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Virginia – Pathology – Excised Tissue Determined As “Changes Consistent With Tonsillitis”
On 8/1/2013, Pathologist A examined excised tissue from a 55-year-old male and diagnosed “changes consistent with tonsillitis.”
In September 2014, the patient discovered a palpable nodule in the right submandibular region of his throat, which was aspirated on 10/20/2014, and determined to be squamous cell carcinoma.
In December 2014, Pathologist B reexamined the original pathology tissue, determined that Pathologist A’s diagnosis had been incorrect, and found that the specimen showed “squamous cell carcinoma poorly differentiated.”
Histologic evidence showed that the poor differentiation of the malignant cells clearly distinguished them from the surrounding benign lymphocytes, and the tumor was present in approximately 80% of the excised tissue.
Pathologist A’s erroneous diagnosis resulted in a fourteen-month delay in the diagnosis and treatment of the patient’s cancer.
The Board issued a Reprimand.
State: Virginia
Date: February 2017
Specialty: Pathology, Otolaryngology
Symptom: Mass (Breast Mass, Lump, etc.)
Diagnosis: Cancer
Medical Error: False negative
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Obstetrics – Postpartum Bleeding Following Early Labor In A Patient With A History Of Anemia
On 9/7/2012 at 8:00 p.m., a 27-year-old female presented to a medical center with a complaint of early labor. The patient had a history of anemia.
At 8:50 p.m., a biophysical profile was ordered for the patient due to heart tracing concerns for the fetus.
By the time the patient arrived back from her biophysical profile, she was found to have made cervical changes from 1-½ cm to 4 cm, and she then very rapidly went from 4 cm to 9 cm.
At 11:15 p.m., the patient’s membranes were artificially ruptured and meconium stained fluid was obtained. At this time, the cervix was now completely dilated.
At 11:55 p.m., an obstetrician applied a fetal scalp lead to better evaluate the monitor tracing.
At 12:15 a.m., the obstetrician then called in additional medical personnel and proceeded to apply a Kiwi vacuum extractor.
At 12:17 a.m., a second vacuum was applied and at 12:27 a.m. a third vacuum was applied.
At 12:27 a.m., the fetus was delivered with the baby weight 9 pounds and 8 ounces
The patient then experienced a severe postpartum hemorrhage, and the obstetrician inspected the cervix and found there to be no lacerations. The obstetrician used appropriate medications to cause the uterus to clamp down.
At 12:45 a.m., the obstetrician repaired episiotomy and third-degree perineal laceration, and the uterus was still boggy in spite of the medications. The bleeding continued.
At 1:00 a.m., the uterus was described as firm, the bleeding had decreased and the patient was sleepy but responsive.
At 1:15 a.m., the patient had a steady trickle of lochia resulting in the obstetrician being called back into the room.
At 1:20 a.m., the obstetrician performed a repair of laceration.
At 1:25 a.m., the patient was administered a Foley catheter per the obstetrician’s instructions.
At 1:35 a.m., following repair of the laceration, the patient was bleeding dark blood vaginally. Additionally, the patient was hypotensive and lethargic.
Sometime after 1:35 a.m. but before 2:10 a.m., the obstetrician left the hospital.
At 2:00 a.m., the patient continued to bleed vaginally, small to moderately.
At 2:10 a.m., the patient’s family called medical staff to the room due to the patient “acting funny” as the patient was lying on her stomach and moving her legs and moaning that she was hurting but would not say where.
At 2:10 a.m., the patient was noted to have bloody fluid in the Foley catheter.
The obstetrician was not present in the hospital at the time. The obstetrician was informed of the patient’s behavior and the continuation of her steady trickle of blood.
At 2:25 a.m., a registered nurse stayed in the room with the patient as the patient became more combative and a large amount of blood poured from the patient’s vagina.
At 2:25 a.m., the obstetrician was called to return to the hospital.
At an unidentified time, the obstetrician was called again to ensure she was on her way back to the hospital.
At 2:55 a.m., the obstetrician arrived back in the hospital room with the patient.
At 3:14 a.m., the patient became unresponsive and a code blue was called. The patient experienced cardiac arrest and cardiopulmonary resuscitation was started.
At 6:03 a.m., the patient was pronounced dead.
The Medical Board of Florida judged the obstetricians conduct to be below the minimal standard of competence given that she failed to determine the source of the bleeding for the patient who had been bleeding heavily after a vaginal delivery. The obstetrician failed to transfer the patient to the operating room for evaluation. She also failed to remain at the physical location of the hospital to monitor the patient who had been bleeding continuously.
It was requested that the Medical Board of Florida order one or more of the following penalties for the obstetrician: permanent revocation or suspension of her license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Medical Board of Florida deemed appropriate.
State: Florida
Date: February 2017
Specialty: Obstetrics
Symptom: Abnormal Vaginal Bleeding
Diagnosis: Obstetrical Hemorrhage
Medical Error: Underestimation of likelihood or severity, Failure to examine or evaluate patient properly, Failure to properly monitor patient
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF
California – Interventional Radiology – Radiologist Uses Profanity And Hits Patient’s Hand In Anger During Procedure
On 5/4/2015, between 6:00 p.m. and 6:45 p.m., an interventional radiologist entered the hospital’s Room 9 to perform a cerebral angiogram. The interventional radiologist intended to perform a procedure on the patient, a 99-year-old patient who had just suffered a stroke. The cerebral angiogram procedure involves the practitioner gaining access to the patient’s femoral artery, near the patient’s groin, by inserting and threading a catheter from the patient’s femoral artery to the brain. The catheter absorbs and/or extracts any blood clots and can control bleeding in the patient’s brain.
Previously, between 5:30 p.m. and 5:50 p.m., three female ancillary staff, namely Registered Nurse (RN) A, Technician A, and Registered Nurse B, prepared both Room 9 and the equipment in Room 9 for the medical procedure. In addition, ancillary staff prepared the patient by restraining the patient’s head and hands to the surgical table, as well as covering portions of her body with drapes. When the interventional radiologist entered the room, he was immediately upset that the ultrasound machine was not fully ready and had not been placed by the patient’s head. The interventional radiologist yelled, using profanity, at Technician A, regarding the fact that the ultrasound machine was not ready.
As the procedure began, the interventional radiologist started to gain access to the femoral artery to insert a guide wire into the femoral artery, near the patient’s groin, while the patient was lying on a table with her head taped to the table and her right arm was restrained to a board. At that time, the patient managed to move or wriggle her hand toward her groin, a sterile field where the interventional radiologist was trying to insert the guide wire. The interventional radiologist immediately grabbed the patient’s right arm with his hands and yelled at the patient, “God Damn It! Don’t F—— Move! I Said Don’t Move.” The interventional radiologist was standing to the side of the patient when he then took the patient’s right hand and hit it with his closed fist hard. The patient was not yet sedated and she cried out in pain. The interventional radiologist then yelled at Technician A, “Look at what you made me do! This is all your fault.”
After the hitting incident occurred, but during the procedure, a charge nurse came into the room to make her observations. As the charge nurse was Technician A’s supervisor, Technician A wrote on a piece of paper, “He hit the patient” and gave the note to the charge nurse. The charge nurse then left the room. This note exchange occurred approximately between 6:45 p.m. and 6:55 p.m.
Once the procedure was completed, the interventional radiologist requested to look at the patient’s right hand. Staff removed the drape over the hand and observed that the hand was bleeding and bruised. The interventional radiologist ordered that the hand be x-rayed. Later, the interventional radiologist returned to the room and told staff that he had informed the son how his mother had received the injury. However, the interventional radiologist’s version as told to the son was that he had grabbed the patient’s hand and not that he hit her hand with a fist. The interventional radiologist never documented in the patient’s chart that the bruising and bleeding of the hand occurred at all nor how it occurred.
The interventional radiologist’s conduct of swearing at the patient when she moved her hand constituted an extreme departure from the standard of care. The interventional radiologist’s act of hitting the patient’s right hand with his closed fist also constituted an extreme departure from the standard of care.
The Board issued a public reprimand against the interventional radiologist. Stipulations included enrolling in a course on anger management and a course on professionalism.
State: California
Date: February 2017
Specialty: Interventional Radiology
Symptom: N/A
Diagnosis: Ischemic Stroke
Medical Error: Ethics violation, Failure of communication with patient or patient relations
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
Washington, D.C. – Ophthalmology – Floaters And Decreased Vision Following Cataract Surgery
On 8/12/2011, an ophthalmologist performed cataract surgery on a patient’s left eye, which resulted in serious complications immediately following the surgery. During the procedure, a rent occurred in the capsule. On the following day, the patient met with the ophthalmologist during a post-operative appointment, and the patient allegedly informed the ophthalmologist that he suffered pain and discomfort in the left eye. The ophthalmologist allegedly told the patient that his eye “looked okay” as there were no floaters, cells, or flair in vitreous, and scheduled a follow-up appointment for the following week.
At the follow-up appointment, the patient complained of floaters and decreased vision in the left eye and the ophthalmologist referred the patient to a retina specialist, who determined that there was a tear of the capsule in the left eye and that there was still some cortex within the eye. The retina specialist performed corrective surgery and the patient received treatment and medical care from the retina specialist thereafter. After the corrective surgery, the patient allegedly continued to suffer pain and decreased vision in the left eye.
At the time of the procedure performed by the ophthalmologist, the patient’s pre-surgical best corrected vision was allegedly 20/40-20/100; after the cataract surgery performed by the ophthalmologist and subsequent retina surgery performed by the retina surgeon, the patient’s vision was reduced to 20/70-20/100. The patient was sent back to the ophthalmologist for glasses but was upset when the ophthalmologist recommended “temporary readers” until his vision became stable. The patient never returned for a follow-up examination.
The Board obtained the patient’s medical records so that those records could be reviewed by an independent peer reviewer. The peer reviewer concluded that the “overall patient management did not meet the standard of care.” Specifically, the peer reviewer found that the ophthalmologist failed to provide a comprehensive evaluation of the patient prior to cataract surgery. The patient’s medical records did not reflect a complete eye examination with visual acuity, refraction for best correct vision, pupil evaluation, slit lamp evaluation for rubeosis iridis, or posterior segment evaluation. In view of the patient’s pre-surgical vision of 20/100, the peer reviewer noted the ophthalmologist’s inadequate discussion of the surgery, the reasons for the surgery, possible complications, and alternative management.
For this allegation and others, the Board judged the ophthalmologist’s conduct to be below the minimum standard of competence given his significant complications post-cataract surgery in several cases, his consistent use of-of the incorrect intraocular lens type when a posterior capsule tear occurred, and his inadequate record documentation.
For this allegation and others, the Board ordered the ophthalmologist not to perform any procedures, make any appropriate and/or necessary referrals for his patients, and undergo an assessment and audit of his practice every 3 months until this requirement is terminated by the Board.
State: Washington D.C.
Date: February 2017
Specialty: Ophthalmology
Symptom: Vision Problems
Diagnosis: Post-operative/Operative Complication, Ocular Disease
Medical Error: Procedural error, Failure to examine or evaluate patient properly, Failure of communication with patient or patient relations, Lack of proper documentation
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 2
Link to Original Case File: Download PDF
Florida – Ophthalmology – Entropion Surgical Repair Performed On Patient’s Right Lower Eyelid Instead Of The Left Lower Eyelid
On 3/18/2015, a patient presented to an ophthalmologist for a left lower eyelid entropion surgical repair.
Prior to initiating the procedure, the ophthalmologist marked the patient’s left lower eyelid as the operative site, performed a timeout identifying the patient and procedure to be performed, and administered a local anesthetic to the patient’s left lower eyelid.
After performing the timeout but prior to beginning the procedure, the ophthalmologist briefly left the operating room.
After returning to the operating room, the ophthalmologist performed a second verbal timeout; however, he failed to create or maintain documentation of performing the second verbal timeout.
Despite the foregoing measures, the ophthalmologist mistakenly made his initial incision on the patient’s right lower eyelid (incorrect site) as opposed to the left lower eyelid (correct site). He recognized this error, closed the incision on the incorrect site, and then proceeded to perform the procedure on the correct site.
The Medical Board of Florida issued a letter of concern against the ophthalmologist’s license. The Medical Board of Florida ordered that he pay a fine of $4,000 against his license and pay reimbursement costs for the case at a minimum of $1,328.84 and not to exceed $3,328.84, The Medical Board of Florida also ordered that the ophthalmologist complete five hours of continuing medical education in “risk management” and complete a one hour lecture/seminar on wrong site surgeries.
State: Florida
Date: February 2017
Specialty: Ophthalmology
Symptom: N/A
Diagnosis: Ocular Disease
Medical Error: Wrong site procedure, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Family Medicine – Weakness Of The Left Hand And Slurred Speech For Three Weeks
On 8/14/2014, a 54-year-old male presented to an urgent care clinic with complaints of weakness in his hands and slurred speech for three weeks.
The patient was initially seen by a triage nurse who noted weakness in the left hand, affected speech, and feeling “stroke-like symptoms.”
The patient’s checklist listed “stroke symptoms” as a concern to be addressed by the family practitioner.
The family practitioner reportedly did a complete neurological exam of the patient with the family practitioner noting weakness as the only finding.
There was a later note by the family practitioner that the neurological exam was normal.
The family practitioner diagnosed the patient with a transient ischemic attack (“TIA”).
The family practitioner also diagnosed the patient with an allergic reaction and increased blood pressure.
The family practitioner treated the patient for the allergic reaction and increased blood pressure but never treated the patient for the TIA.
The next morning, the patient went to an emergency room due to inability to walk.
The patient was diagnosed with a massive cerebral infarction.
The patient became severely incapacitated and had to reside at an assisted living facility.
The Medical Board of Florida judged the family practitioner’s conduct to be below the minimal standard of competence given that he failed to treat the TIA and/or make an urgent referral to a facility for further evaluation including neuroimaging, cervical cephalic vasculature imaging, cardiac evaluation, statin medication, and blood pressure management.
It was requested that the Medical Board of Florida order one or more of the following penalties for the family practitioner: permanent revocation or suspension of his license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Medical Board of Florida deemed appropriate.
State: Florida
Date: February 2017
Specialty: Family Medicine, Internal Medicine
Symptom: Weakness/Fatigue
Diagnosis: Ischemic Stroke
Medical Error: Underestimation of likelihood or severity, Referral failure to hospital or specialist
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Oncology – Oncologist Unable To Load Up Images From Imaging Disc
In the months and/or years leading up to January 2013, an oncologist’s care for a patient included monitoring her for recurrence of lung cancer.
Sometime in 2012, the oncologist ordered diagnostic imaging services for the patient that were to be performed around January 2013.
On 1/8/2013, the patient received diagnostic imaging services. The ensuing diagnostic imaging report noted abnormal densities/masses in the patient’s lungs that were indicative of malignant neoplasm.
On 1/21/2013, the patient presented to the oncologist for an appointment. During the appointment, the oncologist failed to mention any of the January 2013 diagnostic imaging report findings to the patient.
On 1/22/2013, the oncologist electronically signed, and/or otherwise approved, a medical progress note for the patient that acknowledged the diagnostic imaging performed on 1/8/2013. The progress note referenced in the preceding paragraph stated that the patient exhibited no evidence of recurrent disease.
In May 2013, the patient telephoned the oncologist’s office and advised that one of her other physicians was concerned about areas of growth in her lung(s) shown on the patient’s January 2013 diagnostic images.
Personnel affiliated with the oncologist’s office indicated that the oncologist would be advised of the patient’s call.
In the time between the oncologist’s May 2013 telephone call and 1/10/2014, the oncologist did not order or perform any additional diagnostic services for the patient. He did not indicate/communicate concern that the patient’s cancer was returning.
On 1/10/2014, the patient returned to the imaging center for diagnostic imaging services. The ensuing diagnostic imaging report noted an enlarging mass in the patient’s lungs that was concerning for recurrent cancer.
On 1/14/2014, the patient presented to the oncologist for an appointment. During the appointment, the oncologist was unable to load an imaging disc provided by the imaging center. The oncologist instructed the patient that she could follow up with a local oncologist.
Between 1/10/2014 and May 2014, the oncologist did not obtain and/or review the January 2014 diagnostic imaging report for the patient.
Between 1/10/2014 and May 2014, the oncologist did not order or perform any additional diagnostic services for the patient, nor did he indicate/communicate concern that the patient’s cancer was returning.
In May 2014, the patient presented to and was diagnosed with lung cancer by a different physician.
The Medical Board of Florida judged the oncologists conduct to be below the minimal standard of competence given that he failed to accurately interpret or characterize all known and available diagnostic imaging reports of the patient’s lungs. He failed to timely obtain, review, and communicate with the patient regarding any ordered but unreviewed diagnostic imaging reports of the patient’s lungs.
The Medical Board of Florida ordered that the oncologist pay an administrative fine of $7,000 to the Board. He also was ordered to complete five hours of continuing medical education in “risk management” and complete five hours of continuing medical education in the area of diagnosis and treatment of lung cancer. The Medical Board of Florida also placed the oncologist’s license on probation for a period of one year.
State: Florida
Date: February 2017
Specialty: Oncology, Internal Medicine
Symptom: N/A
Diagnosis: Lung Cancer
Medical Error: Failure to follow up, Underestimation of likelihood or severity, Failure of communication with patient or patient relations
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Family Medicine – Discontinuation Of Aspirin And Propafenone For A Patient With Arrhythmia After Repair For A Tibial Fracture
On 9/1/2012, a patient suffered a tibial fracture in her left leg after falling during a seizure. In the aftermath of the fracture, the patient underwent left comminuted tibial open reduction internal fixation (“ORIF”) surgery.
During the patient’s discharge, she was prescribed aspirin and propafenone (Rythmol). The aspirin was intended to help prevent post-surgical pulmonary embolism. The propafenone was intended to control the patient’s atrial fibrillation.
On 9/14/2012, the patient was transferred to a rehabilitation facility for post-surgical rehabilitation.
Throughout her post-surgical rehabilitation, the patient was at an increased risk of pulmonary embolism.
Initially, the patient was continued on aspirin and propafenone at the rehabilitation center.
On 9/28/2012, the physician’s orders for October 2012 included a stop order on the administration of the patient’s aspirin and propafenone, effective 10/13/2012 and 10/14/2012.
In late September and early October 2012, a family practitioner electronically signed, approved, and executed the aforementioned physician’s orders.
On 10/18/2012, the patient suffered shortness of breath and decreased oxygen saturation. Although the family practitioner transferred the patient for treatment at an emergency room, the patient passed away several hours later.
According to the medical examiner, the cause of the patient’s death was pulmonary embolism.
The Medical Board of Florida judged the family practitioners conduct to be below the minimal standard of competence given that he should have facilitated the long-term continuation of aspirin and/or propafenone to the patient. Also, the family practitioner should not have signed, approved, and/or otherwise have executed physician’s orders that were in conflict with the physician’s intended course of prescribing/treatment for the patient.
The Medical Board of Florida issued a letter of concern against the family practitioner’s license. The Medical Board of Florida ordered that the family practitioner pay a fine of $7,500 against his license and pay reimbursement costs for the case at a minimum of $1,708.35 and not to exceed $3,798.35. The Medical Board of Florida also ordered that the family practitioner complete five hours of continuing medical education in “risk management.”
State: Florida
Date: February 2017
Specialty: Family Medicine, Internal Medicine
Symptom: Shortness of Breath
Diagnosis: Cardiac Arrhythmia, Pulmonary Embolism
Medical Error: Accidental Medication Error
Significant Outcome: Death
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Plastic Surgery – Below-The-Knee Liposuction On Obese Patient Results In Post-Operative Complications
On 6/19/2013, a patient presented to a plastic surgeon for an initial consultation regarding liposuction. During the consultation conducted, the plastic surgeon recommended a weight loss plan to the patient.
On 6/20/2013, the patient again presented to the plastic surgeon for another consultation to discuss liposuction.
On 7/1/2013, the patient presented to the plastic surgeon for a formal liposuction consultation.
In July 2013, the plastic surgeon agreed to perform multiple liposuction procedures on the patient.
On 7/20/2013, the plastic surgeon performed liposuction on portions of the patient’s lower body, including but not limited to the patient’s buttocks, thighs, knees, and lower legs.
On 9/18/2013, the patient presented to the plastic surgeon for a pre-operative consultation regarding liposuction to be performed on 9/26/2013.
On 9/25/2013, the patient presented to the plastic surgeon for an additional pre-operative consultation regarding liposuction to be performed on 9/26/2013.
On 9/26/2013, the plastic surgeon performed liposuction on portions of the patient’s lower body including but not limited to the patient’s legs.
In 2013, the plastic surgeon performed VASER and/or Smartlipo liposuction procedures on the patient.
At the time the plastic surgeon performed liposuction on the patient, the patient was a female standing at a height of 5’2”, she weighed 230 pounds, and her BMI was 42.
The patient suffered from and/or had a history of suffering from obesity. Performing liposuction below-the-knee on a morbidly obese patient poses a higher risk of complications. The patient was not a candidate for liposuction. Prior to the plastic surgeon performing liposuction on the patient, the patient informed him that she had previously undergone liposuction and suffered complications.
The plastic surgeon failed to record an operative note for the liposuction procedure performed on the patient on 7/20/2013. He also failed to document in his operative note, for the 9/26/2013 procedure, intraoperative settings for use of the laser-assisted liposuction device, including but not limited to time and/or infiltration amounts.
On at least nine different occasions between 9/27/2013 and 10/23/2013, the patient visited the plastic surgeon for post-surgery follow up appointments.
On October 2013, the family practitioner noticed dark spots on the patient’s legs. The plastic surgeon believed the dark spots on the patient’s legs were from an infection or a VASER burn.
On 10/23/2013, the plastic surgeon examined the patient’s legs and transported the patient to a hospital for the purpose of having the wounds on the patient’s legs treated.
The patient was admitted to the hospital with skin necrosis, which required surgical debridement and wound care.
The Medical Board of Florida judged the plastic surgeon conduct to be below the minimal standard of competence given that he failed to use appropriate surgical judgement in determining whether a patient was a candidate for liposuction. He also should not have performed liposuction on a patient who was not a candidate for such a procedure.
State: Florida
Date: February 2017
Specialty: Plastic Surgery
Symptom: N/A
Diagnosis: Post-operative/Operative Complication
Medical Error: Unnecessary or excessive treatment or surgery, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
Florida – Emergency Medicine – Fever, Cough, Sore Throat, And Shortness Of Breath With An Oxygen Saturation Of 91%
On 1/30/2013, a 33-year-old female presented to an ED physician with complaints of fever, cough, and sore throat, which began three days prior. The patient also complained of shortness of breath.
The ED physician obtained the patient’s vital signs and performed a physical exam.
The ED physician noted the patient’s pulse oximetry was 91%. He interpreted the patient’s pulse oximetry as “mild desaturation.”
The ED physician noted the patient’s heart rate was 129. On cardiac exam, he found the patient to be tachycardic.
The ED physician ordered lab work. The patient’s white blood cell count was found to be elevated at 20.4. The patient was also found to have bandemia.
The ED physician ordered a chest x-ray. He interpreted the chest x-ray as showing no infiltrate and no acute disease. However, the radiologist later reported the chest x-ray as showing right middle lobe infiltrate worrisome for pneumonia.
The patient was administered ketorolac, acetaminophen, and intravenous fluids.
On re-evaluation, the ED physician noted that the patient had diffuse wheezing.
The ED physician discharged the patient home with a diagnosis of viral syndrome, cough, febrile illness, leukocytosis, and tobacco abuse.
The patient’s presentation was consistent with possible septicemia.
On 2/2/2013, the patient returned to the emergency department with complaints of high fever, cough with sputum, and shortness of breath.
The patient was subsequently diagnosed with bilateral pneumonia, septic shock, acute kidney injury, acute respiratory failure, bilateral pleural effusions, and pneumothorax, requiring admission to the hospital, and later transfer to the ICU, for approximately twenty days.
The Medical Board of Florida judged the ED physician’s conduct to be below the minimal standard of competence given that he failed to evaluate, or failed to document evaluating the patient’s septicemia. He also failed to check, or failed to document checking the patient’s lactate level. He failed to obtain, or failed to document obtaining blood cultures for the patient. He failed to treat, or failed to document treating the patient for septicemia. The ED physician failed to administer, or failed to document administering, IV antibiotics for the patient. He also failed to recheck, or failed to document rechecking the patient’s vital signs prior to discharging her home. He failed to admit, or failed to document admitting the patient to the hospital.
The Medical Board of Florida issued a letter of concern against the ED physician’s license. The Medical Board of Florida ordered that the ED physician pay a fine of $5,500 against his license and pay reimbursement costs for the case at a minimum of $2,004.13 but not to exceed $4,004.13. The Medical Board of Florida also ordered that the ED physician complete five hours of continuing medical education in diagnosis of septicemia and five hours of continuing medical education in “risk management.”
State: Florida
Date: February 2017
Specialty: Emergency Medicine
Symptom: Fever, Cough, Head/Neck Pain, Shortness of Breath
Diagnosis: Pneumonia, Sepsis, Pulmonary Disease, Pneumothorax
Medical Error: Diagnostic 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: Hospital Bounce Back
Case Rating: 4
Link to Original Case File: Download PDF