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On 6/1/2015, a 65-year-old male with a history of hypertension, atrial fibrillation, hyperlipidemia, depression, and anxiety, visited his primary care physician (PCP) complaining of spontaneous movement and loss of sensation in his left arm.  On physical examination of this patient, his PCP identified a loss of coordination and sensation in the upper left extremities.  Three years prior, this patient had undergone a surgical C4 partial corpectomy and fusion of cervical level C4 and C5 for cervical cord compression with impaired gait.  On 6/1/2015, his PCP diagnosed intermittent left limb ataxia and transferred the patient to the emergency department of the Veterans Administration Medical Center.

In the emergency department, ED physician A diagnosed upper extremity neuropraxia after obtaining a CT scan of the cervical spine.  ED physician A also ordered an MRI for 6/4/2015 before discharging the patient.

On 6/2/2015, the patient returned to the emergency department.  The patient described to a triage nurse and a direct care nurse symptoms of worsening left arm numbness, light flashes, a change in depth perception, imbalance and overall feeling “a lot worse.”  Thereafter, ED physician B, who was the on-duty emergency physician, saw the patient.  ED physician B documented that the patient had recurrent loss of left upper extremity control and paresthesias and that the patient expressed fear that he was having a stroke and might die.  ED physician B’s medical note further stated that the patient had no vision changes and that his sense and strength were grossly intact.  ED physician B informed the patient that he would have to wait for his cervical MRI until 6/4/2015, and ED Physician B did not appear to complete a brain MRI for the patient.  ED physician B found the patient’s primary diagnosis to be anxiety.

After the patient’s discharge from the emergency department, he continued to have persistence of his symptoms.  The patient was ultimately referred to a neurologist who ordered a brain MRI on 7/27/2015, which showed right cerebral sub-acute watershed infarcts and an occluded right internal carotid artery.  The patient was transferred to a specialty stroke center for additional evaluation and treatment.

According to the Board, when ED Physician B undertook the care and treatment of the patient, a worried patient with substantial risk factors who returned to the emergency department less than 24 hours for progressing complex neurological symptoms, and failed to obtain an accurate history and review of systems.

In addition, the Board judged ED Physician B’s conduct of the patient to be below the minimal standard of care given his failure to perform an effective neurological examination of the patient, failure to perform indicated imaging studies, and failure to obtain a neurology consult.  The Board deemed ED physician B’s failures to collectively constitute an extreme departure from the standard of care.

The Board issued a public reprimand with stipulations to complete a continuing medical education course on the topic of patient communication and a course on medical record keeping.

State: California

Date: May 2017

Specialty: Emergency Medicine

Symptom: Numbness, Vision Problems, Weakness/Fatigue

Diagnosis: Ischemic Stroke

Medical Error: Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Lack of proper documentation

Significant Outcome: Hospital Bounce Back

Case Rating: 3

Link to Original Case File: Download PDF

On 6/22/2010, Gastroenterologist A provided a consultation for a patient after an abdominal ultrasound showed that the patient had cholelithiasis and choledocholithiasis.  The patient’s elevated liver enzymes and dilated bile duct indicated a moderate to high probability of the possibility of stones and warranted a preoperative ERCP and sphincterotomy.  The purpose of the consultation was to remove a suspected common bile duct stone prior to a cholecystectomy.

On 6/28/2010, Gastroenterologist A performed an ERCP with sphincterotomy and balloon sweeping of the common bile duct.  He was unable to determine if he had successfully removed the suspected common bile duct stone from the patient’s dilated bile duct and placed an 8.5-French 5 cm stent into the common bile duct.

In the patient’s chart, Gastroenterologist A noted: “will pull the stent out in 2 months.”

On 11/24/2010, Gastroenterologist A next saw the patient in his office.  A second ERCP was scheduled for 2/10/2011 to remove the stent.  The patient’s medical chart contains no record of instructions given to the patient or his family members regarding the removal of the stent.  The patient’s medical chart contains no explanation for the passage of time between the placement of the stent on 6/28/2010 and the removal of the stent on 2/10/2011.  The Board noted that stents can be expected to occlude after six months and form a nidus for the formation of other stones, mud, and debris.

At 8:30 a.m. on 2/10/2011, Gastroenterologist A performed a second ERCP on the patient and removed the stent.  During the second ERCP, Gastroenterologist A performed a balloon sweep.  The patient’s medical chart contains no clear documentation that all ducts were swept.  No antibiotics were prescribed or administered to the patient immediately before, during, or after the second ERCP.  After the second ERCP, the patient was discharged from the endoscopy facility.  Several hours later, the patient’s wife called Gastroenterologist A’s office to report that the patient was experiencing chills and pain in his back and stomach.  Gastroenterologist A and/or his staff advised that the patient should be brought to Gastroenterologist A’s office right away.

At 6:00 p.m., after efforts to convince the patient’s wife to bring the patient to his office had been unsuccessful, Gastroenterologist A noted in the patient’s chart that he advised the patient’s wife to bring the patient to the office the following morning if the pain were to continue.

Thereafter, Gastroenterologist A prescribed amoxicillin 500 mg to be taken three times a day for the patient.

The following morning, the patient’s condition had not improved.  Further conversations took place between Gastroenterologist A and/or his office staff and the patient’s wife.

At noon on 2/11/2011, the patient arrived at the hospital.

On 10/7/2014, Gastroenterologist A testified that there had been several telephone calls between his office and the patient’s wife on 2/10/2011 and 2/11/2011.  Further, he stated that he and/or his staff had impressed upon the patient’s wife the severity of the patient’s condition and that it was matter of life and death that the patient receive urgent medical attention, but that patient’s wife apparently failed to understand and/or take Gastroenterologist A’s comments seriously.

However, Gastroenterologist A did not document in the cart for the patient.  He did not document the frequency of the conversations, the information given to the patient’s wife, or his wife’s failure or refusal to understand the information.

At 1:30 p.m. on 2/11/2011, the patient was admitted to a hospital and was found to be critically ill with severe sepsis.

Gastroenterologist A consulted Gastroenterologist B, who performed an ERCP on the patient on 2/12/2011.  Gastroenterologist B found “clear evidence of a biliary obstruction as evidenced by darkly pigmented bile and extensive amounts of bloody liquid and sand-like material concerning for hemobilia.”  Gastroenterologist B diagnosed “biliary obstruction resulting in ascending cholangitis and sepsis” and placed a stent in the common bile duct.

On 2/12/2011, the patient passed away.

On 2/16/2011, Gastroenterologist A completed a two-page note in the patient’s medical chart entitled “Death Summary” and marked “Final Report, ” in which he made the following comments.

“Endoscopic retrograde cholangiopancreatography was performed 2 or 3 months ago … for common bile stone retrieval with stenting of the common bile duct … His condition continued to deteriorate.  During the night, his oxygen saturation began to deteriorate, suggesting acute respiratory distress syndrome.  He was intubated and put on the machine.  The blood pressure was kept on Dopamine and Neo-Synephrine.  But, in spite of this, on 2/12/2011 after all the resources have [sic] been pulled out, I have a hunch that he would not make it because of multiorgan [sic] failure.  Therefore, I called the family and explained the grave situation as best that I could.  The patient finally expired on 2/12/2011.”

Gastroenterologist A listed the final diagnosis as “septic shock, death.”

Gastroenterologist’s “Death Summary” for the patient contained no mention of the third ERCP, performed on 2/12/2011, or Gastroenterologist’s B diagnosis of biliary obstruction.

After a hearing, the State Medical Board concluded that Gastroenterologist A committed repeated negligent acts given failure to ensure timely removal of the temporary stent, failure to ensure that the patient had a clear understanding of the importance of timely removal of the temporary stent, failure to ensure that the patient had an understanding of the risks associated with performing the second ERCP and the possible warning signs to monitor after the procedure, and failure to maintain appropriate documentation of his care and treatment of the patient.

The State Medical Board placed Gastroenterologist A on probation with stipulations to complete a professionalism program, complete a medical record keeping course, complete 40 hours annually of continuing medical education for each year of probation, and undergo clinical practice monitoring with an emphasis on medical record keeping.  During probation, Gastroenterologist A was prohibited from performing ERCP procedures.

State: California

Date: May 2017

Specialty: Gastroenterology, Internal Medicine

Symptom: Fever

Diagnosis: Sepsis

Medical Error: Physician concern overridden, Delay in proper treatment, Failure of communication with patient or patient relations, Lack of proper documentation

Significant Outcome: Death, Hospital Bounce Back

Case Rating: 4

Link to Original Case File: Download PDF

On 5/6/2014, a patient was scheduled for an elective right carotid endarterectomy procedure with her vascular surgeon.  An anesthesiologist was assigned to the surgery and was proctored by another anesthesiologist throughout the procedure. The anesthesiologist wrote his pre-operative note at 11:10 a.m.  The note included the patient’s admitting vital signs and past history, which included a recent stroke and that she was a former smoker. His note listed her most recent labwork. The anesthesiologist did not include the patient’s pre-operative Doppler studies or her recent ECG.  The anesthesiologist noted that the patient had a prior Cesarean section, but listed her prior anesthetics as “none.” The anesthesiologist did not perform an exam of her heart or lungs, and he noted that he discussed a risk of nausea.

The anesthesiologist placed a right radial 22-gauge arterial line with local anesthetic prior to the patient being moved to the operating room.  He connected the patient to the proper monitoring machines. The anesthesiologist began anesthesia at 11:36 a.m. He provided 1 mg of midazolam, 5 mg of rocuronium, 40 mg of lidocaine, 40 mg of propofol, and incremental doses of 50 mcg x2 fentanyl.  He also administered sevoflurane and oxygen. The anesthesiologist then administered an additional dose of rocuronium and easily intubated the patient. The anesthesiologist began a phenylephrine infusion of 200 mcg/hr. At 11:45 a.m., the patient’s vital signs were recorded from the arterial line reading 130/55 and from the left cuff measuring 90/55 with pulse of 55.  During intubation, the patient’s blood pressure rose to 135/65 with a pulse of 60. The phenylephrine infusion was increased to 1000 mcg/hr and then decreased to 800 mcg/hr prior to the surgical incision at 12:17 p.m.

Systolic blood pressure prior to incision was 180 and charted at 150/110 shortly thereafter.  Pulse rose from 58 bpm to 75 bpm. Heparin, 5000 units, was administered at 12:22 p.m. prior to surgical cross camp at 12:33 p.m.  During the cross-clamp period, anesthesia was maintained. The cross clamp was removed at 1:11 p.m. The phenylephrine infusion was continued until approximately 1:15 p.m.  Blood pressure during the cross-clamp period ranged between 145/70 and 170/60. At 1:15 p.m., the patient’s blood pressure was 200/60 with a pulse of 70 bpm. The anesthesiologist administered ondansetron at 1:15 p.m.  At 1:30 p.m., he administered 10 mg of hydralazine and 30 mg of esmolol. He provided another 40 mg dose of esmolol shortly thereafter. Surgery ended at 1:37 p.m. The anesthesiologist’s post-operative note, written the following morning, showed that the patient was essentially stable, and she was released home the following day.

The Medical Board of California judged that the anesthesiologist departed from the standard of care because he failed to mention the patient’s prior ECG or Doppler studies in his pre-operative note.  The anesthesiologist did not ask her about a prior history of chest pain or exercise intolerance during his pre-operative evaluation, did not list the type of prior anesthetic that she had received in her prior surgery in his pre-operative note, did not review the degree of patency or stenosis that the non-operative side would provide cerebral blood through the Circle of Willis, did not inform the patient that there would be a small, but not uncommon, risk of stroke, heart attack, or death, and did not examine or document a heart of lung exam of the patient during his pre-operative examination.  He also failed to anticipate the patient’s hemodynamic changes related to surgical incision and cross-clamping and unclamping during surgery. When the anesthesiologist did respond to hemodynamic changes, he provided inadequate responses and prolonged response times. The anesthesiologist failed to adequately reflect the wide variations in the monitored vital signs in his clinical chart and failed to terminate the phenylephrine infusion following removal of the cross-clamp despite the patient’s hypertension. The anesthesiologist failed to promptly adjust the mechanical ventilator after intubation and failed to proactively anticipate blood pressure increases and decreases in response to carotid de-clamping.

The Medical Board of California placed the anesthesiologist on probation for 4 years and ordered him to complete a medical record-keeping course, an education course for at least 20 hours for the first year of probation, 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: May 2017

Specialty: Anesthesiology

Symptom: N/A

Diagnosis: Cardiovascular Disease

Medical Error: Failure to examine or evaluate patient properly, Failure of communication with patient or patient relations, Delay in proper treatment, Improper medication management, Lack of proper documentation, Procedural error

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

A 69-year-old male with diffuse systemic sclerosis, interstitial lung disease, end stage renal disease on hemodialysis, anemia, hypertension, hypoalbuminemia, secondary hypothyroidism, and gastric antral vascular ectasia (“GAVE”) had been referred to a gastroenterology clinic for evaluation of recurrent problems with weight loss and dysphagia.  It was assumed that the patient’s disease had progressed to esophageal scleroderma and that a percutaneous endoscopic gastrostomy (“PEG”) would be necessary to bypass his esophagus and would allow him to take in adequate nutrition without swallowing.  The patient was referred to the gastroenterology clinic for evaluation and a PEG.

On 6/25/2012, the gastroenterologist ordered a PEG, and she scheduled an esophagogastroduodenoscopy (“EGD” or upper endoscopy) and esophageal manometry for the afternoon of 6/25/2012, both elective, non-emergent diagnostic procedures, scheduled to be done on an outpatient basis.  On 6/23/2012 or 6/24/2012, the patient had been discharged from the hospital on antibiotics with home oxygen administration after treatment for aspiration pneumonia.

The gastroenterologist performed a pre-endoscopy history and physical examination in the early afternoon of 6/25/2012 and noted that the patient had active diffuse scleroderma complicated by renal crisis, diffuse systemic sclerosis, interstitial lung disease, GAVE with multiple cauterizations, and end stage kidney disease.  In past medical history, she listed “scleroderma renal crisis, “Started dialysis December 30, 2011,” and “Pneumonia. Admitted to er 6/24/12.”  She noted that the patient had had multiple upper endoscopies for gastrointestinal bleeding prior to this EGD.  Her physical examination listed “Lungs: Clear Auscultation. Clear percussion and Normal Symmetry and Expansion.”  She noted that she, not an anesthesiologist, was ordering sedation.

Sedation was to be administered by a registered nurse.  The gastroenterologist listed Airway as Class 2 and ASA Level (American Society of Anesthesiologists physical status classification system) as 3 (severe systemic disease).

On 6/25/2012 at 2:48 p.m. and ending at approximately 3:15 p.m., the gastroenterologist performed an upper endoscopy on the patient and took biopsies.  Nursing records indicate that sedation consisted of midazolam, 7 mg, administered over the 22 minutes; fentanyl, 175 mcg administered over the 22 minutes, and Cetacaine spray applied to the throat prior to the procedure.

The patient was transferred from the endoscopy procedure room to the recovery area under the care of a registered nurse.  The nurse noted that the patient was unresponsive to verbal and painful stimuli, with blood pressure 108/70, heart rate 86, and O2 saturation 89% on 2 liters delivered by nasal cannula.  A face mask was applied at 10 liters O2 and oxygen saturation went up to 97%.  When the gastroenterologist was notified, she ordered reversal medications: flumazenil 0.25 mg IVP over 15 seconds and Narcan 0.4 mg IVP at 3:40 p.m., and the patient was still unresponsive.  A second dose of flumazenil 0.25 mg IVP was given at 3:43 p.m., and the patient became responsive at 3:44 p.m.  Once the patient was responsive, the gastroenterologist performed the esophageal manometry procedure.  No time is entered in the medical record for this procedure although the gastroenterologist acknowledges that it was done and the results are recorded.

The gastroenterologist was later notified by nursing staff of concerns with the patient’s breath sounds, and the gastroenterologist noted stridor at 4:26 p.m.  She was notified at 5:19 p.m. that the patient’s oxygen saturation was 89% on 5 liters oxygen delivered by nasal cannula.  At 5:20 p.m., the gastroenterologist ordered a chest x-ray due to the inability to wean the patient off oxygen after the endoscopy.  A face mask was applied at 10 liters oxygen at 5:21 p.m., and oxygen saturation went up to 93%.  The chest x-ray indicated “a dense retrocardiac opacity and a left pleural effusion” and a “volume loss in the left lung with mild shift of the mediastinum towards the left.”

After the manometry procedure in the recovery room, the patient’s oxygen saturation was monitored, and when the oxygen saturation remained above 90% for 30 minutes on room air, the patient met endoscopy discharge criteria.  The patient was discharged home with instructions concerning any complications that might arise.

The gastroenterologist states that she arranged to admit the patient to the hospital, but the patient left against medical advice (AMA).  Neither notation of this nor a signed AMA release was found in the record.  Pathology results revealed gastritis and the manometry procedure revealed a condition consistent with esophageal scleroderma.

On 6/27/2012, the patient presented to the emergency department with shortness of breath and cough.  Chest x-ray showed new right lung patchy opacities, and the patient was cachectic.  He was admitted to the intensive care unit for treatment of pneumonia.  The admission diagnosis was “most likely persistent pneumonia, likely aspiration due to esophageal dysmotility.”  The patient failed to improve despite intensive hospital care.  Although the gastroenterologist had scheduled a PEG for 7/2/2012, it was decided that the patient would not go through with the procedure.  Instead, it was decided that the medical team would provide palliative care for the patient.

On 7/4/2012, the patient died with the cause of death listed as aspiration pneumonia due to esophageal dysmotility and end-stage scleroderma with severe malnutrition as a contributing factor.

The Board deemed the gastroenterologist’s conduct as falling below the standard of care for the following reasons:

1) The gastroenterologist failed to provide an accurate analysis of the patient’s suitability for the endoscopic and manometry procedures.

2) She classified the patient as an ASA Level 3, which denotes an individual with stable multiple system disease that limits daily activity without immediate danger of death.

3) At the time of the EGD and manometry done by the gastroenterologist, the patient had just been released from another hospital, where he had been treated for aspiration pneumonia and discharged on antibiotics and home oxygen.

4) By reason of the patient’s recent aspiration pneumonia and the necessity for home oxygen administration, his ongoing scleroderma renal crisis which necessitated hemodialysis, his persistent interstitial lung disease, and his frequent bleeding and cauterizations for GAVE, his condition was not stable, and elective procedures at this time were contraindicated.  The patient’s classification was clearly ASA level 4, which denotes an individual with severe, incapacitating disease, poorly controlled or end-stage, at risk for death due to organ failure.

5) The gastroenterologist failed to provide for an anesthesiology consultation, given the patient’s unstable and life-threatening condition, and instead elected to provide conscious sedation directed by the gastroenterologist and administered by a registered nurse.  The level of sedation administered to the patient during the upper endoscopy procedure was relatively large for an individual with so many co-morbid conditions, and an anesthesiologist or nurse anesthetist should have been in attendance.

6) Since both procedures were elective, the gastroenterologist failed to reschedule the procedures for a time when the patient was stable and able to tolerate conscious sedation directed by the gastroenterologist and administered by a nurse.

7) The patient had a very unstable post-procedure course in the recovery room.  He was unresponsive to verbal and painful stimuli and oxygen saturation was below 90%.  Reversal medications had to be administered before the patient became responsive.  When the patient became responsive, the gastroenterologist performed the esophageal manometry in the recovery room.  This procedure was unnecessary to determine the need for a PEG and further endangered the health of the patient.

8) The respondent approved sending the patient home with instructions after his oxygen saturation was above 93% for 30 minutes.  The patient was a very high-risk patient for elective procedures and had had a very unstable post-procedure course in the recovery room, including the development or exacerbation of pneumonia.  Under these circumstances, in conjunction with his numerous co-morbidities, it was unsafe to send the patient home.  There was no record found of the patient leaving the clinic AMA.

The Board issued a public reprimand against the gastroenterologist.  Stipulations included continuing medical education in the topics of pre-operative patient evaluation, informed consent, sedation, and medical record keeping.

State: California

Date: May 2017

Specialty: Gastroenterology, Hospitalist, Internal Medicine

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

Diagnosis: Gastrointestinal Disease, Pneumonia, Pulmonary Disease

Medical Error: Unnecessary or excessive treatment or surgery, Failure of communication with other providers, Lack of proper documentation

Significant Outcome: Death, Hospital Bounce Back

Case Rating: 5

Link to Original Case File: Download PDF

On 11/17/2011, a 56-year-old female underwent a colonoscopy performed by a gastroenterologist.  The patient had undergone a bone marrow transplant for chronic lymphocytic leukemia.  After the procedure, the patient complained of nausea, vomiting, and epigastric pain.  An endoscopy was performed the prior day to rule out graft versus host disease or cytomegalovirus infection and the colonoscopy was a part of that procedure.

The gastroenterologist performed the coloscopy to the terminal ileum.  The patient was sedated with midazolam 8 mg IV, fentanyl 175 micrograms IV, and diphenhydramine 50 mg IV in divided doses as the patient exhibited any signs of discomfort.  Biopsies and cultures were obtained and submitted for evaluation.  Pathology results indicated apoptosis of the ileum and right colon, but negative findings for CMV.

During the course of the colonoscopic procedure, full sedation was not achieved.  The patient became drowsy, but she became fully awake during the procedure more than once, complained of pain, and asked that the procedure be stopped.  The gastroenterologist continued and completed the procedure despite the patient’s urgent requests.

The Board issued a public reprimand against the gastroenterologist.  Stipulations included continuing medical education in the topics of pre-operative patient evaluation, informed consent, sedation, and medical record keeping.

State: California

Date: May 2017

Specialty: Gastroenterology, Anesthesiology, Hematology

Symptom: Abdominal Pain, Nausea Or Vomiting

Diagnosis: Post-operative/Operative Complication, Hematological Disease

Medical Error: Procedural error

Significant Outcome: N/A

Case Rating: 1

Link to Original Case File: Download PDF

On 1/13/2015, a pediatrician saw a child just short of her second birthday.  She had been diagnosed with asthma and was maintained on corticosteroid and albuterol inhalers.  The patient presented with fever, coughing, and loss of appetite.  Although she had taken an antibiotic prior to this visit, it is not noted in the pediatrician’s chart notes.  The pediatrician diagnosed pneumonia, laryngotracheobronchitis (croup), and asthma and prescribed a different antibiotic for her.

The pediatrician stated that she followed up with the patient by telephone on 1/14/2015 and 1/15/2015.  Based on these follow-up calls, the pediatrician prescribed compounded cough syrup at a daily dose containing 0.55 mg dexamethasone, a corticosteroid.  She prescribed a sufficient amount of the medication to last a month and when the patient’s mother said that she was afraid that the patient would begin to cough again because her entire family had caught the cold, the pediatrician called in a partial refill for the medication.  None of this information was included in the pediatrician’s chart notes for the patient.

The pediatrician’s chart notes for the patient’s follow-up visits on 1/20/2015 and 2/20/2015 did not make reference to the compounded cough medication, instructions on how to take the medication, or to the advice she gave the patient’s mother concerning weaning the patient off the medication.  Although the pediatrician stated that she was concerned about the patient’s reduced “immunity” and recommended an over the counter immune pediatric supplement for the patient on 2/20/2015, this concern was not documented in the patient’s chart notes.

The Board judged the pediatrician’s conduct to have fallen below the standard of care given failure to appropriately prescribe dexamethasone to the patient and given failure to document the follow-up telephone calls, the fact that she had prescribed the compounded cough medication to the patient, instructions for the patient to wean off the dexamethasone, concern for the patient’s reduced “immunity,” and the fact that the patient had taken antibiotics prior to her first visit with the patient.

A public reprimand was issued against the patient with stipulations to take a medical record keeping course.

State: California

Date: May 2017

Specialty: Pediatrics

Symptom: Cough, Fever

Diagnosis: Pneumonia, Asthma

Medical Error: Improper medication management, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 1

Link to Original Case File: Download PDF

On 8/7/2015, a 51-year-old male presented to a surgical center for an outpatient esophagogastroduodenoscopy (EGD) and colonoscopy.

The patient had a history of bipolar disease, schizophrenia, obstructive sleep apnea on continuous positive airway pressure (CPAP), smoking, and morbid obesity.

The patient underwent EGD and colonoscopy via monitored anesthesia care with intravenous propofol.

During the patient’s colonoscopy, he became bradycardic, was mask ventilated, turned supine, and was given atropine, ephedrine, and epinephrine.

Specifically, the patient received two doses of 0.2 mg of epinephrine ten minutes apart.  These doses of epinephrine are not standard advanced cardiovascular life support (ACLS) resuscitation doses for a cardiac arrest.

The patient also received a 0.2 mg dose of atropine followed by a 0.4 mg dose.  The doses of atropine were inadequate for the patient’s size and considering that the patient was experiencing a bradycardic event.

The patient subsequently received cardiopulmonary resuscitation (CPR) and was transferred to a hospital for emergent care.  Shortly after arriving at the hospital, the patient passed away.

Prior to performing the procedures, the anesthesiologist failed to document a complete preoperative history and physical examination for the patient.

During the intraoperative course, the anesthesiologist failed to utilize and/or failed to document utilizing end-tidal CO2 (ETCO2) monitoring usage.

It was requested that the Board order one or more of the following penalties for the anesthesiologist: 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 Board deemed appropriate.

State: Florida

Date: May 2017

Specialty: Anesthesiology

Symptom: N/A

Diagnosis: Post-operative/Operative Complication, Cardiac Arrhythmia

Medical Error: Improper medication management, Failure to examine or evaluate patient properly, Failure to properly monitor patient, Lack of proper documentation

Significant Outcome: Death

Case Rating: 3

Link to Original Case File: Download PDF

A patient was born on 4/3/1993.  Between February 2011 and September 2012, she presented to an obstetrician.

On 6/29/2011, the obstetrician found a small, smooth, mobile lump in the patient’s right breast.

On 7/18/2011, the obstetrician performed a right breast biopsy on the patient.  The obstetrician noted that the right breast lump was likely a fibroadenoma.  The biopsied right breast tissue was found to be benign.

The Medical Board of Florida judged the obstetricians conduct to be below the minimal standard of competence given that he failed to medically manage the patient’s right breast lump with breast exams, breast sonographies, and/or mammograms.   The obstetrician’s performance of a right breast biopsy on the patient was medically unnecessary.

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 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: May 2017

Specialty: Obstetrics

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

Diagnosis: N/A

Medical Error: Unnecessary or excessive treatment or surgery, Failure to order appropriate diagnostic test

Significant Outcome: N/A

Case Rating: 1

Link to Original Case File: Download PDF

On 7/30/2013, a 14-year-old male was seen by a pediatrician for a well-child assessment.  The pediatrician reviewed the patient’s height, weight, temperature, and blood pressure and administered hearing and vision tests.  She reviewed the patient’s development, including body image, home situation, education, school progress, risk-taking behaviors, sexuality, and mental health.  A complete physical examination was performed.

On 7/30/2013, the patient received a routine HPV immunization.  Routine diagnostic laboratory tests were ordered, including urinalysis.  A hemoglobin test by finger stick was performed.  The patient’s urinalysis test result was normal, but his hemoglobin result of 8.2 was significantly lower than normal.  The pediatrician repeated the hemoglobin test by finger stick but did not order a complete blood count by venipuncture.  The patient’s hemoglobin result was again 8.2.  The pediatrician started the patient on iron supplement therapy and instructed him to follow up in three months.  No additional diagnostic tests were done during this visit.

On 8/18/2013, the clinic received a report that the patient was experiencing shortness of breath and chest pain.  The patient was instructed to go to an emergency room.

At the emergency room, the patient experienced a full cardiac arrest.  His complete blood count revealed severe anemia, with a hemoglobin result of 7.5, a hematocrit of 21, 99 atypical lymphocytes, and a critically low platelet count of 39,000.  The patient’s cause of death was acute lymphoblastic leukemia/lymphoma.

The Board deemed the pediatrician’s level of conduct to be below the standard of care given failure to order a complete blood count by venipuncture for the follow-up blood test, failure to schedule a visit and lab check at an earlier date, and failure to consider other diagnoses in addition to iron deficiency anemia.

The Board issued a public reprimand against the pediatrician.  Stipulations included performing sixty hours of free services to a community or a non-profit organization, conducting 40 hours of continuing medical education, enrolling in a professionalism program, and undergoing a clinical competency assessment program.

State: California

Date: May 2017

Specialty: Pediatrics, Hematology

Symptom: Shortness of Breath, Chest Pain

Diagnosis: Cancer, Hematological Disease

Medical Error: Failure to order appropriate diagnostic test, Delay in proper treatment

Significant Outcome: Death

Case Rating: 5

Link to Original Case File: Download PDF

On 4/21/2014, a gynecologist performed a Cesarean section and bilateral tubal ligation on a 29-year-old female at 36 weeks gestation.

The patient suffered from gestational hypertension associated with right upper quadrant abdominal pain and elevated liver function tests consistent with HELLP (Hemolysis, Elevated Liver Enzymes, and Low Platelet Count) Syndrome.

At 5:00 p.m. on 4/21/2014, the patient became hypotensive and tachycardic and was pale and lethargic.

Between 5:00 p.m. and 6:30 p.m. on 4/21/2014, a critical care consultant diagnosed the patient with acute hemorrhagic shock, possibly due to an intraabdominal bleed, transferred the patient to the ICU, ordered a transfusion of 4 L of blood, and called the gynecologist for a possible exploratory laparotomy to control the bleeding.

At 7:11 p.m., the patient was intubated and placed on ventilation due to respiratory failure.

At 9:10 p.m., an ultrasound examination was performed on the patient’s abdomen and pelvis that revealed moderate fluid in the right and left upper quadrants of the patient’s abdomen.

Immediately following the ultrasound examination, the gynecologist diagnosed the patient with a liver rupture.  The patient’s lab testing results did not support or corroborate the gynecologist’s diagnosed.

The gynecologist called the on-call general surgeon and discussed the patient’s case.  After the conversation, at 9:23 p.m., the gynecologist initiated the transfer of the patient to a medical center.

At 1:45 a.m. on 4/22/2014, the patient was transferred to the medical center with a tachycardic heart rate of 140 beats per minute and a hypotensive blood pressure of 89/44.  The gynecologist and a surgeon performed an exploratory laparotomy on the patient, which revealed that the patient had an arterial bleed from the tubal ligation procedure.

The Medical Board of Florida judged that the gynecologist did not appropriately assess, or did not create or maintain adequate documentation of assessing, the patient’s symptoms and condition. He did not timely diagnose, or did not create or maintain adequate documentation of timely diagnosing, the patient with an intraabdominal bleed and hemorrhagic shock.  The gynecologist did not timely perform or order an exploratory laparotomy based on the patient’s deteriorating vital signs.  He did not timely order an ultrasound examination of the patient’s abdomen and pelvis on the patient’s deteriorating vital signs.  Also, the gynecologist did not timely perform or order an exploratory laparotomy based on the patient’s respiratory failure.  He did not recognize, or did not create or maintain adequate documentation of recognizing, that the fluid in the right and left upper quadrants of the patient’s abdomen, in conjunction with the patient’s other symptoms, indicated an intraabdominal bleed.  He did not perform or order an exploratory laparotomy based on the fluid in the right and left upper quadrants of the patient’s abdomen.  The gynecologist inappropriately diagnosed the patient with a liver rupture when the patient’s lab testing results did not support or corroborate the diagnosis.  He also did not order, or did not create or maintain adequate documentation of ordering, a surgery consultation for a surgeon to physically examine the patient upon diagnosing the patient with liver rupture.  He did not consult, or did not create or maintain adequate documentation of consulting, with one or more other OB/GYNs who might have had experience dealing with a patient with a liver rupture or a patient with similar complications and symptoms as the patient had.  The gynecologist did not timely perform or order an exploratory laparotomy after diagnosing the patient with liver rupture.  He also inappropriately transferred the patient to a medical center when the patient was unstable due to being tachycardic and hypotensive.  The gynecologist did not create or maintain adequate documentation related to his diagnosis and treatment of the patient.

The Medical Board of Florida issued a reprimand against the gynecologist’s license.  The Medical Board of Florida ordered that the gynecologist pay a fine of $22,500 against his license and pay reimbursement costs for the case at a minimum of $4,335.85 and not to exceed $6,335,85.  The Medical Board of Florida also ordered that the gynecologist complete ten hours of continuing medical education in diagnosis management of complications relating to cesarean sections, complete five hours in emergency obstetric care, and complete five hours of continuing medical education in “risk management.”

State: Florida

Date: May 2017

Specialty: Gynecology, Critical Care Medicine, General Surgery

Symptom: Abdominal Pain

Diagnosis: Post-operative/Operative Complication, Acute Abdomen, Hemorrhage

Medical Error: Diagnostic error, Delay in proper treatment, Failure to order appropriate diagnostic test, Referral failure to hospital or specialist, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 3

Link to Original Case File: Download PDF