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On 8/4/2013, a 66-year-old female arrived in the emergency room after falling down stairs and was seen by an ED physician.

The patient complained of neck pain and new onset right-handed numbness.  On exam, she had paracervical tenderness.

The ED physician discharged her home with a diagnosis of shoulder contusion.

Approximately 11 hours after the ED physician had discharged the patient, she was re-admitted to the hospital via ambulance complaining of being unable to move her limbs.  Imaging revealed several cervical fractures and a subluxation at C6-C7 with cord compression.  She was transferred to another facility via med flight where she underwent two separate surgeries to repair the cervical fractures, stabilize her spine, and alleviate pressure on her spinal cord.  The patient subsequently underwent four months of inpatient rehabilitation in a skilled nursing facility, followed by seven additional months of outpatient physical and occupational therapy.

In a written statement, the ED physician explained that when he first examined the patient, she complained of right-handed numbness and exhibited left-sided neck stiffness with paracervical tenderness.  He diagnosed her with a neck contusion, ordered imaging of both shoulders and elbows, but did not order any imaging of her neck “based on [his] thorough examination of the affected areas.”  The ED physician also stated that he determined imaging of the patient’s spine was not indicated and noted in the patient’s medical record that he “did not observe any signs of neurological deficit.”  The ED physician further stated that in the future, out of an abundance of caution, he would do neck imaging in similar circumstances.

The Board issued a reprimand.

State: Virginia

Date: September 2016

Specialty: Emergency Medicine

Symptom: Head/Neck Pain, Numbness

Diagnosis: Spinal Injury Or Disorder

Medical Error: Underestimation of likelihood or severity

Significant Outcome: Hospital Bounce Back, Permanent Loss Of Functional Status Or Organ

Case Rating: 3

Link to Original Case File: Download PDF

On 7/17/2011 at 11:23 a.m., a 33-year-old female presented to the emergency department with complaints of a headache with fever and was seen by an ED physician.  ED records indicated that she was seen the day before by another ED physician with a headache but no fever. Past medical history included an occasional migraine with no mention or neurological consult or CT scan.  Vital signs included a temperature of 101 F and a pulse of 140 bpm. Pain scale was 9/10. No abdominal examination was noted. The patient was treated with Demerol and Phenergan 100/25 IM at 11:45 a.m., and pain was noted as 8/10 at 12:40 p.m. without vomiting.  Dilaudid 1 mg was given at 1:00 p.m., and at 1:30 p.m., pain was noted to be 5/10. The ED physician diagnosed the patient’s fever as a viral fever but offered no advice concerning taking antipyretics for fever reduction. The patient was discharged at 1:35 p.m. with a fever of 103 F and a pulse of 130 bpm.

The next day, at 1:45 p.m., the patient returned to the emergency department with abdominal pain.  This was the fourth emergency department visit in 2 days. Subumbilical pain of a severe nature was noted along with fever, nausea, and vomiting.  Past medical history included a hysterectomy and bilateral tubal ligation, facts not included in the ED physician’s history for this patient, but noted by previous and subsequent ED physicians.  The patient was afebrile at this time with a pulse of 113 bpm, but with a significantly lower blood pressure. Pain was noted at 10/10. Laboratory studies indicated infection, and a CT scan showed a complex mass in the right lower quadrant.  Subsequent pre-operative history indicated that the patient had reported a 3-day history of lower abdominal pain associated with episodes of vomiting and fever. The surgery revealed a right tubo-ovarian abscess.

The Medical Board of California judged that the ED physician’s conduct departed from the standard of care because his final diagnosis did not follow from the patient’s history, physical, and work-up.  The ED physician concluded that the patient’s migraine and tachycardia were triggered by a viral fever. The patient reported no symptoms consistent with a viral infection, such as congestion, cough, or nausea/vomiting with diarrhea.  The patient had also presented the previous day with a headache but no fever, but it was unclear whether the ED physician knew this. The ED physician did not treat the patient’s fever with antipyretics and did not check for signs of an infectious process elsewhere.  It was not clear from the ED physician’s records, however, whether the patient complained to him concerning abdominal pain and nausea/vomiting.

The ED physician inappropriately discharged the patient with abnormal vital signs.  Before discharge from the emergency department, all significant vital sign abnormalities should be documented either as resolved (e.g. by treatment) or through an explanation as to why the abnormality was no significant or otherwise pertinent.  The patient was discharged with a significant fever of 103 F and a high heart rate of 130 bpm. There was no appropriate explanation as to why it was safe to discharge the patient with this significant tachycardia and remarkable fever. Treatment with IV fluids and antipyretics was indicated and may have been diagnostic in that lack of resolution would have prompted a search for other causes.

For this case and others, the Medical Board of California placed the ED physician on probation for 5 years and ordered the ED physician to complete a medical record keeping course, an education course (at least 40 hours per 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.  The ED physician was assigned a practice monitor and prohibited from supervising physician assistants.

State: California

Date: September 2016

Specialty: Emergency Medicine

Symptom: Headache, Fever, Nausea Or Vomiting, Abdominal Pain

Diagnosis: Gynecological Disease, Sepsis, Acute Abdomen

Medical Error: Improper treatment, Failure to examine or evaluate patient properly, Improper medication management

Significant Outcome: Hospital Bounce Back

Case Rating: 3

Link to Original Case File: Download PDF

On 8/9/2011 at 3:55 a.m., a 35-year-old non-English speaking, unemployed male presented to the emergency department complaining of 3 days of abdominal pain, nausea, and vomiting with anorexia and was seen by an ED physician.  The patient had no documented prior similar episodes, but had a history of heavy alcohol consumption. Vital signs included a temperature of 98 F and a pulse of 86 bpm. Physical examination indicated normal bowel sounds and mild periumbilical tenderness, and distension.  Rebound or guarding was not addressed. The nurse’s notes indicated that the last alcohol consumption was 1 day prior to admission, and abdominal pain had persisted for 3 days. 4/10 pain level was noted.

At 4:06 a.m., the patient’s treatment began with 2 L wide-open normal IV saline, GI cocktail, 5 mg morphine IV, and 4 mg Zofran IV.  Laboratory results revealed a mildly elevated WBC count of 13.2 with a left shift. Blood glucose was markedly elevated at 260 mg/dL (normal fasting 70-100 mg/Dl; normal non-fasting 125 mg/dL or less; at >200 mg/dL, diabetes is presumed) without evidence of acidosis.  Lipase level was below normal, and liver function tests were elevated. No alcohol was detected in the blood sample.

At 6:15 a.m., the patient was noted to be resting comfortably with a pain rating of 1/10.  Vital signs included a temperature of 99.1 F and a heart rate of 93 bpm. The patient’s temperature and heart rate had risen despite fluid IV and pain medication.  The ED physician approved the patient to be discharged home at 6:30 a.m. with oral instructions given through an interpreter to return if worse.

The patient was returned by ambulance to the emergency department at 10:40 a.m. again complaining of abdominal pain, this time at a level of 10/10.  Physical examination noted abdominal tenderness and distention without rebound or guarding. The patient’s temperature was now 100.4 F and a pulse rate was 95 bpm.  Laboratory findings noted the opiates administered at the previous visit, but also barbiturates of unclear source. WBC count was markedly low at 6.4, and a blood glucose level was now 421 mg/dL.  Further, the patient reported experiencing increased thirst and urination for the last 3 days. A CT scan revealed a possible appendicitis with free fluid and inflammatory mass in the right lower quadrant.  The patient was taken to surgery at 5:00 p.m., where appendicitis was confirmed. The patient was also admitted with a diagnosis of diabetes mellitus and treated with insulin drip to control blood sugar.

The Medical Board of California judged that the ED physician’s conduct departed from the standard of care because he failed to obtain an appropriate history and laboratory studies to rule out life-threatening illness.  The ED physician had not elicited information concerning recurrent abdominal pains under similar circumstances without a surgical cause, and yet he presumed that the patient’s alcohol use was the overriding factor in his abdominal pain.  The ED physician failed to order a urinalysis, a valuable test in the work-up of abdominal pain.

The ED physician’s final diagnosis did not follow from the history, physical, and work-up of the patient.  The patient had WBC count and liver function abnormalities and had a history of heavy alcohol consumption, so the ED physician’s diagnosis of alcoholic gastritis was a reasonable differential diagnosis, but the ED physician did not consider and rule out possible causes of the pain, such as appendicitis and gallbladder disease, which would require surgical intervention.  The ED physician ignored the patient’s high WBC count, which could have been an indication for appendicitis.

The observation period for the patient was inadequate.  The ED physician did not allow enough time to adequately assess the patient’s condition and the risk of serious decline.  The ED physician did not wait until the narcotic pain medication wore off to reexamine the patient over time for a possible surgical abdomen.  The duration of morphine analgesia in 4 to 5 hours, and it was appropriate to relieve pain during the work-up, but repeat examination reporting that the patient was comfortable during the duration of analgesia was inadequate to fully appreciate the course of the illness.

The ED physician failed to record a history for the patient’s high blood glucose level and perform tests to determine the nature and severity of the abnormal finding.  The blood glucose level of 260 mg/dL was suggestive of diabetes, and this was not previously diagnosed and required further history and laboratory studies. Ketones were not tested for in either blood or urine, but serum CO2 level was normal.

The ED physician’s discharge plan was inappropriate.  The patient was given instructions in Spanish at discharge, and he did not record these instructions, but indicated that he would have instructed the patient to return if worse.  No information was given concerning the elevated blood glucose. The ED physician failed to identify and ensure appropriate follow-up for a remarkably elevated blood glucose level.

For this case and others, the Medical Board of California placed the ED physician on probation for 5 years and ordered the ED physician to complete a medical record keeping course, an education course (at least 40 hours per 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.  The ED physician was assigned a practice monitor and prohibited from supervising physician assistants.

State: California

Date: September 2016

Specialty: Emergency Medicine

Symptom: Abdominal Pain, GI Symptoms (GERD, Abdominal Distention, Dysphagia), Nausea Or Vomiting, Urinary Problems

Diagnosis: Acute Abdomen, Diabetes

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

Significant Outcome: Hospital Bounce Back

Case Rating: 4

Link to Original Case File: Download PDF

On 12/10/2012 at 10:39 a.m., a 37-year-old reportedly alcoholic male was brought into the emergency department with mental changes and fever, and an ED physician attended to him.  The patient had reportedly been ill for up to 4 days and had a history of drinking heavily. The patient was unable to give a history for his present illness. Social history consisted of heavy alcohol use around “12/d.”  Vital signs were: temperature 100.3 F, pulse rate 118 bpm, respiratory rate 22, blood pressure 159/97 mmHg, and pulse oximetry 100% at room temperature. Physical examination revealed dry mucosa, lethargic appearance, poor dentition, lung rhonchi, and heart murmur 2/6 systolic.  “Suspect ascites” was written, and jaundice was noted under the skin. The patient was described as “obtunded.”

Laboratory abnormalities included the following: WBC count 23.3 (high); hemoglobin and hematocrit 9.4 g/dL/32% (low); Prothrombin Time/International Normalized Ratio (PT/INR) 21.2/2.03 (high); Sodium 130 (low); anion gap 21 (high); blood urea nitrogen (BUN)/creatinine 42/1.7 mg/dL (high); lipase level 226 (high); total bilirubin 5.6 (high). Alanine aminotransferase (ALT) 112 (high); aspartate aminotransferase (AST) 53 (high); and CRP 13.7 (high).

Urine toxicology screen was negative for alcohol.  Ammonia level was ordered, and 2 days later, it was found to be normal.  No rectal examination for gross blood was recorded and any consideration of a nasal-gastric tube to assess for upper gastrointestinal bleed was not mentioned.  No blood cultures were ordered during the ED physician’s initial evaluation. No consideration of lumbar puncture to assess for meningitis due to altered mental status and fever was documented.

ECG revealed sinus tachycardia, bifascicular block, and ST elevations with no prior ECG obtained for comparison.  Chest x-ray revealed right upper lobe infiltrate. Troponin level was measured at 0.433 (elevated; levels 0.06 to 1.5 signify acute myocardial infarction).

The ED physician clearly recognized that patient as gravely ill and appropriately ordered diagnostic testing as well as medical care.  The ED physician apparently called in a consultant physician for hospital admission and further treatment, but that physician was not available right way.  The patient was acutely ill with fever, mental status changes, jaundice, and abnormal vital signs. The patient was septic with rising fever, tachycardia, severe acidosis, high WBC count, and lung infection.  After the consultant physician was called, and while the patient remained in the emergency department, the ED physician rendered no further care to this patient from the time the consultant was called to the time the consultant appeared to examine and admit the patient to the hospital.

The Medical Board of California judged that the ED physician’s conduct departed from the standard of care because he failed to expedite the care for the patient, who was clearly ill with life-threatening conditions.  The patient was recognized immediately as acutely ill with fever, mental status changes, jaundice, and abnormal vital signs. The admitting consultant was not called until after laboratory tests, x-ray, and ECG were performed.  At this point, the patient was clearly septic with rising fever, tachycardia, severe acidosis, and clear lung infection. The ED physician ordered appropriate fluids and initial laboratory tests, x-rays, and ECG, but failed to render appropriate treatment to this acutely ill patient until the consultant physician arrived to take over care and admit the patient to the hospital.

The ED physician failed to do a rectal examination to rule out rectal bleeding as cause for the patient’s significant anemia and by considering blood transfusion, perform repeat hematocrits, conduct a lumbar puncture or administer antibiotics and corticosteroids immediately after blood cultures were drawn for the mental status changes with fever (treating presumptively for meningitis), order a CT scan to rule out intracranial hemorrhage for the mental status change in a reported alcoholic, and deal with the abnormal ECG with ST elevations, bifascicular block, and significantly elevated troponin, which must be treated as acute MI without an old ECG identifying the abnormalities as old.  The ED physician also failed to rule out alcohol withdrawal or treat it if confirmed since the patient had mental status changes and a zero alcohol level.

The ED physician called for consultation for the acutely ill patient, but the consultant could not arrive promptly to manage and admit the patient or to maintain a sustained presence in the emergency department.  As the ED physician, the ED physician was responsible for the patient’s medical care until he was stabilized or admitted to the hospital under the care of the consultant physician. The ED physician had an independent responsibility to manage the patient’s care while the patient was in the emergency department, and he abdicated his responsibility for a progressively critically ill patient.

For this case and others, the Medical Board of California placed the ED physician on probation for 5 years and ordered the ED physician to complete a medical record keeping course, an education course (at least 40 hours per 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.  The ED physician was assigned a practice monitor and prohibited from supervising physician assistants.

State: California

Date: September 2016

Specialty: Emergency Medicine

Symptom: Fever

Diagnosis: Sepsis

Medical Error: Improper treatment, Diagnostic error, Delay in diagnosis, Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Failure to properly monitor patient, Delay in proper treatment

Significant Outcome: N/A

Case Rating: 3

Link to Original Case File: Download PDF

A gastroenterologist was reprimanded for the treatments of multiple patients given the performance of multiple colonoscopies, gastroscopies, and/or endoscopies without medical indication and documenting the rationale for such procedures.

The gastroenterologist was ordered to undergo 40 hours of continuing medical education.  He was also ordered 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: September 2016

Specialty: Gastroenterology

Symptom: N/A

Diagnosis: N/A

Medical Error: Unnecessary or excessive diagnostic tests, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 1

Link to Original Case File: Download PDF

A 16-year-old female presented to the emergency department and was seen by an ED physician at 1:08 a.m. on 4/11/2012 with nausea, vomiting (x7), and 9/10 epigastric and right flank abdominal pain of 6 hours duration.  The patient had a history of kidney stones from the year before. She had tried an NSAID for the pain, but it caused her to vomit again. She had urgency of stool and urine, and her last menstrual period was in March 2012.  Vital signs were normal. Physical examination revealed a soft but tender abdomen, specifically in the epigastric and right flank area with costovertebral angle tenderness (CVAT) listed as questionable. A positive CVAT could indicate retrocecal appendicitis.  There was a mildly elevated WBC count of 13.9 with a left shift of 92 (indicating possible bacterial infection), a normal hemoglobin and hematocrit, lipase level, and chemistry panel. A pregnancy test was ordered, but no result was recorded. IV fluids were given along with 5 mg of morphine and Zofran 4 mg IV at 1:40 a.m.  The ED physician did a repeat examination on the patient 1 hour and 45 minutes later at 3:25 a.m., and the tenderness had migrated to the subumbilical position. The patient reported the pain at 2/10. Abdomen was still considered soft, and the patient was discharged to family as improved with instructions to return if worse.  Tylenol/Advil was recommended for pain.

The patient returned to the emergency department 12 hours later at 4:00 p.m. with continued low abdominal pain and vomiting (x7 more).  She now had a fever of 102.5 F with a pulse rate of 150 bpm. Pain was now localized in the right lower quadrant, abdomen was still soft, and bowel sounds were decreased.  There was a positive psoas sign (indicating acute appendicitis). The patient’s WBC count was elevated at 26.3. The pregnancy test ordered at the first emergency department visit was negative.  An abdominal ultrasound at 4:30 p.m. failed to adequately visualize the right lower quadrant, so a CT scan with rectal contrast was done at 6:30 p.m. An inflammatory mass was found in the right lower quadrant, and IV antibiotics were administered.  A surgeon was consulted at 7:00 p.m. for a clinical impression of appendicitis.

The Medical Board of California judged that the ED physician’s conduct departed from the standard of care because his medical evaluation was inappropriately limited.  Nausea, vomiting, and abdominal pain in a fertile young female could indicate ectopic pregnancy, which is a life-threatening illness.  A pregnancy test was ordered at the patient’s first visit, but the results were not obtained or documented before discharge. The ED physician failed to rule out a life-threatening illness before discharging the patient.  The ED physician also did not provide for an adequate observation period for the patient. The ED physician administered 5 mg morphine at 1:40 a.m., but reexamined the patient less than 2 hours later before the analgesia worse off.  He reexamined the patient with the effects of the morphine possibly hiding a surgical abdomen. A definitive diagnosis required time for analgesia effects to wear off and serial abdominal examinations. The ED physician did not understand the onset, peak, and duration of the narcotic medication given to the patient and acted precipitously in his reexamination and discharge of this patient.

For this case and others, the Medical Board of California placed the ED physician on probation for 5 years and ordered the ED physician to complete a medical record keeping course, an education course (at least 40 hours per 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.  The ED physician was assigned a practice monitor and prohibited from supervising physician assistants.

State: California

Date: September 2016

Specialty: Emergency Medicine

Symptom: Nausea Or Vomiting, Fever, Abdominal Pain

Diagnosis: Acute Abdomen

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

Significant Outcome: Hospital Bounce Back

Case Rating: 3

Link to Original Case File: Download PDF

On 6/6/2012, a 47-year-old female was transported to the emergency department by EMT’s for a brief syncopal episode.  The patient had been sitting in a chair and had lost consciousness, falling to the floor, but she recovered consciousness right away.  The patient had a medical history of menorrhagia and current bleeding (10-15 pads per day in the nurse’s notes). EMT’s noted tachycardia.  An ED physician’s history of the patient only noted prodromal lightheadedness, 2-3 seconds loss of consciousness, and the fall. He did not mention the current bleeding, and although he indicated a head injury in the record, nothing was mentioned concerning examination, diagnosis or treatment.  The ED physician did note that the patient’s gynecologist had recommended a hysterectomy. The ED physician’s review of systems was checked normal, which was inaccurate because menstrual history was included, and the patient was presently experiencing a very heavy menstrual period, consistent with past episodes of menorrhagia.  Vital signs were low blood pressure at 120/49 mmHg and elevated heart rate at 94 bpm, rising from 96 to 106 from supine to standing on orthostatic measurement. No positives were noted on physical examination except for “pale conjunctiva” and “pale palms.” No pelvic or rectal examination was documented. The ED physician ordered normal saline IV at 150 mL per hour.  Laboratory studies were returned with hemoglobin and hematocrit of 6.4 g/dL (extremely low) and 18.9% (very low).

The ED physician called the on-call family practitioner at 5:18 p.m., and the consultant was at bedside at 6:10 p.m.  The patient was admitted with improved vital signs. The consultant immediately ordered the transfusion of 3 units of blood.  The patient’s hemorrhaging continued after admission, so the following day, she underwent the previously recommended hysterectomy.

The Medical Board of California judged that the ED physician’s conduct departed from the standard of care because his medical examination was inappropriately limited.  The ED physician failed to perform an appropriate history and physical examination and appropriate medical tests as needed to evaluate for potentially life-threatening illness.  The ED physician’s notations appeared to indicate he may have been unaware of the current menstrual bleeding in the patient that was documented in the nurse’s notes, and he did not do a pelvic examination.  Although the ED physician noted a head injury, there was no indication that it was examined or treated. Neither the head injury nor the ongoing bleeding was addressed. The ED physician’s final diagnosis was syncope and anemia with no specific cause.  He failed to adequately examine and document findings pertinent to the patient’s presentation.

The ED physician’s final diagnosis was syncope and anemia, but syncope was a symptom of ongoing hemorrhage, not a diagnosis, and the ED physician did not document the apparent cause for the anemia.  The patient had hemorrhaged to the point where she fainted from hypotension. The ED physician consulted the on-call family practitioner when the appropriate consult would have been a gynecologist. The ED physician did not appreciate that syncope was a symptom of menorrhagia/hemorrhage, not a diagnosis.

For this case and others, the Medical Board of California placed the ED physician on probation for 5 years and ordered the ED physician to complete a medical record keeping course, an education course (at least 40 hours per 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.  The ED physician was assigned a practice monitor and prohibited from supervising physician assistants.

State: California

Date: September 2016

Specialty: Emergency Medicine

Symptom: Syncope, Abnormal Vaginal Bleeding

Diagnosis: Hemorrhage

Medical Error: Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Referral failure to hospital or specialist, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

On 6/18/2012, a 55-year-old female was brought to the emergency department by ambulance after a single-vehicle rollover accident on a local highway.  She was injured, but had walked a distance before someone stopped to help her and called an ambulance. The patient was alert with intact memory of the incident.  On arrival at the emergency department, the patient complained of right chest pain and left hand pain. The patient’s temperature was 97.2 F, pulse rate was 91 bpm, respiratory rate of 14, and blood pressure of 137/89.  Physical examination was positive for tender right chest and tender left hand on the ulnar aspect. The neck was non-tender and full range of motion, so no cervical spine x-ray was deemed necessary. A thoracic spine x-ray indicated 10% wedging of the T-11 and T-12 vertebrae of uncertain age.  This was noted by the radiologist, but not mentioned by the ED physician. An x-ray of the right ribs revealed a single sixth rib fracture without pneumothorax. Another x-ray was positive for left fifth metacarpal fracture.

Laboratory studies revealed an elevated WBC count of 14.8 with a segmented count of 91.  Hemoglobin and hematocrit were normal. Troponin was negative for cardiac injury. Chemistry panel was normal.  Liver function tests (LFTs) were mildly elevated with AST of 73 and ALT of 80. ECG revealed abnormalities, including anterior lateral ST-T wave depressions consistent with ischemia with no old ECG consulted for comparison.  The ED physician ordered a urinalysis, but the Ed physician did not document or address the results in the patient chart. The test was positive for blood and nitrates.

At 4:40 a.m., the patient received 10 mg of IV morphine and 10 mg of IV Zofran.  At 6:00 a.m., the patient was remedicated with IV morphine 10 mg and 37 minutes later, the ED physician documented a repeat examination of the patient and described the patient as “drowsy with meds.”  TDaP vaccine was ordered, and the patient was cleared for discharge, but due to a delay in obtaining the TDaP vaccine, the discharge order was not given until 8:30 a.m. The patient was discharged at 8:48 a.m. with a pulse rate of 82 bpm, respiratory rate of 16, blood pressure of 119/75, and pulse oximetry of 96%.  The patient was discharged with instructions to see an orthopedist for her hand, and she was given a prescription for pain medication and a work release note for approximately 3 weeks.

The patient returned the following day.  She was brought in by paramedics with fever and chest pain, apparently without severe shortness of breath.  The patient had not yet filled her pain prescription. A follow-up x-ray showed bibasilar atelectasis. A CT scan showed a 10% pneumothorax with mild right pulmonary effusion.  An incidental upper lobe pulmonary arteriovenous malformation was noted. Treatment for UTI detected by the urinalysis ordered the day before but not addressed, was provided. It was unclear whether the patient’s fever was caused by the atelectasis or the UTI.

The Medical Board of California judged that the ED physician’s conduct departed from the standard of care because he failed to admit the patient to the hospital for observation.  The patient had been in a motor vehicle accident with a high risk of intra-thoracic and intra-abdominal injury. Her car had rolled over 3 times, and she had at least 2 known fracture, blood in urine, elevated LFT’s, and evidence of cardiac ischemia on the ECG.  The patient had a significant mechanism of injury, evidence of extensive damage, and other unresolved medical problems that should have been addressed through hospital observation to determine the extent of the injuries involved.

The ED physician’s medical evaluation of the patient was inappropriately limited.  He should have done further investigation of the abnormalities with CT scans and other diagnostic mechanisms.  The ED physician also failed to document significant abnormalities or did not address those which were documented.  The ED physician failed to adequately examine the patient and document findings pertinent to the patient’s presentation after a potentially fatal automobile accident.

The ED physician failed to address the ECG abnormalities consistent with ischemia.  The patient’s ECG showed signs of ischemia in the setting of an accident that could have caused cardiac injury.  The ED physician had no previous ECG of the patient to compare, so it must be assumed that the ischemic changes were new.  The patient should have been admitted for this finding alone. A low initial troponin does not rule out cardiac injury.

The ED physician observation period for the patient was inadequate.  In his examination and treatment of the patient, he failed to allow enough time to adequately assess the patient’s condition and risk of serious decline.  The patient had been in an accident with a severe mechanism of injury, multiple fractures, and evidence of internal injury in 3 different systems, and the ED physician ordered 2 large doses of intravenous morphine close together and then precipitously discharged the patient with further reexamination or treatment.  The ED physician also did not appreciate the onset, peak, and duration of narcotic medications given when he reassessed the patient’s pain level.

The ED physician failed to perform and record an adequate back examination and order additional testing as indicated.  Thoracic spine x-rays were ordered, but the ED physician failed to perform or to document a back examination for back tenderness, and this finding was only noted on the patient’s second visit to the emergency department.

The ED physician failed to document or act upon significant abnormal findings.  The patient’s urinalysis was ordered, but the ED physician did not document the results in the patient record.  He did not document evidence of blunt kidney trauma and/or infection. He did not document the significance of an abnormal ECG.  The ED physician either failed to review the abnormalities, and so did not act upon them or he reviewed them, failed to document them, and then failed to appreciate the significance of the abnormalities.  Although he had evidence that the patient had a UTI, the ED physician failed to address the illness, which, left untreated, could have progressed to a serious illness, such as pyelonephritis or sepsis. He failed to adequately examine and document findings pertinent to the patient’s presentation.

For this case and others, the Medical Board of California placed the ED physician on probation for 5 years and ordered the ED physician to complete a medical record keeping course, an education course (at least 40 hours per 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.  The ED physician was assigned a practice monitor and prohibited from supervising physician assistants.

State: California

Date: September 2016

Specialty: Emergency Medicine

Symptom: Chest Pain, Fever, Extremity Pain

Diagnosis: Fracture(s), Pneumothorax

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

Significant Outcome: Hospital Bounce Back

Case Rating: 3

Link to Original Case File: Download PDF

On 9/10/2012 at 5:00 p.m., a 64-year-old male was brought into the emergency department by ambulance on a backboard with cervical spine precautions taken after he fell 8 feet off of a ladder onto a concrete surface.  The patient complained of pain in the chest, right elbow, and back. Medical history was significant for a mechanical heart valve requiring anti-coagulation with warfarin. Vital signs included a normal temperature, pulse rate 57 bpm, respiratory rate 22, and pulse oximetry 96% on room air.  Pain level was listed as 10/10. Tenderness was noted on the right chest and right elbow. A right laceration was noted on one finger. The right elbow had limited range-of-motion (ROM). The ED physician noted a palpable fracture on the right chest and ecchymosis. Breath sounds were marked as questionable/decreased.  Blood work was ordered. CBC and chemistry were unremarkable, and PT/INR indicated anti-coagulation. The ED physician noted no fractures on examining a series of rib x-rays ordered on the patient. The CT scan of the head was negative for bleeding. Lumbosacral (LS) spine x-rays were also read by the ED physician as negative.

The ED physician ordered an intramuscular (IM) injection of 10 mg of morphine given at 5:15 p.m., and he ordered a second dose of 10 mg morphine given at 5:36 p.m.  The ED physician’s last note was entered at 7:09 p.m. indicating that the patient was improved and that a posterior splint was applied. At 7:20 p.m., the patient could not walk due to pain in his tailbone.  At 8:40 p.m., the patient was discharged home with a supply of Norco, and vital signs before discharge included normal temperature, pulse rate 66 bpm, respiratory rate 18, blood pressure 112/73, and pulse oximetry down to 94%.

The following morning, the radiologist noted in the x-rays a 30% pneumothorax and a sixth-rib fracture and informed the ED physician.  The ED physician called the patient back to the hospital, and he was admitted and treated with a chest tube.

The Medical Board of California judged that the ED physician’s conduct departed from the standard of care because he failed to detect a large pneumothorax apparent on x-rays ordered and read by the ED physician on the patient’s initial emergency department visit. Traumatic rib fractures present a known risk of life-threatening pneumothorax.  The patient had experienced a significant mechanism of injury with an 8-foot fall onto concrete, clinical evidence of rib fracture, and falling pulse oximetry readings.

The ED physician ordered and had administered 2 large doses of IM morphine approximately 21 minutes apart.  The onset of IM narcotic medication is between 10-30 minutes with analgesia peaking between 30-60 minutes and of 4-5 hours duration.  The administration of 2 doses of IM morphine 10 mg, so close together before the first dose had a chance to take effect was virtually the same as giving one dose of 20 mg morphine, an excessive amount.  The ED physician documented no reason for the patient needing the back-to-back administration and noted no results for either injection. Furthermore, despite an aggressive initial approach to pain management, no additional pain medications were given to the patient 2 hours later when the patient was unable to walk due to tailbone pain.  The ED physician did not appreciate the onset, peak, and duration of the narcotic medications given to the patient.

For this case and others, the Medical Board of California placed the ED physician on probation for 5 years and ordered the ED physician to complete a medical record keeping course, an education course (at least 40 hours per 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.  The ED physician was assigned a practice monitor and prohibited from supervising physician assistants.

State: California

Date: September 2016

Specialty: Emergency Medicine

Symptom: Chest Pain, Back Pain, Joint Pain

Diagnosis: Pneumothorax, Trauma Injury, Fracture(s)

Medical Error: False negative, Improper medication management

Significant Outcome: Hospital Bounce Back

Case Rating: 3

Link to Original Case File: Download PDF

In 2010, a nurse approached a family practitioner with an offer to become a fifty-one percent co-owner and the Medical Director of MedSpa XL, an existing aesthetic practice that provided cosmetic injections to patients.

The nurse, who owned a forty-nine percent interest in MedSpa XL, offered to pay the general practitioner $1,500 per month to review charts and perform good faith examinations of MedSpa XL’s patients by telephone or by Skype.

From 1/1/2011 to 6/30/2012, the family practitioner served as the Medical Director of MedSpa XL.  During this time, the family practitioner was developing her own medical practice and was not on site at MedSpa XL.  The nurse performed the cosmetic injections to MedSpa XL’s patients.

On 5/21/2012, the nurse prescribed and administered Restylane by injection or injections to a MedSpa XL Patient A, and thereby inflicted bodily injury on the patient.

On 6/13/2012, the nurse prescribed and administered Restylane by injection or injections to MedSpa XL Patient B, and thereby inflicted bodily injury on Patient B.

On 5/30/2014, the District Attorney’s Office filed charges against the nurse and the family practitioner.

On 5/30/2014, in the case entitled, The People of the State of California v. [the nurse and the family practitioner], the family practitioner was charged with the violation of Count 3 and Count 6: treating the sick/afflicted without a certificate – conspiring, a felony, as to Patient A and Patient B.

On 10/3/2014, the family practitioner pled nolo contendere to Counts 3 and 6.

On 11/13/2014, the family practitioner’s motion to reduce Counts 3 and 6 from felonies to misdemeanors was granted, and the family practitioner was convicted of Count 3 and Count 6: treating the sick/afflicted without a certificate – conspiring, a misdemeanor, as to Patient A and Patient B.

On 11/13/2014, the family practitioner was sentenced to one year summary probation with terms and conditions, including but not limited to commitment to the Sheriff for 1 day with credit for 1 day of time served and payment of a fine of $245.00.

The family practitioner was placed on probation for five years with stipulations to complete an ethics course, complete 40 hours of free community services,  and to undergo monitoring.  The family practitioner was prohibited from holding any type of ownership interest in more than one medical practice or medical spa.

State: California

Date: September 2016

Specialty: Family Medicine, Plastic Surgery

Symptom: N/A

Diagnosis: N/A

Medical Error: Ethics violation

Significant Outcome: N/A

Case Rating: 1

Link to Original Case File: Download PDF