Found 30 Results Sorted by Case Date
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California – Hospitalist – Post-Operative Complications Of Tachycardia, Abdominal Swelling, And Respiratory Distress After Knee Replacement Surgery



On 12/5/2011, a patient underwent knee replacement surgery.  In the course of his post-operative recovery in the hospital, the patient developed a rapid heartbeat.

On 12/6/2011, he was seen by Hospitalist A in the morning.  Hospitalist A attributed the patient’s rapid heart rate to his pre-existing atrial fibrillation and ordered an oral beta-blocker.  The patient’s heart rate was soon restored to a more moderate level.  The patient was transferred to the telemetry unit for closer monitoring at about 11:00 a.m.  Hospitalist A saw the patient again the following morning, noting that the patient was on nasally-administered supplemental oxygen, that his cardiac rhythm was irregular, that he was anemic, and that he had diminished bilateral breath sounds.  The hospitalist ordered chest x-rays and a blood transfusion.  The hospitalist’s order for a chest x-ray read “?chf” under “Indications.”

On 12/8/2017 at 8:40 a.m., nursing notes stated that the patient was receiving 2 liters of oxygen per minute via nasal cannula and his oxygen saturation level was 94%.  Hospitalist A’s chart entries made at about 10:40 a.m. indicate the patient was anemic, displayed some mental confusion, and had abdominal distention.  Hospitalist A opined that the distention “(m)ay be ileus due to oral morphine SR plus PRNs But r/o bleeding.”

Hospitalist A ordered x-rays of the patient’s abdomen, which confirmed the presence of an intestinal ileus.  Hospitalist A did not obtain a CT scan of the patient’s abdomen.  At about 3:50 p.m., Hospitalist A directed a nasogastric tube be placed to decompress the ileus.  Nursing notes from that evening indicate that the patient’s abdomen was “very distended, rounded” with hypoactive bowel sounds.

On 12/9/2017 at 2:30 a.m., a chart entry by Hospitalist B noted that the patient was “extremely uncomfortable with increased abdominal distention.”  She ordered a Harris flush procedure to reduce the patient’s intestinal pressure.

On 12/9/2017 at 3:58 p.m., the patient’s oxygen monitor alarm was sounding.  His oxygen saturation was 74% despite 2 liters per minute of supplemental oxygen.  Nurses repositioned the patient in bed and increased the oxygen flow rate to 5 liters per minute.  The indicated oxygen saturation increased to 88%.  The nasal cannula was moved to the patient’s mouth and the indicated oxygen saturation increased to 91-93%.  Hospitalist A was notified of the patient’s condition.

At 4:30 p.m., the attending nurse again called Hospitalist A to report that the patient was extremely short of breath with “labored” respirations and an indicated oxygen saturation “in the low to mid 80s.”  Hospitalist A directed that the patient be repositioned higher in bed; the nurse informed Hospitalist A that the patient was in the highest possible position.  Hospitalist A gave no new orders regarding the patient’s care.

The attending nurse’s chart entry for 5:10 p.m. states the following:

“(p)t’s condition continues to worsen.  Pt unable to hold O2 sats about low to mid 80’s on 5 liters NC.  Respiratory called to put on non-rebreather mask.  Pt’s LOC is decreased.  Pt repositioned up in bed.  NG tube flushed.  Pt requiring one-to-one nursing care.  Follow-up call to break and relief nurse’s call to [Hospitalist A] to ask that he come to the floor to see pt, d/t pt’s deteriorating respiratory status.  [Hospitalist A] still not answering the phone.”

The attending nurse placed a “Rapid Response” call to summon a physician to assess the patient at 5:20 p.m.  Hospitalist A came to the patient’s room, and his notes state that the patient’s oxygen saturation improved when he was repositioned in bed, “up to the 90s and stayed above 92” per measurement by the respiratory care provider.  Hospitalist A decided to continue with the current treatment on the medical floor rather than transferring the patient to the intensive care unit.

The medical record indicates that at 5:50 p.m., the patient’s oxygen saturation level is “in the 90’s but the O2 sat is variable with sat going down into the 80’s.”  The patient was still receiving supplemental oxygen via the 100% non-rebreathing mask.  The nursing notes for this time state that the patient’s daughter, a nurse, believed the patient should be monitored in the intensive care unit rather than on the medical floor and conveyed that desire for transfer to nursing staff, the nursing supervisor, and to Hospitalist A.

Nursing notes for 6:45 p.m. state the following:

“BP 92/63 HR 120’s.  Pt minimally responsive, respirations increasingly labored.  Telemetry and O2 sat monitors frequently alarming.  Pt requiring RN at bedside at all times.  pt hands cyanotic and remain cool to touch and forehead now appears slightly bluish in color.  [Hospitalist A] aware.  Family tearful, verbalizing anger w/staff regarding pt not being transferred to ICU.”

At 7:05 p.m., Hospitalist B ordered the patient to be transferred to the intensive care unit, apparently in deference to the fact that the “family, rn, supervisor want the pt moved to icu though it was discussed with all by the rounding hbs that there are not criteria for icu…”  The patient was taken to the intensive care unit at about 7:35 p.m.

The intensive care nurse’s notes state that the patient arrived at the ICU unresponsive with his oxygen saturation reading in the 70% range despite being on 15 liters of supplemental oxygen per minute via non-rebreather mask.  The patient’s fingers and toes were cyanotic and his body mottled.

On 12/10/2011 at 3:10 a.m., the patient died despite additional care.

The Board expressed concern that Hospitalist A practiced below the standard of care by failing to order an abdominal CT scan in a patient with an identified bowel obstruction that was not responding to care.  He failed to recognize clinical indicators of early septic shock and make a timely transfer of the patient to a higher level of care.  He failed to recognize and respond to the patient’s acute respiratory distress.

The Board issued a public reprimand.  He was ordered to take a course in early recognition of septic shock.

State: California


Date: January 2017


Specialty: Hospitalist, Internal Medicine


Symptom: Shortness of Breath, GI Symptoms (GERD, Abdominal Distention, Dysphagia)


Diagnosis: Sepsis, Acute Abdomen


Medical Error: Delay in proper treatment, Diagnostic error, Failure to order appropriate diagnostic test, Failure of communication with patient or patient relations, Failure to properly monitor patient


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



California – Cardiology – Decreased LV Systolic Function Misinterpreted As Normal



A pediatric cardiologist followed a patient after surgery for a congenital heart defect with poor LV systolic function.  The patient underwent an echocardiogram on 1/15/2010, 2/12/2010, 3/12/2010, 3/17/2010, and 4/9/2010. The narrative in the pediatric cardiologist’s reports stated “normal LV systolic motion” and/or “normal LV systolic and diastolic function.”  The reported quantitative function was anywhere between 10% and 24%, which should have been stated as decreased rather than normal.

The Medical Board of California judged that the pediatric cardiologist’s conduct departed from the standard of care because he misinterpreted the echocardiograms as normal rather than decreased LV systolic function.

The Medical Board of California ordered the pediatric cardiologist to surrender his license.

State: California


Date: January 2017


Specialty: Cardiology, Pediatrics


Symptom: N/A


Diagnosis: Cardiovascular Disease


Medical Error: False negative


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Arizona – Emergency Medicine – 4-Year-Old Girl With Complex Congenital Heart Disease Presents With Headache, Shaking, And Vomiting



The Board received notification of a malpractice settlement regarding the care and treatment of a 4-year-old girl.

The patient was a product of triplet gestation.  Her past medical history included complex congenital heart disease.  She also had a history of asplenia, heterotaxy syndrome, hydrocephalus, and failure to thrive.  Her surgical history included multiple open cardiac surgeries, ventriculo-peritoneal shunt placement, and gastrostomy tube placement.

Before 9:00 a.m., on 01/03/2013, the patient presented to the outpatient registration area of a children’s hospital for a scheduled cardiac catheterization to assess her right superior vena cava shunt.  The patient’s parents reported that she had an upper respiratory tract infection during the prior 7 days.  Several days prior she had finished a course of amoxicillin.  Otherwise, she had been in her usual state of health.

Shortly after the patient presented to the hospital registration area, she was found to have a temperature of 103 degrees Fahrenheit.  She was complaining of a headache, “shaking,” and vomiting.  The parents remarked that at that time she appeared to be cyanotic around the mouth.  At 9:15 a.m., the rapid assessment team arrived.  It was recommended that she be immediately transferred to the pediatric emergency department for further evaluation.

At 9:35 a.m., the ED physician saw the patient and documented that the patient had a temperature of 36.7 degrees Celsius, a respiratory rate of 24, a blood pressure of 101/59, and a heart rate of 187.  The ED physician documented that the patient was “pale and mottled and looked unwell.”  His exam documented a capillary refill time of 2 seconds.

The ED physician ordered the placement of a peripheral intravenous line and lab tests including viral swabs and a nasopharyngeal swab for pertussis.  The patient was started on 40 ml/hour of normal saline and 1.5 mg of IV ondansetron for nausea.  No dextrose containing solutions were ordered and the patient did not receive a fluid bolus.

The patient was periodically reassessed by various nurses throughout her emergency department stay.  She remained persistently tachycardic despite fever control.  The patient’s scheduled cardiac catheterization was postponed.  The patient’s labs returned showing a mild elevation of her total white blood cell count with a left shift (neutrophils were at 90%) with no bandemia.  The patient had mild hemo-concentration with hemoglobin and hematocrit of 14.1 and 42.4 with platelets at 98 with clumping noted.

The patient’s total CO2 on the BMP was 20 with an increased BUN:creatinine ratio of 40:1, suggesting pre-renal azotemia.  The viral swabs were negative.  An MRI of the brain showed no evidence of interval change with respect to the ventricular size, ruling out shunt malfunction.  The chest x-ray was normal and her EKG showed sinus tachycardia.

At time of discharge, the patient remained tachycardic despite fever control.  It was documented that 20 minutes prior to the PIV removal, the patient had a heart rate of 180 and an increased respiratory rate at 40.  The patient was afebrile, but she was noted at that time to have a delay in her capillary refill at 4 seconds (all previous measurements were normal at 2 seconds).  The hospital records for the patient document more than once and by more than one provider that the parents wanted to take the patient home.

Approximately two hours after arriving home, the patient was tachycardic and tachypneic.  Emergency responders were called, and they found the patient in cardiac arrest.  She was flown to a tertiary care facility where the patient arrived in active cardiopulmonary arrest.  She was hypoglycemic and received a glucose bolus and 10 rounds of IV epinephrine.  She also received calcium and two rounds of rocuronium, the later of which was given for unsuccessful attempts at re-intubation.  Despite lifesaving efforts, the patient was pronounced dead at 5:29 p.m.  The blood culture eventually grew out streptococcus pneumonia the next day.

The Board judged ED physician’s conduct to be below the minimum standard of competence given failure to provide antibiotics in a patient without a spleen who was tachycardic, tachypneic, and febrile.

The Board ordered the physician to be reprimanded.

State: Arizona


Date: January 2017


Specialty: Emergency Medicine, Pediatrics


Symptom: Fever, Headache, Nausea Or Vomiting


Diagnosis: Pneumonia


Medical Error: Diagnostic error


Significant Outcome: Death, Hospital Bounce Back


Case Rating: 4


Link to Original Case File: Download PDF



California – Cardiology – Echocardiogram For Heart Murmur Misinterpreted



On 10/10/2012, a 2-month-old child presented to a pediatric cardiologist with a heart murmur.  The pediatric cardiologist ordered an echocardiogram and a Holter test. He then sent the child home.  The pediatric cardiologist interpreted the results of the echocardiogram that day as “large ASD with left to right shunt, probable membranous VSD, marked right atrial and right ventricular and pulmonary artery dilatation.”  The following day, the patient returned to have the Holter removed. The child was noted to have a bluish tint to his skin caused by oxygen-poor blood. The patient was immediately sent to the emergency department, where a cardiologist reinterpreted the echocardiogram and found critical congenital heart disease, cor triatriatum with severe pulmonary hypertension.  The patient was immediately transferred to a tertiary care center via helicopter.

On 10/12/2012, the pediatric cardiologist amended his initial echocardiogram report of the patient to include the possibility of Ebstein anomaly and to state that the images transmitted over the internet were poor.

The Medical Board of California judged that the pediatric cardiologist conduct departed from the standard of care because he failed to admit the patient with significant pulmonary hypertension and ordered a Holter test for the evaluation of a heart murmur in the absence of an irregular heart rhythm.

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

State: California


Date: January 2017


Specialty: Cardiology, Pediatrics


Symptom: N/A


Diagnosis: Cardiovascular Disease


Medical Error: Diagnostic error, Unnecessary or excessive diagnostic tests


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Cardiology – Discrepancy Between Echocardiogram Interpretation And Progress Note



On 4/7/2010, a pediatric cardiologist started following a patient for a small atrial communication, a patent foramen ovale (PFO).  On examination, the patient had a heart murmur with normal splitting of the second heart sound. An echocardiogram revealed the PFO.  He was asked to return in 1 year.

On 4/6/2011, the patient underwent a subsequent echocardiogram.  The results were normal. The pediatric cardiologist’s interpretation was “spontaneous closure of a PFO/ASD.”  His progress note of the same day stated “today’s echo/Doppler confirms the PFO is still present.”

The Medical Board of California judged that the pediatric cardiologist’s conduct departed from the standard of care because his progress note did not reflect the results of the echocardiogram from 4/6/2011.

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

State: California


Date: January 2017


Specialty: Cardiology, Pediatrics


Symptom: N/A


Diagnosis: N/A


Medical Error: Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Cardiology – Patient With Dizziness And Trivial Mitral Insufficiency Diagnosed With Mitral Valve Prolapse



A 13-year-old female was initially seen by a pediatric cardiologist on 10/28/2009 for frequent dizzy episodes.  She had an echocardiogram, which showed trivial mitral insufficiency. The patient also underwent a stress echocardiogram.  The pediatric cardiologist noted that he felt the patient did not have any cardiac condition. There was no clinical or echocardiographic suggestion of mitral valve prolapse.  The pediatric cardiologist, however, diagnosed the patient with mitral valve prolapse. He did not explore any other diagnoses.

The consultation letter to the patient’s primary care physician for the 10/28/2009 visit was not generated until 11/7/2009 and was not signed by the pediatric cardiologist until 11/9/2009.  The pediatric cardiologist saw the patient on 1/4/2012. The consultation letter, however, was not generated until 3/4/2012 and not signed by the pediatric cardiologist until 3/7/2012.

The Medical Board of California judged that the pediatric cardiologist’s conduct departed from the standard of care because he diagnosed the patient with mitral valve prolapse in the absence of clinical or echocardiographic indication, failed to explore alternative diagnoses, delayed the production of the consultation letters, and ordered a stress echocardiogram work-up for pre-syncope in a teenager with a normal cardiac examination.

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

State: California


Date: January 2017


Specialty: Cardiology, Pediatrics


Symptom: Dizziness


Diagnosis: N/A


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


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Massachusetts – Obstetrics – Postpartum Bleed With Difficulty Identifying The Source Of Bleed



At 12:35 a.m. on 4/2/2009, an obstetrician performed an unscheduled Cesarean section on a patient who began to bleed heavily after birth.  The obstetrician incorrectly identified the major source of bleeding as a uterine tear.  The obstetrician failed to properly administer medications to stop the bleeding pursuant to a uterine hemorrhage protocol.  The obstetrician failed to obtain assistance until between 2:00 and 2:15 a.m.  A trauma resident arrived at 2:30 a.m. and another physician from the obstetrician’s practice arrived at 2:45 a.m., who repaired a laceration of the uterine artery.

Ultimately, the Board revoked the obstetrician’s license.

State: Massachusetts


Date: January 2017


Specialty: Obstetrics


Symptom: Bleeding


Diagnosis: Obstetrical Hemorrhage


Medical Error: Procedural error, Delay in proper treatment, Diagnostic error, Improper treatment


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Orthopedic Surgery – Incidentally Found Soft Tissue Mass on Scapula In Patient With Shoulder Pain



On 2/2/2012, an orthopedic surgeon first saw an 81-year-old male when he performed surgery on the patient’s left shoulder for shoulder impingement, subacromial decompression, and distal clavicle resection.

Prior to the date of the surgery, the patient had been seen once in the emergency department on 12/13/2011 for complaints of shoulder pain.

On 12/22/2011, the patient was seen by the orthopedic surgeon’s physician assistant, at which time the patient reported 70% improvement.  The physician assistant provided the patient with anesthetic and steroid injections.

On 1/5/2012, the patient returned to the physician assistant and reported that he was 50% improved from the last visit and had full range of motion.

On 1/5/2012, the physician assistant ordered an MRI of the patient’s shoulder, which was performed on 1/12/2012.

The orthopedic surgeon did not see the patient during his visit to the physician assistant, did not sign off on any of the physician assistant’s notes or treatment plan, and did not order the MRI of the patient’s shoulder.

On 1/16/2012, the physician assistant discussed the radiology report and options for care with the patient.

On 1/12/2012, the MRI report stated three impressions: one related to degenerative changes of the lateral end of the clavicle; one related to degenerative changes of the acromioclavicular joint; and one related to a “3.1 X 1.5 cm expansile soft tissue mass of the scapula.  Etiology [was] unknown.  Neoplastic process cannot be excluded.  Clinical correlation [was] recommended.”

The radiologist documented that the “report [would] be notified to the referring physician by the department staff.”  The MRI report was forwarded to the physician assistant.

The physician assistant failed to recognize the significance of the reported mass on the MRI and failed to report the mass to the orthopedic surgeon.

The standard of care requires that an orthopedic surgeon review the MRI and the MRI report prior to initiating surgery.  The orthopedic surgeon failed to do either.  Instead, he proceeded with the surgery based only on the diagnosis of his physician assistant.

The pre-procedure verification sheet states that the relevant radiographic images and results were available.  A nurse signed, verifying that these images and reports were available to the orthopedic surgeon prior to the procedure.

Had the orthopedic surgeon reviewed the MRI report it would have been evident that the patient had a lesion in his scapula that needed immediate attention and referral.  Instead, the orthopedic surgeon failed to recognize the lesion, discuss it with the patient, or make any appropriate referrals.  By failing to take any of these actions, the orthopedic surgeon fell below the standard of care.

The orthopedic surgeon is the physician responsible for the action and supervision of his physician assistant.  The physician assistant’s failure to adequately review the MRI report or discuss it with the orthopedic surgeon was also a failure to meet the standard of care on the part of the orthopedic surgeon.

The Medical Board of Florida judged the orthopedic surgeons conduct to be below the minimal standard of competence given that the orthopedic surgeon failed to adequately supervise the physician assistant when the orthopedic surgeon proceeded with the surgery based on the physician assistant’s diagnosis and without personally reviewing the MRI and MRI report.  The orthopedic surgeon was ultimately responsible and, regardless of whether he was told by his physician assistant of the lesion, he should have reviewed the MRI and MRI report, discovered and followed up on the existence of the lesion, and not have inappropriately followed through with the surgery.  The orthopedic surgeon failed to document the existence of the lesion in the 1/12/2012 MRI and to document making the appropriate referrals.  He failed to document what the patient was told regarding the MRI reports and what procedures were listed on the consent for the 2/6/2012 surgery.  The orthopedic surgeon failed to document personally reviewing the 1/12/2012 MRI or MRI report.

The Medical Board of Florida issued a reprimand against the orthopedic surgeon’s license.  The Medical Board of Florida ordered that the orthopedic surgeon pay a fine to the Board for $7,500 and pay reimbursement costs for the case at a minimum of $6,139.35 and not to exceed $8,139.35.  The Medical Board of Florida also ordered that the orthopedic surgeon complete ten hours of continuing medical education in imaging studies and five hours of continuing medical education in “risk management.”

State: Florida


Date: January 2017


Specialty: Orthopedic Surgery, Physician Assistant


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


Diagnosis: Musculoskeletal Disease


Medical Error: Failure to examine or evaluate patient properly, Failure of communication with other providers, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Virginia – General Surgeon – Insertion Of Trocar Causes Laceration Of The Right Common Iliac Artery



On 2/2/2012, a 33-year-old female was undergoing exploratory laparotomy conducted by a general surgeon.  At 10:30 p.m., the general surgeon inserted a trocar into the right lower abdomen under direct visualization.  During the insertion, the general surgeon used such force sufficient to cause a laceration of the right common iliac artery.

The patient became hypotensive and tachycardic.  At 10:50 p.m., the general surgeon converted to an open laparotomy.  She converted to an open laparotomy when she noted active bleeding.

The general surgeon stated that she believed the Board would be informed of the medical malpractice payment automatically as a result of the report to the National Practitioner Data Bank.  The general surgeon did not intend to mislead or not adhere to the Board’s requirement of separately reporting medical malpractice to the Board.

She failed to report the medical malpractice settlement she made in September 2014 to the Board within 30 days, as required by Virginia Code.  She failed to update her practitioner’s profile on the Board’s website to include that she made a malpractice settlement within 30 days, as required by the Board’s General Regulations.

The Board issued a reprimand and fine.

State: Virginia


Date: January 2017


Specialty: General Surgery


Symptom: Bleeding


Diagnosis: Post-operative/Operative Complication


Medical Error: Procedural error


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



North Carolina – Urology – Difficult Robotic Assisted Laparoscopic Prostatectomy Leads To Extensive Bleeding And A Prolonged Procedure



On 12/30/2013, a 73-year-old male with prostate cancer underwent a Da Vinci robotic-assisted laparoscopic prostatectomy.  The general surgeon encountered various problems with difficult visualization and dissection, leading to extensive bleeding which resulted in a prolonged procedure.  After the procedure, the patient was transferred to the ICU in critical condition.  The following morning, the patient died despite attempted resuscitation.

The Board obtained the patient’s records and sent them to a qualified independent medical expert for review.  The independent medical expert expressed concern that the procedure took longer than would be expected and involved extensive blood loss.

The Board received two Affidavits from physicians knowledgeable about the urologist, which included a urologist who performs robotic laparoscopic prostatectomies and a family medicine practitioner who has referred urology patients to the urologist for thirteen years.  Both physicians opined that the complication involving the patient was an aberration.

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

State: North Carolina


Date: January 2017


Specialty: Urology


Symptom: N/A


Diagnosis: Prostate Cancer


Medical Error: Procedural error


Significant Outcome: Death


Case Rating: 1


Link to Original Case File: Download PDF



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