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A 56-year-old female was referred by her primary care physician to a neurologist.  The patient’s primary care physician noted neck pain and numbness of the upper extremities, left greater than right, present for 1 year.  Her medications were lisinopril 5 mg daily, Lyrica 50 mg 3 times daily, Flexeril 10 mg 3 times daily, Mobic 15 mg daily, and Nexium 40 mg daily.  Her primary care physician noted that she had lumbar laminectomy for disk herniation in the past for low back pain and tingling of the left leg. He also noted that the MRI of her cervical spine was abnormal and requested a neurological evaluation.  It revealed an abnormal signal intensity C2-3 affecting posterior columns with the radiologist’s comment of “could account for arm numbness and tingling.” The x-ray of her cervical spine performed on 11/5/2012 ordered by her primary care physician showed moderate degenerative changes.  The x-ray of her lumbar spine performed on 2/23/2012 showed similar findings.

The neurologist first saw the patient on 12/10/2012 for the abnormal cervical spine MRI.  The patient’s complaints were “neck pain; left neck and arm numb; right arm and right knee; losing urine; and generalized weakness on the left.”  The patient also complained that she “also feels ‘dead’ hips down, [d]izzy spells several times, no energy, difficult to concentrate.” The neurologist noted the “neuro exam essentially normal.”  The neurologist’s diagnoses were demyelinating disease; paresthesias of face and her extremities, vertigo, and memory loss. The neurologist ordered the following tests: EMG/NCV lower extremities, though later she also did upper extremities; MRI of the brain; neuromuscular junction tests with EMG; BAER with vestibular testing; VEP; EEG, overnight; and EEG awake and sleep with digital analysis 95957.

The upper extremity EMG/NCV study was performed on 1/3/2013.  She tested 4 motor nerves, 5 sensory nerves, and F waves. The neurologist tested every muscle, which was present in the upper extremities.  The results of the study were normal.

The electrodiagnostic study of the lower extremities were performed on 1/10/2013.  The neurologist tested 4 motor nerves, 6 sensory nerves, 2 H reflexes, bilateral F waves of the motor nerves.  She did a needle EMG of all muscles in the lower extremities and paraspinal muscles. The results of the study were normal.

There was a report of a video-monitored EEG utilizing a 32-channel digital EEG system manufactured by Cadwell.  This test was performed on 12/26/2012. The report stated that the technician performed hyperventilation, but the patient reported she did not, and that the patient was videotaped, though the patient reported she was not.  It was read as normal.

The ambulatory EEG was performed on 2/5/2013 to 2/6/2013.  In the report, it was termed a 2-day ambulatory EEG despite lasting only 1 day.  The neurologist prepared the report. The report contained a printout of 1 page. It was timed 6:21 a.m., and it contained widespread artifacts lasting 10 seconds.  This was the exact time that the patient reported she stood in front of her microwaves. The neurologist read this as “Isolated sharp waves were noted in the frontal left hemispheric area. The isolated sharp waves may be epileptogenic in nature.”  The visual and brainstem auditory evoked potentials were normal.

On 2/26/2013, the neurologist saw the patient for a follow-up visit.  The test results were available to the neurologist at the visit. The neurologist noted that the EEG for the patient was normal for both awake and drowsy.  The neurologist also noted that the 2-day EEG, which lasted only 1 day and the MRI of the brain showed a corpus callosum lesion. Her assessment and plan contained the same diagnoses as the first visit of 12/10/2012, and she failed to consider new information that should have changed her initial diagnoses.

The neurologist did not diagnose seizures in the assessment and plan, but she prescribed Depakote.  The neurologist discussed with the patient that she met criteria for relapsing and remitting Multiple Sclerosis with an acute exacerbation.  The neurologist also noted that the patient had pain with neck movement, which was sharp and went to the toes. She believed that the symptom was consistent with the finding of the ambulatory EEG and thus started the patient on Depakote 500 mg b.i.d.  The neurologist failed to recognize Lhermitte’s sign, consistent with the myelopathy. The neurologist ordered laboratory studies for Lyme disease, lupus, and lumbar puncture. She ordered monitoring labs for Depakote, CBC, and liver function tests to be done before the next visit.

The MRI of the brain the neurologist referred to in the 2/26/2013 follow-up visit was performed at the neurologist’s request on 12/28/2012.  The report indicated 20 FLAIR hyperintensities and a possible tiny corpus callosum lesion. The neurologist concluded it was consistent with multiple sclerosis.  The 12/28/2012 report contained a comparison to a previous MRI of the brain performed on 7/1/2007. The radiologist thought the new MRI showed abnormalities “probably very slightly more numerous” than the 2007 MRI.  He further considered the appearance to be nonspecific, and the tiny lesion in the corpus callosum was considered possible.

The 2007 MRI was requested by another physician.  It was read as showing “a few nonspecific scattered punctate of unlikely clinical significance.”  Multiple sclerosis was not raised as a possible cause. Referring diagnosis was “recent vertigo and left-sided dizziness.”  The neurologist failed to question the patient on symptoms that occurred in 2007.

On 3/12/2013, the patient was seen in the emergency room for nausea and vomiting.  She was diagnosed with Depakote toxicity with a level of 108. She was told to stop the medication.  She was scheduled for the lumbar puncture the following day and was told to keep that appointment. The day following the lumbar puncture, she developed symptoms consistent with a postspinal headache.  She was seen by the neurologist in her office on the same day and diagnosed with Depakote toxicity. At this point, the neurologist erroneously believed that the patient had “definite” multiple sclerosis.  She also erroneously believed that “the patient wrongfully assumed” Depakote caused her symptoms and believed that they were from the lumbar puncture.

The neurologist next saw the patient on 3/26/2013 for an office visit.  The neurologist noted that the patient had a postspinal headache. She noted that the spinal fluid was negative for oligoclonal bands, but incorrectly thought the IgG synthesis was abnormal.  She incorrectly diagnosed “primary stabbing headache” despite her earlier entry of postspinal headache.

In a subsequent interview with a Medical Board investigator, the neurologist was questioned as to why she did not take a history of previous symptoms, such as optic neuritis, that help to establish a diagnosis of multiple sclerosis.  She was questioned if the examination was normal and why she did not check the “saddle” area for sensory loss, and she reported, “Why should I check the saddle area?” There were no “incontinence of stools.” When asked if she would have documented Lhermitte’s symptom or sign if present, she answered yes.  She obtained a history of symptoms consistent with Lhermitte’s, but did not recognize it as such. Memory loss was given as a diagnosis, but when asked how it was based, she could not recall. When asked to explain the reasons that each test was ordered, she responded that the EMG was based on symptoms, the neuromuscular test was based on the possibility of myasthenia gravis causing general weakness, the BAER and VEP as part of the multiple sclerosis work-up, and the EEG to rule out seizures as the cause of numbness and weakness.  She stated video monitoring on EEG was standard practice. Hearing loss was her reason for performing the BAER, but no hearing loss or visual disturbance was documented. She stated that the 2007 MRI showed infratentorial and supratentorial lesions whereas there was no mention of an infratentorial lesion in the radiology report. She ordered the EMG of the upper extremities to “rule out any other diseases” and stated “EMG is part of differential diagnosis,” and the indication she believed was numbness and tingling in the hands. When asked why she did 24 upper extremity and 6 cervical paraspinal muscles on EMG, she stated she wanted to make sure there was “no polyradiculopathy,” but she admitted there were no findings to suggest that diagnosis.  Further, she believed that numbness and tingling and incontinence would indicate polyradiculopathy. When questioned regarding indications for EMG of the lower extremities, she stated back problems, numbness right arm and right knee, and feeling the hips on down were “dead.” In the lower extremities, she tested 12 different muscles and 6 paraspinal muscles. She was then questioned about what were the indications for the EEG, and she believed they were generalized weakness, dizzy spells, no energy to work, and difficulty focusing. She was questioned as to why the first EEG was not sufficient. She stated that on 2/26/2013 visit, she had findings of generalized seizure disorder, but this was not the wording in the EEG report nor was it in her letter to the Board.  She was not aware that a microwave can cause artifacts. Regarding indication for Depakote, her answer was because of the EEG and numbness and tingling. She thought it would be trial and error to see if it would help. She thought that the patient’s symptom of “neck killing her” would be consistent with a multiple sclerosis plaque. When asked why she ordered Lyme disease and lupus blood tests, she stated that they were “on my mind.”

The Medical Board of California judged that the neurologist’s conduct departed from the standard of care because she failed to recognize symptoms and findings on the MRI of a partial transverse cervical myelopathy, ordered an EMG for the upper and lower extremities, video EEG, and ambulatory EEG without medical indication, conducted an excessive number of nerve tests for any diagnosis, misdiagnosed epilepsy, lacked knowledge in reading EEGs, and had no knowledge and/or did not consider the important interaction between Depakote and the patient’s other medications.  The neurologist also lacked knowledge in several fundamental areas.  She failed to recognize symptoms of a partial transverse cervical myelopathy and Lhermitte’s symptoms even though it was described to her by the patient.  She did not recognize or, if she did, did not reflect in her records that almost all of the patient’s symptoms were caused by the cervical myelopathy. The neurologist erroneously believed that a multiple sclerosis plaque could cause severe neck pain and that IgG synthesis could indicate active or inactive multiple sclerosis.  She diagnosed multiple sclerosis on the basis of the McDonald criteria, and she included the original report, but she gave no information in her records how those criteria fit the patient. She failed to question the patient for previous symptoms, which might establish an initial exacerbation of multiple sclerosis. The neurologist was aware that the patient had an MRI in 2007 and did not question the patient regarding her symptoms at that time.  She ordered laboratory studies for possible Lyme disease or “lupus” and a monophasic cervical myelopathy despite the fact that it was exceedingly unlikely to be caused by any of those disorders. She failed to consider alternative causes for the patient’s presentation, specifically B12 deficiency or adrenomyeloneuropathy.

For this case and others, the Medical Board of California placed the neurologist on probation and ordered the 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 neurologist was assigned a practice monitor and was prohibited from supervising physician assistants and advanced practice nurses.

State: California

Date: January 2018

Specialty: Neurology

Symptom: Head/Neck Pain, Dizziness, Headache, Nausea Or Vomiting, Numbness, Urinary Problems, Weakness/Fatigue

Diagnosis: Spinal Injury Or Disorder, Drug Overdose, Side Effects, or Withdrawal

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

Significant Outcome: N/A

Case Rating: 4

Link to Original Case File: Download PDF

On 4/15/2015, a 48-year-old female presented to the Mayo Clinic for an assessment regarding cancer treatment.

The patient presented with a history of a palpable rectal mass and bloody stool.  The patient presented to an oncologist after undergoing a colonoscopy and after a CT scan at Borland Grover Clinic revealed tumors suspicious for metastases.

The Borland Grover Clinic took a biopsy of the affected area.  Initial pathology indicated suspicion for adenocarcinoma.  Borland Grover clinic sent the sample to Cleveland Clinic for confirmation.  Cleveland Clinic returned a diagnosis of endometriosis, not cancer.

The oncologist did not obtain the pathology reports from Borland Grover Clinic or Cleveland Clinic.  The oncologist diagnosed the patient with rectal cancer with possible spread to the liver, lungs, and mediastinum.  The oncologist ordered an endobronchoscopic ultrasound (EBUS). The patient’s EBUS showed some concern for cancer, but the pathologist deemed the results of the EBUS insufficient for a definitive cancer diagnosis.

Despite not having a pathologic diagnosis of cancer, from May to July 2015, the oncologist ordered the patient receive a port placement and three chemotherapy treatments.

Due to continuing rectal pain, on 7/6/2015, the oncologist referred the patient to a colorectal surgeon.  As part of his review, the colorectal surgeon obtained the patient’s pathologic results from Borland Grover Clinic and Cleveland Clinic, which showed that the patient had endometriosis and not cancer.

On 7/16/2015, a Mayo Clinic pathologist reviewed the patient’s previous biopsy sample and came to a final diagnosis of endometriosis.  On 9/3/2015, two doctors performed a procedure to remove the endometrioma.

The Board judged that the oncologist’s conduct to be below the minimum standard of competence given her failure to obtain a pathologic diagnosis of cancer prior to initiating cancer treatment for the patient.

The Board ordered the oncologist have her license revoked, pay an administrative fine, and have remedial education.

State: Florida

Date: December 2017

Specialty: Oncology, Internal Medicine

Symptom: Blood in Stool, Mass (Breast Mass, Lump, etc.)

Diagnosis: Gynecological Disease

Medical Error: Diagnostic error

Significant Outcome: N/A

Case Rating: 4

Link to Original Case File: Download PDF

On 10/19/2011 at 5:23 p.m., a 35-year-old male presented to the emergency department at a hospital with a chief complaint of abdominal pain and vomiting, which started approximately five hours before he presented to the hospital.

The patient was admitted to the hospital under the service of an intensivist and was notified of his arrival and condition at 5:35 p.m.

Between the hours of 5:50 p.m. and 7:22 p.m. the intensivist gave verbal orders of Dilaudid and ketorolac to the patient’s nurse.

At 9:20 p.m., the intensivist gave telephonic orders to the patient’s nurse, to place him on his home BIPAP mask.

On 10/20/2011, at 3:15 a.m. a rapid response was called due to an acute change in the patient’s respiratory status.

During the rapid response, an arterial blood gas (“ABG”) was drawn that revealed critical metabolic acidosis.

The intensivist never presented to the emergency room to assess the patient when he demonstrated medically dangerous/life-threatening signs at 3:15 a.m. or any time thereafter.

The intensivist never attended to the patient when his clinical situation was from an unknown cause and when a clear treatment plan had not been determined.

From 3:43 a.m. to 4:15 a.m., the critical care practitioner was contacted approximately five times with information on the patient’s medically unstable and deteriorating condition.

At 3:45 a.m., the patient became short of breath, restless, diaphoretic, and seizure episodes followed.  He was then transported to an intensive care unit.

At 5:25 a.m., a second rapid response was called due to a further decline in the patient’s health.  The rapid response turned into a code blue.

The patient underwent a cardiopulmonary arrest, and the code team was unable to resuscitate him.

On 10/20/2011, the patient expired at 6:25 am.

The autopsy results were consistent with acute hemorrhagic pancreatitis with diffuse pancreatic necrosis.

The Medical Board of Florida judged the intensivist’s conduct to be below the minimal standard of competence given that he failed to presented to the emergency room to assess the patient when the patient demonstrated medically dangerous/life-threatening signs on 10/20/2011 at 3:15 a.m.

The Medical Board of Florida issued a letter of concern against the critical care practitioner’s license.  The Medical Board of Florida ordered that he pay a fine of $7,500 against his license and pay reimbursement costs for the case at a minimum of $4,503.10 and not to exceed $6,503.10.  The Medical Board of Florida ordered that the critical care practitioner complete ten hours of continuing medical education in the area of critical care medicine and complete five hours of continuing medical education in “risk management.”

State: Florida

Date: December 2017

Specialty: Critical Care Medicine, Emergency Medicine, Pulmonology

Symptom: Abdominal Pain, Nausea Or Vomiting

Diagnosis: Gastrointestinal Disease

Medical Error: Failure to properly monitor patient

Significant Outcome: Death

Case Rating: 4

Link to Original Case File: Download PDF

On 11/15/2013, a patient complained of chest pain radiating to his neck, throat, and across his back.  The patient stated the onset of the pain was noted to be one hour prior to his arrival at the hospital while he was screwing something into the wall, and that the pain was exacerbated by movement.

An ED physician performed an initial EKG, labs, and a chest x-ray on the patient.

The ED physician initially treated the patient with nitroglycerin and a GI cocktail, and subsequently with diazepam, morphine, Toradol, and Dilaudid.

The ED physician’s final assessment of the patient noted that the patient was still complaining of left side neck pain and “trap pain.”

The ED physician discharged the patient with a diagnosis of “musculoskeletal chest pain” and prescribed naproxen, Norco, and diazepam, along with instructions to follow up with him in three to five days.

The patient returned to the hospital the following day in cardiac arrest and expired on 11/16/2013.

The Medical Board of Florida judged the ED physician’s conduct to be below the minimal standard of competence given that he failed to perform a CT of the patient’s chest to evaluate for aortic dissection.  He also failed to adequately document bilateral pulses and/or blood pressures in the patient.  He failed to pursue other etiologies of the patient’s reported pain.  The ED physician failed to admit the patient for further observation.

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

State: Florida

Date: December 2017

Specialty: Emergency Medicine

Symptom: Chest Pain, Back Pain, Chest Pain, Head/Neck Pain

Diagnosis: Aneurysm

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

Significant Outcome: Death

Case Rating: 4

Link to Original Case File: Download PDF

On 8/15/2013, a 34-year-old female presented to a gynecologist for an annual gynecological exam.  At the exam, the patient expressed concerns about infertility.  The gynecologist and the patient discussed various tests that may be used to address infertility and the gynecologist began ordering tests.

On 2/23/2015, the patient gave blood for a complete blood count (“CBC”) test that was ordered by the gynecologist.

On 3/5/2015, the gynecologist received and signed for the results of the CBC test.  The CBC test indicated the patient had an abnormal white blood cell count, marked leukopenia, and severe neutropenia.

The gynecologist failed to notify the patient of the abnormal results of the CBC test.

The gynecologist failed to ensure that the patient had otherwise established a plan of care to address the abnormal results of the CBC test.

On 5/28/2015, the patient presented to the gynecologist for an annual gynecological exam.  At the exam, it was determined that the patient was pregnant, and the gynecologist ordered blood tests for the patient.  The gynecologist failed to order a repeat CBC test.

On 7/17/2015, the gynecologist received and signed for the results of the repeat CBC test.  The repeat CBC test indicated that the patient’s white blood cell count had decreased further, the neutropenia had worsened, and she now had pancytopenia with a drop in the red blood cell and platelet count.

On 7/30/2015, the gynecologist notified the patient of the results of her repeat CBC test and referred her to a hematologist.

On 8/8/2015, the patient experienced a massive intracranial hemorrhage with herniation, as well as severe pancytopenia.

On 8/12/2015, the patient expired in the hospital.  The fetus was also lost at that point.

The Medical Board of Florida judged the gynecologists conduct to be below the minimal standard of competence given that she failed to ensure that the patient had been notified of the abnormal results of the CBC test.  The gynecologist failed to ensure that the patient had otherwise established, a plan of care to address the abnormal results of the CBC test.  The gynecologist failed to order a repeat CBC test at the patient’s May exam.

The Medical Board of Florida issued a letter of concern against the gynecologist’s license.  The Medical Board of Florida ordered that the gynecologist pay a fine of $8,500 against her license and pay reimbursement costs for the case at a minimum of $3,126.31 and not to exceed $5,126.31.  The Medical Board of Florida ordered that the gynecologist complete five hours of continuing medical education in “risk management.”

State: Florida

Date: December 2017

Specialty: Gynecology, Obstetrics

Symptom: N/A

Diagnosis: Hematological Disease, Intracranial Hemorrhage

Medical Error: Failure to follow up, Delay in proper treatment, Failure of communication with patient or patient relations

Significant Outcome: Death

Case Rating: 4

Link to Original Case File: Download PDF

A 24-year-old female was transferred from a physician to an obstetrician.  The patient first saw the obstetrician on 6/24/2009, and she was due with her first child in July 2009.  Her patient chart listed her at 120 lbs and 4’0” tall, but when she came to see the obstetrician, she weighed 170 lbs.

The patient was seen by the obstetrician twice in June and every week in July until 7/27/2009.  The patient was scheduled to be induced 7/29/2009. There was nothing in the records about her bony pelvic exam or pelvic adequacy for vaginal delivery.  The obstetrician did not do an ultrasound. The patient was admitted to the hospital on 7/29/2009. There was no risk assessment, no estimate fetal size, no ultrasound ordered, and a Bishop score of 4.

The patient was started on Pitocin at 9:30 a.m. and had made no progress by 6:00 p.m. that evening.  The patient was allowed to rest, and the next morning, on 7/30/2009 at 7:30 a.m., Pitocin was started again.  During this time, it was noted that she had “reactive” fetal heart tracings. The nurses did not place an order for an internal fetal monitor.  When the fetal heart tones were low, the Pitocin should be turned off. If the mother keeps having contractions, the baby gets no rest, which is what likely occurred in this case.

At 8:18 p.m., she was only dilated 4-5 cm.  The patient had spontaneous rupture of the membranes with thick meconium noticed.  At 8:50 p.m., the patient was dilated to 8 cm, 0 station. There was no mention of a possible Cesarean section in the notes.  On 7/31/2009, a female infant weighing 9 lbs 5 oz was delivered using a vacuum because a shoulder dystocia was encountered. Unfortunately, the baby was deceased.

The Medical Board of California judged that the obstetrician’s conduct departed from the standard of care because he failed to estimate the fetal size, fetal lie, and pelvic adequacy.  The obstetrician also did not mention the application of a fetal electrode. This is important because the obstetrician did not know if the heart rate was coming from the mother or the baby; thus, an internal electrode would have been an accurate way to measure the baby’s heart rate.  Review of the fetal monitor strips showed back to back contractions and inadequate recordings. During labor and delivery, Pitocin should have been stopped in the contractions showed a low fetal heart rate and tachysystole (no rest between contractions). This patient was also a poor candidate for induction because she had a Bishop score of 4.  When the membranes were ruptured with 3+ meconium, this should have alerted the obstetrician that the baby was somehow compromised and action by the obstetrician was required. Also, the patient was a transfer patient, but the obstetrician did not order lab studies or an ultrasound. There were many errors which lead to the untimely demise of this baby.  Had there been an estimate of fetal weight, or an ultrasound performed within 6 weeks of induction of labor, the obstetrician would have known the patient was having a big baby, and the obstetrician might have performed a Cesarean section.

The Medical Board of California issued a public reprimand and ordered the obstetrician to complete a clinical competence assessment program.

State: California

Date: November 2017

Specialty: Obstetrics

Symptom: N/A

Diagnosis: Obstetrical Complication

Medical Error: Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Failure to properly monitor patient, Improper treatment, Improper medication management

Significant Outcome: Death

Case Rating: 4

Link to Original Case File: Download PDF

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

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

On 4/28/2015, a 69-year-old female presented to the emergency department with complaints of nausea and vomiting, which had persisted for two to three days.

The patient reported that members of her family had recently experienced similar symptoms.

The patient presented with a history of diabetes and high blood pressure.

An ED physician ordered a general chemistry lab.  The patient’s lab work revealed a high blood glucose level of 383 with a reference range of 65-99.  The patient’s lab work also showed that her bicarbonate level was low at 15 with a reference range of 21-32.  The low bicarbonate level indicated possible acidosis.

The ED physician treated the patient with insulin and antinausea medications and discharged her.  The ED physician did not further investigate the patient’s low bicarbonate level.  The ED physician did not assess the patient for diabetic ketoacidosis.

On 4/29/2015, the patient returned to the emergency department with recurrent nausea, vomiting, and worsening shortness of breath.

The patient was diagnosed with diabetic ketoacidosis and severe sepsis.

The patient’s condition deteriorated and she expired in the hospital on 5/4/2015.

The Board judged the ED physician’s conduct to be below the minimal standard of competence given that he failed to further investigate a low bicarbonate level by ordering additional laboratory studies such as a serum ketone, serum beta-hydroxybutyrate, or serum pH.

It was requested that the Board order one or more of the following penalties for the ED physician: 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: Emergency Medicine

Symptom: Nausea Or Vomiting, Shortness of Breath

Diagnosis: Diabetes, Sepsis

Medical Error: Failure to order appropriate diagnostic test

Significant Outcome: Death

Case Rating: 4

Link to Original Case File: Download PDF

On 1/25/2013, a 65-year-old male, underwent an artery bypass grafting procedure on his right leg by a cardiothoracic surgeon at a medical center.

During the course of the procedure, the cardiothoracic surgeon took a biopsy of the patient’s right groin lymph node, which was sent off to pathology for analysis.

The patient was never notified by the cardiothoracic surgeon that a biopsy of the right groin lymph node was taken during the procedure.

The cardiothoracic surgeon should have documented the right groin lymph node biopsy as part of the procedure in the operative report for the procedure but failed to do so.

On 1/29/2013, the pathology report for the biopsied tissue revealed a pathologic diagnosis of mantle cell lymphoma.  The pathology report was sent via facsimile to the cardiothoracic surgeon’s office.  The cardiothoracic surgeon should have listed “abnormal lymphadenopathy” as the post-operative diagnosis and failed to do so.

On 1/30/2013, the patient was discharged from the medical center.

The Board judged the cardiothoracic surgeons conduct to be below the minimal standard of competence given that he should have notified the patient of the pathology results and failed to do so.  He also should have obtained oncologic consultation for the patient and failed to do so.  The cardiothoracic surgeon should have provided the patient’s primary care physician and the referring physician with a copy of the pathology report and failed to do so.

The Board issued a letter of concern against the cardiothoracic surgeon’s license.  The Board ordered that the cardiothoracic surgeon pay a fine of $5,000 against his license and pay reimbursement costs for the case for a minimum of $5,063.26 but not to exceed $7,063.26.  The Board ordered that the cardiothoracic surgeon complete a board approved medical records course and complete five hours of continuing medical education in “risk management.”

State: Florida

Date: August 2017

Specialty: Cardiothoracic Surgery, Oncology

Symptom: N/A

Diagnosis: Cancer

Medical Error: Failure to follow up, Failure of communication with other providers, Referral failure to hospital or specialist, Failure of communication with patient or patient relations, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 4

Link to Original Case File: Download PDF