Found 12 Results Sorted by Case Date
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Virginia – Physician Assistant – Administration Of Orthovisc Instead Of Cortisone



On 3/14/2014, without verifying the medication/dosage or consulting the patient’s record, a physician assistant confirmed that the patient was to receive an injection of Orthovisc when asked for guidance by a registered nurse.

In actuality, the patient’s treatment plan provided that he was to receive cortisone injections, not Orthovisc.  The physician assistant administered the Orthovisc medication laid out for her without confirming what medication was needed or what medication she was injecting.  Upon realizing her error, she noted in the patient’s record that she “assumed” the patient was to receive Orthovisc due to the note that “bilateral knee injections” were due.

Further, the physician assistant claimed in a written statement to the Board’s investigator that, before injecting a patient, she did “not make a habit of questioning [the] nurses because they have all been extremely competent.”

The physician assistant told the Committee that she never tried to cover up her error.  She informed the patient about the error, documented it in the patient’s record, and discussed the issue with the clinic supervisor.  In an effort to avoid this type of error from recurring, the physician assistant told the Committee that she now draws up the medications herself, checks the chart, and counts back the appropriate number of months to ensure that the administration of a particular medication is timed correctly.

When she was contacted by a Board investigator, she panicked and feared that she was about to lose her job.  As a consequence of her anxiety, she took a family member’s alprazolam.  On 2/27/2015, she submitted to a urine drug screen as part of the Board’s investigation, which turned up positive for the benzodiazepine.

The Board investigated two other medication errors that had occurred as well as a posting of the physician’s assistant on Facebook that contained sensitive medical information.

She stated that these incidents occurred during a time when she had an extremely busy schedule and after another physician assistant left the clinic requiring her to increase her workload.  She also was planning her wedding around this time.

She reported being employed by a new practice for almost a year.  Her new position did not include nights or weekends, as did her last employment.  She also has her own medical assistant compared to her prior practice when she had to share her medical assistant with another provider.

She submitted a letter written by her current supervising physician who reported that she “has performed well as a provider and an employee.”  She told the Committee that she had learned from her mistakes and had made changes in her practice and personal life to ensure she would be diligent in her work and that she would avoid any repeat problems.  In her current practice, she wrote all of her own prescriptions and her medical assistant double-checked each one behind her.

She was administered a reprimand.  Within 45 days of the order, she was to submit a written statement certifying that she had read the laws and regulations governing the practice of Physician Assistants.  She was to submit documentation that she completed courses in ethics and pain management.

State: Virginia


Date: April 2016


Specialty: Physician Assistant, Family Medicine, Internal Medicine


Symptom: Joint Pain


Diagnosis: Musculoskeletal Disease


Medical Error: Accidental Medication Error, Ethics violation


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



Virginia – Physician Assistant – Dosing Regimen Error When Prescribing Coumadin



On 6/26/14, a physician assistant erroneously prescribed Coumadin 10 mg every evening for a patient.  The patient was hearing impaired, and the physician assistant did not use an interpreter when communicating with her or did not use any other assistive devices to communicate with the patient.  The patient took 10 mg of Coumadin every night for six nights prior to her scheduled surgery instead of one 10 mg tablet of Coumadin the evening prior to surgery.

On 7/2/2014, the patient was admitted with a pre-operative INR level of 3.8, and her surgery was rescheduled.

The physician assistant stated that the electronic medical record defaulted to 30 tablets in a prescription, and she forgot to change the pill number from 30 to 1.  Unintentionally, the patient was sent home with the “default number” of 30 tablets instead of the one tablet.

On 12/13/2014, the physician assistant prescribed Coumadin 2.5 mg for a different patient with instructions to “take 30 tabs by mouth every evening.”  The correct instructions would have been for the patient to take one tablet every evening.

She stated that these incidents occurred during a time when she had an extremely busy schedule and after another physician assistant left the clinic requiring her to increase her workload.  She also was planning her wedding around this time.

She reported being employed by a new practice for almost a year.  Her new position did not include nights or weekends, as did her last employment.  She also has her own medical assistant compared to her prior practice when she had to share her medical assistant with another provider.

She submitted a letter written by her current supervising physician who reported that she “has performed well as a provider and an employee.”  She told the Committee that she had learned from her mistakes and had made changes in her practice and personal life to ensure she would be diligent in her work and that she would avoid any repeat problems.  In her current practice, she wrote all of her own prescriptions and her medical assistant double-checked each one behind her.

She was administered a reprimand.  Within 45 days of the order, she was to submit a written statement certifying that she had read the laws and regulations governing the practice of Physician Assistants.  She was to submit documentation that she completed courses in ethics and pain management.

State: Virginia


Date: April 2016


Specialty: Physician Assistant, Family Medicine, Internal Medicine


Symptom: N/A


Diagnosis: N/A


Medical Error: Accidental Medication Error, Failure of communication with patient or patient relations


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



North Carolina – Obstetrics – Failure To Recognize Preeclampsia In Early Preterm



The Board was notified of a professional liability payment made on 05/06/2015.

The Board expressed concern that an obstetrician was insufficiently aware of preeclampsia in a patient.  The Board expressed concern that the obstetrician’s conduct was below the minimum standard of competence given failure to manage a Category II (indeterminate) fetal heart tracing on the patient by continued observation.  The obstetrician obtained a biophysical profile on the patient in response to the Category II fetal heart tracing, but the study was insufficient to assure fetal well-being.  The Board acknowledged that the patient’s pregnancy was early preterm making the diagnosis of pre-eclampsia difficult, but remained concerned that the management of the patient fell below the standard of care.

The Board ordered the obstetrician to complete the ACOG course on Fetal Heart Rate Monitoring and complete the ACOG Task Force Publication on Hypertensive Disorders in Pregnancy Status.

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

State: North Carolina


Date: April 2016


Specialty: Obstetrics


Symptom: N/A


Diagnosis: Preeclampsia


Medical Error: Diagnostic error


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Radiology – Incorrect Interpretation Of CT Scan In A Patient With Groin and Abdominal Pain



On 3/5/2013, a patient presented to the emergency department with pain in his groin and in the left lower quadrant of his abdomen.

Following the patient’s presentation to the emergency department, a computerized tomography scan (CT scan) of the patient’s abdomen and pelvis was ordered.

A radiologist interpreted the patient’s 3/5/2013 CT scan.  He failed to correctly interpret the patient’s scan and failed to report one or more abnormalities evident in the patient’s scan including: a large mass in the patient’s lower abdomen, discoid atelectasis and fibrosis at the patient’s lung bases, significant coronary artery calcification, severe aortoiliac atherosclerotic disease, and fluid in the patient’s pelvis.

In August 2013, a follow-up CT scan was performed that revealed a malignant mass in the patient’s lower abdomen.

The Medical Board of Florida issued a letter of concern against the radiologist’s license.  The Medical Board of Florida ordered that the radiologist pay a fine of $7,000 against his license and pay reimbursement costs for the case at a minimum of $3,396.68 and not to exceed $5,396.68.  The Medical Board of Florida also ordered that the radiologist complete ten hours of continuing medical education in the diagnosis of abdominal cancer and complete five hours of continuing medical education in “risk management.”

State: Florida


Date: April 2016


Specialty: Radiology


Symptom: Pelvic/Groin Pain, Abdominal Pain


Diagnosis: Cancer


Medical Error: False negative


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



North Carolina – Internal Medicine – A Patient Treated For Hyperkalemia With Subsequent Hypokalemia



The Board was notified of a professional liability payment made on 06/15/2015.

A patient presented to the hospital for treatment of sepsis secondary to septic arthritis and associated with bacteremia.  The patient also suffered from a urinary tract infection, heart murmur, and lower back pain.  She was immunocompromised from daily prednisone use for severe rheumatoid arthritis.

When the patient was admitted to the hospital, her potassium level was elevated.  Another physician ordered medications to lower the patient’s potassium level.  The medications had the desired effect.  When a hospitalist assumed care, the patient’s potassium level was within the normal range.  The hospitalist cared for the patient over the next six days.

The following day, while under the care of another physician, the patient developed a cardiac arrhythmia, and her potassium level was found to be low.  The patient died from a cardiac arrhythmia, which may have been caused by the patient’s potassium deficiency.

The hospitalist acknowledged that he should have but did not monitor the patient’s potassium level during his care of her.

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: April 2016


Specialty: Internal Medicine


Symptom: N/A


Diagnosis: Cardiac Arrhythmia, Septic Arthritis


Medical Error: Failure to properly monitor patient


Significant Outcome: Death


Case Rating: 2


Link to Original Case File: Download PDF



Virginia – Internal Medicine – Hemodynamically Stable Patient With Hemoglobin Of 4.6



On 6/30/2015, a 57-year-old female had blood work, which revealed that her hemoglobin was at 4.6 gm/dL.  According to the internist who had ordered the blood work, his office telephoned the patient several times regarding the low hemoglobin level.  When the patient did not answer her phone, the internist’s nurse left a message for the patient.  The internist called in a prescription for iron supplements.  The internist said that in a follow-up conversation with the patient and her husband, the patient informed him that she had been staying at a hotel and did not receive the message from his office.

On the morning of 7/7/2015, the patient replied to the previously left messages from the internist’s office.  The patient came to the office later that afternoon, and the internist evaluated her and found her hemodynamically stable.  The internist sent the patient to the lab next door to his office for a type and crossmatch in order to prepare for a transfusion.

The lab report indicated that the patient’s hemoglobin level was critically low at 2.9 gm/dL.  Upon receiving the results, the internist immediately contacted the lab but was not able to reach the technician.  The patient was advised by lab personnel to report to the emergency department.  The patient was admitted to the hospital for immediate treatment and was discharged on 7/9/2015.

The Board noted that the internist did not immediately refer the patient to a gastroenterologist despite a history of gastroesophageal reflux disease and dysphagia in the setting of severe anemia.

The internist stated that should a similar situation arise where the patient is unreachable by phone and is experiencing a medical emergency, he plans to contact the Sheriff’s office to have a deputy go to the patient’s home.

The Board ordered the internist to complete a continuing medical education course on the subject of anemia.

State: Virginia


Date: April 2016


Specialty: Internal Medicine, Family Medicine


Symptom: GI Symptoms (GERD, Abdominal Distention, Dysphagia)


Diagnosis: Hematological Disease


Medical Error: Failure of communication with patient or patient relations, Improper treatment


Significant Outcome: N/A


Case Rating: 5


Link to Original Case File: Download PDF



Virginia – Orthopedic Surgery – Multiple Pain Prescriptions For Ankle Injury



From 3/14/2011 to 6/19/2014, an orthopedic surgeon treated a 57-year-old female for an ankle fracture and subsequent chronic pain.  Between 5/6/2013 and 6/19/2014, he prescribed the patient fifty-one prescriptions for oxycodone/acetaminophen absent an evaluation or physical examination during this time period.

The orthopedic surgeon failed to obtain Prescription Monitoring Program reports during his care and treatment of the patient.  He failed to regularly conduct or fully document the results of random urine drug screens.

The orthopedic surgeon said that the patient had been well known to the office and had been a patient for over twelve years.  He had performed five surgeries on the patient.  The patient had come to his office frequently and for so long that he had the impression he was seeing her regularly, even though from May 2013 to June 2014, he had not seen the patient.

The orthopedic surgeon noted that the patient had never demonstrated any aberrant behaviors.  In a review of the patient’s chart, the orthopedic surgeon noted that she had missed two appointments, but at the time the office did not have a policy in place to address missed appointments and the chart did not reflect that information in a clear way.  Since this incident, the office policy was changed to correct both of these issues.

The orthopedic surgeon made changes to his practice.  He required patients to be seen every ninety days.  If a patient missed an appointment, the patient was notified that he must be seen before receiving a refill.  His practice started to coordinate with chronic pain management and addiction providers in their building.

Given that some of his patients injure themselves due to substance abuse issues that lead to repeated falls, the orthopedic surgeon had met with treatment providers at the intensive substance abuse treatment program at his hospital in an effort to improve the referral process for substance abuse treatment.

The orthopedic surgeon submitted documentation that he had completed the Boston University School of Medicine, SCOPE of Pain: Safe and Competent Opioid Prescribing Education; the University of Nebraska Medical Center’s Risk Assessment, Patient Selection, and Treatment Planning; and the Case Western Reserve University, School of Medicine, Intensive Course in Controlled Substance Prescribing.

The Board issued the orthopedic surgeon a reprimand.

State: Virginia


Date: April 2016


Specialty: Orthopedic Surgery


Symptom: Extremity Pain


Diagnosis: Musculoskeletal Disease


Medical Error: Improper medication management, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Gynecology – Abnormal Pap Smear While Pregnant Shows A High Grade Squamous Intraepithelial Lesion



On 12/17/2007, a patient began prenatal care in a gynecologist’s office.  She underwent a Pap smear that day.

On 12/28/2007, the report of the results came out showing a high grade squamous intraepithelial lesion.

This result is noted in the record on the patient’s next visit on 1/6/2008 and was presumably communicated to her as a colposcopy was scheduled for 1/11/2008.

On 1/11/2008, the colposcopy was performed by the gynecologist.  He described white epithelium at the squamocolumnar junction.

He performed a biopsy, which was reported out on 1/14/2008 as “…squamous epithelium consistent with at least carcinoma-in-situ.  The possibility of microinvasion cannot be entirely excluded.”  There was no further mention of this result in the prenatal record, although the gynecologist was aware of it, because insurance authorization for cervical excision was requested on 1/16/2008 and approved the same day.  The gynecologist saw the patient on 1/16/2008 and the only notation in the prenatal record was “doing well.”

The gynecologist saw the patient for at least four more prenatal visits after 1/16/2008.  He saw her for a post-partum visit on 8/5/2008.  There is no record of a physical examination on that date or of a repeat Pap smear being done.  There is no mention at all of the patient’s cervical pathology in any of those visits.

On 9/10/2008, the gynecologist next saw the patient for a pre-operative visit prior to a tubal ligation.  “Abnormal Pap smear” is listed as an active problem in the record of that visit, and yet the problem remained unaddressed.

The next visit was on 1/6/2011.  On the record of this visit, the active problem list no longer mentions the abnormal Pap smear.  Instead, the diagnostic history specifically says “no abnormal Pap smear.”  The physical examination at that visit includes no description of the appearance of the cervix.  The patient then developed irregular vaginal bleeding later that year.

Later in 2011, she saw another physician who biopsied her cervix and diagnosed cervical cancer at an advanced stage.

The Board judged the gynecologist’s conduct as having fallen below the minimum level of competence given failure to follow up on the severely abnormal cervical biopsy results during and after her pregnancy.

The Board issued a public reprimand with the stipulation for the gynecologist to take the Medical Record Keeping Course offered by the Physician Assessment and Clinical Education Program at the University of California, San Diego School of Medicine.

State: California


Date: April 2016


Specialty: Gynecology


Symptom: Bleeding


Diagnosis: Gynecological (Endometrial, Ovarian, Cervical) Cancer


Medical Error: Failure to follow up


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Pediatrics – Premature Baby Tests Positive For Methamphetamine And Fails To Thrive



On 9/23/2011, the patient, a baby boy, was born prematurely at a hospital. He was estimated to be approximately 32 weeks gestation at birth, weighing 2 pounds 15 ounces.  Both he and his mother tested positive for methamphetamine.

The patient remained in the neonatal intensive care unit (NICU) for five weeks and was discharged on 10/30/2011.  The patient’s weight at discharge was 5 pounds, 10 ounces. The discharge instructions to his mother directed her to follow up with several resources and appointments for the patient, including the following:

1) Central Valley Regional Center, Children’s High-Risk Infant Follow Up program,

2) a local ophthalmologist,

3) the Public Health Nurse, and

4) a pediatrician.

On 11/2/2011, the patient’s mother brought him for his appointment with the pediatrician.  The records of this appointment reflected a normal physical examination. The pediatrician recorded that the patient was 6 pounds, 9 ounces; his height was 71.5 inches; and no head circumference was recorded.

The past medical history was stated as “premature.” The assessment was “medical exam routine.” The follow-up plan was for the patient to return in three months, 2/7/2012, for a California Department of Public Health Physical (CDHP) examination.

The pediatrician’s notes did not reference the NICU discharge summary, and there was only a partial copy of the discharge summary in the chart.

Although the pediatrician did not begin a growth chart for the patient at the 11/2/2011 visit, the patient’s weight and age place him approximately at the 30th percentile for growth at this visit.  This notation is presumably a typographical error in the record.

On 2/7/2012, the patient’s mother brought him back to the pediatrician for the next regularly scheduled appointment. At this appointment, the patient’s weight was 9 pounds 3 ounces, his height was 20.5 inches, and his head circumference was 38 centimeters.

The pediatrician did not chart a physical examination.  The pediatrician listed his assessment at this appointment as “Routine Infant,” and his plan included anticipatory guidance, immunizations, and follow-up in two months.  The pediatrician did not begin a growth chart for the patient at the 2/7/2012 visit. If the pediatrician had been charting the patient’s growth, the chart would have shown that his recorded weight and age place the patient below the first percentile for growth at the 2/7/2012 visit.  The patient’s mother did not bring him back for his next appointment, which should have been in March 2012.

Instead, she returned on 6/28/2012 with a presenting complaint that the patient had congestion and dry skin.  At this appointment, the pediatrician recorded that the patient weighed 10 pounds and 13 ounces, had a height of 22 inches, and had a temperature of 99.7 degrees Fahrenheit.

If a growth chart had been maintained, it would have shown that the patient had fallen even further below the first percentile for growth at this visit. Upon examination, the pediatrician found “cracking of the skin around the ear,” “Nose; congested for 2 days,” and “Chest and Lungs; Cough and congestion X 2 days, tight cough. Exp. Phase of resp is increased with respect to the inspiratory phase of respiration, Rx with nebulized Xoponex.”

A respiratory rate or oxygen saturation was not documented. Under assessment, the pediatrician found the patient had impetigo, asthma, acute bronchitis, iron deficiency anemia, and seborrheic dermatitis.

He prescribed an antibiotic ointment twice a day, a Hydrocortisone 1% ointment, a ten-day course of amoxicillin, an iron supplement, and a nebulizer. The pediatrician directed the patient’s mother to return if he had no improvement, and otherwise to return in two months for follow-up of his asthma.

On 8/9/2012, the patient’s mother called 911 to report that the patient was not breathing. An ambulance arrived and transported the patient to the hospital where he was pronounced dead. Upon examination, the patient’s body had several areas of skin breakdown, and he was found to be severely malnourished. At the time of his death, the patient’s weight was 7 pounds 6 ounces.

The Board judged the pediatrician’s conduct to have fallen below the minimum level of competence given failure to have the infant return in one week after his first pediatrician visit, failure to elucidate the extent of his prematurity in the past medical history, failure to reference the full discharge summary from the NICU, failure to make a growth chart for the patient, and failure to address the patient’s failure to thrive.

The Board issued a public reprimand with stipulations to complete a medical record keeping course and enroll in a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California – San Deigo School of Medicine.

State: California


Date: April 2016


Specialty: Pediatrics


Symptom: Weight Loss, Cough, Dermatological Abnormality


Diagnosis: N/A


Medical Error: Failure to properly monitor patient, Diagnostic error, Improper treatment, Lack of proper documentation


Significant Outcome: Death


Case Rating: 2


Link to Original Case File: Download PDF



North Carolina – Ophthalmology – Loss Of Vision Secondary To Glaucoma



In July 2015, the Board received a complaint.

In March 2005, a patient presented with blurry vision.  The patient was seen frequently by an ophthalmologist over the subsequent nine years.  The patient had cataract surgery on her right eye in March 2007.  In 2013, the patient developed elevated intraocular pressure and was treated for glaucoma, but had progressive loss of vision in both of her eyes, including severe loss of vision in her right eye.

As a result of the complaint, the Board opened an investigation.  The Board obtained the patient’s records and sent them to a qualified independent medical expert for review.  The independent medical expert judged the ophthalmologist’s conduct to be below the minimum standard of competence given failure to treat the patient’s high intraocular pressure level within a reasonable amount of time and that the ophthalmologist’s medical records were incomplete.

The Board ordered the ophthalmologist to be reprimanded.  The incident was reported to the Federation of State Medical Boards and to the National Practitioner Data Bank.

State: North Carolina


Date: April 2016


Specialty: Ophthalmology


Symptom: Vision Problems


Diagnosis: Ocular Disease


Medical Error: Improper treatment, Lack of proper documentation


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 1


Link to Original Case File: Download PDF



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