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California – Neurology – Three EEGs Ordered Without Indication And Diagnosis Of Epilepsy
A 9-year-old girl was referred by her pediatrician to a child neurologist for headaches. The child neurologist first saw the patient on 9/10/2009. The patient’s mother stated that the patient’s headaches started in 7/20/2009. The patient had no episodes of loss of consciousness of any type. The child neurologist’s review of systems revealed headaches, neck pain, and back pain. The child neurologist noted headaches following a viral infection in July 2009 described as constant tension and pressure with nausea, photophobia, and difficulty concentration. The child neurologist’s diagnosis was childhood migraine and prescribed 10 mg amitriptyline. The child neurologist ordered an MRI to rule out neoplasm and aneurysms. The child neurologist also ordered an EEG, which was not indicated for headaches.
On 9/18/2009, the EEG was performed. The technician described the EEG with “sharp and slow waves.” On 9/30/2009, the child neurologist saw the patient for an office visit. The child neurologist read the EEG as showing “generalized polyspike and wave which was synchronous bilaterally over both hemispheres which is highly suggestive of a generalized seizure disorder.” The child neurologist stopped the amitriptyline 10 mg she prescribed at the last visit because of “seizures on EEG.” She ordered a neurosurgery consult and planned a separate meeting with the mother.
The child neurologist next saw the patient on 11/4/2009. The child neurologist prescribed Depakote at 250 b.i.d. The patient’s Depakote level was at 72. The patient reported no seizures or auras, but the child neurologist in her diagnosis documented “seizures, breakthrough.” The child neurologist ordered a second video EEG with computer analysis without medical indication. The EEG was performed on 11/25/2009. The technician report showed no abnormality. The child neurologist’s report was of generalized polyspike and slow waves bilaterally, “highly suggestive of generalized epilepsy,” with localized slowing in the left temporal area.
On 2/11/2010, the child neurologist saw the patient for a follow-up visit. The chief complaint was learning difficulty. The Depakote level was 53. The patient denied experiencing any auras and/or any seizures. On the next visit, on 5/11/2010, the patient still did not report any auras or seizures. The child neurologist’s diagnoses were generalized epilepsy, childhood headaches, adverse effect of medication, and learning disability. The child neurologist ordered a third video EEG with computer analysis to rule out seizures and BAER (brainstem auditory evoked response) to rule out hearing loss, despite no medical indication. The video EEG was performed on 6/28/2010 and was normal. On 7/12/2010, the child neurologist saw the patient for a follow-up visit. The patient denied having headaches and seizures. The child neurologist ordered a 72-hour ambulatory EEG despite the normal EEG.
The child neurologist next saw the patient on 1/19/2011 for a follow-up visit. The patient’s mother complained that the patient’s math and history test results were still low. The patient had no witnessed seizures and was tolerating Keppra well. Despite the negative findings, the child neurologist diagnosed “seizures, breakthrough, rule out.” The child neurologist ordered another video EEG. At this point in time, the 72-hour video EEG she previous ordered on 7/12/2010 had not been performed.
On 2/18/2011, a 72-hour ambulatory EEG was performed. The child neurologist’s last visit with the patient was on 3/14/2011. On the last visit, the child neurologist noted that the 72-hour ambulatory EEG was normal. She discontinued Keppra. She diagnosed the patient with “arachnoid cyst, middle cranial fossa; generalized epilepsy; learning disability; and adverse effect of medication given correctly.”
The Medical Board of California judged that the child neurologist’s conduct departed from the standard of care because she ordered 3 video EEGs and an ambulatory EEG without medical indication, ordered a BAER with no medical indication, misdiagnosed epilepsy on a patient with no medical history of seizures of any type, and made diagnoses of breaththrough seizures with no basis, contrary to her own findings that were no auras or seizures reported.
The Medical Board of California placed the child neurologist on probation and ordered the child neurologist to complete a medical record keeping course, a professionalism program (ethics course), an education course (at least 40 hours per year for each 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. The child neurologist was assigned a practice monitor and was prohibited from supervising physician assistants and advanced practice nurses.
State: California
Date: January 2018
Specialty: Neurology, Pediatrics
Symptom: Headache, Nausea Or Vomiting, Back Pain, Head/Neck Pain
Diagnosis: N/A
Medical Error: Unnecessary or excessive diagnostic tests, False positive
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
Florida – General Surgery – Right Colectomy Of The Patient’s Ascending Colon Instead Of A Left Colectomy Of The Descending Colon
A 49-year-old female presented to a general surgeon for a colonoscopy. During the colonoscopy the general surgeon documented a 25mm polyp in the patient’s descending colon. Due to its size, the general surgeon was only able to partially resect the polyp. He placed a hemostatic clip to prevent bleeding and tattooed the area.
The patient was subsequently referred to the general surgeon for surgical resection of the left colon.
On 7/15/2015, the patient presented to the general surgeon for a preoperative history and physical. On 7/15/2015, the general surgeon documented that a doctor incompletely resected a polyp in the patient’s colon, and identified the planned procedure as a right colectomy.
On 7/20/2016, the patient presented to the general surgeon at a community hospital. On 7/20/2016, the general surgeon performed a right colectomy of the patient’s ascending colon.
The Board judged that the general surgeon’s conduct to be below the minimum standard of competence given that he performed a wrong-site procedure when he performed a right colectomy of the patient’s ascending colon instead of a left colectomy of her descending colon.
The Board ordered the general surgeon to pay a fine of $4,015.23. The general surgeon was ordered to complete five hours of continuing medical education in “Risk Management.” Also, the Board ordered that the general surgeon present a one hour lecture/seminar on wrong site and/or wrong procedures to medical staff at an approved medical facility.
State: Florida
Date: December 2017
Specialty: General Surgery
Symptom: N/A
Diagnosis: Gastrointestinal Disease
Medical Error: Wrong site procedure
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
Florida – Family Medicine – Treatment Of Elevated Blood Pressure And Headaches From Illicit Testosterone Injections
On 2/17/2014, a male patient in his early twenties presented to a family practitioner for medical assessment and/or treatment.
On 2/17/2014, the patient disclosed to the family practitioner that he was obtaining injectable testosterone from a source unknown to the family practitioner. The patient indicated that he was utilizing the testosterone for bodybuilding purposes.
On 2/17/2014, the patient reported to the family practitioner that he was suffering from headaches and elevated blood pressure.
On 2/17/2014, the family practitioner surmised that the patient’s symptoms were likely the result of excess estrogen production secondary to the patient’s high-dose testosterone use.
On 2/17/2014, the family practitioner wrote the patient a prescription for Anastrozole, an estrogen-blocking substance.
On 2/20/2014, the patient presented to the family practitioner for medical assessment and/or treatment. The family practitioner continued the patient on Anastrozole.
In February 2014, the family practitioner did not obtain or review any medical records establishing that the patient was experiencing excess estrogen production. He also did not obtain bloodwork or perform other diagnostic testing to confirm whether the patient was experiencing excess estrogen production.
On 4/6/2014, the patient presented to the family practitioner for medical assessment and/or treatment. The patient reported to the family practitioner that he was continuing to use testosterone, and that he was continuing to experience headaches. The family practitioner surmised that the patient’s ongoing headaches were caused by elevated prolactin levels. The family practitioner wrote the patient a prescription for Cabergoline, a prolactin-blocking substance.
On 4/10/2014, the patient presented to the family practitioner for medical assessment and/or treatment. The family practitioner continued the patient on Cabergoline.
In April 2014, the family practitioner did not obtain or review any medical records establishing that the patient was experiencing elevated prolactin levels. He did not obtain bloodwork or perform other diagnostic testing to confirm whether the patient was experiencing elevated prolactin levels.
On one or more occasions between 6/27/2014, and 1/9/2015, the family practitioner prescribed the following substances to the patient: clindamycin, Bactroban ointment, doxycycline, Zithromax, oral prednisone, Neurontin, and diazepam. On one or more occasions in 2015, the family practitioner also prescribed the patient Anastrozole.
The family practitioner did not keep any contemporaneous medical records regarding the medical assessment and/or treatment that he provided to the patient between 2/17/2014 and 1/9/2015.
To the extent that the family practitioner had medical records regarding the medical assessment and/or treatment that he provided to the patient between 2/17/2014 to 1/9/2015, such records were all created in October 2015.
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 $8,000 and pay reimbursement costs for the case at a minimum of $1,457.57 and not to exceed $3,457.57. The Medical Board of Florida ordered that the family practitioner complete a drug course, a medical records course, and five hours of continuing medical education in “risk management.”
State: Florida
Date: December 2017
Specialty: Family Medicine, Endocrinology, Internal Medicine
Symptom: Headache
Diagnosis: Drug Overdose, Side Effects, or Withdrawal
Medical Error: Failure to order appropriate diagnostic test, Improper medication management, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
Florida – Gynecology – Unnecessary Biopsies Performed When Lumps Are Noted on A Patient’s Breasts
Between December 2010 and August 2013, a patient presented to her gynecologist.
On 5/19/2011, the gynecologist found small, smooth, mobile lumps in the patient’s left and right breasts.
On 6/17/2011, the gynecologist performed a right breast biopsy on the patient. The gynecologist noted that the right breast lump was likely a fibroadenoma. The biopsied right breast tissue was found to be benign.
On 7/5/2011, the gynecologist performed a left breast biopsy on the patient. The gynecologist noted that the left breast lump was likely a fibroadenoma. The biopsided left breast tissue was found to be benign.
At all times, the patient was at a low risk for having breast cancer.
The Board judged the gynecologist’s conduct to be below the minimum standard of practice given that the prevailing professional standard of care required that the gynecologist medically manage the patient’s left and right breast lumps with breast exams, breast sonographies, and/or mammograms. The obstetrician’s performance of left and right breast biopsies on the patient was medically unnecessary.
The Board ordered that the gynecologist pay a fine of $16,000 against his license. Also, the Board ordered that the case fine be set at $9,486.57. The Board ordered that the gynecologist complete five hours of continuing medical education in “Risk Management.”
State: Florida
Date: December 2017
Specialty: Gynecology, Gynecology
Symptom: Mass (Breast Mass, Lump, etc.)
Diagnosis: N/A
Medical Error: Failure to order appropriate diagnostic test, Unnecessary or excessive treatment or surgery
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
Florida – Anesthesiology – Wrong Site Procedure For A Transforaminal Epidural Steroid Injection
On 4/28/2015 an 80-year-old female, presented to an anesthesiologist for an initial consultation for possible epidural steroid injections. On 4/28/2015, the patient had a history of left sided lower back pain and left lower extremity pain.
On 4/28/2015, the anesthesiologist scheduled the patient for a left transforaminal epidural steroid injection (TFESI) to be performed on 4/29/2015.
On 4/29/2015, the patient presented to the anesthesiologist at outpatient surgery and laser center for the planned left TFESI. On 4/29/2015, the patient and anesthesiologist signed a consent form for a left TFESI. After the patient was prepped for the procedure, the anesthesiologist performed a TFESI on the patient’s right side (the wrong site). While the patient was still in the procedure room, the anesthesiologist was informed that he performed the TFESI on the incorrect side. The anesthesiologist then performed a TFESI on the patient’s left side (the correct site).
The anesthesiologist’s procedure report on 4/29/2015 procedures did not accurately document the anesthesiologist’s performance of TFESI procedures on two different sides of the patient.
The Board ordered the anesthesiologist to pay a fine of $5,000 against his license. Also, the Board ordered that the anesthesiologist pay reimbursement costs of $5,857.63. The Board ordered that the anesthesiologist complete a medical records course. The Board ordered that the anesthesiologist complete five hours of continuing medical education on “Risk Management.” Also, the Board ordered the anesthesiologist to complete a one hour lecture on wrong site surgeries to medical staff at an approved site.
State: Florida
Date: December 2017
Specialty: Anesthesiology, Neurology
Symptom: Pain
Diagnosis: Spinal Injury Or Disorder
Medical Error: Wrong site procedure, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
Florida – Internal Medicine – Patient With Worsening Chronic Kidney Disease Presents With Arm Pain, Numbness, And Shortness Of Breath
From 2009 until 2014, an internist served as the patient’s primary care physician.
In 2009, the internist referred the patient to Cardiologist A for a cardiology evaluation. The results of the 2009 cardiology evaluation revealed that the patient’s electrocardiogram and stress test were both abnormal.
At this time, Cardiologist A recommended that the internist increase the patient’s medication as needed in order to get the patient’s cholesterol to below seventy.
The patient was evaluated by Cardiologist A again in June 2010.
The June 2010 cardiac evaluation revealed that the patient had shortness of breath on exertion at times, possibly related to hypertension and subclinical congestive heart failure.
On 7/17/2013, the patient underwent lab work, the results which showed that his glomerular filtration rate (GFR) was thirty-four. The internist staged the patient’s chronic kidney disease (CKD) at a stage III/IV.
The patient’s next set of lab work was conducted on 11/18/2013, the results of which showed that his GFR was twenty-two. The internist wrote in a progress note that the patient’s CKD was a stage III/IV.
On 1/13/2014, the patient had lab work done again, the results which showed that his GFR was twenty-six. In his progress note he wrote that the patient’s CKD was now a stage IV.
Despite a dramatic decline in the patient’s GFR levels indicative of worsening CKD, the internist did not refer the patient to a nephrologist.
On 1/13/2014, the patient presented to the internist complaining of left arm pain, numbness radiating to both hands, and shortness of breath. The internist ordered an EKG, chest x-ray, and lab work. His assessment of the patient at this time was dyspnea on exertion, questionable coronary artery disease, questionable pulmonary disease, and questionable anxiety.
On 1/14/2014, the patient returned to the office for an echocardiogram. After the echocardiogram, the internist referred the patient to Cardiologist B for a consult. The patient could not obtain an appointment with Cardiologist B until 2/3/2014.
The internist ordered that a stress test be conducted prior to the patient’s visit with Cardiologist B, and advised that the patient bring the results of the stress test to his appointment with Cardiologist B.
On 1/23/2014, the stress test was performed and the results were abnormal.
The Medical Board of Florida judged that the internist failed to adequately evaluate the patient’s symptoms and recognize the patient’s worsening coronary artery disease, development of congestive heart failure, and worsening chronic kidney disease. He failed to refer the patient to a nephrologist for further evaluation upon seeing a dramatic decline in the patient’s GFR levels. He also failed to send the patient to the emergency department for treatment when the patient presented to him with exhibiting cardiac symptoms and had a known history of heart disease.
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 $2,500 against his license and pay reimbursement costs for the case at a minimum of $5,756.36 and not to exceed $7,756.36. The Medical Board of Florida also ordered that the internist complete five hours of continuing medical education in the treatment of patients with chronic kidney disease and chronic heart disease.
State: Florida
Date: December 2017
Specialty: Internal Medicine
Symptom: Extremity Pain, Numbness, Shortness of Breath
Diagnosis: Heart Failure, Cardiovascular Disease, Renal Disease
Medical Error: Failure to examine or evaluate patient properly, Referral failure to hospital or specialist
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
Florida – Internal Medicine – Worsening Chronic Kidney Disease, Abnormal Stress Test, And Cardiac Symptoms
From 2009 until 2014, an internist served as a patient’s primary care physician.
In 2009, the internist referred the patient to Cardiologist A for a cardiology evaluation. The results of the 2009 cardiology evaluation revealed that the patient’s electrocardiogram and stress test were both abnormal. At this time Cardiologist A recommended that the internist increase the patient’s medication as needed in order to get the patient’s LDL cholesterol below seventy.
The patient was evaluated by Cardiologist A again in June 2010. The June 2010 cardiac evaluation revealed that the patient had shortness of breath on exertion at times, possibly related to hypertension and subclinical congestive heart failure.
On 7/17/2013, the patient underwent lab work, the results which showed that his glomerular filtration rate (“GFR”) was thirty-four. The internist stated the patient’s chronic kidney disease (“CKD”) as stage III/IV.
The patient’s next set of lab work was conducted on 11/18/2013, the results of which showed that his GFR was twenty-two. The internist wrote in a progress note that the patient’s CKD was stage III/IV.
The patient had lab work done again on 1/13/2014, the results of which showed that his GFR was twenty-six. In a progress noted created on 1/13/2014, the internist wrote that the patient’s CKD was now at stage IV.
Despite the dramatic decline in the patient’s GFR levels indicative of worsening CKD, the internist did not refer the patient to a nephrologist.
On 1/13/2014, the patient presented to the internist complaining of left arm pain, numbness radiating to both hands, and shortness of breath. The internist ordered an EKG, chest x-ray, and lab work. The internist’s assessment of the patient at this time was dyspnea on exertion, questionable coronary artery disease, questionable pulmonary issue, and questionable anxiety.
The internist had the patient return to the office on 1/14/2014 for an echocardiogram. After the echocardiogram, the internist referred the patient to Cardiologist B for a consult.
The patient could not obtain an appointment with Cardiologist B until 2/3/2014.
The internist ordered that a stress test be conducted prior to the patient’s visit to Cardiologist B, and advised that the patient bring the results of the stress test to his appointment with Cardiologist B. The stress test was performed on 1/23/2014, and the results were abnormal.
The Board judged the internist’s conduct to be below the minimum standard of competence given that the internist failed to adequately evaluate the patient’s symptoms and recognize the patient’s worsening coronary artery disease, development of congestive heart failure, and worsening of chronic kidney disease. The internist should have referred the patient to a nephrologist for further evaluation upon seeing a dramatic decline in the patient’s GFR levels. When the patient, with a known history of cardiac disease, presented with cardiac symptoms, the internist should have should have sent the patient to an emergency department for treatment.
The Board ordered that the internist pay a fine of $2,000 imposed against his license. The Board also ordered that the internist pay reimbursement costs of a minimum of $5,756.36 and not to exceed $7,756.36. The internist was ordered to complete five hours of continuing medical education in the treatment of patients with chronic kidney disease and five hours of continuing medical education in the treatment of patients with chronic heart disease.
State: Florida
Date: December 2017
Specialty: Internal Medicine
Symptom: Extremity Pain, Numbness, Shortness of Breath
Diagnosis: Renal Disease, Cardiovascular Disease
Medical Error: Referral failure to hospital or specialist
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
Florida – Interventional Radiology – Guidewire Found In Patient’s Abdomen Following CT-Guided Percutaneous Drainage
On 8/24/2015, a 63-year-old male presented to a medical center for a CT-guided percutaneous aspiration with possible drainage of an abdominal abscess.
During the course of the procedure, an interventional radiologist placed a guidewire into the operative field. Once the procedure was completed the patient had stable vital signs and no immediate complications were known.
On 9/12/2015, the patient was re-admitted to the medical center with complaints of abdominal pain. A subsequent CT scan revealed a foreign body on the left side of the patient’s abdomen.
On 9/15/2015, a general surgeon performed laparoscopic retrieval of the foreign body, at which time a portion of the guidewire, measuring 11.0 centimeters in length, was found and removed intact.
The Board ordered that the interventional radiologist pay a fine of $5,000 against his license and that the radiologist pay reimbursement costs for the case at a minimum of $4,737.16 and not to exceed $6,737.16. The Board also ordered that the interventional radiologist complete five hours of continuing medical education in “Risk Management” and that the interventional radiologist complete a one hour lecture/seminar on retained foreign body objects.
State: Florida
Date: November 2017
Specialty: Interventional Radiology
Symptom: Abdominal Pain
Diagnosis: Post-operative/Operative Complication, Acute Abdomen
Medical Error: Retained foreign body after surgery
Significant Outcome: Hospital Bounce Back
Case Rating: 2
Link to Original Case File: Download PDF
Florida – Emergency Medicine – Sharp Chest Pain After Intercourse
On 4/4/2015, a 47-year-old male presented to the emergency department with sharp chest pain after intercourse.
The RN on duty noted taking the patient’s vitals and performing an EKG, chest radiograph, and labs.
In his physician note, the ED physician documented the following: the patient did not take his medication for hypertension or dyslipidemia despite having a history of hypertension and homelessness; the patient reported a history of coronary artery disease and possible coronary artery stent placement; and the patient reported chest discomfort and dyspnea for the week prior to presentation as well as a history of tobacco use.
The ED physician recorded a differential diagnosis including acute myocardial infarction, non-ST segment elevation myocardial infarction (“NSTEMI”), angina, and acute coronary syndrome.
The ED physician did not diagnose the patient with possible cardiac etiology of chest discomfort. He also did not contact the on-call cardiologist. The ED physician did not perform provocative testing or cardiac catheterization. He also did not admit the patient for hospitalization and cardiology consultation. The ED physician discharged the patient without requiring any further evaluation/treatment or serial EKG/troponin. He did not arrange for close outpatient follow-up prior to discharge.
The Board issued a letter of concern against the ED physician’s license and ordered that he pay a fine, reimburse costs for the proceedings, and complete 5 hours of continuing education in risk management.
State: Florida
Date: November 2017
Specialty: Emergency Medicine
Symptom: Chest Pain
Diagnosis: Cardiovascular Disease
Medical Error: Failure to order appropriate diagnostic test, Referral failure to hospital or specialist, Failure to follow up
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
Florida – Internal Medicine – Retained Guide Wire Found After Replacement Of Dialysis Catheter
On 3/19/2015, a patient presented to a hospital with complaints of chest pain, history of acute stent thrombosis, and renal failure.
On 3/21/2015, a physician referred the patient to an internist for replacement of temporary dialysis catheter to address her acute kidney failure. The internist placed a double-lumen dialysis catheter in the patient’s left subclavian vein.
Due to the catheter not functioning properly, another physician performed a catheter exchange procedure on the patient on 3/23/2015. After the procedure, the inspection of the catheter revealed that the guide wire remained in one of the lumens of the catheter.
Neither the internist nor his staff removed the guide wire from the catheter prior to the insertion of the catheter into the patient’s left subclavian vein.
The Board judged the internist’s conduct to be below the minimum standard of competence given that he left a foreign body in a patient.
The Board ordered that the internist pay a fine of $3,500 against his license and pay reimbursement costs for the case for a minimum of $3,419.35 and not to exceed $5,419.35. The Board also ordered that the internist complete five hours of continuing education in “Risk Management” and complete a lecture/seminar on retained foreign body objects to medical staff.
State: Florida
Date: November 2017
Specialty: Internal Medicine, Nephrology
Symptom: Chest Pain
Diagnosis: Renal Disease
Medical Error: Retained foreign body after surgery
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF