016


Specialty: Anesthesiology, Physician Assistant


Symptom: Head/Neck Pain, Back Pain


Diagnosis: N/A


Medical Error: Improper supervision, Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Failure to properly monitor patient, Improper medication management, Unnecessary or excessive treatment or surgery, Lack of proper documentation, Procedural error


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



North Carolina – Radiology – Evaluation Of A Chest X-Ray In A Patient With Shortness Of Breath And COPD



The Board was notified of a professional liability payment on 06/20/2014.

A 79-year-old female received general medical care at a Washington state clinic for many years.

in January 2011, the patient presented to that clinic with complaints of cough shortness of breath, and wheezing.  The patient’s chest x-ray was read by a radiologist.  A diagnoses of chronic obstructive pulmonary disease (COPD) was made, along with “blunting of both posterior costophrenic angles.”  In December 2012, the patient was found to have lung cancer.

The Board obtained the patient’s records and sent them to a qualified independent medical expert for review.  The reviewing expert noted that the x-ray the radiologist read revealed a spiculated mass adjacent to the right hilum that was suspicious for lung cancer.  The expert further opined that this mass clearly showed asymmetric density and should have been identified as suspicious for cancer.  The Board noted that the radiologist had some concerns that the x-ray the Board reviewed was not the same as the original x-ray the radiologist reviewed for the patient.

The Board expressed concern that the radiologist’s conduct was below the minimum standard of competence given failure to appreciate the mass on the chest x-ray.

The Board issued a public letter of concern, which was reported to the Federation of State Medical Boards.  It was not reported to the National Practitioner Data Bank.

State: North Carolina


Date: January 2016


Specialty: Radiology


Symptom: Shortness of Breath


Diagnosis: Lung Cancer


Medical Error: Diagnostic error


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Washington – Family Practice – Warfarin Dose Texted To Nurse Who Enters Incorrect Dosing Schedule



A family practitioner saw an 81-year-old patient, who lived in an assisted living facility, to help manage his multiple chronic medical conditions which required several medications.  One of the medications was warfarin.  The family practitioner would have the patient’s blood level tested monthly using the prothrombin time (PT) test and the international normalized ratio (INR) method.  In March 2014, the patient’s INR level was measured at 2.3 and the family practitioner continued the patient’s dosage of warfarin to remain at 1 mg four days a week, alternating 2 mg for the other three days.

On 4/24/2014, the family practitioner received a text message from a nurse at the assisted living facility stating that the patient’s INR had increased to 3.2.  This level was slightly higher than the 2.0-3.0 target range.  The family practitioner replied via text message ordering the patient’s warfarin to be decreased to 1 mg five a days a week with 2 mg administered on the other two days.  The nurse incorrectly transcribed the new order as “5 mg by mouth 5 days per week and 2 mg for 2 days per week” which increased the patient’s dosage exponentially.  The plan was for a lab recheck in one month.

The family practitioner made her routine visits over the next couple of weeks and signed off on the incorrectly transcribed 4/24/2014 order while also signing off on other orders and lab results she would review from a binder the facility collected for her.

On 5/4/2014, the family practitioner received a text message saying the patient had some bleeding from his gums while brushing his teeth.  The family practitioner ordered a new PT and INR to be done later that week.

On 5/8/2014, the patient had his blood work done.  On 5/9/2014, the family practitioner was advised the patient’s INR was at 15.2.  She inquired as to the amount of warfarin the patient had been receiving.  The nurse responded that he had been receiving 5 mg for five days and 2 mg for two days per week.  The family practitioner knew this was not the correct dosage she ordered on 4/24/2014.  She ordered the warfarin to be discontinued and to immediately administer 10 mg vitamin K as an antidote.

On 5/10/2014, the patient was found in his bed with “coffee ground emesis, and not responding.”  The facility called 911 and the patient was transported to a nearby hospital.  Later that day, the patient passed away from an internal brain hemorrhage.

The Commission stipulated the family practitioner reimburse costs to the Commission, allow a representative to conduct an annual audit of her records, and write and submit a paper of at least 1000 words, with references, on the proper management of anticoagulation therapy and critical INR patients and how she has changed her anticoagulation-related patient care.  She will also present this paper and discuss the events that occurred in this case and the policy and procedural changes that have since been implemented at the facility where the patient resided.

State: Washington


Date: January 2016


Specialty: Family Medicine, Internal Medicine


Symptom: Bleeding


Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Intracranial Hemorrhage


Medical Error: Accidental Medication Error


Significant Outcome: Death


Case Rating: 5


Link to Original Case File: Download PDF



Washington – Pathology – Specimen Labeled Urinary Bladder Neck And Fossa Of The Urinary Bladder Sent To Pathology



On 7/27/2011, a patient underwent a prostate core biopsy procedure at a urology clinic.  Twelve prostate core biopsy specimens were sent to Pathologist A’s clinic and were examined by the Pathologist A’s colleague.  The diagnosis was poorly differentiated adenocarcinoma in all twelve specimens.

On 2/27/2012, Pathologist A’s clinic received two separately labeled biopsies that came from the patient.  One was labeled fossa of the urinary bladder and the other was from the urinary bladder neck.  The biopsies were done to determine whether abnormal areas seen in the patient’s bladder were bladder tumor versus prostate cancer.

On 2/28/2012, Pathologist A performed a microscopic examination of the biopsies and diagnosed both prostatic adenocarcinoma and urothelial carcinoma.  Pathologist A did not use immunostains to make these diagnoses.

In March 2012, based on the Pathologist A’s diagnoses, a urologist performed an aggressive radical cystoprostatectomy (removal of the urinary bladder and prostate gland) on the patient.  This surgery left the patient with having to use a urine drainage bag for the rest of his life.

Following the radical cytoprostatectomy, Pathologist B examined the bladder and prostate specimen, used immunostaining, and only found prostate cancer and no bladder cancer.  A second opinion consultation was obtained from another pathology department which concurred with the differential diagnosis that only prostate cancer was present.

The Commission stipulated Pathologist A reimburse costs to the Commission and write and submit a paper of at least 1000 words, with references and bibliography, related to the proper use of immunostains to distinguish high-grade prostatic adenocarcinoma from a high-grade urothelial carcinoma.  The paper will explain how she has changed her practices, and what specific quality assurance or quality improvement processes she has incorporated into her practice.  She will also present her research paper to her pathology colleagues.

State: Washington


Date: January 2016


Specialty: Pathology, Oncology


Symptom: N/A


Diagnosis: Prostate Cancer


Medical Error: Diagnostic error, Procedural error


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 5


Link to Original Case File: Download PDF



Washington – Emergency Medicine – COPD, Shortness Of Breath, And Tachycardia With Administration Of Adenosine



On 8/28/2013, a patient who had chronic obstructive pulmonary disease (COPD) was admitted to the emergency department (ED) with shortness of breath.  The patient was transferred to telemetry for COPD exacerbation and persistent tachycardia.  The ED physician conducted various tests and an EKG.  He identified the patient’s medical issue as acute COPD exacerbation secondary to acute bacterial bronchitis with sinus tachycardia.

The patient was admitted to an internist for COPD exacerbation.  The admitting internist misread the EKG as supraventricular tachycardia (SVT).  Based on this, the internist administered adenosine without first consulting a cardiologist.  The internist failed to understand that using adenosine can cause worsening bronchospasm and must be used with caution in COPD patients.  The internist misinterpreted the patient’s severe bronchospastic response to the adenosine as anxiety and gave the patient Ativan, which would be expected to exacerbate this patient’s problem.  Shortly after, the patient experienced respiratory arrest.  Fortunately, the patient was resuscitated successfully.

The patient’s cardiologist felt that the respiratory arrest had been a side effect of the adenosine.  Adenosine has a side effect of causing bronchospasm, which means adenosine is contraindicated in patients with bronchospasm and cautioned for use in any patient with a history of COPD.  The internist failed to identify that the patient may have been suffering from severe bronchospasm or severe COPD.

The internist’s practice fell below the standard of care in the following ways:

1)     The internist misread the EKG.

2)     The internist administered a contraindicated drug.

3)     The internist failed to recognize the expected adverse reaction of that drug.

4)     The internist gave the patient a different drug which potentially exacerbated the adverse reaction.

5)     The internist’s treatment in this case resulted in the patient arresting.

The Commission stipulated the internist reimburse costs to the Commission, allow a Commission representative to audit patient records and review practices related to the internist’s assessment and treatment of patients with COPD, complete 6 hours of continuing education in the area of interpretation and management of cardiac arrhythmias, and write and submit a paper of at least 1000 words, with bibliography, on the subject of arrhythmias and their treatment in COPD patients.

State: Washington


Date: January 2016


Specialty: Hospitalist, Cardiology, Emergency Medicine, Internal Medicine


Symptom: Shortness of Breath


Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Pulmonary Disease


Medical Error: Improper medication management


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



Washington – Urology – 5 And ½ Hours Long Partial Nephrectomy Operation



In June 2013, a 55-year-old male underwent an open hemicolectomy to remove colon cancer.  Subsequent CT imaging revealed a 3.5 cm mass on the patient’s left kidney.  PET scan imaging suggested that the kidney mass was not a metastasis of the colon cancer.

The patient was referred to a surgeon to address the mass on his left kidney.  The surgeon elected to proceed directly to surgery.  On 9/18/2013, the surgeon performed an open left partial nephrectomy in an attempt to remove the kidney mass.  He experienced some difficulty in identifying the kidney mass during surgery and was assisted by a radiologist who performed an intraoperative ultrasound to help confirm the mass.  However, post-operative pathology testing identified the excised tissue as normal kidney tissue.  Subsequent abdominal imaging confirmed that the kidney tumor remained.

The surgeon’s unsuccessful operation took approximately 5 and ½ hours, including 62 minutes of ischemia due to clamping.  The length of the surgery and the period of ischemia were excessive and created increased risk to the patient.

A subsequent treating surgeon biopsied the now 4 cm left kidney mass, which was confirmed by pathology testing to be clear cell renal carcinoma.  In June 2013, the subsequent treating surgeon performed a laparoscopic, robotic-assisted surgical procedure to remove the patient’s left kidney (radical nephrectomy).

The Commission stipulated the surgeon reimburse costs to the Commission, allow a representative of the Commission to conduct annual practice reviews of his patient charts, have a proctor for all partial and radical nephrectomies, complete a course on the diagnosis and treatment of renal cancer, and write and submit a paper of at least 1000 words discussing this course and its application to his practice.

State: Washington


Date: January 2016


Specialty: Urology, Oncology


Symptom: N/A


Diagnosis: Cancer, Colon Cancer


Medical Error: Procedural error


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



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