Found 35 Results Sorted by Case Date
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Florida – Pain Management – Wrong Concentration Of Hydromorphone Programmed Into Intrathecal Pain Pump



In December 2007, a 55-year-old male had an intrathecal pain pump inserted for pain control at the recommendation of his pain management specialist.  He had been prescribing the patient hydromorphone with a concentration of 10 mg/ml.

From 1/31/2012 to 2/15/2012, upon referral by his physician, the patient presented to a new pain management specialist for pain management.

At the initial visit, on 1/31/2012, the pain management specialist ordered a prescription of hydromorphone injectable solution with a concentration of 30 mg/ml to refill the patient’s intrathecal pain pump.

On 2/15/2012, the patient presented to a pain management center to have his intrathecal pain pump refilled with the hydromorphone prescription and reprogrammed.

A physician assistant refilled the patient’s intrathecal pain pump with hydromorphone with a concentration of 30 mg/ml; however, the concentration of the hydromorphone that was programmed into the intrathecal pain pump remained at 10 mg/ml.

The Medical Board of Florida judged the pain management specialists conduct to be below the minimal standard of competence given that he failed to verify that the correct concentration of hydromorphone was administered into the intrathecal pain pump after it was refilled on 2/15/2012 and he failed to verify the correct concentration of the hydromorphone was programmed into the intrathecal pain pump.

The patient expired at his home on 2/15/2012.

It was requested that the Medical Board of Florida order one or more of the following penalties for the pain management specialist: 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: April 2017


Specialty: Pain Management, Anesthesiology


Symptom: Pain


Diagnosis: Drug Overdose, Side Effects, or Withdrawal


Medical Error: Accidental Medication Error, Improper supervision


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



New York – Internal Medicine – Chronic Fatigue, Disturbed Sleep, Joint Pains, Nausea, Diarrhea, And An Abnormal MRI Diagnosed As Chronic Fatigue Syndrome



From 10/15/1998 to 3/7/2008, Physician A treated a 38-year-old female who presented with complaints of severe fatigue, disturbed sleep, irritability, joint pains, frequent sore throats, nausea, and diarrhea.  At her initial visit, the patient reported that 9 years earlier she had been told she had a borderline Lyme test and was treated with antibiotics.  In the past 5 years, she had frequent bouts of fatigue and was diagnosed with Chronic Fatigue Syndrome.

In December 1998, the patient was seen by a neurologist who, based on an abnormal MRI, recommended a lumbar puncture but one was not done.  In June 1999, the patient had an abnormal brain SPECT.  In January 2002, the patient had her first and only physical examination at Physician A’s practice.  In January 2008, ten years after the initial MRI, the patient had a second MRI, which was again abnormal.  A neurologist performed a lumbar puncture.

The results of the lumbar puncture were negative for Lyme disease but revealed positive oligoclonal band proteins which are consistent with the diagnosis of multiple sclerosis.

The Board judged Physician A’s conduct to have fallen below the standard of care given failure to take an adequate history of present illness, failure to obtain prior medical records, failure to perform a physical examination, failure to construct a differential diagnosis, failure of prescribing medications without appropriate medical conditions, failure to perform a lumbar puncture, and failure to timely diagnose the patient’s multiple sclerosis.

The Board charged Physician A with professional incompetence and gross negligence.

State: New York


Date: April 2017


Specialty: Internal Medicine, Family Medicine, Neurology


Symptom: Weakness/Fatigue, Nausea Or Vomiting, Joint Pain


Diagnosis: Neurological Disease, Autoimmune Disease


Medical Error: Diagnostic error


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



New York – Internal Medicine – Pain Associated With PICC Line



From 7/8/2008 to August 2008, Physician A treated a 46-year-old woman with a history of Parkinson’s disease diagnosed in May 2008.  At her initial visit, she reported that in early May 2008, she had a tick bite with subsequent bull’s eye rash.  She had been treated with antibiotics and intramuscular injections for approximately seven weeks.

Physician A ordered a PICC line for the administration of parenteral antibiotics, which was placed on 7/17/2008.  One week later, the patient complained of pain in her neck and shoulder.  On 7/31/2008, the patient reported extreme pain.  The patient had a venous Doppler study, which indicated deep vein thrombosis.  The patient was admitted to the hospital where the PICC line was removed, and the patient was placed on anticoagulant therapy.

The Board judged Physician A’s conduct as having fallen below the minimum level of competence given failure to take an appropriate history, failed to perform a physical exam, failure to construct a differential diagnosis, and failure to evaluate her pain in a timely fashion.

State: New York


Date: April 2017


Specialty: Internal Medicine, Family Medicine


Symptom: Extremity Pain, Head/Neck Pain


Diagnosis: Deep Vein Thrombosis/Intracardiac Thrombus


Medical Error: Diagnostic error


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Internal Medicine – Tissue Plasminogen Activator Administered To A Patient With A History Of Intracranial Hemorrhage



On 3/12/2014, a 78-year-old male presented to the medical center.  Upon admission, a brain CT revealed a history of intracranial hemorrhage.

On 3/15/2014, a stroke alert was called due to the belief that the patient had suffered a stroke, setting in motion a hospital protocol to check for stroke.

A stat CT scan revealed subacute or chronic left suboccipital stroke, which did not correspond with the patient’s acute symptoms.

An internist ordered a neuro consult and gave a history that did not include intracranial hemorrhage.  He ordered and confirmed tissue plasminogen activator (“tPA”) to be administered to the patient, which is contraindicated for patients with a history of intracranial hemorrhage.  He did not obtain an MRI of the brain.

The Medical Board of Florida judged the internists conduct to be below the minimal standard of competence given that he did not order an MRI of the brain since symptoms and the stat CT did not correspond.  He ordered tPA for a patient with a history of intracranial hemorrhage.  He also failed to give an accurate history of intracranial hemorrhage to the neurologist.

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: April 2017


Specialty: Internal Medicine, Neurology


Symptom: N/A


Diagnosis: Neurological Disease


Medical Error: Improper medication management, Failure to order appropriate diagnostic test, Failure of communication with other providers


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Pain Management – Infection Of Left Prosthetic Knee Following Injections Of Zeel And Traumeel With Bupivacaine



On 9/15/2011, a 57-year-old male presented to a pain management specialist with complaints of knee pain in his prosthetic knees.

On 10/13/2011, the pain management specialist established a treatment plan to obtain x-rays of the patient’s knees and refer him to an orthopedic surgeon for evaluation of his prosthetic knees.

The pain management specialist failed to review, or document reviewing, x-rays of the patient’s prosthetic knees.  He also failed to refer the patient to an orthopedic surgeon for evaluation of his knee pain, per his treatment plan.

On 2/2/2012, the pain management specialist injected Zeel and Traumeel (both homeopathic products) with bupivacaine into the patient’s prosthetic left knee.

The pain management specialist did not create or maintain records documenting an examination of the patient’s left knee for the 2/2/2012 appointment.

On 2/8/2012, the pain management specialist performed a second injection of Zeel and Traumeel with bupivacaine into the patient’s prosthetic left knee.  He did not create or maintain records documenting an examination of the patient’s left knee for the 2/8/2012 appointment.

Shortly after the second injection, the patient’s left knee began to swell, and on 2/21/2012, he presented to an orthopedic institute with complaints of pain, swelling, and redness.

An orthopedic surgeon admitted the patient to a hospital for further evaluation.  At the hospital, the patient was diagnosed with acutely infected left total knee arthroplasty and, on 2/25/2012, underwent surgery to remove part of the left knee prosthesis, insert an antibiotic disc and PICC line, and begin IV antibiotics.

The Medical Board of Florida judged the pain management specialists conduct to be below the minimal standard of competence given that he should not have injected homeopathic substances into the patient’s prosthetic left knee and he did not refer the patient to an orthopedic surgeon for evaluation of his left knee pain.

It was requested that the Medical Board of Florida order one or more of the following penalties for the pain management specialist: 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: April 2017


Specialty: Pain Management, Anesthesiology, Orthopedic Surgery


Symptom: Joint Pain, Swelling


Diagnosis: Procedural Site Infection


Medical Error: Unnecessary or excessive treatment or surgery, Failure to examine or evaluate patient properly, Referral failure to hospital or specialist, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Oncology – Wrong Area Excised When Attempting To Remove Melanoma Of The Posterior Upper Left Arm



On 5/1/2013, a patient presented to an oncologist for a sentinel lymph node biopsy and a radical excision of a melanoma on the posterior aspect of her left upper arm.

When attempting to excise the melanoma on the posterior aspect of the patient’s left upper arm, the oncologist performed the excision on the wrong area of the posterior aspect of the patient’s left upper arm.

Post-operatively, the oncologist sent a specimen from the patient’s left upper arm excision to pathology.

On 5/6/2013, a surgical pathology report was issued stating that the specimen from the left upper arm excision was negative for melanoma.

On 5/6/2013, the patient underwent a second surgical procedure, and the melanoma was excised from the correct area of the posterior aspect of the patient’s left upper arm.

The Medical Board of Florida judged the oncologist’s conduct to be below the minimal standard of competence given that the oncologist performed the wrong site procedure when he performed a surgical excision on the wrong area of the posterior aspect of the patient’s left upper arm.

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


Specialty: Oncology, Dermatology


Symptom: N/A


Diagnosis: Cancer


Medical Error: Wrong site procedure


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Emergency Medicine – Pelvic Pain And Vaginal Bleeding With Urinalysis Revealing A Glucose Level >1000



On 8/21/2014, a patient presented with complaints of pelvic pain and vaginal bleeding.  The patient was examined by a physician assistant supervised by an ED physician.

The physician assistant ordered laboratory evaluation for the patient, which included bloodwork, cervical/vaginal swabs, pelvic ultrasound, and urinalysis.

The urinalysis revealed the patient’s glucose level to be >1000, which was so high that it could not be measured.

The physician assistant gave the patient a prescription for Flagyl, an antibiotic, gave her education materials on uterine bleeding, bacterial vaginosis, dehydration, and ovarian cysts, and instructed her to follow up with her primary care physician and gynecologist.   The physician assistant discussed the patient’s case with the ED physician and the ED physician agreed with the plan of care.

The ED physician did not perform or order a finger stick glucose test or a basic metabolic panel.

The ED physician did not discuss and/or did not order the physician assistant to discuss the patient’s glucose level in relation to her possible new onset of diabetes and did not recommend or order the physician assistant to recommend further evaluation and treatment of her elevated glucose levels.

The ED physician did not administer or order the administration of intravenous fluid and insulin.

On 8/26/2014, the patient expired due to diabetic ketoacidosis.

The Medical Board of Florida judged the ED physician’s conduct to be below the minimal standard of competence give that she failed to administer or order the administration of a finger stick glucose test or basic metabolic panel, discuss or instruct the physician assistant to discuss the patient’s glucose levels in relation to her possible new onset of diabetes and recommend further evaluation and/or treatment of her elevated glucose levels, and failed to administer or order the administration of intravenous fluid and insulin.

It was requested that the Medical Board of Florida order one or more of the following penalties for the ED physician: 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: April 2017


Specialty: Emergency Medicine, Endocrinology, Physician Assistant


Symptom: Pelvic/Groin Pain, Abnormal Vaginal Bleeding


Diagnosis: Diabetes


Medical Error: Failure to follow up, Failure to order appropriate diagnostic test, Failure of communication with other providers, Improper supervision, Improper medication management


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Arizona – Cardiology – Hypotension, Tachycardia, Respiratory Distress, And Hypovolemic Shock During Pericardiocentesis



A 67-year-old woman with a history of Crohn’s disease presented to a cardiologist in consultation for a pericardial effusion.

On 04/10/2014, the cardiologist performed a pericardiocentesis.  1400 ml of bloody drainage had been removed when the patient developed hypotension, tachycardia, respiratory distress, and hypovolemic shock.  She required intubation.  The cardiology removed another 2000 ml of fluid before he removed the catheter used for the pericardiocentesis.  The patient required 6 units of PRBC’s, 4 units FFP, and 2 liters of NS to get stabilized.  In the intensive care unit, the patient was on phenylephrine and dopamine before she was gradually weaned off of pressors and the ventilator.  The patient was discharged in good condition.

The Board judged the cardiologist’s conduct to be below the minimum standard of competence given failure to recognize that he was not in the pericardial space and failure to use echocardiography to verify proper placement.  The cardiologist deviated from the standard of care by continuing to withdraw fluid from the patient and failing to verify that he was in the pericardial space.

The Board ordered the cardiologist to be placed on probation given complications among several patients he had managed.  He was prohibited from performing interventional cardiology until the Board granted him permission.  The cardiologist must provide evidence that he is able to safely perform interventional cardiology before the Board would consider lifting the prohibition.

State: Arizona


Date: April 2017


Specialty: Cardiology


Symptom: N/A


Diagnosis: Post-operative/Operative Complication


Medical Error: Procedural error


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



Arizona – Cardiology – Cardiac Catheterization With Questionable Indications Results In Complications



A 76-year-old woman was diagnosed with severe aortic stenosis.

On 03/20/2014, the cardiologist performed cardiac catheterization which consisted of left and right coronary angiograms and left ventriculogram.  The patient experienced chest pain and syncope after the catheterization.  A STAT echocardiogram was performed and revealed aortic stenosis, normal LV function, and no pericardial effusion.  Troponins were elevated after the cardiac catheterization.

On 03/22/2014, the patient was taken to the operating room and was reported to have a pericardial effusion with non-clotting blood and evidence of early tamponade.  The aortic valve was replaced.  After surgery, the patient had difficulty weaning from the cardiopulmonary bypass machine and an intra-aortic balloon pump was required.  The patient was subsequently weaned off pressors and the IABP, and she was extubated one day postoperatively.  The patient had episodes of atrial fibrillation postoperatively and was discharged on 03/27/2014.

The Board judged the cardiologist’s conduct to be below the minimum standard of competence given failure to perform a left heart catheterization and left ventriculogram without proper indications.  Further details are unclear as to why the Board focused on this concern (given that left heart catheterization is often done in a patient with severe aortic stenosis to evaluate for coronary artery disease in case bypass graft surgery is required during aortic valve replacement, although one could argue the left ventriculogram was not warranted).

The main concern appeared to be that the cardiologist had a pattern of complications with concern that the complication of hemopericardium after cardiac catheterization indicated a deficiency of skills that increased the risk of complications among his patients.

The Board ordered the cardiologist to be placed on probation given complications among several patients he had managed.  He was prohibited from performing interventional cardiology until the Board granted him permission.  The cardiologist must provide evidence that he is able to safely perform interventional cardiology before the Board would consider lifting the prohibition.

State: Arizona


Date: April 2017


Specialty: Cardiology


Symptom: Chest Pain, Syncope


Diagnosis: Post-operative/Operative Complication


Medical Error: Procedural error


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Family Medicine – Patient With Hypotension And Tachycardia Treated With 2 Liters Of Intravenous Normal Saline



On 11/12/2013, a patient presented with complaints of nausea, vomiting, and abdominal pain.  The patient also had a history of deep vein thrombosis (DVT) and renal cell carcinoma.

The patient’s pertinent physical findings included a hypotensive blood pressure of 84/56 and a pulse of 158 beats per minute.  The patient received two liters of intravenous normal saline without improvement in his blood pressure.

On 11/13/2013, at 2:00 a.m., a family practitioner admitted the patient to the hospital and implemented a plan of care to include a routine lab work, normal saline, chest x-ray, and medications.

The family practitioner failed to address the patient’s history of DVT and anticoagulation therapy.

At 3:50 a.m., the patient suffered a fall, became unresponsive, and could not be resuscitated.

The prevailing standard of care in an urgent care setting is to identify the patients who can be treated with basic intervention and be safely discharged to the ambulatory setting, or alternatively to identify the patients who are at risk of losing life or limb and must be transferred to a higher level of care where resources are available to address, diagnose, and treat the life-threatening condition in a timely manner.

The Medical Board of Florida judged the family practitioner’s conduct to be below the minimal standard of competence given that he failed to recognize and address the patient’s grossly abnormal vital signs, which included a heart rate of 158 beats per minute and a systolic blood pressure under 100 mmHg, which did not stabilize after an intravenous fluid bolus.  The family practitioner also failed to treat the patient with more aggressive intravenous fluid resuscitation.  He failed to order STAT lab work, instead of routine lab work.  He failed to acknowledge, document, or treat the patient’s anticoagulated blood by reversing the anticoagulation with intravenous vitamin K and transfusing fresh frozen plasma.

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 $7,500.00 against his license and pay reimbursement costs for the case at a minimum of $2,023.11 and not to exceed $4,023.11.  The Medical Board of Florida also ordered that the family practitioner complete five hours of continuing medical education in emergency medicine and five hours of continuing medical education in “risk management.”

State: Florida


Date: April 2017


Specialty: Family Medicine, Emergency Medicine, Internal Medicine


Symptom: Abdominal Pain, Nausea Or Vomiting


Diagnosis: Cardiovascular Disease


Medical Error: Underestimation of likelihood or severity, Failure to order appropriate diagnostic test, Referral failure to hospital or specialist, Improper medication management


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



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