Found 14 Results Sorted by Case Date
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California – Cardiology – CT Coronary Angiogram On Hemodynamically Compromised Patient For Chest Pain, Abnormal Electrocardiogram, Right Atrial Enlargement, And Elevated Cardiac Enzymes



On 4/16/2012, a 23-year-old female presented to the emergency department with chest pain, acute nausea, vomiting, and diarrhea.  The patient had a history of pulmonary hypertension. Laboratory measurements were taken that revealed a hemoglobin of 17.2, hematocrit of 49.9, an acidotic pH of 7.12, an elevated WBC count of 15,900, potassium of 6.6, BUN of 31, and creatinine level of 1.4.  These measurements were consistent with mild renal insufficiency. An electrocardiogram test revealed sinus tachycardia, which was consistent with the findings of an electrocardiogram performed on the patient approximately 1 year earlier.

On 4/17/2012, the patient was admitted to the hospital.  The patient was initially treated with sodium bicarbonate to treat her lactic acidosis and IV fluids for dehydration.  The patient also received a dialysis catheter in her right femoral artery due to the increase in the BUN/creatinine measurements.  However, this catheter was never used.

On 4/17/2012, a cardiologist performed a telephonic cardiology consult with the hospitalist and ordered a CT coronary angiogram due to the patient’s chest pain, abnormal electrocardiogram, right atrial enlargement, and elevated cardiac enzymes (troponin).  The cardiologist also ordered 100 ml of ionic contrast to facilitate the CT angiogram despite the patient’s continued elevated BUN and creatinine levels. The cardiologist also ordered 50 mg of metoprolol orally and 5 mg intravenously to improve visualization on the CT angiogram despite the patient’s clinical condition.  The cardiologist did not perform a physical examination of the patient, measure the patient’s pulmonary pressure, or review the patient’s diagnostic or laboratory tests prior to ordering ionic contrast, CT angiogram, or administering metoprolol.

On 4/17/2012, the patient deteriorated and became hypotensive approximately 90 minutes after the CT angiogram and administration of metoprolol.  At approximately 8:00 p.m., the patient expired due to cardiac arrest.

The Medical Board of California judged that the obstetrician’s conduct departed from the standard of care because he failed to physically examine the patient prior to ordering a potentially dangerous procedure and drugs, review the patient’s previous diagnostic testing and laboratory testing prior to ordering a potentially dangerous procedure and drugs, and order a pulmonary artery catheter to measure pulmonary pressure in a hemodynamically compromised patient.

The Medical Board of California placed the cardiologist on probation for 3 years and ordered the cardiologist to complete a medical record keeping course and an education course (at least 40 hours per year for each year of probation).  The cardiologist was also assigned a practice monitor.

State: California


Date: March 2017


Specialty: Cardiology


Symptom: Chest Pain, Diarrhea, Nausea Or Vomiting


Diagnosis: Cardiovascular Disease, Renal Disease, Sepsis


Medical Error: Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Improper medication management


Significant Outcome: Death


Case Rating: 5


Link to Original Case File: Download PDF



Arizona – Anesthesiology – Cardiac Arrest During Elective Face And Brow Lift After Administration Of Propofol, Fentanyl, And Lidocaine



The Board was notified that an anesthesiologist had his privileges suspended.

On 08/25/2015, a 52-year-old woman presented for an elective face and brow lift.

At 8:13 a.m., on the morning of the surgery, the anesthesiologist administered anesthesia to the patient.  When the surgeon began to inject lidocaine around the patient’s face, the anesthesiologist began injecting propofol on a regular basis during the local injection and supplemented it with fentanyl boluses.  Based on the patient’s medical records, it appeared that the anesthesiologist administered at least 200 mg of propofol and 100 mcg of fentanyl during this time.

During the first 2-3 hours of the surgery, the patient was responding more than usual, and the anesthesiologist administered regular boluses of propofol and fentanyl.  Based on the patient’s medical records, it appears that the anesthesiologist administered approximately 2000 mg of propofol and 500 mcg of fentanyl during this time period.

The anesthesiologist documented in the patient’s records that the patient experienced short periods of apnea, which caused the pulse oximetry readings to decrease.  The anesthesiologist recognized that he was using significantly more propofol and fentanyl during the 2-3 hour time period after the surgery began.  Because a portion of the procedure involved the use of an endoscope, which is painful, the anesthesiologist requested the surgeon to inject the patient with additional lidocaine.  The patient continued to respond and reach for her face in response to the painful stimulus.

At approximately 11:30 a.m., the patient unexpectedly and violently reached towards her face and nearly sat up.  The anesthesiologist gave the patient a 50 mg dose of propofol.  However, the patient’s pulse oximetry readings began to fall and her heart rate dropped.  The patient’s color became blue around her mouth.  The anesthesiologist placed a laryngeal mask airway, but the patient’s pulse oximeter readings and heart rate continued to drop.

The surgery was halted and the anesthesiologist elected to intubate the patient.  After intubation, the patient went into cardiac arrest and a full code was called.  The patient was given atropine, IV epinephrine, and chest compressions.

The anesthesiologist used a video laryngoscope to determine whether the endotracheal tube was properly positioned and realized that the intake tube was still connected to the nasal oxygen tubing and not the anesthesia circuit, which resulted in not getting a CO2 reading.

After two rounds of chest compressions, the patient’s heart rate started to increase.  The anesthesiologist claims that the patient’s heart rate and blood pressure returned to reassuring levels and that the whole episode transpired within approximately 3-5 minutes of coding.

The surgeon and the anesthesiologist agreed that the patient would spend the night in the hospital, which the anesthesiologist believed was only precautionary.  The anesthesiologist and the surgeon discussed if the patient’s surgery should be continued, if the extensive excision should be closed, or if the patient should be transferred to a different hospital for a higher level of care.

They elected to proceed with the surgery, but not perform the endoscopic brow lift.  At the same time, arrangements were made to transfer the patient to a hospital with a higher level of care.  The surgery took approximately 2 hours and 45 minutes to complete.

After the patient was brought to the recovery room, her vital signs were stable with minimal chin lift required.  After the anesthesiologist gave a report to the PACU staff, he went to participate in a short surgical case with the same surgeon.

During the second surgery, the PACU nurses reported to the anesthesiologist that the patient did not appear to be waking up from the anesthesia normally and needed a nasal airway because her breathing was obstructed without constant chin lift.  The anesthesiologist evaluated the patient and agreed that her emergence from anesthesia was not normal.  The patient then started to demonstrate seizure-like activity.  The anesthesiologist inquired about the status of the patient’s transport to the hospital.  He was informed that a transport team had not been called to the surgery center.  The anesthesiologist immediately instructed the staff to call for transport.

After the patient’s transfer, the anesthesiologist received a call from the intensive care physician at the hospital who reported that the patient had suffered profound brain damage with a very poor prognosis.  The intensive care physician initiated hypothermia protocol.

On 09/3/2015, the patient expired.  The discharge diagnosis included diffuse anoxic encephalopathy related to the outpatient cardiac arrest; recurrent seizures related to global brain injury; cardiomyopathy with an ejection fraction of 45-50% presumed related to the cardiac arrest; and abnormal troponin levels consistent with myocardial infarction.

The Board judged anesthesiologist’s conduct to be below the minimum standard of competence given several failures.  He failed to switch to another form of anesthesia when the patient was not responding to the current anesthesia plan.  He failed to immediately send a patient who had had a code to a hospital with a higher level of care.  He failed to immediately make arrangements for the patient to be transferred to a hospital with a higher level of care.  He failed to stay with a patient who had had a code and manage the transfer to a hospital to ensure that there is no miscommunication between the facilities.  The Board finds that the anesthesiologist deviated from the standard of care by electing to participate in another surgery case instead of staying with the patient.

The Board ordered the physician to be reprimanded.

State: Arizona


Date: March 2017


Specialty: Anesthesiology, Plastic Surgery


Symptom: N/A


Diagnosis: Post-operative/Operative Complication


Medical Error: Improper medication management, Procedural error


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Arizona – Family Medicine – Unaddressed Cervical Issue And Unnecessary Genetic Testing



A 26-year-old woman made an appointment for a well woman exam and refill of her birth control medications at a clinic.  When the woman arrived, she was told that the physician with whom she had made an appointment was not available and that she would be seen by another physician.

Two MAs saw the patient.  One performed an examination, the other acted as a translator.  The patient requested a PAP smear and an STD test.  The patient was not offered a breast exam.  A detailed history was not obtained.  The patient underwent a PAP smear performed by the MA.  A urine sample was requested for the performance of a pregnancy test.  The patient again requested an STD test and was told that she would have to return for another visit for that test, and that she would have to return for a third visit to discuss the results of the lab tests and the PAP smear.  At that time, another MA entered the room and suggested that the patient complete genetic testing.  She reassured the patient that it would be covered by her insurance.  The patient agreed to proceed with the test and submitted to a cheek swab for the testing.

The physician arrived after the examination was completed and asked the patient if she had any questions.  The patient was given a three month prescription for birth control with no refills at the front desk.  The patient asked for additional refills and was told she would have to return for additional appointments.  After consultation with the physician, staff members told the patient that she would not be receiving additional refills because she was probably sterile due to the length of time she had been on birth control.  The patient cancelled her labs, informed the staff that she would not come back, and requested reimbursement and return of her registration fee and paperwork.  The physician returned the patient’s registration paperwork, refunded the registration fee, and called the police due to the patient’s agitated behavior.

The documentation for the examination indicated that the patient’s cervix was “red” or inflamed; however, there is no record that this was addressed or treated during the patient’s visit.

The physician’s office subsequently sent the patient’s sample for genetic testing.  The patient’s insurance denied coverage for the test, and the patient received an explanation of benefits from her insurer stating that she owed $3,800 for it.

In his response to the Board, the physician denied that he allowed his MA to perform the PAP smear on the patient and stated that he entered into the treatment room after the patient was prepped, draped, and “with her legs in the ‘up position’…With her head down and her legs up, the patient was unable to see me perform the Pap smear.”

The Board judged  physician’s conduct to be below the minimum standard of competence given failure to obtain a medical and family history, a medication list, an allergy list, a review of systems, and a complete physical examination.  The abnormal finding on exam was not addressed.  The patient had to pay for unnecessary genetic testing.

The Board ordered the physician to be reprimanded and take 10 of continuing medical education on well-woman examinations.

State: Arizona


Date: March 2017


Specialty: Family Medicine, Gynecology


Symptom: Gynecological Symptoms


Diagnosis: N/A


Medical Error: Failure to examine or evaluate patient properly


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



North Carolina – Internal Medicine – Prescribing Opiates Without Checking Controlled Substance Reporting System



In January 2016, a patient presented with a history of anxiety, depression, schizophrenia, bipolar disorder, and drug abuse.  The patient also had a history of chronic obstructive pulmonary disease and liver disease.  An internist took care of the patient until her death in June 2016 from opiate overdose.

The Board obtained the patient’s records and sent them to a qualified independent medical expert for review.  The independent medical expert judged the internist’s conduct to be below the minimum standard of competence given failure to obtain a full medical history, request medical records from other providers, and obtain a current list of medications taken by the patient.  During the patient’s first office visit, the internist obtained a blood test that showed evidence of liver disease.  In subsequent visits, the abnormal blood test with the possibility of liver disease was not addressed.

In addition, the independent medical expert was concerned that the internist failed to recognize and appropriately address aberrant behavior that may have been an indication of drug abuse or diversion.  Urine drug screens were not performed.  A controlled substance agreement was not signed.  The North Carolina Controlled Substance Reporting System (NCCSRS) was not checked until after the patient’s death.

In February 2016, the internist prescribed hydrocodone to treat the patient for wrist pain associated with an injury.  Because he did not search the NCCSRS, the internist did not know that the patient had received three prescriptions for hydrocodone and oxycodone from three providers in less than one month.

In March 2016, the patient reported that she had lost her prescription and needed an early refill.  Without checking the NCCSRS, the internist refilled a prescription for oxycodone.  If the internist had searched the NCCSRS, he would have seen that the patient had not lost her prescription, but had filled the prescription the same day she received it.  Additionally, the internist would have seen that just five days prior to her office visit, the patient had filled a second prescription for oxycodone written in the internist’s name.  Finally, the internist would have also seen that the patient had continued to receive oxycodone from another provider.

The Board expressed concern that the physician failed to conform to the standard of care.

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: March 2017


Specialty: Internal Medicine


Symptom: Extremity Pain


Diagnosis: Drug Overdose, Side Effects, or Withdrawal


Medical Error: Improper medication management, Procedural error


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Internal Medicine – Patient Prescribed Flurbiprofen Cream, Baclofen, Cyclobenzaprine, Gabapentin, And Lidocaine For Neuropathic Pain After Telephone Consultation



On April 2015, an internist had a telephone consultation with a patient.

On 4/23/2015, the internist prescribed the patient a cream consisting of flurbiprofen.  The patient was also given baclofen, cyclobenzaprine, gabapentin, and lidocaine to apply for neuropathic chronic pain.

At the time the prescription was written, the patient lived in New York.

The Medical Board of Florida judged the internists conduct to be below the minimal standard of competence given that she failed to create or maintain a documented patient evaluation that she had with the patient.  The internist did not perform or document performing a physical exam on the patient.  Also, the internist did not create or maintain medical records of having discussed treatment options and the risks and benefits of treatment with the patient.

It was requested that the Medical Board of Florida order one or more of the following penalties for the internist: 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: March 2017


Specialty: Internal Medicine


Symptom: Pain


Diagnosis: Neurological Disease


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


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Internal Medicine – History Of Atrial Fibrillation On Warfarin With INR Of 4.3 Started On Levofloxacin



On 3/26/2013, an 80-year-old female presented to a medical center with complaints of epigastric and right upper quadrant pain related to acute diverticulitis.

Upon the patient’s admission to the medical center, her medical records noted a history of atrial fibrillation and seizure disorder.  The records also indicated that she was on warfarin.

On 3/26/2013, the patient’s INR (admission INR) was recorded in the therapeutic range between 2.0 and 3.0.

On 3/26/2013, an internist improperly assessed the daily amount of warfarin that the patient was receiving prior to her admission to the medical center.  The internist increased the amount of the patient’s daily warfarin dosage.

The internist also prescribed Levaquin, an antibiotic, to treat the patient’s diverticulitis.  Levaquin can increase the anticoagulant effect of Warfarin.  On 3/28/2013, the patient’s INR was recorded as 4.3  On 3/29/2013, the patient’s INR was recorded as 8.9.

The administration of vitamin K and/or fresh frozen plasma is associated with anticoagulant reversal or moderation.  On 3/29/2013, the internist facilitated the oral administration of vitamin K to the patient.  Parenteral administration of vitamin K is indicated over oral administration in treating acute coagulopathy of the nature then-exhibited by the patient.

On 4/1/2013, the patient suffered an intracranial hemorrhage.

The internist did not facilitate the administration of fresh frozen plasma until 4/1/2013, after the patient exhibited neurologic change.  He did not facilitate the parenteral administration of vitamin K until 4/2/2013.

On 4/9/2013, the patient died from an intracranial hemorrhage due to Coumadin coagulopathy.

The Medical Board of Florida judged the internists conduct to be below the minimal standard of competence given that he failed to accurately assess the amount of warfarin that the patient was receiving prior to admission and treat with appropriate dosages accordingly.  The internist failed to recognize that the patient’s treatment for an acute infection, ingestion of Levaquin, and age put her at increased risk for acute coagulopathy, and treat accordingly.  He also failed to treat earlier for acute coagulopathy and with more aggressive methods, especially including earlier parenteral vitamin K and/or fresh frozen plasma.

It was requested that the Medical Board of Florida order one or more of the following penalties for the internist: 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: March 2017


Specialty: Internal Medicine


Symptom: Abdominal Pain


Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Cardiac Arrhythmia, Acute Abdomen


Medical Error: Improper medication management, Delay in proper treatment


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



California – Obstetrics – Postpartum Hemorrhage Diagnosed As Uterine Atony



On 1/15/2014, an obstetrician performed a Cesarean section on a patient.  The obstetrician documented no complications and a 600 ml blood loss.  Shortly after reaching the recovery room, the patient began vaginally hemorrhaging postpartum from what was diagnosed as uterine atony.  The obstetrician determined the patient was unstable and would need to return to the operating room (OR) after administering fluids and blood products and conducting a uterine massage.  Once in the OR, the patient was stabilized, yet continued persistent vaginal bleeding.  The decision was made by the obstetrician to reopen the abdomen and explore the prior Cesarean section.  After inspecting the uterus, the obstetrician made the determination that a supracervical hysterectomy was necessary.

A supracervical hysterectomy was performed by the obstetrician and another physician.  Once completed, a bimanual exam showed ongoing bleeding from the cervix.  An unsuccessful attempt was made to control the bleeding.  At this point, the determination was made to remove the cervix through the abdominal incision and a full hysterectomy was performed by the obstetrician and another physician. After the second surgery, the patient was taken to recovery in stable condition.

A discharge summary of the patient showed both placenta accreta and placenta increta in the endometrium and upper myometrium.

When the patient began hemorrhaging postpartum, the obstetrician appropriately returned to the patient’s bedside and examined her and ordered fluids and blood products as she alerted staff that the patient would need to return to the OR.

Once in the OR, however, the obstetrician failed to attempt more conservative therapies, including B-lynch suture, intrauterine balloon, uterine artery ligation, hypogastric artery ligation, and dilation and curettage.  There is no documentation that the obstetrician considered these options or ruled them out as potential actions prior to performing a hysterectomy on the patient.

On 6/7/2016, the obstetrician underwent an evaluation by a Board appointed psychiatrist.  The psychiatrist concluded that the obstetrician suffers from Major Depressive Disorder, Recurrent, and an Unspecified Anxiety Disorder, conditions that impair her ability to safely practice medicine.

The obstetrician was placed on probation for three years with stipulations to complete 40 hours annually for each year of probation of continuing medical education, complete a medical record keeping course, and undergo psychotherapy.

State: California


Date: March 2017


Specialty: Obstetrics


Symptom: Bleeding


Diagnosis: Obstetrical Hemorrhage


Medical Error: Improper treatment, Lack of proper documentation, Practicing while not being sound physically or mentally


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Dermatology – Pathologist Performs Botox And Radiesse Injections Resulting In Complications



On 6/20/2014, a pathologist performed Botox injection to a patient’s forehead and Radiesse injections to her cheeks in the pathologist’s home.

Three days later, on 6/23/2014, the patient complained of severe swelling and redness at the injection sites on her cheeks.

The pathologist advised the patient to use a cold compress, to apply hydrocortisone cream, to take Claritin and ibuprofen, and to return for follow up in two days.

Shortly thereafter, the patient began to experience more swelling and draining at the injection sites.

On 6/26/2014, the patient presented to the pathologist for a follow-up appointment.  The pathologist documented that the patient’s swelling had subsided and that her pain was mainly relieved.  The patient was instructed to continue to take Claritin and ibuprofen for two weeks.

On 7/10/2015, the patient presented to a physician with complaints of pain, swelling, and drainage at the injection sites.  The physician treated the patient for abscesses that had occurred at the injection sites.

The Medical Board of Florida judged the pathologists conduct to be below the minimal standard of competence given that the pathologist did not record the lot number of the Radiesse in the patient’s chart.  Also, the pathologist placed the injection too close to the patient’s eye area.  The pathologist placed the injections too superficially in the patient’s skin.  The pathologist incorrectly diagnosed the patient with a hypersensitivity reaction.

The Medical Board of Florida issued a letter of concern against the pathologist’s license.  The Medical Board of Florida ordered that the pathologist pay a fine of $5,000 against her license and pay reimbursement costs for the case at a minimum of $5,175.43 and not to exceed $7,175.43.  The Medical Board of Florida also ordered that the pathologist complete a records course within one year of the final order, complete ten hours of continuing medical education in cosmetic procedures, and complete five hours of continuing medical education in “risk management.”

State: Florida


Date: March 2017


Specialty: Dermatology, Pathology


Symptom: Dermatological Abnormality, Swelling, Wound Drainage


Diagnosis: Dermatological Issues


Medical Error: Diagnostic error, Lack of proper documentation, Procedural error


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Internal Medicine – Narcotic Medication Mismanagement And Lack Of Treatment For Hypertension And Weight Gain



A 31-year-old man was a history of anxiety and chronic left shoulder pain from a left labral tear documented by a shoulder Magnetic Resonance Imaging (MRI) in July 2009.  The patient was 77 inches tall and weighed 325 pounds.

On 6/11/2007, the patient first saw an internist.  He was diagnosed with a “sprain of the scapula.”  The only positive finding noted was tenderness of his left scapula wing, and he was prescribed hydrocodone/acetaminophen 10 mg/325 mg and alprazolam.

On 6/18/2007, the patient returned complaining of insomnia.  The internist prescribed zolpidem and carisoprodol.

On 7/6/2007, the patient came back complaining of abdominal pain that was attributed to ibuprofen.  He was given esomeprazole and hydrocodone/acetaminophen was discontinued.  He was given a dietary supplement called “Sleep Tight” for his sleep disorder, which he preferred to zolpidem.

On 8/21/2007, the patient returned.  His gastritis had resolved, and he was given alprazolam for anxiety and tramadol for pain.

On 11/9/2007, the patient was given alprazolam 2 mg every 6 hours.

On 12/7/2007, the patient was seen for anxiety.  The internist prescribed buspirone daily and continued alprazolam 2 mg every 6 hours.  The patient was then not seen by the internist for a year and a half.

On 5/6/2009, the patient presented with complaints of anxiety and insomnia.  Blood pressure was noted to be 185/98.  The internist advised the patient to start on a 2 gm per day sodium-restricted diet.  The internist continued the patient on alprazolam.  The Board noted that the internist neither took an adequate history nor performed an adequate physical examination.  The internist neither recommended a weight loss program and nor medications to address the patient’s elevated blood pressure.

On 6/19/2009, the patient came in for a dislocation of his shoulder.  The patient’s blood pressure was better.  The internist prescribed oxycodone/acetaminophen.  The internist tapered his alprazolam and again noted the patient’s problems with anxiety and insomnia.  The internist prescribed the patient tramadol and hydromorphone.

On 7/1/2009, the patient returned for a clinic visit and stated that he had obtained an MRI.  He was found to have had a torn labrum and had been seen by an orthopedic surgeon with plans to perform a left shoulder arthroscopy.  The patient had been prescribed hydromorphone.

On 7/22/2009, the internist prescribed a fentanyl patch for baseline pain control and hydromorphone for breakthrough pain.  There was no documentation that the internist had communicated with the orthopedic surgeon.

On 8/10/2009, the patient visited the internist and said that he had undergone arthroscopic surgery, which went well.

On 08/31/2009, the patient returned and stated that his shoulder pain had resolved.  He complained of low back pain.  The internist then prescribed a fentanyl patch at a dose of 125 mcg (100 mcg plus 25 mcg).  Hydromorphone was discontinued.  The patient’s blood pressure was 180/100 and was not addressed.

On 9/25/2009, the patient had lost a substantial amount of weight.  Blood pressure decreased down to 150/92.  The internist continued to prescribe fentanyl.

On 11/20/2009, the internist refilled the fentanyl patch prescription for both the 100 mcg and 25 mcg patches.

On 1/15/2010, the patient’s weight had gone up to 244 pounds.  He was using hydrocodone/acetaminophen.  The internist prescribed citalopram 60 mg (which the Board noted was a high starting dose that may increase the risk of cardiotoxicity).

On 4/26/2010, the patient presented for a clinic visit.  The internist had switched from a sparsely documented written record to an electronic typed record.  It was noted that the patient was on hydrocodone/acetaminophen 7.5 mg/325 mg and alprazolam 2 mg three times a day.  His blood pressure was 156/88, and his weight had increased to 283 pounds.  The hydrocodone/acetaminophen was stopped and hydrocodone/acetaminophen 10 mg/325 mg was prescribed.  Per the Board, this note had much better documentation, but still no analysis of the patient’s clinical problem.  The Board noted that the patient had Kaiser Insurance and noted that the internist did not document why the patient was getting pain medications outside of Kaiser’s clinics.  The internist did not address the patient’s weight gain or hypertension.

On 9/30/2010, the internist’s assessment was a sprain of the shoulder, and he again prescribed hydrocodone/acetaminophen 10 mg/325 mg.  He suggested heat, ice, and physical therapy.

The patient’s last visit with the internist occurred on 10/26/2010.  The patient explained that he had hurt his back.  He had been taking hydrocodone/acetaminophen, which reduced the pain from a 10 to a 7.  His blood pressure was 178/106.  His weight had increased to 308 pounds.  The internist did not address the patient’s weight gain or hypertension.  The only diagnosis was sprain/strain at the unspecified site of the upper arm.  Hydrocodone/acetaminophen 10 mg/325 mg was prescribed with 8 mg hydromorphone for breakthrough pain.  The patient was later seen by a different doctor who prescribed methadone.

On 11/11/2010, the patient was found unconsciousness and brought to an emergency department where he was pronounced dead.

The Board judged the internist’s conduct to have fallen below the standard of care given failure to coordinate with other physicians regarding pain control, failure of documentation, failure to address the patient’s hypertension, failure to monitor the efficacy of the narcotic medications, failure to appropriately prescribe narcotic medications, and failure to administer citalopram at a reasonable starting dose.

The internist was placed on probation for 35 months with the stipulations that he complete 20 hours of continuing medical education per year for each year of probation, complete a prescribing practices course, complete a medical record keeping course, and undergo monitoring by a designated clinical monitor.

State: California


Date: March 2017


Specialty: Internal Medicine


Symptom: Pain, Back Pain, Extremity Pain, Joint Pain, Psychiatric Symptoms


Diagnosis: Drug Overdose, Side Effects, or Withdrawal


Medical Error: Improper medication management, Failure to examine or evaluate patient properly, Failure of communication with other providers, Failure to properly monitor patient, Improper treatment, Lack of proper documentation


Significant Outcome: Death


Case Rating: 2


Link to Original Case File: Download PDF



California – Plastic Surgery – Smart-Lipo On Entire Thigh Circumference



On 1/19/2012, a 27-year-old female had a consultation with a plastic surgeon for Smart-Lipo to her thighs from the knee to the buttock and laser skin rejuvenation.  The plastic surgeon recommended that Smart-Lipo be performed. The patient completed several pre-printed forms, including an “Information Regarding Patients with High BMI” form and a “Consent for Surgical Procedure and/or Treatment” form.  On the “Consent for Surgical Procedure” form. The patient checked the boxes for surgery to be performed on her outer thighs, inner thighs, knees, and “banana rolls”.

The patient also completed a pre-printed “Smart-Lipo Medical History and Intake” form where she circled the following medical issues: recreational drugs, recent weight loss or gain, contact lenses, depression, anxiety, and hospitalizations.  The patient then wrote that she had trouble with anxiety and depression in her twenties; she gained 30 pounds in the past year following a broken ankle; and she was hospitalized 3 years ago for a broken nose. There was no further discussion or documentation about the patient’s use of recreational drugs.  On this same form, the patient wrote that she had smoked 5 cigarettes per day for the past 2 years. The patient also wrote that she got “drunk every Saturday night.” There was no further discussion or documentation in the medical record about the patient’s alcohol or cigarette use.

After the initial patient consultation, pre-operative lab testing was performed, which revealed an elevated hematocrit and an elevated fasting glucose level.  An EKG was also performed. There was no mention in the medical records of any further work-up or physical examination nor any notation that the patient was notified of the elevated hematocrit and glucose levels.  The surgery was scheduled for 2/8/2012. There was also no pre-operative discussion or documentation in the medical records about the surgical goals. The plastic surgeon also did not conduct a urine pregnancy test before surgery to ensure the patient was not pregnant.

On 1/25/2012, the patient arrived at the surgery center for a pre-procedural evaluation by a Licensed Vocational Nurse (LVN).  The “Pre-Procedural Evaluation for Smart-Lipo” form indicated that the patient was 5’5”, 156.6 pounds, and had a BMI of 26.1 at the time of surgery.  The LVN took a circumference measurement of the patient’s left and right thighs (inner and outer) and her knees. There was no record in the file that the patient met with the plastic surgeon or any other physician before the surgery.

On 2/8/2012, the plastic surgeon performed Smart-Lipo on the patient.  Additional leg circumference measurements were taken of the patient’s knees and thighs.  The patient was pre-medicated with Vicodin, Ativan, and Keflex before the surgery. The plastic surgeon infused the patient with 5.9 L of tumescent fluid containing 50 mL per L of lidocaine with 1 mL of epinephrine (500 mg of lidocaine per L).  The patient received 2,950 mg of lidocaine. A dose of more than 2,481 mg of lidocaine could be potentially toxic to the patient. The plastic surgeon noted that she removed “2,400 cc” of aspirate, of which “1,400 cc” was deemed fat.

On 9/17/2012, at the 6-month follow-up appointment, the patient expressed concern about the results and that she expected more of a noticeable change to her thighs.  The note indicated that the patient would be scheduled to meet with the plastic surgeon to “address her concerns.” Leg circumference measurements were taken at the 2 other post-operative follow-up appointments as well.

On 12/17/2012, staff at the surgery center completed a pre-procedure checklist for Smart-Lipo revision surgery scheduled for 12/19/2012 with the plastic surgeon.  No new lab work was performed, including the failure to conduct a pregnancy test. The patient was advised to stop smoking 2 weeks before the surgery, but the surgery was already scheduled to take place in 2 days from this pre-operative appointment.

On 12/19/2012, the patient underwent a second Smart-Lipo procedure in order to try to reduce the contours differences.  The plastic surgeon infused 2.8 L of tumescent fluid into the patient’s thighs and removed “1,800 cc” of total aspirate, of which “800 cc” was fat.

The patient continued to see staff at the surgery center for follow-up appointments.  The staff continued recording thigh circumference measurements. At the 6-month follow-up appointment, the patient expressed dissatisfaction with her results.  She indicated that people would comment about “indentations” to her thighs, that she had pain in her legs, and veins were “popping out” in her thighs. The patient informed staff that she had an estimate for a revision surgery from another surgeon for $4,000.  Staff scheduled a follow-up appointment with another plastic surgeon because the patient refused to see the plastic surgeon.

On 9/25/2013, the patient met with the other plastic surgeon to discuss her concerns.  The other plastic surgeon noted that the patient had “irregular thighs” and that the patient was “not happy” with the results.  The other plastic surgeon wrote that she “advised correction” to the thighs. No further information was included in the record about the extent of the revision of which portion of the thighs needed correction.

The post-operative pictures of the patient clearly showed dents and veins in the thighs, but the photos the plastic surgeon that did the initial Smart-Lipo were not labeled and appeared to be out of order, which made it difficult to determine the overall effectiveness of the initial surgery and subsequent revision surgery.

The Medical Board of California judged that the plastic surgeon’s conduct departed from the standard of care because he failed to recognize that the patient was not an appropriate candidate for Smart-Lipo surgery, address the patient’s cigarette usage before performing surgery, adequately inform the patient of the risks associated with smoking, drinking, and recreational drug use before surgery, perform a pregnancy test before performing both surgeries on the patient, and document any discussions with the patient.  The plastic surgeon’s use of Smart-Lipo on the patient’s entire thigh circumference showed a lack of knowledge because this procedure should not be used to contour such large areas without expecting to see dents and waviness.

The Medical Board of California issued a public reprimand and ordered the plastic surgeon to complete a medical record keeping course and a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California


Date: March 2017


Specialty: Plastic Surgery


Symptom: Extremity Pain


Diagnosis: N/A


Medical Error: Unnecessary or excessive treatment or surgery, Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Failure of communication with patient or patient relations, Improper medication management, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



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