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The Board was notified of a professional liability payment on 08/27/2015.

A 2003 ultrasound report indicated that a patient had a possible 6 cm solid mass on his right kidney.  The written report from the radiologist recommended further evaluation utilizing a CT scan of the kidneys, and specifically noted that “these findings were discussed with the referring physician.”  No follow-up evaluation was obtained.  Several years later, the patient was diagnosed with renal cell cancer.

The Board expressed concern that the family practitioner’s conduct fell below the minimum standard of competence given that he failed to follow up properly on the radiological study.

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: May 2016

Specialty: Family Medicine, Internal Medicine

Symptom: Mass (Breast Mass, Lump, etc.)

Diagnosis: Cancer

Medical Error: Failure to follow up

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

On 4/23/2009, the patient saw a gynecologist to establish herself as a patient for gynecological care.  During this initial visit, the patient reported lower abdominal pain, shifting from left to right over the previous 2 weeks.  A pelvic ultrasound performed 3 weeks before the visit showed a thickened endometrium of 1.2 cm, a small anterior fibroid, and a minimally complex follicle in the right ovary, 1.8 cm.  The gynecologist scheduled the patient for the following surgical procedures: a dilation and curettage, hysteroscopy, laparoscopy, and possible removal of fallopian tube and ovary. The gynecologist did not include any notation in the chart that he discussed alternatives to the surgery to treat the patient, such as repeat ultrasound, endometrial biopsy, or blood work monitoring.  This failure to document that alternatives to surgery were offering or discussed constituted a simple departure from the standard of care.

The patient completed standard consent forms for these procedures, which did not make reference to any unique risk factors due to her specific physical condition.  The patient was morbidly obese when she saw the gynecologist on 4/23/2009. She weighed 321 pounds and had undergone 2 previous abdominal surgeries, an appendectomy, and a cholecystectomy.  Obesity causes additional risks for abdominal surgery, including but not limited to, an increased risk of infection, pneumonia, pulmonary embolism, or other thromboembolic complications, as well as reducing the ability to successfully enter the abdomen and complete the procedure.  Previous abdominal surgeries increase the risk of adhesions, particularly of the bowel to the anterior abdominal wall, which can increase the risk of bowel perforation and its complications. The gynecologist’s failure to provide informed consent on the specific risks of the proposed surgeries to the patient, given her size and previous surgeries, constituted a simple departure from the standard of care.

On 5/5/2009, the gynecologist performed surgery on the patient.  During the surgery, the gynecologist noted that the patient had adhesions of the omentum and bowel to the anterior abdominal wall with only a small window on the right side extending to the pelvis.  The uterus was retroverted and the left tube, ovary, and uterus could not be visualized because of adhesions. The gynecologist removed the right tube and ovary and performed a dilation and curettage and hysteroscopy.  The gynecologist was unable to visualize the tubal ostia. Due to the patient’s large size and adhesions discovered during surgery, the surgery was prolonged. Although it would not be discovered until 6 days later, during the corrective surgery, the gynecologist had perforated the patient’s uterus during the 5/5/2009 surgery and failed to recognize that he had done so.  Although uterine perforation is a known complication of the surgical procedure, the gynecologist’s failure to recognize the complication was poor practice and constituted a simple departure from the standard of care.

On 5/6/2009, the gynecologist received a telephone call from the pathology department indicating that the results of the patient’s pathology showed serous cystadenoma with focal serous adhesions.  The right tube showed hydrosalpinx. The endometrium revealed fragments of inactive atrophic endometrium and fragments of myometrium and finally mature fibroadipose tissues. These findings were suggestive of uterine perforation.  The gynecologist stated that he called the patient on 5/6/2009 to inform her of this finding and set up an office appointment, but that the patient reported she was feeling fine and would keep her appointment of 5/8/2009. The gynecologist did not chart that phone call in the medical record.  The gynecologist did not include a notation in the patient’s chart that he had the telephone call with the patient to inform her of the pathologist’s findings. On 5/8/2009, the gynecologist saw the patient in his office with complaints of bleeding, but no report of fever or abdominal pain other than around the incision.  The gynecologist charted that he performed bimanual examination, which was negative. The gynecologist stated that he offered a CT scan during the appointment on 5/8/2009, which the patient declined. The gynecologist’s failure to place a note in the patient’s medical record indicating that he had a telephone call with her on 5/6/2009 to inform her of the pathologist report, or that he offered a CT scan on 5/8/2009, constituted a simple departure from the standard of care.

On 5/9/2009, the patient called to report continued bleeding.  A group physician took the call on behalf of the gynecologist and directed the patient to report any serious pain, hemorrhage, or fever, but otherwise to follow-up with the gynecologist for an appointment in 2 days.

Two days later, on 5/11/2009, the patient kept her appointment with the gynecologist.  At that appointment, the patient’s condition had deteriorated. The gynecologist diagnosed her with uterine perforation and gastritis and sent her directly to the hospital.  At the hospital, the patient underwent immediate surgery revealing a rectal perforation and multiple pockets of infection throughout the abdomen. The patient had corrective surgery including colostomy.  Postoperatively, the patient had a difficult hospital course, including pulmonary insufficiency, pneumonia, sepsis due to E. Coli, transfusion, and wound care complications. The patient required subsequent, additional corrective surgery.

The Medical Board of California judged that the gynecologist’s conduct departed from the standard of care because he failed to provide specific informed consent, chart that he had advised the patient of surgical alternatives, recognize that he perforated the uterus, and chart the 5/6/2009 telephone call and 5/8/209 offer of a CT scan.

For this case and others, the Medical Board of California ordered the gynecologist to surrender his license.

State: California

Date: May 2016

Specialty: Gynecology

Symptom: Abdominal Pain, Bleeding

Diagnosis: Post-operative/Operative Complication, Sepsis

Medical Error: Procedural error, Delay in diagnosis, Failure of communication with patient or patient relations, Lack of proper documentation

Significant Outcome: Hospital Bounce Back

Case Rating: 3

Link to Original Case File: Download PDF

On 3/1/2014, a patient arrived at the hospital by air ambulance.  The patient presented with intermittent respiratory difficulties, and his throat was constricted.  The patient could only open his mouth 1 cm. CT scans of the patient’s neck showed a 6.8 x 4.8 cm abscess at the right mandibular angle.  The CT scans indicated that there were severe edema and tracheal narrowing. The patient complained of respiratory difficulty when lying down.  The patient was prepped for the surgical drainage of the neck abscess. The anesthesiologist assigned to the procedure noted that he performed an assessment at 4:15 p.m.  The patient entered the operating room at 4:23 p.m.

The anesthesiologist documented a compromised airway and noted a CT scan that showed a left shift of pharyngeal tissues.  The anesthesiologist noted the need to perform awake intubation if the airway was compromised. The anesthesiologist administered IV sedation, providing 1 mg x 2 of midazolam and 100 mcg of fentanyl, to the patient.  The anesthesiologist had the patient lay down in a supine position. At 4:30 p.m., the anesthesiologist administered general anesthesia consisting of oxygen and sevoflurane. He then provided the patient with a dose of 80 mg of succinylcholine.

The anesthesiologist attempted to obtain endotracheal intubation while the patient was sedated.  The anesthesiologist repeatedly used a trachlight, also known as a light wand, in an attempt to transilluminate the soft tissues of the patient’s neck for placement of the endotracheal tube.  The anesthesiologist attempted to use different pieces of equipment as he repeatedly tried to intubate the patient. Additional airway equipment was not immediately available and had to be brought to the operating room.  The anesthesiologist did not attempt to wake the patient to try an awake intubation. The anesthesiologist’s multiple attempts at intubation were unsuccessful, and surgical intervention was required. At 5:10 p.m., a surgeon performed a tracheostomy.  The patient’s preoperative note was written at 5:42 p.m., and he signed the note at 5:53 p.m.

The Medical Board of California judged that the anesthesiologist’s conduct departed from the standard of care because he failed to appreciate the degree of airway difficulty in preparation for the administration of general anesthesia despite documenting swelling, a restricted mouth opening, a CT scan showing severe edema and tracheal narrowing, and a complaint of respiratory difficulty when lying down.  The anesthesiologist also failed to prepare for and manage a known difficult airway by inadequately documenting the case before attempts at intubation began, failing to use proper equipment, and failing to have the necessary intubation equipment available in case initial intubation attempts were unsuccessful.

The Medical Board of California placed the anesthesiologist on probation for 4 years and ordered him to complete a medical record-keeping course, education course for at least 20 hours for the first year of probation, and clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California

Date: May 2016

Specialty: Anesthesiology

Symptom: Shortness of Breath, Swelling

Diagnosis: Ear, Nose, or Throat Disease

Medical Error: Procedural error, Underestimation of likelihood or severity, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 3

Link to Original Case File: Download PDF

On 3/5/2014, a 55-year-old, 5’3”, and 109 kg (BMI 44.2) female was scheduled for a left arm arteriovenous fistulogram and possible revision of her dialysis fistula to prevent re-bleeding.  An anesthesiologist assumed the anesthesia care of this patient prior to the start of surgery. The patient suffered from a history of end-stage renal disease, had been on dialysis for 15 years, suffered from obesity, asthma, rheumatoid arthritis, diabetes, and sleep apnea, and used home oxygen at night.  The patient also had a history of atrial fibrillation, cardiomyopathy with an ejection fraction of 28%, moderate-severe aortic insufficiency and stenosis, coronary artery disease with stents placed in 2013, and chronic congestive heart failure. The patient had begun to experience bleeding from the AV fistula five days prior to admission.

In his pre-operative note, the anesthesiologist documented that the patient was 100 kg, had chronic renal failure, had coronary disease with stents, had a left bundle branch block, and suffered from occasional gastric reflux.  The anesthesiologist did not note that the patient suffered from sleep apnea, cardiomyopathy, chronic heart failure, atrial fibrillation, aortic valve disease, or diabetes. The anesthesiologist’s note did not document the last time the patient had received dialysis.   The anesthesiologist’s pre-operative note showed that he saw the patient at 3:40 p.m. Anesthesia start time was noted at 3:49 p.m. The note was filed at 4:24 p.m. and signed at 5:18 p.m.

The patient’s vital signs were charted at 3:55 p.m. and were listed as followed: blood pressure of 160/70, pulse of 78/min sinus rhythm, respiratory rate of 20, and 100% oxygen saturation on the 10 L mask.  At 3:50 p.m., the anesthesiologist administered 1 mg of midazolam and 50 mcg of fentanyl and began a propofol infusion. The dose of propofol was not charted. At 4:05 p.m., the anesthesiologist administered 1 mg of midazolam and 50 mcg of fentanyl.  Just prior to the surgeon injecting local anesthetic, the anesthesiologist administered 30 mg propofol, but did not chart the dosage. The anesthesiologist attached the pulse oximeter trace distal to the blood pressure cuff on the same limb. The anesthesiologist also had the patient wear a non-rebreathing oxygen mask.  At 4:20 p.m., the surgery began. During the surgery, the surgeon noticed the patient’s blood had turned dark and that the patient was cyanotic. At 4:28 p.m., it was noted that the surgeon could not feel a pulse, and a code was called.

The anesthesiologist provided 0.4 mg of atropine and 1 mg of epinephrine.  The patient’s blood pressure was 90/40. The anesthesiologist provided a second dose of epinephrine.  The code blue team note began at 4:28 p.m. The patient was intubated at 4:29 p.m. Compressions began at 4:31 p.m.  The code blue team provided one amp of bicarbonate. The patient’s pulse was obtained. Then the patient’s pulse could not be felt a second time.  A second code was called at 4:50 p.m. Further work was done of the patient. The patient was transferred to the ICU, where she remained unresponsive.  She was converted to comfort care and expired that evening.

The Medical Board of California judged that the anesthesiologist departed from the standard of care because he administered doses of sedation to an obese patient with a history of sleep apnea, who was sensitive to the effects of respiratory depressants.  The anesthesiologist was not vigilant during the time that she developed hypoventilation and obstruction. Prior to the surgeon realizing that the patient had no pulse, the anesthesiologist failed to promptly and adequately rescue her.  Once the code was called, the anesthesiologist failed to take an active role in the resuscitation of the patient. The anesthesiologist also failed to recognize and treat respiratory depression, bradycardia, and pulseless arrest. The anesthesiologist’s failure to recognize the patient’s condition led to intubation and airway rescue being delayed, only occurring after the code team had arrived.  The pre-operative note was written and submitted after the patient received IV sedation and signed after she coded a second time. The anesthesiologist did not create a summary note of the code blue events that occurred in the operating room or of the patient’s subsequent death. The anesthesiologist failed to document this intraoperative sentinel event.

The Medical Board of California placed the anesthesiologist on probation for 4 years and ordered him to complete a medical record-keeping course, an education course for at least 20 hours for the first year of probation, and a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California

Date: May 2016

Specialty: Anesthesiology

Symptom: Bleeding

Diagnosis: Cardiovascular Disease, Asthma, Pulmonary Disease

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

Significant Outcome: Death

Case Rating: 4

Link to Original Case File: Download PDF

On 4/10/2014, a 74-year-old male was scheduled for surgery to the right lobe of his thyroid and possibly a total thyroidectomy because of a right thyroid mass.  An anesthesiologist, who was assigned to this procedure, created a pre-operative note at 7:03 a.m. He noted that the patient had a history of cardiac murmur, prostate cancer, and macular degeneration.  The anesthesiologist noted that the patient had a history of previous right carotid surgery under general anesthesia without problems. He performed a physical exam that showed the patient had an unremarkable airway.  The anesthesiologist did not examine the patient’s heart or lungs, and he did not evaluate the patient’s neck for tracheal deviation. The anesthesiologist informed the patient of a risk of nausea.

The anesthesiologist began anesthesia at 7:31 a.m.  The anesthesiologist was proctored by another anesthesiology, who observed the anesthesiologist during the surgery.  The patient’s initial blood pressure was charted at 140/70, with a pulse of 75, and oxygen saturation of 99%. The anesthesiologist induced general anesthesia by administering 40 mg of lidocaine, 1 mg x2 of midazolam, 50 mg x2 of propofol, and 50 mcg x2 of fentanyl.  The anesthesiologist then administered 5 mg + 25 mg of rocuronium and easily intubated the patient with an 8.0 NIM (neural integrity monitor) endotracheal tube, and he positioned the patient in a reverse Trendelenburg (head up) position in preparation for surgery. Within 5 minutes of induction of anesthesia, charted blood pressure was 110/60 and a pulse of 75.  At 7:45 a.m., the blood pressure was charted at 80/50 and a pulse of 70. At 7:50 a.m., the anesthesiologist first administered 5 mg ephedrine and then an additional 10 mg of ephedrine. At 7:50 a.m., the patient’s blood pressure was charted at 90/50 with a pulse of 70. Surgery began at 7:56 p.m.

The proctoring anesthesiologist took photos of the monitor screen between 7:39 a.m. and 7:59 a.m. that was recording the patient’s signs as the anesthesiologist prepared him for surgery.  At 7:39 a.m., the machine showed a blood pressure of 109/53 with a pulse of 74. At 7:44 a.m., the machine showed a blood pressure of 80/49 with a pulse of 61. Every minute thereafter, from 7:45 a.m. to 7:54 a.m., the machine showed blood pressures at approximately 70/44 with a pulse of 62-63.  At 7:56 a.m., the blood pressure on the monitor was 80/52 with a pulse of 68-70. At 7:59 a.m., the blood pressure was 95/52. The anesthesiologist’s chart did not reflect the ten minute period where the patient’s systolic blood pressure was at 70.

Anesthesia was maintained with oxygen, sevoflurane, and incremental doses of rocuronium.  Neither sevoflurane or rocuronium was circled on the chart. Subsequent intraoperative blood pressure were charted 90 to 95/50 with pulses between 70 to 75 per minute.  The anesthesiologist charted that end tidal carbon dioxide varied from 30-55, and oxygen saturation remained at 99% throughout. Surgery ended at 8:58 a.m. The surgical note indicated a right hemithyroidectomy was performed.  The anesthesiologist extubated the patient, and he was brought to recovery. In recovery, the anesthesiologist charted that the patient’s vital signs were blood pressure of 161/84, pulse of 86, respiratory rate of 14, and oxygen saturation of 97%.  Anesthesia end time was charted at 9:11 a.m.

The Medical Board of California judged that the anesthesiologist departed from the standard of care because he did not record a heart or lung exam in his per-operative note, evaluate the patient’s neck for tracheal deviation due to the thyroid mass or prior carotid surgery, and make the patient aware of the possible risks of stroke, hoarseness, or vocal paralysis.  The anesthesiologist also paralyzed the patient with rocuronium while using a NIM endotracheal tube rather than using a short acting muscle relaxant, which can interfere with monitoring recurrent laryngeal nerve function. He failed to accurately chart the true period of time the patient was hypotensive, and he prematurely positioned the patient in a heads up position before surgery.

The Medical Board of California placed the anesthesiologist on probation for 4 years and ordered him to complete a medical record-keeping course, an education course for at least 20 hours for the first year of probation, and a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California

Date: May 2016

Specialty: Anesthesiology

Symptom: N/A

Diagnosis: N/A

Medical Error: Failure to examine or evaluate patient properly, Failure of communication with patient or patient relations, Improper medication management, Lack of proper documentation, Procedural error

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

On 4/17/2014, a 79-year-old patient was scheduled for placement of an epicardial lead on the surface of the left ventricle by a cardiothoracic surgeon.  An anesthesiologist assigned to the procedure documented seeing the patient on 4/17/2014 at 4:05 p.m. in his per-operative note. The anesthesiologist submitted his note at 5 p.m. and signed his noted 5:06 p.m.  He indicated that the patient had medical problems, including atrial fibrillation, arthritis, gout, cardiomyopathy, skin cancer, peripheral artery disease, congestive heart failure, and acute renal failure. The anesthesiologist did not record performing a heart or lung exam and the patient’s last solid food intake or risk for aspiration.  The anesthesiologist also did not document the patient’s most recent lab work prior to surgery or comment regarding the lab values from the day of surgery.

The anesthesiologist did not place a transesophageal echo probe, and he did not place a biventricular pacer.  The anesthesiologist did not check arterial blood gas or electrolytes during surgery. During surgery, the patient’s blood pressure dropped, as a large left pleural effusion was evacuated, to a systolic of 50.  The anesthesiologist provided multiple doses of phenylephrine, ephedrine, and epinephrine. The anesthesiologist increased the dobutamine infusion. The epicardial lead was placed, and the surgeon closed the patient’s chest with resultant hypotension.  Surgery ended at 5:11 p.m.

The Medical Board of California judged that the anesthesiologist departed from the standard of care because he did not perform a heart or lung exam, did not document the patient’s last solid food intake or aspiration risk, and did not document the patient’s most recent lab work prior to surgery or comment on the patient being hyponatremic at a serum sodium level of 128 mEq/L, which increases the risk for severe arrhythmias and hypotension.  The anesthesiologist also did not utilize additional methods or techniques to manage intraoperative hypotension or ask for assistance from the proctoring cardiac trained anesthesiologist.

The Medical Board of California placed the anesthesiologist on probation for 4 years and ordered him to complete a medical record-keeping course, an education course for at least 20 hours for the first year of probation, and a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California

Date: May 2016

Specialty: Anesthesiology

Symptom: N/A

Diagnosis: Cardiovascular Disease, Cardiac Arrhythmia, Heart Failure

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

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

On 08/28/2015, while serving as the psychiatrist on call at a mental health facility, the psychiatrist was notified by the nursing staff that a patient, who had a documented history of multiple suicide attempts, reported taking approximately 100 risperidone and/or olanzapine pills she had been hoarding.  The psychiatrist told the nursing staff that he would not examine the patient; instead, he gave telephonic orders to perform checks of the patient every 15 minutes, vital signs every hour, and remove all items from the room that could pose a danger to the patient.

After several calls from the nursing staff and the nursing supervisor requesting that the psychiatrist examine the patient and informing him that the patient had refused the hourly vital sign checks, the psychiatrist arrived on the ward approximately two hours after he was notified of the reported overdose.  Instead of examining the patient, he reported that he observed her from the doorway of her room and then left the ward.  The psychiatrist did not give any additional orders for the care or monitoring of the patient and did not make any entries into the patient’s medical record about his observations.

The psychiatrist acknowledged that he made an error in judgment in not immediately examining the patient and that this episode is not indicative of the way he practices medicine.  He stated that when he went to the ward, he determined that the patient’s vital signs were stable, she was sitting up in bed awake, and he did not want to reinforce her behavior by entering her room and engaging.

The Board issued the psychiatrist a reprimand.

State: Virginia

Date: May 2016

Specialty: Psychiatry

Symptom: Psychiatric Symptoms

Diagnosis: Psychiatric Disorder

Medical Error: Failure to examine or evaluate patient properly

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

In March 2015, the Board was notified of a professional liability payment.

In October 2009, a 64-year-old female presented to the emergency department for admission due to weakness and difficulty walking.  The patient had a known past medical history of moderate-severe aortic stenosis, congestive heart failure, diabetes, and chronic low back pain.  At the time of this emergency department visit, the patient also presented with a urinary tract infection.  The patient was treated empirically with ceftriaxone for a presumptive urinary tract infection.  After the patient improved, she was discharged with oral levofloxacin to cover both a urinary tract infection and the coagulase-negative staphylococcus bacteremia.

On 12/21/2009, the patient again presented to the emergency department with worsening back pain as well as nausea, vomiting, and a low-grade fever.  All work-up regarding the patient’s fever were negative, her symptoms improved with pain medications and physical therapy, and the patient was discharged.

On 01/17/2010, the patient again presented to the emergency department experiencing falls and confusion.  The patient was started on ceftriaxone for coverage for empiric coverage for a urinary tract infection.  By the next day, the urine cultures were negative and blood cultures were positive for staphylococcus epidermidis.  At this point, a cross-covering physician added vancomycin to the patient’s treatment.  The patient’s condition deteriorated from this point forward, and ultimately, because of the patient’s poor prognosis, the patient’s family withdrew care and she 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 hospitalist’s conduct to be below the minimum standard of competence given failure to recognize two positive blood cultures drawn at separate times with the same organism as a likely infective agent.

The Board ordered the hospitalist to be reprimanded.

State: North Carolina

Date: May 2016

Specialty: Emergency Medicine, Internal Medicine

Symptom: Back Pain, Confusion, Fever, Nausea Or Vomiting, Weakness/Fatigue

Diagnosis: Sepsis

Medical Error: Improper treatment, Underestimation of likelihood or severity

Significant Outcome: Death

Case Rating: 2

Link to Original Case File: Download PDF

In 2006, an internist diagnosed a fourth-year medical student with attention deficit hyperactivity disorder and prescribed her Adderall.  She reported that she was having problems focusing and paying attention in medical school.   The Board expressed concern there was a lack of testing and a lack of an independent, adequate work up to establish the diagnosis.

From July 2010 to September 2010, the internist treated the patient.  On 7/2/2010, the internist resumed treatment with the patient, now a physician in a fellowship program, when she returned to the Charlottesville area after a four-year absence from his practice.

During this office visit, based solely upon the patient’s representations that she had been treated for ADHD with up to 160 mg per day of Adderall by her psychiatrist in Norfolk, the internist prescribed Adderall (90 dosage units, 30 mg tid) and Adderall XR (40 dosage units, 20 mg po bid) to the patient.  Per the Board, the dosage that was prescribed is more than three times the maximum recommended dose to treat adult ADHD.

Prior to prescribing Adderall, the internist did not obtain records of testing and/or documentation from any other treatment provider and did not perform any independent work up to establish the ADHD diagnosis and/or the need for Adderall.  Throughout the course of treatment, the internist allowed the patient to self-titrate her dosages and failed to properly monitor and manage the patient’s use of Adderall when he repeatedly escalated his prescribing to coincide with the patient’s medication decisions and self-determined doses, which resulted in the prescription of 1074 dosage units of Adderall in 71 days.

Specifically, on 7/14/2010, just 12 days after receiving a 30-day prescription, the patient informed the nurse practitioner under the internist’s supervision that she had stopped taking Adderall XR because it kept her awake and that already she had taken all 90 pills of her short-acting Adderall.  Despite noting concerns in the patient’s treatment record that the patient was “taking too much Adderall,” the nurse practitioner prescribed an additional 54 dosage units of Adderall (20 mg tid) to last until the patient could see the internist.

When the internist saw the patient on 7/19/2010, he increased her dosage of Adderall from 30 mg tid to 30 mg qid.

On 7/30/2010, without documenting any reason for another change in dosage, the internist increased the patient’s Adderall dosage to 30 mg q4h (max 5 tabs in 24 hrs) while also noting that the patient’s symptoms of distractibility were “fairly stable.”

The internist prescribed another 150 dosage units of Adderall (30 mg q4h with a max of 5 tablets in 24 hours) for the patient.

On 9/9/2010, after the patient telephoned him requesting an early prescription because she had “upped” the Adderall to 1.5 tablets every four hours, the internist prescribed 210 dosage units of Adderall (30 mg q4h with a max of 5 tablets in 24 hours.

Despite the foregoing evidence that the patient was misusing or abusing her medications, the internist failed to address these concerns or refer her for substance abuse evaluation and treatment.

In a letter to the Board dated 9/14/2015, the internist stated that he recognized that the patient was taking an unusually high dose of Adderall in 2010, but he believed the treatment was effective for her.  He stated that he was concerned about drug-seeking behavior and discussed the issue with the patient, but she assured him that she sought additional medication only because she lost her medications and because it had gotten wet on at least one occasion.  (This discussion with the patient is not documented in the internist’s records.)

The internist stated “looking back,” he wished he had obtained the records of her prior treating psychiatrist and that it had been his “consistent practice to…obtain treatment records from any previous treaters who prescribed Adderall” for his patients.  He explained that he did not attempt to obtain prior treatment records for the patient because he “knew her from the time [he] treated her as a patient in 2006.”  He stated that only a few of his patients are treated with Adderall.

The internist was issued a reprimand.  He was to complete 15 hours of continuing medical education in the subject of the proper prescribing of controlled substances and recognizing the signs of abuse/misuse of prescription medication.

State: Virginia

Date: May 2016

Specialty: Internal Medicine, Family Medicine

Symptom: Psychiatric Symptoms

Diagnosis: Psychiatric Disorder

Medical Error: Improper medication management, Failure of communication with other providers, Physician concern overridden, Failure to properly monitor patient

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

On 6/25/2015, a family practitioner ordered that resuscitation efforts be stopped for a patient, that the patient be extubated, and that all medications be discontinued, even though the patient had a measurable heartbeat, blood pressure, and spontaneous respirations.

Approximately ten minutes after the family practitioner pronounced the patient deceased, the assigned registered nurse informed the family practitioner that the patient continued to have a heartbeat, measurable blood pressure, and spontaneous respirations.  Yet, the family practitioner failed to re-examine the patient, attributing signs of life to medications administered during the resuscitation.  The family practitioner then informed the family that the patient was “gone.”

Upon repeated questioning from the family as to why the family practitioner informed them that the patient was “gone” when he appeared alive to them (he was breathing on his own, and the monitor showed a heartbeat), the family practitioner did not speak to or offer any further explanation or information to the family.  Rather, the family practitioner requested that the in-house hospitalist speaks with the family.

At 6:50 p.m., the in-house hospitalist received a telephone call from the family practitioner, requesting that he speak with the patient’s family to explain why the patient’s heart still had electrical activity.  The hospitalist examined the patient and noted a palpable femoral pulse, reactive pupils, and an appropriate response to painful stimuli.

The family practitioner acknowledged that he had made an error in judgment in prematurely pronouncing the patient dead, and he hopes to learn from this experience.  He is no longer practicing emergency medicine and has been working at an urgent care clinic since 9/1/2015.  He does not intend to return to emergency medicine.  If he were to ever be in a resuscitation effort again, he stated that he would “err on the side of caution” and continue the effort until it is either successful or clearer that further efforts would be unsuccessful.

The Board issued a reprimand

State: Virginia

Date: May 2016

Specialty: Emergency Medicine, Family Medicine

Symptom: N/A

Diagnosis: N/A

Medical Error: Underestimation of likelihood or severity

Significant Outcome: N/A

Case Rating: 4

Link to Original Case File: Download PDF