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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 – Multiple Complications During Cardiac Catheterization With Repeat Thrombosis Of The Right Coronary Artery
On 05/30/2014, a 56-year-old man presented with acute onset chest pain. The cardiologist discovered that the left anterior descending (LAD) and right coronary artery (RCA) had significant stenosis. The cardiologist first intervened up on the LAD with a stent, but found the proximal edge had “haziness” so he did not intervene further. The cardiologist then focused on the RCA. The first stent was deployed, but had a dissection for which the cardiologist deployed multiple other stents to correct. Brisk flow in all coronaries was reported at the conclusion of these procedures.
The patient experienced a sudden thrombosis of the RCA two days later. The cardiologist placed 3.5 diameter stents and used 2.0 and 2.5 mm balloons to reopen the RCA. The patient also developed cardiogenic shock and acute respiratory failure from probably aspiration and required emergency intubation, which was described as traumatic. The patient was on pressors and an intra-aortic balloon pump (IABP) was placed.
On 06/02/2014, the patient was noted to be improving with decreased dependence on pressors. The IABP was removed the following day, but the patient became progressively agitated and experienced increased ST changes.
On 06/05/2014, the patient became hypoxic with ST elevation and was taken back to the catheterization lab where it was determined that the RCA was thrombosed. The cardiologist performed balloon angioplasty on the RCA during which a perforation of the posterior descending (PDA) branch occurred. The cardiologist made several attempts to stop the bleeding, including prolonged balloon inflations, which failed, and an attempt to completely occlude the PDA branch by placing a covered stent. The stent could not be placed or withdrawn in the location of concern and was deployed more proximally. A wire was left in the mid-RCA, which was ultimately coiled by an interventional radiologist due to ongoing bleeding. The cardiologist noted a pericardial effusion, which did not demonstrate tamponade and did not require pericardiocentesis.
Over the next several days, the patient continued to experience worsening abdominal distention, right heart failure, episodes of bradycardia (which the Board deemed was not adequately addressed by the cardiologist), mottling of the lower extremities, liver congestion, and acute renal failure. On 06/08/2014, the IABP was removed.
On 06/10/2014, the patient went into multi-organ system failure. The decision was made to make the patient comfortable. The patient had runs of ventricular arrhythmias and passed away that evening.
The Board judged that while there was no single defined even in the cardiologist’s treatment of the patient that would be considered a deviation of a standard of care, there were several areas of concern regarding his treatment of the patient.
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
Diagnosis: Acute Myocardial Infarction
Medical Error: Procedural error
Significant Outcome: Death
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Obstetrics – Pitocin Dosing Of 18 milliunits/hour To 30 milliunits/hour Prescribed For Labor
On 1/7/2012, a patient was admitted to a medical center for the birth of her child.
At 4:30 p.m., an obstetrician ordered the patient to receive intravenous Pitocin 20 m units/1000 ml, starting at 2 m units/minute (6ml/hour). From 4:30 p.m. to 7:00 p.m., Pitocin was increased in increment of 2 m units/minute, as per the obstetrician’s order. By 7:00 p.m., the patient was administered 10 m units/minute (30ml/hour) of Pitocin.
Over the next nine hours, the dosage of Pitocin was intermittently increased and decreased, vacillating between 6 m units/minute (18ml/hour) and 10 m units/minute (30 ml/hour).
The increases and decreases in Pitocin administered were not substantially justified by the frequency of the patient’s contractions.
During the patient’s labor, she displayed a pattern of uterine hyperstimulation.
The Medical Board of Florida judged the obstetrician’s conduct to be below the minimal standard of competence given that she failed to adequately treat the patient for uterine hyperstimulation, to include the discontinuation of Pitocin. The obstetrician failed to adequately assess and/or appropriately respond to the child’s level of distress, indicated by the fetal monitoring strip, by failing to utilize internal monitoring of uterine activity and/or fetal heart tracing. The obstetrician failed to undertake intrauterine resuscitation, and/or failed to expeditiously deliver the child via Cesarean section or operative vaginal delivery.
The Medical Board of Florida issued a letter of concern against the patient’s license. The Medical Board of Florida ordered that the obstetrician pay a fine of $8,000 against her license and pay reimbursement costs for the case at a minimum of $6,859.96 and not to exceed $8,859.96. Also, the Medical Board of Florida ordered the obstetrician to complete five hours of continuing medical education in labor induction and five hours of continuing medical education in “risk management.”
State: Florida
Date: April 2017
Specialty: Obstetrics
Symptom: N/A
Diagnosis: Obstetrical Complication
Medical Error: Improper medication management, Failure to properly monitor patient
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
Florida – Internal Medicine – Patient Presents With Chest Pain That Started To Radiate To His Arms
From 2/22/2010 through 11/2/2011, a patient presented to an internist for medical assessment and/or treatment.
The patient presented to the internist with chest pain, unknown family medical history, several comorbid medical problems related to possible heart disease, and possible reflux esophagitis.
On 6/22/2011, during a medical evaluation, the internist noted that the chest pain changed in characteristic and began to radiate to his arms.
Despite the change in chest pain noted by the internist on 6/22/2011, he did not recommend a cardiologic evaluation and continued to treat the patient for possible reflux esophagitis.
On 10/4/2011, during a medical evaluation, the internist noted no complaints of heartburn but continued complaints of chest pain.
Between 6/22/2011 and 12/3/2011, the internist failed to refer the patient for cardiological evaluation.
On 12/3/2011, the patient died from a cardiac arrest.
The Medical Board of Florida issued a letter of concern against the internist’s license. The Medical Board of Florida ordered that the internist pay a fine of $7,500 against his license and pay reimbursement costs for the case at a minimum of $3,458.14 and not to exceed $5,458.14. The Medical Board of Florida ordered that the internist complete ten hours of continuing medical education in cardiovascular medicine and five hours of continuing medical education in “risk management.”
State: Florida
Date: April 2017
Specialty: Internal Medicine
Symptom: Chest Pain
Diagnosis: Acute Myocardial Infarction, Cardiac Arrhythmia
Medical Error: Referral failure to hospital or specialist
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF