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California – Obstetrics – Blood Type A Negative And Having A Sister Who Had A Pregnancy Complicated By Spina Bifida
On 7/29/2011, a 19-year-old female 15 weeks pregnant with estimated due date 1/20/2012 first saw an obstetrician. The patient had all appropriate prenatal lab tests completed, including a blood type. She was noted to be blood type A negative.
On 9/29/2011, the obstetrician noted that “Sister … had pregnancy with spina bifida.” The obstetrician also performed an HIV test, a cystic fibrosis test, an ultrasound, and a quad screen (blood tests to screen for certain birth defects including trisomies and neural tube defects such as spina bifida). The obstetrician noted that the patient asked for a maternal-fetal medicine consult.
On 8/25/2011, the obstetrician saw the patient for a follow-up visit. The patient was 18 weeks and 6 days pregnant. Ultrasound showed that the baby was a girl. The obstetrician noted that the CMV IgG and IgM tests were done due to echogenic bowel (a soft marker for various conditions, including trisomies). There was no evidence of spina bifida on the ultrasound. The obstetrician scheduled a follow-up ultrasound scheduled for early November.
The obstetrician saw the patient several times for follow-up visits and tests on 8/25/2011, 9/22/2011, 10/6/2011, 10/7/2011, 10/11/2011, 10/18/2011, 11/15/2011, 12/15/2011, 12/29/2011, and 1/5/2012.
On 1/1/2012, the obstetrician saw the patient. She was 39 weeks and 6 days pregnant. No fetal heart tones were audible, and the diagnosis of intrauterine fetal demise was made and confirmed. The patient was sent to Labor and Delivery for confirmation and labor induction. She ultimately delivered a baby that was stillborn.
The Board judged the obstetrician’s conduct to have fallen below the minimum level of competence given failure to address the patient’s Rh-negative status and to provide Rh immune globulin to the patient. She failed to fully inform, discuss, and document her discussion with the patient of the fact that she was Rh-negative and of her treatment options.
The Board issued a public reprimand with the stipulation to complete the Physician Assessment and Clinical Education Program (PACE) offered at the University of California, San Diego School of Medicine.
State: California
Date: February 2016
Specialty: Obstetrics
Symptom: N/A
Diagnosis: N/A
Medical Error: Failure to follow up, Failure of communication with patient or patient relations, Lack of proper documentation
Significant Outcome: Death
Case Rating: 3
Link to Original Case File: Download PDF
California – Gynecology – Postmenopausal Bleeding While On Estrogen Therapy
On 6/10/2010, a 75-year-old female was seen at an urgent care facility by a registered nurse practitioner with a complaint of postmenopausal bleeding. She was initiated on progesterone. The nurse practitioner did an endometrial biopsy but felt that she did not get an adequate intrauterine specimen in the office and referred the patient to a gynecologist.
The patient previously had been taking hormone replacement therapy through age 70. She was on a combination pill. The patient was not aware if she was taking progestin with the combination pill. She reported having some off and on bleeding for the 5 years prior to her urgent care visit, even off of the estrogen therapy. She reported more persistent bleeding 6 weeks prior to being seen by the gynecologist.
The patient was scheduled to see the gynecologist on 7/7/2010. In the meantime, she continued to take Provera 20 mg. The endometrial biopsy results showed endometrial adenocarcinoma, grade one. The patient was scheduled for a hysteroscopy and dilatation of the cervix with curettage of the uterus for diagnosis of her postmenopausal bleeding.
On 7/7/2010, the gynecologist saw the patient for a preoperative appointment. The gynecologist noted the results of the endometrial biopsy revealing adenocarcinoma. In addition, a prior ultrasound showed a “focal thickened endometrial and medium, possible extension into the myometrium.” The preoperative notes by the gynecologist stated: “Assessment: endometrial carcinoma” and “Plan: discussed with patient the possible risks and benefits to surgery to include but not limited to bleeding, infection, damage to other tissue, possible need for transfusion, possible need for additional surgery. Patient has no further questions at this time.” The surgery certification provided for an abdominal hysterectomy with bilateral salpingo-oophorectomy for postmenopausal bleeding.
On 7/13/2010, the patient underwent an abdominal hysterectomy, bilateral salpingo-oophorectomy, omental biopsy, and posterior cul-de-sac biopsy. During the procedure, there are no notations in the doctor’s dictation that lymph nodes were palpated or that there was consideration of doing lymph node biopsies. Postoperatively, the patient recovered.
The gynecologist sent a referral to a gynecologic oncologist. The Board notes that the gynecologist failed to evaluate, discuss, or document the patient’s menopausal symptoms and discuss or document an alternative treatment. The gynecologist failed to discuss or document informed consent following a fully informed discussion of the risks, benefits, and alternatives.
On 8/24/2010, the patient was seen at a cancer center in Sacramento, California. At that time, the patient reported that she was not taking any medications although, in her personal questionnaire, she did state that she was taking estrogens. The patient declined referrals and stated that she would call when ready.
On 9/26/2011, the patient left a message with the gynecologist. The patient stated that she was given samples of Enjuvia 0.3 instead of Premarin. She indicated that she would like to have Enjuvia 0.3 “called in “because “it is a little bit cheaper.” The gynecologist continued to prescribe estrogen to the patient.
On 10/4/2011 and 10/5/2011, the patient called the gynecologist’s office to report an ongoing “murky” vaginal discharge. The gynecologist saw the patient in her office on 10/11/2011 where a large vaginal mass was cauterized and scheduled for excision.
On 11/7/2011, the gynecologist saw the patient for an excisional biopsy of the vaginal cuff mass and vaginal discharge. The excisional biopsy at that time confirmed recurrent carcinoma.
On 11/9/2011, the gynecologist spoke with the patient over the phone and documented that she discussed the findings of recurrent endometrial carcinoma. In addition, she noted that the patient was not interested in radiotherapy or a follow-up gynecologic oncology evaluation.
In late May 2012, there was a series of phone calls and messages between the gynecologist and the patient. The patient requested a refill for an ongoing prescription of her estrogen replacement therapy. The gynecologist noted, “I refilled the prescription for her. I again told her that estrogen replacement can make an occult cancer grow. She understands the risks but feels that her quality of life is the most important thing. She will follow with me as needed.”
On 12/2/2012, the gynecologist saw the patient and in an addendum, the gynecologist noted that the patient was made aware of the recurrent carcinoma and that the patient refused any additional therapy.
The Board judged the gynecologist’s conduct as having fallen below the minimum level of competence given failure to evaluate and document the patient’s symptoms, failure to provide a fully informed discussion of alternative treatments, and failure to consider obtaining a sample of any lymph nodes during the initial surgery on 7/13/2010.
The Board issued a public reprimand with the stipulation to enroll in the Physician Assessment and Clinical Education Program (PACE) offered at the University of California, San Diego School of Medicine.
State: California
Date: February 2016
Specialty: Gynecology, Oncology
Symptom: Bleeding
Diagnosis: Gynecological (Endometrial, Ovarian, Cervical) Cancer
Medical Error: Failure of communication with patient or patient relations, Lack of proper documentation, Procedural error
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
California – Gynecology – Migration Of IUD Leads To Challenging Removal
A 26-year-old woman with five prior pregnancies and a Cesarean section delivery in October 2009, had an IUD placed in early December 2009.
On 1/7/2010, a gynecologist saw the patient. The patient complained that she could not feel the IUD strings. The gynecologist was not able to see her strings on exam visually. She performed a transvaginal ultrasound that showed the IUD to be in the cervical canal. The gynecologist tried to remove the IUD with forceps in the office but was not able to do so. The gynecologist scheduled the patient for a hysteroscopy and IUD removal.
The preoperative history and physical was completed on 1/7/2010 and the patient was counseled for hysteroscopic removal of the IUD and replacement. The gynecologist indicated that the risks and benefits of the procedure were discussed and informed consent was obtained.
On 1/11/2010, the gynecologist performed the hysteroscopy, but the IUD could not be located. An x-ray was obtained in the operating room and the IUD was seen in the pelvis. The gynecologist then proceeded with a diagnostic laparoscopy for the IUD removal. This operation was accomplished without complication using a two puncture technique (two incisions were used for laparoscopic ports). Following the procedure, the patient was observed in the recovery room until stable and discharged home with antibiotics. The patient was taken once again to the operating room on 2/16/2010 for laparoscopic bilateral tubal ligation, which was completed without complication.
The Board judged the gynecologist’s conduct to have fallen below the minimum level of competence given her failure to fully apprise the patient of the fact that the IUD may have perforated through the uterus. The Board expressed concern that the gynecologist failed to maintain adequate and accurate medical records.
The Board issued a public reprimand with the stipulation for the gynecologist to enroll in the Physician Assessment and Clinical Education Program at the University of California, San Diego School of Medicine.
State: California
Date: February 2016
Specialty: Gynecology
Symptom: N/A
Diagnosis: Medical Device Malfunction Or Implantation Failure
Medical Error: Failure of communication with patient or patient relations, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
California – Pulmonology – Fecal Matter Noted On PEG Tube
On 9/25/2008, a 38-year-old patient was admitted to the neuro-care unit at a hospital under a pulmonologist’s care. The patient had an extensive medical history, which included diabetes mellitus, prior cerebrovascular accident, bipolar disorder, schizophrenia, ventilator dependent tracheostomy, gastrostomy feeding tube, pituitary tumor, hypertension, and blindness from diabetes. At the time of admission, the patient was ventilator dependent and had a percutaneous endoscopic gastrostomy (PEG) tube.
In January 2009, the patient was weaned off of the ventilator and oral feedings were initiated. Medications were still administered via the PEG tube. After the patient was stabilized, he was transferred to the nursing home, still under the pulmonologist’s care. The pulmonologist evaluated the patient on 1/4/2009, 1/10/2009, 1/18/2009, and 1/22/2009, but there was no documentation by the pulmonologist about the PEG tube on physical examination.
On 2/22/2009, the patient was seen by the pulmonologist. The pulmonologist was advised that the PEG tube, which was still inserted in the patient, may have become loose and may need to be removed. On 2/25/2009, the patient was seen by the pulmonologist.
On 2/27/2009, the pulmonologist consulted with Physician A and a physician assistant about the PEG tube. The patient was seen by the physician assistant, who noted that there was fecal matter on the PEG tube and gave verbal orders for a KUB with Gastrografin to confirm whether the PEG tube was in the stomach.
On 2/28/2009, the pulmonologist gave verbal orders that the patient could receive medication or meals orally or via the PEG tube.
On 3/11/2009, the physician assistant gave another verbal order for a KUB with Gastrografin to confirm that the PEG tube was in the stomach. The pulmonologist signed the verbal orders. The KUB showed that the PEG tube was in the wrong place. During this time, the PEG tube was being used for medicine, meals, and water flushes.
On 3/15/2009, the pulmonologist gave verbal orders not to use the PEG tube until it was clear, but did not document why he gave this order.
On 3/20/2009, a radiology report noted that the patient had “nausea and vomiting” and the feeding tube was in the colon. Physician B, who was covering for the pulmonologist on this date, was notified of the findings and noted this in the patient’s chart. No steps were taken to remove the PEG tube on this date.
On 3/29/2009, the pulmonologist documented a physical examination but did not document any issues or concerns with the PEG tube.
On 3/31/2009, a radiology report from the hospital reported that the patient had mild ileus with moderate constipation.
On 3/31/2009, the patient was seen by the pulmonologist, who noted that the PEG tube was “close to the skin” and transferred the patient to the hospital to have the PEG tube removed. The pulmonologist noted that he had been aware that the PEG tube was in the wrong place since 3/20/2009.
On 4/9/2009, the patient was discharged from the hospital. The discharge summary report was dictated on 6/20/2009.
On 10/31/2011 and 11/22/2011, the pulmonologist saw the patient for routine visits.
The Board judged the patient’s conduct to have fallen below the standard of care given failure to timely intervene when he became aware the PEG tube was misplaced and when the patient had signs and symptoms of a possible ileus; failure to document adequate history and physical examinations including routine abdominal examinations; failure to provide explanations as to why orders were given; and failure to follow-up with consulting providers regarding the status of his patient. He routinely failed to document a plan of care or treatment for the patient.
The Board issued a public reprimand with stipulations to complete a continuing medical education course and a medical record keeping course.
State: California
Date: February 2016
Specialty: Pulmonology, Hospitalist, Internal Medicine
Symptom: Nausea Or Vomiting
Diagnosis: Gastrointestinal Disease
Medical Error: Delay in proper treatment, Failure of communication with other providers, Failure to follow up, Failure to properly monitor patient, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
Colorado – Radiology – Headache, Vertigo, And Vomiting With Head CT Read As Having No Acute Pathology
In September 2009, a patient presented to the emergency department with complaints of headaches, vertigo, dizziness, and vomiting. The treating ED physician ordered a non-contrasted head computed tomography (CT) as part of the patient’s workup. The final report for this head CT recommended a contrast-enhanced head CT and magnetic resonance imaging for further evaluation.
The radiologist read the subsequent contrast-enhanced head CT as essentially negative with “no definite hemorrhage” and “no acute intracranial pathology.” The patient was discharged home and the next day was readmitted to the ED with a decreased level of consciousness, went into a coma, and was ultimately diagnosed with posterior fossa subdural hematoma. The finding was visible on the 2009 contrast-enhanced head CT.
The Board judged the radiologist’s conduct as having fallen below the generally accepted standards of practice for a radiologist.
The Board issued a letter of admonition.
State: Colorado
Date: February 2016
Specialty: Radiology
Symptom: Headache, Dizziness, Nausea Or Vomiting
Diagnosis: Intracranial Hemorrhage
Medical Error: False negative
Significant Outcome: Hospital Bounce Back
Case Rating: 2
Link to Original Case File: Download PDF
North Carolina – Physician Assistant – Bandage Wrap Applied To Patient’s Foot Before Surgery To Prevent Slippage Of The Leg
The Board was notified of a professional liability payment paid on 04/21/2015.
In March 2013, a patient had surgery as a result of a right hip fracture. The physician assistant was present in the operating room as the surgical assistant. Following the surgery, the physician assistant provided post-operative care for the patient. As a routine part of the surgical procedure, a bandage wrap was applied to the patient’s foot before surgery to prevent slippage of the leg out of a leg traction device. This bandage wrap is usually removed by the operating room nurse or the surgical assistant in the operating room after surgery. In this case, the physician assistant did not remain in the operating room following surgery. The operating room nurse did not remove the bandage wrap. The wrap was also not removed during the patient’s post-operative hospitalization or after her transfer to a rehabilitation facility.
The Board noted that it was the physician assistant’s responsibility to conduct post-operative assessments of the patient and that the physician assistant missed several opportunities during examinations to discover that the wrap had not been removed. The wrap was not removed for approximately six days after surgery causing the patient to develop vascular compromise resulting in foot ulcers. Ultimately, the patient required a lower leg amputation.
The Board obtained the patient’s records and sent them to a qualified independent medical expert for review. The independent medical expert judged the physician assistant’s conduct to be below the minimum standard of competence given failure to remove the bandage wrap in a timely fashion.
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: February 2016
Specialty: Physician Assistant, Orthopedic Surgery, Vascular Surgery
Symptom: Extremity Pain
Diagnosis: Acute Ischemic Limb, Post-operative/Operative Complication
Medical Error: Procedural error, Failure to follow up
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 4
Link to Original Case File: Download PDF
North Carolina – Orthopedic Surgery – Failure to Timely Diagnose Cause of Leg Pain
The Board was notified of a professional liability payment made on behalf of an orthopedic surgeon on 04/01/2015.
A patient was referred to an orthopedic surgeon for an evaluation after months of increasing lower left leg pain. An MRI scan was ordered for the patient. She was prescribed hydromorphone and celecoxib. At a follow-up visit, the result of the patient’s MRI scan was discussed with her, but a diagnosis of her medical condition remained uncertain.
Five days after this visit, the patient was seen by her family practitioner who referred her to a vascular surgeon. The patient was diagnosed with having an acute arterial insufficiency to her leg and three days later she required a below the knee amputation.
The Board obtained the patient’s records and sent them to a qualified independent medical expert for review. The independent medical expert judged the orthopedic surgeon’s conduct to be below the minimum standard of competence given failure to properly diagnose and treat the patient.
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: February 2016
Specialty: Orthopedic Surgery, Vascular Surgery
Symptom: Extremity Pain
Diagnosis: Acute Ischemic Limb
Medical Error: Diagnostic error
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 1
Link to Original Case File: Download PDF
Arizona – Cardiology – Patient With Chest Pain And Elevated Troponin Requesting Transfer To The VA
The Board initiated an investigation into a the cardiologist’s practice after receiving a report from the hospital where the cardiologist worked. He had resigned during a review of multiple patient charts and concerns regarding poor clinical judgment and inattention to details.
A 59-year-old man presented to the hospital with chest pain. Cardiac markers suggested myocardial infarction. EKG’s were unremarkable. The patient initially wanted to leave the hospital and seek care at the Veterans Administration Hospital (VA), but he was convinced to stay. Though he was clinically stable, his cardiac markers increased and was strongly suggestive of a non-ST elevation myocardial infarction. He was treated with low molecular weight heparin, aspirin, beta blockade, and nitrates. The patient insisted on going to the VA. After a day of clinical stability that included a ten minute walk on the ward, he was then discharged from the hospital by the cardiologist. An ambulance was not used to transfer the patient to the VA. The cardiologist was unable to contact cardiology at the VA. For this reason, the patient did not have an established VA cardiologist that knew of his medical history and the reason for transfer.
The Medical Consultant stated that the patient should have been transferred by a resuscitation-capable transport. Medical therapy for acute coronary syndrome should have been interrupted. The cardiologist at the VA should have been contacted to accept the patient as a cardiology admission.
The cardiologist that he could not find any cardiologist at the VA facility.
The Board judged the cardiologist’s conduct to be below the minimum standard of competence given failure to transfer the patient by ambulance and reach a cardiologist at the outside hospital to transfer care.
From 06/06/2014-06/07/2014, the cardiologist underwent Phase I of the Physician Assessment and Clinical Education (“Pace”) Program. The initial report stated that his performance was variable and recommended that the cardiologist complete a neuropsychological fitness for duty evaluation prior to completion of Phase II.
On 03/09/2015, the cardiologist presented to Phase II of PACE without undergoing the neuropsychological evaluation recommended in the Phase I report. The cardiologist did not complete Phase II due to alleged unprofessional conduct during the clinical evaluation portion of the program, resulting in the cardiologist being “indefinitely barred” from returning to complete Phase II without a neuropsychological evaluation.
On 06/25/2015, the cardiologist completed a neuropsychological evaluation, although he failed to ensure the evaluator was approved by the Board. The evaluator found that the cardiologist exhibited areas of poor performance compared to a younger population, but he was deemed not to have a cognitive disorder and his difficulties during the test did not account for his episodes of poor judgment.
The Board questioned the cardiologist’s unprofessional conduct during the interview of the cardiologist. They remained concerned that allowing him to practice would not be safe for his patients’ safety. He was placed probation with recommendation for him to complete a neuropsychological evaluation, CME, and practice monitoring.
On 0923/2016, the physician informed the Board that he was planning to retire.
State: Arizona
Date: February 2016
Specialty: Cardiology
Symptom: Chest Pain
Diagnosis: Cardiovascular Disease
Medical Error: Procedural error, Failure of communication with other providers
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
Arizona – Cardiology – Failure To Interrogate Pacemaker
The Board initiated an investigation into a cardiologist’s practice after receiving a report from the hospital where the cardiologist worked. He had resigned during a review of multiple patient charts and concerns regarding poor clinical judgment and inattention to details.
An 80-year-old man was admitted to the hospital with near syncope. The hospital records did not contain any reference to a pacemaker interrogation. However, the cardiologist responded that the pacer interrogation was “normal” when checked several months prior. The Medical Consultant found that the patient’s pacer Holter function should have been reviewed to exclude concerns regarding interactions between neurostimulators and pacers that can lead to tachycardias and bradycardias.
The cardiologist said that he had checked the pacemaker.
From 06/06/2014-06/07/2014, the cardiologist underwent Phase I of the Physician Assessment and Clinical Education (“Pace”) Program. The initial report stated that his performance was variable and recommended that the cardiologist complete a neuropsychological fitness for duty evaluation prior to completion of Phase II.
On 03/09/2015, the cardiologist presented to Phase II of PACE without undergoing the neuropsychological evaluation recommended in the Phase I report. The cardiologist did not complete Phase II due to alleged unprofessional conduct during the clinical evaluation portion of the program, resulting in the cardiologist being “indefinitely barred” from returning to complete Phase II without a neuropsychological evaluation.
On 06/25/2015, the cardiologist completed a neuropsychological evaluation, although he failed to ensure the evaluator was approved by the Board. The evaluator found that the cardiologist exhibited areas of poor performance compared to a younger population, but he was deemed not to have a cognitive disorder and his difficulties during the test did not account for his episodes of poor judgment.
The Board questioned the cardiologist’s unprofessional conduct during the interview of the cardiologist. They remained concerned that allowing him to practice would not be safe for his patients’ safety. He was placed probation with recommendation for him to complete a neuropsychological evaluation, CME, and practice monitoring.
On 0923/2016, the physician informed the Board that he was planning to retire.
State: Arizona
Date: February 2016
Specialty: Cardiology
Symptom: N/A
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
Arizona – Cardiology – Left Ventricular Dysfunction With Event Monitoring Showing Monomorphic Ventricular Tachycardia
The Board initiated an investigation into a cardiologist’s practice after receiving a report from the hospital where the cardiologist worked. He had resigned during a review of multiple patient charts and concerns regarding poor clinical judgment and inattention to details.
A 56-year-old man presented for a follow-up to address multiple episodes of near syncope and chest discomfort. He was seen by the cardiologist to review results of outpatient testing. A transesophageal echocardiogram revealed severe left ventricular dysfunction, event monitoring revealed episodes of monomorphic ventricular tachycardia, and nuclear stress imaging revealed an inferior wall infarct. The patient was admitted, and the cardiologist performed cardiac catheterization, which revealed normal coronary arteries and severe global LV dysfunction. The cardiologist diagnosed the patient with non-ischemic cardiomyopathy and treated him with intravenous and oral amiodarone. It is assumed that the plan was for implantation of an implantable cardioverter-defibrillator, but the hospital did not perform that procedure. For this presumed reason, the patient was subsequently discharged and transported by car to another hospital for implantation of an implantable cardioverter-defibrillator.
The Medical Consultant noted that VT ablation should have been considered. Furthermore, the Medical Consultant did not think it was safe for the patient to be transferred to another hospital without cardiac monitoring given the risk of ventricular tachycardia.
The cardiologist said that the patient had declined transfer.
The Board judged the cardiologist’s conduct to be below the minimum standard of competence given failure to transfer the patient by ambulance.
From 06/06/2014-06/07/2014, the cardiologist underwent Phase I of the Physician Assessment and Clinical Education (“Pace”) Program. The initial report stated that his performance was variable and recommended that the cardiologist complete a neuropsychological fitness for duty evaluation prior to completion of Phase II.
On 03/09/2015, the cardiologist presented to Phase II of PACE without undergoing the neuropsychological evaluation recommended in the Phase I report. The cardiologist did not complete Phase II due to alleged unprofessional conduct during the clinical evaluation portion of the program, resulting in the cardiologist being “indefinitely barred” from returning to complete Phase II without a neuropsychological evaluation.
On 06/25/2015, the cardiologist completed a neuropsychological evaluation, although he failed to ensure the evaluator was approved by the Board. The evaluator found that the cardiologist exhibited areas of poor performance compared to a younger population, but he was deemed not to have a cognitive disorder and his difficulties during the test did not account for his episodes of poor judgment.
The Board questioned the cardiologist’s unprofessional conduct during the interview of the cardiologist. They remained concerned that allowing him to practice would not be safe for his patients’ safety. He was placed probation with recommendation for him to complete a neuropsychological evaluation, CME, and practice monitoring.
On 0923/2016, the physician informed the Board that he was planning to retire.
State: Arizona
Date: February 2016
Specialty: Cardiology
Symptom: N/A
Diagnosis: Cardiovascular Disease
Medical Error: Improper treatment, Lack of proper documentation, Procedural error
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF