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A payment of $775,000 had been made on the gastroenterologist’s behalf to settle a civil malpractice action brought against him by a patient.

It was alleged the gastroenterologist failed to follow-up on pathology results that revealed cancer after he had performed a colonoscopy on the patient, which led to a delay in the diagnosis of colorectal cancer.

On 8/12/2009, a 55-year-old woman presented to a gastroenterologist with complaints of abdominal pain and rectal bleeding.  The patient’s medical history revealed a family history of colon cancer.  The gastroenterologist recommended that the patient have a diagnostic colonoscopy to evaluate her persistent rectal symptoms.

On 9/17/2009, the gastroenterologist performed a colonoscopy on the patient.  During the procedure, the gastroenterologist identified internal hemorrhoids associated with a sessile polyp in the mid-rectum.  The gastroenterologist removed the polyp and submitted the specimen for pathologic analysis.  The patient was discharged from the hospital on 9/17/2009.

On 9/18/2009, pathology diagnosed the polyp to be a moderately differentiated adenocarcinoma arising within a tubular adenoma.  On 10/6/2009, the gastroenterologist entered a progress note in the patient’s hospital chart directly documenting the finding of adenocarcinoma made in the pathology report.  Despite entering that chart note, the gastroenterologist never advised the patient of the finding of adenocarcinoma that had been made.

The gastroenterologist thereafter had no further contact with the patient until he saw her in his office on 8/23/2010, approximately eleven months after the colonoscopy had been performed.  At that visit, the gastroenterologist diagnosed the patient with hemorrhoids and prescribed steroid suppositories; however, he once again failed to inform her of the finding of cancer that had been made following the September 2009 colonoscopy.  Additionally, the gastroenterologist did not then recommend that the patient schedule a repeat colonoscopy.

The patient ultimately had a repeat colonoscopy performed by another physician on 4/27/2011.  Following that procedure, she was found to have an invasive carcinoma of the mid-rectum, and she commenced receiving treatment for colon cancer.

When appearing before the panel, the gastroenterologist testified that he was aware of the pathology findings that had been made following the colonoscopy but did not specifically advise the patient of those findings because he considered the pathology findings to be “benign.”  The gastroenterologist further testified that he was confident that he had removed the entirety of the rectal polyp at the time of the colonoscopy.  The gastroenterologist maintains that, after completing the colonoscopy, he advised the patient that she would need to see him again in “about” a year, but there is no documentation in either the gastroenterologist’s medical record or the hospital chart which memorializes respondent’s having advised the patient to have a repeat colonoscopy within one year.  Further, although the gastroenterologist entered a note in the patient’s hospital chart on 10/6/2009 documenting the pathology findings, he failed to record the pathology findings in his office medical record, and he failed to obtain and/or maintain a copy of the pathology report in his office record.

The Board judged the gastroenterologist’s conduct to have fallen below the standard of care given failure to document that he advised the patient to have a repeat colonoscopy performed within one year of the date on which the original colonoscopy was performed and failure to have documented the pathology findings of adenocarcinoma in his office record.

The Board assessed a fine against the gastroenterologist with stipulations to complete courses in medical record keeping and medical ethics.

State: New Jersey

Date: March 3017

Specialty: Gastroenterology

Symptom: Blood in Stool, Abdominal Pain

Diagnosis: Colon Cancer

Medical Error: Failure to follow up, Failure of communication with patient or patient relations, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 3

Link to Original Case File: Download PDF

A 14-year-old girl was referred by her pediatrician to a child neurologist for seizures.  The child neurologist first saw the patient on 8/10/2009. The patient’s first seizure occurred at age 10, early morning on 2/21/2006, and a second episode occurred in the early morning sometimes around December 2008.  At the time the patient saw the child neurologist, her medication included Klonopin 0.5 mg p.m., Depakote at 750 b.i.d., and Vistaril 10 mg p.m. The patient’s MRI on October 2008 was normal. The patient’s EEG performed on October 2007 noted 3-13 seizures.  The child neurologist’s assessment was “juvenile myoclonic epilepsy; rule out adverse effect of med correctly given; insomnia unspecified; depressive disorder; and cafe au lait spots x 2.” The child neurologist ordered a video EEG “to rule out any epileptogenic foci.”

On 8/12/2009, the video EEG was performed.  The technician reported sharp and slow waves left F3-C3.  The child neurologist read it as normal. A BAER was performed on the same day even though it was not ordered by the child neurologist.  The BAER was not indicated, and the referring diagnosis for the BAER was not in the record and was used only for billing.

The child neurologist next saw the patient on 8/21/2009 for a follow-up visit.  The child neurologist noted that the patient was tolerating Depakote well. The Depakote level was 101.  The child neurologist diagnosed breakthrough seizures despite the fact that no seizures were reported. The child neurologist added Topamax Sprinkles 25 mg to increase to 50 mg b.i.d.  She stopped the Klonopin and Vistaril.

On 11/2/2009, the child neurologist saw the patient for a follow-up visit.  She noted that patient was gaining weight with Topamax and wanted to stop Depakote, though it was well tolerated.  The patient had no seizures and no myoclonic jerks. The child neurologist ordered another video EEG without medical indication.  The result of the second video EEG was normal. The child neurologist’s reading of the video EEG followed a template and was the same with all of her video EG reports except for the first paragraph regarding time of sleep, wake, and meals.

The child neurologist next saw the patient on 5/3/2010.  The patient reported no auras or seizures. The child neurologist noted under past medical history that the patient had suicidal thoughts.  The child neurologist did not address this issue during this visit. The child neurologist continued Topamax 50 mg b.i.d., even though there was a note of memory problems.  The child neurologist reduced Depakote to 500 b.i.d. She ordered labs and a 4-day ambulatory EEG without any medical indication. The 2 previous video EEGs were normal, and the patient did not have any seizures.  The patient underwent a third video EEG on this visit, which was not ordered nor medically indicated.

On 6/8/2010, the child neurologist saw the patient for a follow-up visit.  The patient was taken off Topamax. Her memory improved, but her headaches recurred.  The child neurologist diagnosed migraines without asking sufficient questions to make that diagnosis.  She added amitriptyline 10 mg, Imitrex 100 mg, and continued Depakote 500 b.i.d.

The 4-day ambulatory EEG ordered on 5/3/2010 was performed on 7/6/2010.  It was completed despite the fact that the patient just underwent a third video EEG on 5/3/2010.  There was no medical indication for the 3 previous EEGs and the 4-day ambulatory EEG. The 4-day ambulatory EEG was read as normal.

On 8/23/2010, the child neurologist saw the patient for 2 back-to-back seizures that occurred on 8/11/2010.  The patient was taken to the emergency room with a history of early morning twitching since the seizures. The child neurologist’s assessment was breakthrough seizures.  The child neurologist added Lamictal 100 mg b.i.d. and raised Depakote from 500 mg b.i.d. to 1000 mg b.i.d. The child neurologist failed to recognize that on 7/29/2010, the patient was having myoclonic jerks, which were described as twitches.  The patient had been on 750 mg b.i.d. with a level of 100 and had been seizure free for 2 years. The child neurologist failed to recognize the important interaction between Lamictal and Depakote. The child neurologist failed to consider that it was very likely that the patient had toxic levels of both Depakote and Lamictal.  The child neurologist did not check the patient’s blood levels. The child neurologist ordered another video EEG and another ambulatory EEG. The video EEG was performed on September 2010 and was normal. The child neurologist used the same template on her report.

The child neurologist next saw the patient on 11/4/2010.  The patient was unable to sleep, had difficulties with coordination and balance, was forgetful; all symptoms consistent with medication toxicity.  The child neurologist failed to recognize it as such. The patient was on Depakote 500 mg b.i.d. and Lamictal 100 mg b.i.d. Suicidal ideation was noted in the child neurologist’s previous notes, but the child neurologist failed to address this issue.  The child neurologist added Prozac 20 mg, which had a black box warning for suicidal ideation.

The Medical Board of California judged that the child neurologist’s conduct departed from the standard of care because she ordered 4-5 video EEGs and an ambulatory EEG without medical indication, ordered a BAER with no medical indication, lacked knowledge and/or did not consider the important interaction between Depakote and Lamictal.  The child neurologist diagnosed migraines without establishing diagnostic criteria, diagnosed circadian sleep disorder without asking any questions regarding symptoms and adding the polysomnogram report in the chart, and prescribed Prozac to patient with a history of suicidal thoughts despite the black box warning.

For this case and others, 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

Diagnosis: Neurological Disease, Drug Overdose, Side Effects, or Withdrawal, Psychiatric Disorder

Medical Error: Improper medication management, Diagnostic error, Failure to examine or evaluate patient properly, Unnecessary or excessive diagnostic tests

Significant Outcome: N/A

Case Rating: 3

Link to Original Case File: Download PDF

On 6/26/2015, a patient presented to an interventional radiologist’s outpatient clinic for a left lower extremity arteriogram and intervention for a thrombosed left lower extremity bypass graft, originally placed in 2007.  The patient had an extensive medical history including a renal transplant, diabetes, right leg amputation, and multiple revascularization procedures, including prior thrombectomies of the left lower extremity graft.

The patient reportedly had pain both at rest and with activity, and had a cold left leg prior to and immediately before the procedure.  In order to improve blood flow in the patient’s left leg, the interventional radiologist performed an arteriogram, angioplasty, tPA administration, atherectomy, and stent placement within the left lower extremity, including an attempt to revascularize the native superficial femoral artery.

Images show an initially thrombosed femoral artery to popliteal bypass graft and deep femoral artery.  Further images show balloons inflated in various parts of the graft and native arteries.  Final images show flow through a patent common femoral artery (CFA), bypass graft, and peroneal and anterior tibial arteries.  The deep femoral artery appeared occluded shortly beyond its origin.

After the procedure, a nurse noted the patient’s foot was cold.  The interventional radiologist also assessed the patient post-procedure and found the foot to be cold, both two (2) and four (4) hours post-procedure.  The interventional radiologist recommended to the patient that she travel to the emergency department of a university hospital.

The patient was then driven by her companion two hours to the emergency department, where she was assessed by an ED physician and a vascular surgeon.  She was taken to the operating room where she underwent surgery, which included a left leg above-the-knee amputation and a deep femoral artery thrombectomy.

The Board stated that the standard of care for an interventional radiologist when performing an intervention is to recognize complications and to take appropriate steps to manage them.  Although the patient’s foot was reportedly cold and painful immediately post-procedure, it can take some time for the foot to warm, and pain could be caused by reperfusion.  However, it is clear that two to four hours after the procedure, the interventional radiologist recognized that the patient’s leg had not improved and was worsening and that further care was needed.  Thus, when it became clear to the interventional radiologist that the foot was not improving, he recommended that the patient seek more treatment.

The records of the interventional radiologist’s care of the patient were inadequate in that they do not state whether the patient’s clinical status post-procedure was worse than before the procedure.  A post-procedure pulse examination was lacking which would have helped in determining the patient’s clinical status.

The patient reported to the ED physician that the pain began after the procedure and steadily worsened, which indicates that the patient rethrombosed her bypass graft and deep femoral artery (source of collateral flow) immediately.  This event should have been recognized by the interventional radiologist.

However, the interventional radiologist’s documentation for this patient was inadequate and sparse.  The medical records lacked documentation of the change in the patient’s status post-procedure, the discussion with the patient leading up to the discharge from his center, and the patient’s disposition.  The interventional radiologist discharged the patient to her own care directly from his clinic instead of calling Emergency Medical Services (EMS), which indicates that the interventional radiologist failed to recognize the gravity of what was occurring.

His conduct did not ensure that the patient would be attended continuously until definitive treatment was given.  The patient arrived at the emergency department at approximately 8:00 p.m., two hours after the patient was discharged from the interventional radiologist’s clinic.

Had the process of discharge and transfer occurred earlier, it is possible that the outcome could have been different.  The interventional radiologist failed to communicate with the ED physician ahead of the patient’s arrival.  The interventional radiologist gave the patient a CD of the procedure, a copy of the medical records, and his phone number, as an attempt of communicating with the emergency department personnel regarding the events that occurred at the interventional radiologist’s clinic.

However, the interventional radiologist failed to telephone the ED physicians at the emergency department to give a verbal report on the patient and to provide a more informative transition and preparation for continued care.  In expecting the practitioners at the emergency department to call the interventional radiologist to gain more information, the interventional radiologist improperly sought to shift his responsibility to provide needed information about the patient to the staff at the emergency department.

The interventional radiologist failed to maintain documentation regarding the change in the patient’s status post-procedure, the discussion leading up to the discharge from his center, and the patient’s disposition.  He stated that he was not sure if he documented these events, and if he did, he sent them with the patient.  Documentation sent with the patient has since been lost.  Documentation of a change in the patient’s clinical status was lacking.  The medical records lacked documentation of what was discussed regarding the patient’s disposition and where she was told to go for further care.

The Board judged the interventional radiologist’s conduct to have fallen below the standard of care for the following reasons:

1) The interventional radiologist failed to offer to transport the patient by ambulance or EMS services to ensure that she would be attended continuously until definitive treatment was given. His failure to do so indicates that he failed to understand the gravity of the situation which was occurring.

2) The interventional radiologist failed to adequately communicate with the emergency department, to call ahead of time to inform them that the patient was in transit, and to inform them of the circumstances.

3) The interventional radiologist failed to maintain adequate and accurate records.

The Board issued a public reprimand.

State: California

Date: December 2017

Specialty: Interventional Radiology, Vascular Surgery

Symptom: Extremity Pain

Diagnosis: Acute Ischemic Limb, Post-operative/Operative Complication

Medical Error: Diagnostic error, Delay in proper treatment, Underestimation of likelihood or severity, Failure of communication with other providers, Lack of proper documentation

Significant Outcome: Permanent Loss Of Functional Status Or Organ

Case Rating: 3

Link to Original Case File: Download PDF

On 6/23/2014, a 66-year-old male presented to the Physicians Regional Medical Center for gastric bypass surgery.

Following the gastric bypass procedure, on 6/24/2014, a radiologist performed a Gastrografin upper GI series on the patient to ascertain whether there was a leak or obstruction in the patient’s digestive tract.  A leak of contrast material was visible on radiographic images obtained by the radiologist during the procedure;  however, the radiologist failed to detect the leak in the patient’s digestive tract and reported a negative GI series.  The patient was subsequently discharged from the hospital.

Approximately thirty hours after his discharge, the patient returned to the hospital suffering from abdominal pain and sepsis.  It was discovered that the patient had a perforation in his digestive tract.  During surgery to repair this perforation, the patient suffered cardiac arrest and anoxic brain injury.  The patient ultimately expired as a result of these complications on 7/10/2014

The Board judged the radiologist’s conduct to be below the minimum standard of competence given his failure to detect a leak in the patient’s digestive tract during the performance of a Gastrografin upper GI series.

State: Florida

Date: December 2017

Specialty: Radiology

Symptom: N/A

Diagnosis: Acute Abdomen

Medical Error: False negative

Significant Outcome: Death, Hospital Bounce Back

Case Rating: 3

Link to Original Case File: Download PDF

On 11/6/2016, a 61-year-old female presented to the emergency department, suffering from confusion and weakness after a fall.  A CT scan revealed that the patient had a large, left-sided subdural hematoma.

That same day, a neurosurgeon was asked to evaluate the patient.  The neurosurgeon correctly documented that the patient was suffering from a left-sided subdural hematoma.  The neurosurgeon further documented his intention to remove a blood clot from the left side of the patient’s subdural space.

Shortly thereafter, the patient was brought to the operating room and preparations were begun for a left-sided craniotomy.  However, at some point during the preparation process, the patient’s head was turned and the neurosurgeon began to operate on the right side.

After the neurosurgeon made an incision through the skin, he removed a bone flap and punctured the dura mater on the right side of the patient’s brain.  The neurosurgeon realized that he was operating on the incorrect side.  The neurosurgeon closed the operating site and proceeded to perform the correct procedure.

It was requested that the Board order one or more of the following penalties for the neurosurgeon:  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: December 2017

Specialty: Neurosurgery

Symptom: Confusion, Weakness/Fatigue

Diagnosis: Intracranial Hemorrhage, Trauma Injury

Medical Error: Wrong site procedure

Significant Outcome: N/A

Case Rating: 3

Link to Original Case File: Download PDF

On 12/7/2016, a 30-year-old female was admitted to University Behavioral Center (“UBC”) while suffering from acute psychotic symptoms and was placed under a psychiatrist’s care.  The patient remained under the psychiatrist’s care at UBC for approximately eleven days.

On the day of the patient’s admission, the psychiatrist began treating the patient with lithium.  The psychiatrist continued treating the patient with lithium until 12/17/2016.

The patient had previously been prescribed lisinopril (an ACE inhibitor) and hydrochlorothiazide (a thiazide diuretic) for hypertension.  The psychiatrist continued treating the patient with hydrochlorothiazide until 12/16/2016.  The psychiatrist continued treating the patient with lisinopril for the duration of her stay at UBC.

During the course of the patient’s confinement at UBC, her condition worsened, and she experienced incontinence and increasing levels of confusion.  After falling in the shower on 12/18/2016, the patient was transferred to a hospital for medical treatment, where it was determined that the patient was experiencing lithium toxicity.  As a result of the lithium toxicity, the patient suffered kidney failure, which required dialysis.

The Board judged the psychiatrist’s conduct to be below the minimum standard of competence given that she should have been aware of the potential drug interactions with lithium and to prescribe alternative antipsychotic drug to a patient taking both a thiazide diuretic and an ACE inhibitor, as each of these drugs has a known interaction with lithium which presents risk of lithium toxicity.  The psychiatrist also failed to monitor the patient for signs of lithium toxicity, and she failed to immediately discontinue treatment with lithium when the patient began experiencing symptoms of lithium toxicity.

It was requested that the Board order one or more of the following penalties for the psychiatrist: permanent revocation or suspension of her license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Board deemed appropriate.

State: Florida

Date: December 2017

Specialty: Psychiatry

Symptom: Psychiatric Symptoms, Confusion, Urinary Problems

Diagnosis: Drug Overdose, Side Effects, or Withdrawal

Medical Error: Improper medication management, Failure to properly monitor patient

Significant Outcome: N/A

Case Rating: 3

Link to Original Case File: Download PDF

At 1:45 a.m. on 7/26/2014, a 46-year-old female presented to the emergency department with complaints of severe abdominal pain.  Upon arrival at the emergency department, the patient was evaluated by the ED physician.

The patient complained of severe abdominal pain and stated the pain was “10 out of 10.”  The patient then underwent laboratory studies and a CT scan of the abdomen/pelvis with intravenous and oral contrast.

A radiologist reviewed the CT scan at some time before 4:16 a.m., when he read and signed the preliminary report.  Upon review of the CT scan results the radiologist recorded in the preliminary report “intussusception involving loop of small bowel in the left lower quadrant with involved loops appearing edematous.”  The radiologist relayed the results of the CT scan to the ED physician via teleradiology.

The ED physician recorded the results of the CT scan in the patient’s emergency provider report and noted “thickened loop of small bowel in the left lower quadrant, [m]ay be intussuception [sic].”

At 4:32 a.m. the ED physician discharged the patient to her home with a magnesium citrate prescription and no additional discharge instructions.

At 8:28 a.m. a physician signed the final radiology report and noted “[i]ntussesception involving loop of small bowel in the left lower quadrant” and “preliminary report related to referring physician teleradiology at the time of the exam by the radiologist.”

Later that day, the patient developed worsening pain, and presented to another emergency department, and underwent an emergency surgery for resection of necrotic bowel.

The Board judged the ED physician’s conduct to be below the minimum standard of competence given his failure obtain emergent surgical consultation for further evaluation and treatment and continue hospitalization for operative intervention or ongoing evaluation of abdominal pain.

The Board ordered the ED physician to pay an administrative fine in the amount of $8,000.  Also, the Board ordered the ED physician to complete five hours of continuing medical education in the area of emergency medicine.

State: Florida

Date: December 2017

Specialty: Emergency Medicine

Symptom: Abdominal Pain

Diagnosis: Acute Abdomen

Medical Error: Improper treatment, Referral failure to hospital or specialist

Significant Outcome: Hospital Bounce Back

Case Rating: 3

Link to Original Case File: Download PDF

On 5/16/2014, a patient presented to an orthopedic outpatient surgery center with a left-hand work-related injury.  During the visit, an orthopedic surgeon properly diagnosed the patient with a flexor pollicis longus (FPL) tendon laceration of her left thumb.

The FPL tendon laceration was confirmed by the MRI scan performed on the patient on 7/3/2014.

On 8/7/2014, during the follow-up visit, the orthopedic surgeon wrongly documented the patient’s injury as an extensor pollicis longus (EPL) tendon laceration in the patient’s medical records

Consequently, on 9/10/2014, the patient presented to the orthopedic surgeon at the center, for an EPL tendon surgery (the wrong site, and/or medically unnecessary procedure) of her left thumb.  During the EPL tendon surgery, the orthopedic surgeon realized that the FPL tendon laceration repair should have been performed on the patient instead.  On 10/10/2014, the orthopedic surgeon performed the FPL tendon laceration repair on the patient’s left thumb.

The Board ordered the orthopedic surgeon pay a fine of $3,000 to the Board. Also, the Board ordered the orthopedic surgeon pay a reimbursement cost of $4,670.40.  The Board ordered that the orthopedic surgeon complete five hours of continuing medical education in “Risk Management.”  The Board ordered that the orthopedic surgeon complete one hour of lecture on wrong site procedure.

State: Florida

Date: December 2017

Specialty: Orthopedic Surgery

Symptom: N/A

Diagnosis: Musculoskeletal Disease, Trauma Injury

Medical Error: Wrong site procedure, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 3

Link to Original Case File: Download PDF

On 2/24/2014, a 36-year-old female presented to an obstetrician for fatigue, breast tenderness, and absence of menstruation.  At the aforementioned visit, the obstetrician diagnosed the patient with amenorrhea and sent her to have blood work.

On 2/25/2014, the patient was notified of her positive pregnancy test.

On 3/10/2014, 3/17/2014, 3/24/2014. 4/24/2014, 8/7/2014, and 9/25/2015, the obstetrician ordered obstetrical ultrasounds and/or sonograms for the patient.

On 4/23/2014 and 8/20/2014, the patient presented to the obstetrician with thick vaginal fluid and blood discharge, morning sickness, nausea, chills, fever, and back pain.

On 5/23/2014, 6/20/2014, 7/16/2014, 8/15/2014, 9/12/2014, 10/13/2014, 10/20/2014, and 10/27/2014, the patient presented to the obstetrician for follow-up visits.

On 11/2/2014, the patient gave birth to her son, who was born with spina bifida/myelomeningocele.

The obstetrician failed to diagnose neural tube defect on imaging studies.

The obstetrician failed to order a maternal serum alpha-fetoprotein (MSAFP) test and did not maintain adequate legible documentation of ordering an MSAFP test.

The obstetrician failed to order an anatomical survey sonogram.

The Board ordered that the obstetrician pay a fine of $7000 against his license. The Board ordered that the obstetrician pay reimbursements costs of a minimum of $3,786.18 and not to exceed $5,786.18.  The Board also ordered that the obstetrician complete a course on “Quality Medical Record Keeping for Health Care Professionals” and that he  complete five hours of continuing medical education on “Risk Management.”

State: Florida

Date: December 2017

Specialty: Obstetrics

Symptom: Fever, Bleeding, Nausea Or Vomiting, Back Pain

Diagnosis: Obstetrical Complication, Spinal Injury Or Disorder

Medical Error: Failure to order appropriate diagnostic test, Failure to follow up, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 3

Link to Original Case File: Download PDF

A 27-year-old female was a patient of a family practitioner.  On 2/11/2014, the patient started complaining to the family practitioner about a potential kidney stone.

The family practitioner had records indicating that the patient was being treated with tramadol, Percocet, fluoxetine, and promethazine.

On 5/12/2014, the family practitioner prescribed morphine 60 mg, extended release, to the patient, to be taken twice a day, but the family practitioner never adequately documented medical justification for the prescription.  The standard starting dose for morphine is 15 mg every eight to twelve hours.

The patient was also taking fluoxetine and promethazine and the family practitioner signed a CVS form indicating the patient could start morphine despite possible contraindications.

The family practitioner did not take additional precautions to monitor the patient, despite her taking fluoxetine and promethazine in combination with morphine.

At 5:25 p.m. on 5/14/2014, the patient’s husband found her unresponsive in the bedroom and 911 was called immediately.

The patient ultimately was transported to a hospital and diagnosed with poisoning by opiates and related narcotics.

The Board judged the family practitioners conduct to be below the minimum standard of competence given his failure to prescribe morphine for medically justified reasons.  The family practitioner failed to start with an initial dose of morphine at 15 mg every eight to twelve hours.  The family practitioner failed to take additional precautions regarding monitoring for central nervous system or respiratory depression when the morphine was prescribed with the fluoxetine and promethazine.  The Board judged that the family practitioner failed to adequately create or maintain medical records that justified the course of treatment for the patient.

The Board ordered that the family practitioner have a reprimand against his license.  The Board ordered that the family physician pay a fine against his license of $7,500 and that the family practitioner pay reimbursement costs for the case between a minimum of $820.04 and a maximum of $2,820.04.  The Board ordered that the family practitioner complete a drug prescribing course and a medical records course and that the family practitioner complete five hours of continuing medical education in nephrology.

State: Florida

Date: November 2017

Specialty: Family Medicine, Internal Medicine

Symptom: Abdominal Pain

Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Renal Disease

Medical Error: Improper medication management, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 3

Link to Original Case File: Download PDF