Found 284 Results Sorted by Case Date
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California – Family Practice – Failure Of Monitoring And Increasing Blood Pressure While On Phentermine



On 8/5/2008, a 24-year-old male presented himself to a clinic for an initial consultation to enroll in a weight loss program.  The patient completed a health information questionnaire, in which he indicated that he had asthma and that he was not taking any medications.

On 8/6/2008, Physician A began treating the patient for weight loss.  At his initial clinic visit at the clinic, the patient was too large to be weighed on their scale but self-reported his weight at 460 pounds.  The patient’s height was not recorded during this visit, and no baseline body mass index was recorded either.  The patient’s blood pressure tested normal (136/84 mmHg) but his pulse rate was measured at an elevated pulse of 113 beats per minute.  An electrocardiogram (EKG) was performed on the patient, which showed he was in sinus tachycardia; however, Physician A failed to chart any discussion of differential diagnoses with the patient regarding his rapid heartbeat.  Physician A did not attempt to obtain the patient’s medical records or order blood lab reports for the patient prior to beginning his weight loss treatment.  On this visit, Physician A started the patient on phentermine, two 15 mg tablets per day.

Between 8/6/2008 and 8/20/2009, the patient had a total of 38 visits to the clinic where he received treatment.  During the treatment period, the patient was prescribed the following escalating dosage of phentermine:

1) 8/6/2008 – 15 mg two times per day.

2) 8/27/2008 – 15 mg three times per day.

3) 9/10/2008 – 30 mg three times per day.

4) 11/7/2008 – 37.5 mg three times per day.

5) 12/12/2008 – 37.5 mg four times per day.

6) 5/12/2009 – 37.5 mg four times per day, and an additional 15 mg of phentermine was prescribed to be used as needed.

7) 5/20/2009 – 37.5 mg four times per day, and an additional 30 mg of phentermine was prescribed to be used as needed.

As the patient’s dosages of phentermine were increased, his blood pressure also increased.  On numerous visits to the clinic during the patient’s treatment period, very high blood pressure measurements were recorded in the clinical notes.  In fact, on eleven clinic visits during his treatment period, the patient had diastolic blood pressure measurements of over 100 mmHg.  During the patient’s treatment period at the clinic, no attempt was made to permanently titrate down the dosage of phentermine to lower and/or control his very high blood pressure.  Significantly, on 2/17/2009, the patient’s blood pressure was measured at 192/125 mmHg, which should have resulted in immediate emergency care in a hospital setting.  However, the patient was not hospitalized, no evaluations for end-organ damage were made, and no EKG or urinalysis was ordered.  Rather, despite the patient’s hypertensive crisis, the patient was again prescribed phentermine, 37.5 mg four times per day, without any consideration of permanently titrating down his phentermine medication to lower and/or control his very high blood pressure.

During the entire course of Physician A’s treatment of the patient, he had a rapid pulse.  Initially, Physician A ordered an EKG to rule out cardiac arrhythmia as a cause of his rapid heartbeat; however, she failed to document any differential diagnoses that would address other causes of patient’s sinus tachycardia.  Nor did Physician A attempt to use pharmacologic agents to slow down the patient’s heart rate during the time she treated him for weight loss.

Documentation of visits for patients in a weight loss program should follow the SOAP note guidelines.  Between 8/6/2008 and 8/20/2009, Physician A failed to follow the SOAP note guidelines.  She documented very little subjective data on the patient.  Also, objective data did not contain blood pressure readings.  Chart notes from 14 visits did not contain the patient’s pulse measurements.

Further, Physician A failed to accurately document the patient’s percentage of body fat, percentage of water, and muscle mass.  Lastly, Physician A documented very few discussions with the patient on behavioral modification strategies, such as dietary changes or change in exercise habits.

On 8/20/2009, the patient wrote a letter to Physician A and complained of signs and symptoms suggestive of congestive heart failure, including nausea, drowsiness, difficulty breathing, and pitting edema.  The next day, for the first time, Physician A ordered metabolic panel tests for the patient.  The results of the patient’s lab tests indicated his creatinine was 8.19, at which point Physician A advised the patient to go directly to an emergency department for management of renal failure.  Prior to this lab test – during the entire course of Physician A’s treatment of the patient for weight loss – only one blood draw was ever obtained.

The Board notes that Physician A failed to order a complete blood count, comprehensive metabolic panel, and urinalysis for the patient prior to initiating him on phentermine.  These labs should be obtained to screen obese patients for anemia, kidney disease, liver disease, and hypothyroidism.

The Board judged the Physician A’s conduct as having fallen below the minimum level of competence given failure to review the patient’s medical records prior to beginning his weight loss treatment, failure to document discussions regarding progress in the weight loss program, and failure to monitor and control the patient’s hypertension.

The Board placed Physician A on probation for four years.  Stipulations included forty hours of continuing medical education in any areas of deficient practice, completion of the Prescribing Practices Course at the Physician Assessment and Clinical Education Program, completion of a medical record keeping course, and completion of a clinical training program equivalent to the Physician Assessment and Clinical Education Program.  The Board prohibited Physician A from practicing in the area of medical weight loss management.

State: California


Date: September 2014


Specialty: Family Medicine, Internal Medicine


Symptom: Shortness of Breath, Swelling


Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Heart Failure


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


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Indiana – Family Medicine – ALCAT Ordered With Ambiguity On Patient’s Consent And Insurance Coverage



On 5/15/2012, an osteopathic medicine practitioner began treating a patient.  On 5/15/2012, the patient specifically sought treatment for ankle and back injuries following a fall down a flight of stairs, and he asked to be screened for Attention Deficit Disorder (ADD).  The patient was diagnosed with depression, anxiety, and ADD, in addition to the lower back injury (with spina bifida occulta noted on the x-ray) and left ankle sprain.  The osteopathic medicine practitioner prescribed Adderall and Pristiq, with a follow-up scheduled in a month.  The patient presented an insurance card and paid his copayment at the time of the office visit.

On 5/16/2012, the osteopathic medicine practitioner’s office staff verified the patient’s insurance coverage.

On 6/5/2012, the patient presented for a follow-up appointment.  The patient did not request a treatment for any new symptoms at this time, but requested spinal manipulation for back pain and a refill of his Adderall prescription.  The patient’s insurance coverage was verified by the osteopathic medicine practitioner’s office staff.  During the patient’s physical examination, the osteopathic medicine practitioner noted a right thyroid nodule, and recommended a thyroid ultrasound.  In addition to other diagnostic laboratory tests (e.g., CBC, lipid panel, and TSH), the osteopathic medicine practitioner also recommended an antigen leukocyte cellular antibody test (“ALCAT”) to determine if the patient suffered from certain food intolerances or sensitivities in order to then work with the patient on a diet plan for adjunctive treatment of ADD, depression, anxiety, and joint pain.  The osteopathic medicine practitioner claimed this plan of treatment was discussed with the patient, although he did not discuss the cost.  The osteopathic medicine practitioner claimed that he informed the patient that the patient’s insurance would cover the cost of the ALCAT.  The patient claimed no discussion of the treatment took place.  No discussion of the treatment plan was documented in the medical records.  While the osteopathic medicine practitioner had the patient sign a generic consent form agreeing to “any necessary medical diagnosis or treatment,” he did not have the patient fill out forms explaining any of the specific tests the osteopathic medicine practitioner had ordered.  The patient went to the lab to have the blood work performed and did not object to any of the tests.

On 6/11/2012, the osteopathic medicine practitioner’s office staff learned that the patient’s insurance coverage had lapsed as of 5/31/2012, despite verification from the insurance company on 6/5/2012.  The osteopathic medicine practitioner’s office stated and documented that it contacted the patient on 5/12/2012 to discuss payment options and mailed monthly invoices to the patient, but no payment was ever received for the services rendered on 6/5/2012.

On 2/10/2013, the patient filed a consumer complaint stating that he was not informed of the cost of the ALCAT, and that the ALCAT was experimental and not covered by insurance companies.  The patient stated that he was billed for the full cost of the ALCAT, was not informed of the cost in advance, and that he had not requested an allergy test.

Certain commercial insurers’ coverage determinations state that the ALCAT is deemed to be “experimental” or “investigational” with respect to food allergy testing.  The osteopathic medicine practitioner depended on scientific studies and white papers provided by Cell Science Systems (the manufacturer of the ALCAT) which confirm that the ALCAT is a diagnostic tool to determine food sensitivities and intolerances.  Certain commercial insurers will pay for ALCAT testing for purposes of food sensitivity/intolerance testing.  The literature on the use of the ALCAT was present in the patient waiting area in the office of the osteopathic medicine practitioner.  Because the patient’s insurance covered the cost of the ALCAT test for food sensitivity/intolerance testing, and the osteopathic medicine practitioner’s office accepted insurance payment as payment in full for the test, he believed no payment would be owed by the patient for the ALCAT testing.

The Board judged the osteopathic medicine practitioners conduct to be below the minimum standard of competence given his failure to sufficiently document the patient’s treatment plan, the purpose for utilizing the diagnostic test at issue, and the patient’s understanding and consent to such testing.

The Board ordered that the osteopathic medicine practitioner complete 10 hours of continuing medical education related to documentation and the informed consent process, update his written policies and consent forms, and pay a fine of $5.00.

State: Indiana


Date: September 2014


Specialty: Family Medicine


Symptom: Back Pain


Diagnosis: Psychiatric Disorder, Spinal Injury Or Disorder


Medical Error: Failure of communication with patient or patient relations, Ethics violation, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Washington – General Surgery – Segmental Or Simple Mastectomy And Follow-Up



On 9/16/2011, an 85-year-old woman was referred to a diagnostic imaging center by her primary care physician pursuant to a suspected right breast lesion.  The lesion was localized with ultrasound.  Using ultrasound guidance, three 10 gauge cores were obtained and a biopsy marker clip was deployed at the biopsy site.  Post-biopsy mammographic imaging showed that the marker clip was well positioned.

Pathology results determined that the specimens were malignant ductal carcinoma in-situ (DCIS) arising in association with an intraductal papilloma.  The recommendation was that the patient be further referred for a surgical consultation.

The patient was referred to a surgeon.  The surgeon examined the patient on 9/27/2011.  The patient stated that she did not feel the mass.  The surgeon noted that there was a faint mass palpable on the right side, at the site of the biopsy, and he questioned whether it was from the biopsy itself.  The surgeon planned to perform a simple mastectomy using monitored sedation with local anesthesia rather than a full general anesthetic.  The surgeon sought to avoid the need for post-operative radiation therapy.  However, the patient presented with co-morbidities and at her age radiation therapy might not have been recommended.

The surgeon performed a segmental mastectomy procedure rather than a simple mastectomy on 10/17/2011.  There were no complications during the surgery.  However, the operative report does not describe the typical limits of dissection and the surgeon did not postoperatively perform a specimen mammogram to verify that the non-palpable lesion had been removed.

The patient returned to the surgeon on 3/9/2012, after feeling a mass in her right upper chest wall area.  The mass was very palpable.  An ultrasound performed prior to the visit showed the previously placed biopsy marker in the lesion.  The patient underwent two subsequent surgical procedures to eliminate the risk of recurrence.

The Commission stipulated the surgeon reimburse costs to the Commission and write and submit a paper of at least 1000 words, with bibliography, addressing the management of DCIS in elderly patients, including a discussion of circumstances favoring mastectomy, segmental mastectomy with post-operative radiation, and segmental mastectomy without post-operative radiation.  The surgeon will make a presentation on this subject to other providers in his clinic.

State: Washington


Date: September 2014


Specialty: General Surgery, Oncology


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


Diagnosis: Breast Cancer


Medical Error: Improper treatment, Failure to follow up


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Wisconsin – Oncology – Patient With Leukemia On Chlorambucil Found To Have Renal Failure



A 68-year-old man with chronic lymphocytic leukemia, splenomegaly, and acute renal failure presented to a hematologist.

Oral chlorambucil was initiated.  The hematologist conducted no further testing for the renal failure.  He had hoped that chlorambucil would treat the leukemia and consequently resolve the renal failure.  However, it is noted that leukemia is rarely the cause of renal failure, and one would not expect renal failure to resolve with leukemia treatment.

Subsequently, the patient did not get appropriate treatment for his renal failure.

State: Wisconsin


Date: September 2014


Specialty: Oncology, Hematology


Symptom: N/A


Diagnosis: Renal Disease, Cancer


Medical Error: Improper treatment


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Wisconsin – Hematology – Anemia, Leukocytosis, And Thrombocytosis



A 63-year-old man presented to his primary care physician with anemia.  He was sent to hematologist A.  Hemoglobin was noted to be 7.6, WBC 17.7, platelet count 847, iron level 15, TIBC 189, iron saturation 8%, and ferritin 587.

He was diagnosed with iron deficiency and treated with ferrous sulfate and vitamin C.

3 weeks later, he presented to hematologist B who ordered a bone marrow biopsy and diagnosed myeloproliferative disorder.

State: Wisconsin


Date: September 2014


Specialty: Hematology, Internal Medicine, Oncology


Symptom: N/A


Diagnosis: Cancer


Medical Error: Failure to order appropriate diagnostic test


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Wisconsin – Anesthesiology – Intubation After Right Coronary Artery Perforation



On 5/26/2013, a patient presented to the ED with chest pain diagnosed as STEMI and taken to the catheterization lab.

During the procedure, the right coronary artery was perforated.  A “code blue” was called.  Anesthesiologist A was on-call and at the bedside within 1-2 minutes of the code being called.  He intubated the patient and confirmed placement with a carbon dioxide sensor.  Auscultation of the lungs confirmed placement of the endotracheal tube.  The patient’s oxygen levels remained critically low for 15 minutes after intubation before Anesthesiologist A discovered that he had placed the endotracheal tube in the esophagus.  Anesthesiologist A reintubated the patient.  Immediately, oxygen levels rebounded to appropriate levels.  The patient ultimately died.

Autopsy listed anoxic encephalopathy and prolonged esophageal intubation as the cause of death.  Anesthesiologist A was deemed to have fallen underneath the minimally accepted standard of care.

State: Wisconsin


Date: August 2014


Specialty: Anesthesiology


Symptom: Chest Pain


Diagnosis: Post-operative/Operative Complication, Acute Myocardial Infarction


Medical Error: Procedural error


Significant Outcome: Death


Case Rating: 2


Link to Original Case File: Download PDF



California – Obstetrics – Excessive Pitocin And 43 Decelerations During Labor



On 2/21/2008 at 4:30 p.m., a 28-year-old multigravida pregnant female was admitted to a medical center at term for induction of labor.  An obstetrician was the attending physician for the patient. The patient was given misoprostol for cervical ripening and was started on Pitocin.

The patient had not progressed in labor by the afternoon of 2/22/2008.  An external fetal monitor had been placed on the patient, which showed occasional decelerations.  However, neither an internal fetal monitor nor a fetal electrode was placed in the patient to monitor fetal heart rate and fetal intolerance to labor.  Between 3:22 p.m. to 9:59 p.m. on 2/22/2008, the patient displayed varied concerning symptoms during labor, including but not limited to, the baby’s fetal heart rate showed approximately 43 recorded decelerations.  During periods of time from 3:22 p.m. to 9:59 p.m., on 2/22/2008, the patient’s fetal monitoring strips were uninterpretable and showed tachysystole, hyperstimulation, saw tooth patterns, overshoots to 180 and decelerations, as well as elevated baseline for long periods of time, without appropriate action taken by the obstetrician.  The obstetrician allowed the patient to continue with labor and continue to receive Pitocin and did not schedule a Cesarean delivery for her.

On 2/22/2008, at 7:59 p.m., the patient became completely dilated and pushed for about 2 hours until she vaginally delivered a female infant weighing approximately 6 pounds 10 ounces, at 9:59 p.m.  At the time of delivery, the infant was floppy, blue, and not breathing.

The Neonatal Intensive Care Unit team was called immediately and helped with resuscitation of the baby whose Apgar scores were 1 at 1 minute, 3 at 5 minutes, and 6 at 10 minutes.  The baby was later diagnosed with significant neurological deficits.

The obstetrician committed gross negligence in his care and treatment of the patient, including: failure to appropriately interpret the external fetal monitoring strips placed on the abdomen of the patient for the baby and allowing the patient to receive too much Pitocin, which depleted the baby’s reserves.

The Medical Board of California ordered that the obstetrician be placed on a three-year probation, attend 65 hours of a CME education course, a prescribing practice course, a PACE program, and receive a practice monitor. During this probationary period, the obstetrician was prohibited from supervising physician assistants.

State: California


Date: July 2014


Specialty: Obstetrics


Symptom: N/A


Diagnosis: Obstetrical Complication


Medical Error: Failure to properly monitor patient, Diagnostic error, Delay in proper treatment, Unnecessary or excessive treatment or surgery


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 2


Link to Original Case File: Download PDF



California – Cardiology – Excessive Dye Loads And Fluoroscopy Time During Catheterization



A 68-year-old male was admitted to a medical center with known heart disease, coronary artery disease, and had undergone a previous bypass surgery.  He also had poor heart muscle function. His ejection fraction was 36%.

The patient had chest pain and underwent cardiac catheterization to assess any blockage and to improve his heart function by opening the artery.  The cardiologist spent about 69.4 minutes in fluoro time, which meant an extremely high indication of radiation exposure. The cardiologist also used dye excessively during the cardiac catheterization.

The cardiologist’s failure to use rotablator in heavily calcified arteries was a departure from the standard of care. His conduct of engaging in excessive fluoroscopy radiation time and using excessive dye loads was a departure from the standard of care.

For this allegation and others, the Medical Board of California ordered that the cardiologist be placed on probation for five years, attend a medical record keeping course, a clinical training program, be assigned a practice monitor for the duration of the probation, and be prohibited from supervising physician assistants for the duration of the probation.

State: California


Date: July 2014


Specialty: Cardiology


Symptom: Chest Pain


Diagnosis: Cardiovascular Disease


Medical Error: Procedural error


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Virginia – Emergency Medicine – Presentation Of Suicidal Thoughts With Missed Incidental Findings



On 1/10/2012, a teenage male presented to the emergency department after being referred for a psychiatric referral by his high school for making a “suicide pact” with his girlfriend.  The patient’s mother accompanied him to the emergency department.  His admitting diagnoses were suicidal thoughts and depression.

An ED nurse conducted a “suicide screening.”  The nurse elicited and documented a history from the patient regarding the suicide pact that he made in September 2011 with his girlfriend who lived in Kansas.  The patient told his friends about the suicide pact, and his friends reported the information to school officials.

The nurse evaluated and documented the patient’s vital signs, including his blood pressure, which was elevated at 182/114 mmHg.

There was no documentation in the patient’s medical record that his blood pressure was repeated.

The nurse started an intravenous line and obtained a urinalysis, drug abuse screen, comprehensive metabolic panel, complete blood count, thyroid stimulating hormone level, and an alcohol level.  The patient’s BUN level was elevated at 33.  His urine creatinine level was elevated at 3.5.  His urine had red blood cells and protein present.  A second nurse documented on a computer-generated form that she had conducted a physical assessment of the patient.

A social worker conducted a 27-minute mental health evaluation and determined that the patient could be discharged from the emergency department.  She notified the ED physician.

The ED physician circled “major depression” on a pre-printed physical examination form and checked off the box stating “cleared medically for psychiatric referral” and discharged the patient home.  The ED physician failed to document any history, physical examination, medical decision-making or any plan for the patient or that he had ordered and/or reviewed any laboratory tests or procedures.

The patient had a history of juvenile rheumatoid arthritis.  He had been treated with methotrexate from 2000 to 2006.  The ED physician failed to document this history.

On 1/4/2013, the patient was evaluated at a clinic for decreasing vision and headaches.  His blood pressure was 200/130.  The staff repeated the reading three times.  He was diagnosed with hypertensive urgency/emergency.  Later that day, he went to an emergency department where he was then transported by helicopter to another hospital, admitted to the intensive care unit, and diagnosed with end-stage renal disease and severe hypertension.

On 2/7/2013, the Board received a complaint from the mother of a patient.  She alleged that the ED physician failed to address her son’s high blood pressure reading and abnormal laboratory results.

In May 2013, the patient received a kidney transplant.

The Board judged the ED physician’s conduct to be below the standard of care given failure to address the abnormal labs and hypertension of the patient.

The Board reprimanded the ED Physician, ordered him to pay a fine, ordered him to complete a course in medical recordkeeping, ordered him to complete a course in pediatric/adolescent emergency medicine, and stipulated that agents may conduct a chart review or peer review of ED physician A’s practice.

State: Virginia


Date: June 2014


Specialty: Emergency Medicine


Symptom: Psychiatric Symptoms, Headache, Vision Problems


Diagnosis: Renal Disease, Hypertensive Emergency, Psychiatric Disorder


Medical Error: Failure to follow up


Significant Outcome: Hospital Bounce Back


Case Rating: 2


Link to Original Case File: Download PDF



Kansas – Urology – Penile Sores Develop Following Transurethral Microwave Therapy



An 86-year-old male presented on 2/4/2005 to a urology center for consultation regarding his enlarged prostate with a chief complaint of urinary frequency.  The patient was diagnosed with benign prostatic hyperplasia.

Initial management of the patient’s treatment was with 0.4 mg Flomax daily.  The patient reported responding to the Flomax regimen but complained of adverse effects.  He was then prescribed a trial of afluzosin.  Eventually, a transurethral microwave therapy (TUMT) procedure was scheduled on 12/5/2005.  No consent form for the procedure appears in the patient’s medical record that was provided to the Board.  The urologist also failed to create a post-procedure note for the patient’s procedure.

On 12/5/2005, the urologist performed a TUMT procedure on the patient.  The patient complained of pain during and after the TUMT.  The urologist failed to document the patient’s procedure and pre-procedure medications.  Three days after the TUMT procedure,  the patient developed an open sore on his penis and complained of a hard rope-like lump extending from his penis to the back of his anus.

On 1/9/2006, the patient presented with complaints of continued post-operative pain and penile/scrotal sores.  The patient discovered the urologist performed the procedure without the patient’s informed consent instead of being performed by the urologist’s supervisor.

The patient’s records provided to the Board show two different progress notes authored by the urologist.  The urologist’s notes contain different information.  The urologist also failed to sign or date both notes.  No explanation for the differences in these two notes or why the urologist failed to sign the records was provided by the urologist.

A complaint against the urologist was filed by the patient on 4/12/2006.

The urologist responded to the complaint on 5/2/2006.  In his response, the urologist stated that he supervised the procedure as well as placed the rectal probe and urethral catheter.  The urologist also indicated that his supervising physician was aware of the scheduled procedure and was aware that the urologist was performing it.

The urologist’s response further stated: “I have been involved in urology since 1976.  I was trained in the military, and I have been involved in urology since 1975.  I was trained in the military, and I was an Instructor at the Naval School of Health Sciences for urology technicians in San Diego, CA.  I have also received specific training on TUMT by [my supervising physician], and through a training program sponsored by Urologix, which uses the Tagris system for TUMT.  In conclusion having performed [sic] between 100 and 150 of these procedures, I feel I am more than adequately qualified to perform these without hesitation and that all requirements for supervision were met.”

The Board ordered the urologist complete a medical record keeping seminar put on by the Center for Personalized Education for Physicians (CPEP).  Also, the Board ordered that the urologist could not perform any type of urological surgical procedure.  The urologist was prohibited from ordering, prescribing, dispensing, or administering medications to any employee, family members, significant others or any person whom he had a personal relationship.

State: Kansas


Date: June 2014


Specialty: Urology


Symptom: Urinary Problems


Diagnosis: Post-operative/Operative Complication


Medical Error: Lack of proper documentation, Ethics violation


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



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