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Virginia – Psychiatry – Adjusting Lithium Dosage Based Only On Patient Symptoms
A psychiatrist increased and decrease a patient’s lithium dosage based on the patient’s symptoms. She did not test the patient’s lithium blood serum level.
On 8/28/2015, the patient was admitted to a hospital for lithium toxicity. The psychiatrist stated that lithium blood serum levels for long-term lithium patients should be tested at least annually, but also at any time a patient complains of adverse side effects. The psychiatrist admitted her failure to test the patient’s lithium levels and stated that it “was an inadvertent oversight for which [she] is remorseful.” The psychiatrist reported that following the patient’s hospitalization for lithium toxicity, she reviewed the charts for her other patients on lithium and determined if they needed testing for lithium blood serum levels.
She provided evidence that she completed 99 hours of CME in psychiatry in 2015 and 58 credit hours of CME in psychiatry in 2017. She provided a spreadsheet that she created for use in monitoring her patients on lithium. She was reprimanded by the Virginia Board of Medicine.
State: Virginia
Date: October 2017
Specialty: Psychiatry
Symptom: N/A
Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Psychiatric Disorder
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 – Obstetrics – Excessive And Unindicated Antepartum Testing Performed Over the Course Of A Pregnancy
Between May 2011 and December 2011, an obstetrician provided obstetric services to a 16-year-old female and followed the course of her pregnancy.
The patient had an estimated delivery date of 12/1/2011 and ultimately delivered her baby on 12/1/2011.
On 5/5/2011 and 5/19/2011, the obstetrician performed first-trimester ultrasounds on the patient to monitor the patient’s fetus.
On 6/17/2011, the obstetrician performed a second-trimester ultrasound on the patient to monitor the patient’s fetus.
On 10/11/2011, the obstetrician performed a third-trimester ultrasound on the patient to monitor the patient’s fetus. The patient’s fetus was in the 29th percentile for growth, which was normal.
On 10/20/2011, the obstetrician performed a third-trimester ultrasound on the patient to monitor the patient’s fetus. The patient’s fetus was in the 44th percentile for growth, which was normal.
There was no indication for the third-trimester ultrasound that the obstetrician performed on the patient on 10/20/2011.
On 10/28/2011, the obstetrician performed a biophysical profile with ultrasound on the patient and her fetus in order to monitor the patient’s fetus.
The indications documented for the biophysical profile with ultrasound that the obstetrician performed for the patient and her fetus on 10/28/2011 were intrauterine growth restriction and “size less than dates.” Both intrauterine growth restriction and “size less than dates” were ruled out by the ultrasound conducted on 10/11/2011 and 10/20/2011.
There was no indication for the biophysical profile with ultrasound that the obstetrician performed on the patient and her fetus on 10/28/2011.
On 11/4/2011, the obstetrician performed a biophysical profile with ultrasound on the patient and her fetus in order to monitor the patient’s fetus. The indications documented for the biophysical profile with ultrasound that the obstetrician performed on the patient and her fetus on were intrauterine growth restriction and “size less than dates.”
Both intrauterine growth restriction and “size less than dates” were ruled out by the ultrasound conducted on 10/11/2011 and 10/20/2011, and the biophysical profile performed on 10/28/2011.
There was no indication for the biophysical profile with ultrasound that the obstetrician performed on the patient and her fetus on 11/4/2011.
On 11/11/2011, the obstetrician performed a third-trimester ultrasound on the patient to monitor the patient’s fetus. The patient’s fetus was in the 34th percentile for growth, which was normal. There was no indication for the third-trimester ultrasound the obstetrician performed on the patient on 11/11/2011.
On 11/18/2011, the obstetrician performed a third-trimester ultrasound on the patient to monitor the patient’s fetus. The patient’s fetus was in the 68th percentile for growth, which was normal. There was no indication for the third-trimester ultrasound that the obstetrician performed.
The standard of care required that the obstetrician adequately manage the patient’s pregnancy through the use of only indicated antepartum testing and to refrain from performing excessive and unindicated antepartum testing.
It was requested that the Board 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 Board deemed appropriate.
State: Florida
Date: October 2017
Specialty: Obstetrics
Symptom: N/A
Diagnosis: N/A
Medical Error: Unnecessary or excessive diagnostic tests
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
Florida – Interventional Radiology – Epidural Steroid Injection On A Patient Taking Plavix
On 1/21/2014, an 85-year-old female was admitted to the hospital with complaints of lower back pain and chest pain.
The patient’s medication list, at the time of her admission, listed a prescription for 75 mg of Plavix daily.
On 1/23/2014, a radiologist performed an epidural steroid injection on the patient while she was taking Plavix. Shortly after the procedure, the patient developed an abrupt sudden onset of diffuse abdominal pain with nausea, vomiting, and a large retroperitoneal hematoma extending from the left upper abdomen into the pelvis.
The patient had a stroke, among other complications.
The Board judged the radiologists conduct to be below the minimal standard of competence given that he performed an epidural injection on a patient while the patient had been receiving antiplatelet therapy for a significant period of time.
It was requested that the Board order one or more of the following penalties for the radiologist: 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: October 2017
Specialty: Interventional Radiology
Symptom: Back Pain, Nausea Or Vomiting, Chest Pain
Diagnosis: Drug Overdose, Side Effects, or Withdrawal
Medical Error: Improper medication management
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 4
Link to Original Case File: Download PDF
Florida – Interventional Radiology – Assigning A Diagnosis To The Wrong Patient Leads To Cardiac Catheterization Performed On The Wrong Patient
On 1/28/2015, Patient A, a 47-year-old male, presented to the hospital with chest pain and was admitted for treatment. A radiological technician was ordered to complete a CT angiogram of the heart for Patient A.
On 1/29/2015, a radiologist received Patient A’s angiogram images to review, as well as heart images for another Patient B. The radiologist assigned a diagnosis of sixty to seventy percent stenosis to Patient A.
The diagnosis of sixty to seventy percent stenosis was intended for Patient B, not Patient A, who did not have any noticeable blockage or stenosis.
On 1/29/2015, subsequent to the radiologist assigning the diagnosis of sixty to seventy percent stenosis to Patient A, Patient A underwent an unnecessary cardiac catheterization without further incident.
On 1/30/2015, the radiologist conducted a corrected review and diagnosis of Patient A’s angiogram.
On 2/3/2015, the radiologist informed Patient A of the error.
The Board judged the radiologist’s conduct to be below the minimal standard of competence given that he assigned a diagnosis to the wrong patient, which resulted in the patient undergoing a medically unnecessary procedure, a cardiac catheterization.
It was requested that the Board order one or more of the following penalties for the radiologist: 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: October 2017
Specialty: Interventional Radiology
Symptom: Chest Pain
Diagnosis: Cardiovascular Disease
Medical Error: Accidental error, False positive, Unnecessary or excessive treatment or surgery
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Internal Medicine – Failure To Justify Suboxone Prescribing Practices
From 7/8/2011 to 8/13/2015, an internist treated a 37-year-old female with an opioid dependency for seven years with Suboxone therapy. During the treatment period, the internist prescribed the controlled substance Suboxone to the patient on one or more occasions. During the treatment period, the internist failed to substantiate, by test or positive exam, the patient’s history of opiate use to justify the use of Suboxone.
During the treatment period, the internist did not obtain a history of substance abuse, including illicit substances, or a complete medical history from the patient’s prior healthcare provider to support his diagnosis of opioid dependence and opiate withdrawal.
During the treatment period, the internist inappropriately diagnosed the patient, as his physical examination of the patient failed to indicate clinical opiate withdrawal symptoms, to help support his diagnosis of continuous opioid dependence and opiate withdrawal.
During the treatment period, the internist failed to perform tests, including screening for hepatitis B and C, complete metabolic panel, and complete blood count, to completely assess the patient’s condition.
During the treatment period, the internist failed to completely and accurately maintain medical records that justify Suboxone therapy as a proper course of treatment.
During the treatment period, the internist failed to document a clear treatment plan and time frame for detoxification, and/or thoroughly educate the patient about additional recovery.
During the treatment period, the internist failed to perform and/or maintain records of frequent urine toxicology for the patient to prevent noncompliance, dependence, addition, or diversion of controlled substances.
During the treatment period, the internist failed to document, incorporate in the medical records, or comment on all urine toxicology screens performed on the patient on one or more occasions.
During the treatment period, the internist failed to include all logs of prescriptions within his electronic medical record (“EMR”).
During the treatment period, the internist did not pursue, or document pursuing, psychological counseling, prescription drug monitoring (“PDMP”) and follow-up urine toxicology screens to guide optimal therapy.
It was requested that the Board 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 Board deemed appropriate.
State: Florida
Date: October 2017
Specialty: Internal Medicine
Symptom: N/A
Diagnosis: Drug Overdose, Side Effects, or Withdrawal
Medical Error: Failure to properly monitor patient, 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: 1
Link to Original Case File: Download PDF
Florida – Ophthalmology – Lack Of Diagnostic And Preoperative Testing To Assess An Epiretinal Membrane
From 8/12/2015 to 4/1/2016, (“treatment period”) a 69-year-old male presented to an ophthalmologist with complaints of blurred vision in his eyes.
During the treatment period, the ophthalmologist diagnosed the patient with a mature cataract in his right eye, and complicated cataract, proliferative diabetic retinopathy, and epiretinal membrane (“ERM”) in his left eye.
During the treatment period, the ophthalmologist did not perform or document performing the appropriate objective preoperative diagnostic testing, such as an Optical Coherence Tomography (“OCT”), of the retina to adequately assess the ERM in the patient’s left eye.
During the treatment period, the ophthalmologist did not thoroughly examine or document a thorough examination of the patient’s eyes by performing objective preoperative testing and imaging, such as fundus photos documenting the ERM, an Amsier grid showing distortion of the patient’s vision, an Amsier grid on either eye, or showing the patient’s retina and irregularities in the retina to support the epiretinal membrane peel in the patient’s left eye.
During the treatment period, the medical records maintained by the ophthalmologist did not clearly document any indication of the ERM on the patient’s left eye preoperatively.
During the treatment period, the ophthalmologist did not perform or document performing, objective preoperative testing and imaging studies, such as an OCT of the retina, an Amsier grid showing distortion or metamorphopsia, taking fundus photos, or a fluorescein angiogram to justify his course of treatment in the patient’s left eye.
During the treatment period, the ophthalmologist did not thoroughly discuss with the patient or document thoroughly discussing with the patient the option of cataract surgery alone versus cataract surgery with the ERM.
On 8/27/2015, the ophthalmologist performed a cataract removal and intraocular lens implantation on the patient’s right eye.
On 10/8/2015, the ophthalmologist performed a cataract removal and epiretinal membrane peel on the patient’s left eye.
During the treatment period, the ophthalmologist did not maintain medical records that justified an appropriate plan or treatment for the patient’s condition.
The Board judged the ophthalmologist’s conduct to be below the minimal standard of competence given that he failed to perform and document appropriate diagnostic and preoperative testing. The ophthalmologist also failed to discuss with the patient the option of cataract surgery alone versus cataract surgery with the ERM.
It was requested that the Board order one or more of the following penalties for the ophthalmologist: 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: October 2017
Specialty: Ophthalmology
Symptom: Vision Problems
Diagnosis: Ocular Disease
Medical Error: Failure to order appropriate diagnostic test, 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: 2
Link to Original Case File: Download PDF
Florida – Vascular Surgery – Arteriogram Performed On A Patient’s Right Leg Instead Of The Left Leg
On 8/15/2016, a patient presented to a vascular surgeon with peripheral vascular disease, a non-healing ulcer on his left third toe tip, and diminished arterial blood flow in both legs.
Based on his initial evaluation, the vascular surgeon determined that a left leg arteriogram was necessary.
On 8/18/2016, the patient’s family consented to a left leg arteriogram and the vascular surgeon pre-operatively marked the patient’s left and correctly performed a timeout.
After the vascular surgeon performed the timeout, he performed a right leg arteriogram instead of the planned left leg arteriogram.
The Board judged the vascular surgeon’s conduct to be below the minimal standard of competence given that he performed a wrong-site procedure by performing an arteriogram on the patient’s right leg (wrong site) instead of the patient’s left leg (correct site).
It was requested that the Board order one or more of the following penalties for the vascular surgeon: 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: October 2017
Specialty: Vascular Surgery
Symptom: N/A
Diagnosis: Cardiovascular Disease
Medical Error: Wrong site procedure
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
Florida – Psychiatry – Female Admitted With Depression And Psychosis Started On Quetiapine 200 mg Nightly
On 3/27/2013, a 44-year-old female presented to a behavioral health center after being “Baker Acted,” or involuntarily institutionalized, for depression and psychosis.
Upon the patient’s admission to the behavioral health center, a psychiatrist was called to place medication orders.
The psychiatrist called back one hour later and ordered Seroquel 200 mg at bedtime, among other medication orders.
Shortly after administration of the Seroquel, the patient experienced an episode of syncope and fell forward, sustaining a loss of consciousness, lacerations to her face, and a broken jaw.
The Board judged the psychiatrist’s conduct to be below the minimal standard of competence given that she failed to order an initial dose of 50 mg or less of Seroquel and titrate the dosage up as needed.
It was requested that the Board order one or more of the following penalties for the psychiatrist: 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: October 2017
Specialty: Psychiatry
Symptom: Psychiatric Symptoms
Diagnosis: Drug Overdose, Side Effects, or Withdrawal
Medical Error: Improper medication management
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Orthopedic Surgery – Damage To Inferior Vena Cava And Other Complications After Guidewire Improperly Placed In Disk Space
On 12/24/2014, a 59-year-old female was admitted to a medical center for a Microscopic Extraforaminal Lumbar Discectomy of L4-L5. An orthopedic surgeon was assigned to perform the patient’s procedure. He began the procedure by utilizing image intensification to use a guidewire for initial placement of dilators in the patient’s spine.
After removal of the guidewire, the orthopedic surgeon noted that he felt the guidewire had gone into the disk space slightly.
After sixty percent of the procedure was completed, the orthopedic surgeon was advised by the anesthesiologist that there was a decrease in the patient’s CO2. It was subsequently noted that the patient’s blood pressure began to drop.
The orthopedic surgeon then placed an OpSite over the patient’s incision, turned the patient to a supine position, and called for assistance from a vascular surgeon.
On 12/24/2014, after becoming hypotensive and then experiencing pulseless electrical activity during the lumbar discectomy, the patient underwent an exploratory laparotomy with repair of inferior vena cava injury.
During the exploratory laparotomy, after approximately one hour of cardiopulmonary resuscitation and advanced cardiac life support protocol, the patient expired on the operating table.
At all times relevant to this case, the prevailing professional standard of care requires that when dealing with patients such as this one, a physician should place instruments into a patient’s body in a manner to do the least possible harm.
The Board judged the orthopedic surgeons conduct to be below the minimal standard of competence given that he allowed an instrument to pass into the patient’s cavity in such a way that injured underlying structures and by failing to recognize the penetration of the guidewire at the time of placement of the initial dilator, which lead to the injury of the patient’s inferior vena cava.
It was requested that the Board order one or more of the following penalties for the orthopedic surgeon: 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: October 2017
Specialty: Orthopedic Surgery
Symptom: N/A
Diagnosis: Post-operative/Operative Complication, Spinal Injury Or Disorder
Medical Error: Procedural error
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF
California – Family Practice – Providing Medical Clearance For A Tummy Tuck Procedure
A family practitioner cleared a patient for a tummy tuck procedures. The patient had a history of sickle cell anemia and a respiratory infection.
The Board judged the family practitioner’s conduct as having fallen below the minimum level of competence given failure to address the status of the patient’s sickle cell anemia and failure to assess the patient’s respiratory infection.
The Board issued a public letter of reprimand.
State: California
Date: October 2017
Specialty: Family Medicine, Internal Medicine
Symptom: N/A
Diagnosis: Hematological Disease, Infectious Disease
Medical Error: Improper treatment
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF