Found 80 Results Sorted by Case Date
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Virginia – Neurosurgery – All-Terrain Vehicle Rollover Accident Causes L1 Compression Fracture

On 1/19/2008, a 32-year-old man suffered an L1 compression fracture following an all-terrain vehicle rollover accident.  He saw a neurosurgeon who placed him in a rigid back brace and prescribed pain medications.  The patient’s fracture appeared to be clinically stable and appeared to be improving.  The Board deemed the long-term risk of developing a kyphotic deformity low in this patient.

On 3/7/2008,  the neurosurgeon performed a kyphoplasty of the spine the patient.  During the kyphoplasty, the vertebral body was too dense to accept the cement.  As a consequence, the cement extruded out of the fracture plans into the epidural space.

The neurosurgeon addressed this complication by performing a posterior laminectomy and decompression of the thecal sac.  The Board stated that the laminectomy procedure subjected the patient to a far greater risk for development of kyphosis than had existed prior to the kyphoplasty.

The Board considered the surgery unwarranted and issued a reprimand.  The neurosurgeon was ordered to complete 10 hours of continuing medical education in the subject of patient selection for spinal surgery.

State: Virginia

Date: November 2017

Specialty: Neurosurgery

Symptom: Back Pain

Diagnosis: Spinal Injury Or Disorder, Fracture(s)

Medical Error: Unnecessary or excessive treatment or surgery, Procedural error

Significant Outcome: N/A

Case Rating: 5

Link to Original Case File: Download PDF

Washington – Physician Assistant – History Of Diabetes And Hypertension With Chest Pain, Left-Sided Weakness, Headache, And Loss Of Vision

On 11/7/2011, a patient presented as a “medical emergency” and was seen by a physician assistant at a correctional facility.  The patient was a 62-year-old man whose medical record included a history of arthritis, diabetes, and hypertension for which he was treated with blood pressure medication.

The patient told the physician assistant he thought he had a stroke three days earlier and described symptoms of chest pain, left-sided tingling, left-sided weakness, headache, and loss of vision in the bottom visual field of his left eye.  The patient’s presenting blood pressure was 180/94 with a repeat at the end of the visit of 127/82.  The physician assistant noted normal pupil, funduscopic, heart and lung exams.  Cranial nerves II-XII were intact.  The patient’s strength was equal bilaterally.  An EKG was done and interpreted as having a normal sinus rhythm.  The physician assistant’s diagnosis was “No evidence of stroke.”  The patient was given a GI cocktail and released to his unit.

The physician assistant did not verify the patient’s complaint by conducting a visual field exam.  The physician assistant did not consider temporal arteritis as a possible cause of the patient’s vision loss.  Also, he did not at that time discuss his care of the patient with a supervising physician.  The physician assistant failed to recognize the emergent nature of the complaint of sudden vision loss by a patient.

The patient again presented to the physician assistant a week later on 11/14/2011.  He reported continued loss of vision in the bottom visual field of his left eye. The physician assistant completed a form recommending the patient be referred to an ophthalmologist.

The patient was seen two weeks later on 11/29/2011 by a local ophthalmologist who ordered a sed rate to help rule out temporal arteritis and placed the patient on clopidogrel.  The ophthalmologist diagnosed “[a]cute anterior ischemic optic neuropathy OS.”  He stated that at the visit the patient was “already showing signs of superior optic atrophy and inferior visual field loss from superior involvement approximately three weeks previous.”

The Commission stipulated the physician assistant reimburse costs to the Commission and write and submit a paper, with bibliography, on the evaluation of a patient with non-traumatic sudden vision loss.

State: Washington

Date: August 2017

Specialty: Physician Assistant, Family Medicine, Internal Medicine

Symptom: Vision Problems, Headache, Chest Pain, Weakness/Fatigue

Diagnosis: Ocular Disease

Medical Error: Diagnostic error

Significant Outcome: N/A

Case Rating: 5

Link to Original Case File: Download PDF

Florida – Gastroenterology – Patient And Provider Not Notified Of Amended Pathology Biopsy Results From Colonoscopy

On 5/6/2013, a 55-year-old female presented to a digestive health center for a colonoscopy with biopsy.  During the colonoscopy, a gastroenterologist found a mass in the patient’s rectosigmoid region.  He obtained multiple biopsies of the mass and sent the specimens for in-house pathologic evaluation.  The colonoscopy was completed without complication and the patient was brought to recovery in stable condition.

On 5/7/2013, an in-house pathologist rendered a preliminary gastrointestinal pathology report which reported that the specimen was highly suspicious for a signet ring adenocarcinoma.  The initial pathology report indicated that the case was sent to a second pathologist for another opinion.

The gastroenterologist received and reviewed the initial pathology report.  He referred the patient to a colorectal surgeon for surgical intervention.

On 5/8/2013, the second pathologist issued a pathology report which stated that the specimen was negative for signet cells and adenocarcinoma and recommended a re-biopsy to completely rule out malignancy.  The gastroenterologist received and reviewed the copy of the report by the second pathologist.

On 5/16/2013, the in-house pathologist issued an amended gastrointestinal pathology report which stated that the specimen was negative for signet ring cells.  The gastroenterologist received and reviewed the amended pathology report.

Despite receiving and reviewing the pathology report from both the pathologists, the gastroenterologist failed to notify the patient of the change in the reading of the specimen.  The gastroenterologist also failed to ensure that the colorectal surgeon was notified of the change in the reading of the specimen.

On 6/11/2013, the patient underwent a low anterior resection, mobilization of splenic flexure, and diverting loop ileostomy with colonic J pouch.

The Board judged the gastroenterologists conduct to be below the minimal standard of competence given that he failed to notify the patient of the change in the reading of the specimen and ensure that the colorectal surgeon was notified of the change in the reading of the specimen.

The Board issued a letter of concern against the gastroenterologist’s license.  The Board ordered that the gastroenterologist pay a fine of $10,000 against his license and pay reimbursement costs of a minimum of $3,008.71 and not to exceed $5,008.71.  The Board also ordered that the gastroenterologist complete five hours of continuing medical education in “risk management.”

State: Florida

Date: June 2017

Specialty: Gastroenterology

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

Diagnosis: Cancer

Medical Error: Failure of communication with patient or patient relations, False positive, Failure of communication with other providers

Significant Outcome: N/A

Case Rating: 5

Link to Original Case File: Download PDF

California – Gastroenterology – Endoscopy In High Risk Patient With Esophageal Scleroderma Results In Complications

A 69-year-old male with diffuse systemic sclerosis, interstitial lung disease, end stage renal disease on hemodialysis, anemia, hypertension, hypoalbuminemia, secondary hypothyroidism, and gastric antral vascular ectasia (“GAVE”) had been referred to a gastroenterology clinic for evaluation of recurrent problems with weight loss and dysphagia.  It was assumed that the patient’s disease had progressed to esophageal scleroderma and that a percutaneous endoscopic gastrostomy (“PEG”) would be necessary to bypass his esophagus and would allow him to take in adequate nutrition without swallowing.  The patient was referred to the gastroenterology clinic for evaluation and a PEG.

On 6/25/2012, the gastroenterologist ordered a PEG, and she scheduled an esophagogastroduodenoscopy (“EGD” or upper endoscopy) and esophageal manometry for the afternoon of 6/25/2012, both elective, non-emergent diagnostic procedures, scheduled to be done on an outpatient basis.  On 6/23/2012 or 6/24/2012, the patient had been discharged from the hospital on antibiotics with home oxygen administration after treatment for aspiration pneumonia.

The gastroenterologist performed a pre-endoscopy history and physical examination in the early afternoon of 6/25/2012 and noted that the patient had active diffuse scleroderma complicated by renal crisis, diffuse systemic sclerosis, interstitial lung disease, GAVE with multiple cauterizations, and end stage kidney disease.  In past medical history, she listed “scleroderma renal crisis, “Started dialysis December 30, 2011,” and “Pneumonia. Admitted to er 6/24/12.”  She noted that the patient had had multiple upper endoscopies for gastrointestinal bleeding prior to this EGD.  Her physical examination listed “Lungs: Clear Auscultation. Clear percussion and Normal Symmetry and Expansion.”  She noted that she, not an anesthesiologist, was ordering sedation.

Sedation was to be administered by a registered nurse.  The gastroenterologist listed Airway as Class 2 and ASA Level (American Society of Anesthesiologists physical status classification system) as 3 (severe systemic disease).

On 6/25/2012 at 2:48 p.m. and ending at approximately 3:15 p.m., the gastroenterologist performed an upper endoscopy on the patient and took biopsies.  Nursing records indicate that sedation consisted of midazolam, 7 mg, administered over the 22 minutes; fentanyl, 175 mcg administered over the 22 minutes, and Cetacaine spray applied to the throat prior to the procedure.

The patient was transferred from the endoscopy procedure room to the recovery area under the care of a registered nurse.  The nurse noted that the patient was unresponsive to verbal and painful stimuli, with blood pressure 108/70, heart rate 86, and O2 saturation 89% on 2 liters delivered by nasal cannula.  A face mask was applied at 10 liters O2 and oxygen saturation went up to 97%.  When the gastroenterologist was notified, she ordered reversal medications: flumazenil 0.25 mg IVP over 15 seconds and Narcan 0.4 mg IVP at 3:40 p.m., and the patient was still unresponsive.  A second dose of flumazenil 0.25 mg IVP was given at 3:43 p.m., and the patient became responsive at 3:44 p.m.  Once the patient was responsive, the gastroenterologist performed the esophageal manometry procedure.  No time is entered in the medical record for this procedure although the gastroenterologist acknowledges that it was done and the results are recorded.

The gastroenterologist was later notified by nursing staff of concerns with the patient’s breath sounds, and the gastroenterologist noted stridor at 4:26 p.m.  She was notified at 5:19 p.m. that the patient’s oxygen saturation was 89% on 5 liters oxygen delivered by nasal cannula.  At 5:20 p.m., the gastroenterologist ordered a chest x-ray due to the inability to wean the patient off oxygen after the endoscopy.  A face mask was applied at 10 liters oxygen at 5:21 p.m., and oxygen saturation went up to 93%.  The chest x-ray indicated “a dense retrocardiac opacity and a left pleural effusion” and a “volume loss in the left lung with mild shift of the mediastinum towards the left.”

After the manometry procedure in the recovery room, the patient’s oxygen saturation was monitored, and when the oxygen saturation remained above 90% for 30 minutes on room air, the patient met endoscopy discharge criteria.  The patient was discharged home with instructions concerning any complications that might arise.

The gastroenterologist states that she arranged to admit the patient to the hospital, but the patient left against medical advice (AMA).  Neither notation of this nor a signed AMA release was found in the record.  Pathology results revealed gastritis and the manometry procedure revealed a condition consistent with esophageal scleroderma.

On 6/27/2012, the patient presented to the emergency department with shortness of breath and cough.  Chest x-ray showed new right lung patchy opacities, and the patient was cachectic.  He was admitted to the intensive care unit for treatment of pneumonia.  The admission diagnosis was “most likely persistent pneumonia, likely aspiration due to esophageal dysmotility.”  The patient failed to improve despite intensive hospital care.  Although the gastroenterologist had scheduled a PEG for 7/2/2012, it was decided that the patient would not go through with the procedure.  Instead, it was decided that the medical team would provide palliative care for the patient.

On 7/4/2012, the patient died with the cause of death listed as aspiration pneumonia due to esophageal dysmotility and end-stage scleroderma with severe malnutrition as a contributing factor.

The Board deemed the gastroenterologist’s conduct as falling below the standard of care for the following reasons:

1) The gastroenterologist failed to provide an accurate analysis of the patient’s suitability for the endoscopic and manometry procedures.

2) She classified the patient as an ASA Level 3, which denotes an individual with stable multiple system disease that limits daily activity without immediate danger of death.

3) At the time of the EGD and manometry done by the gastroenterologist, the patient had just been released from another hospital, where he had been treated for aspiration pneumonia and discharged on antibiotics and home oxygen.

4) By reason of the patient’s recent aspiration pneumonia and the necessity for home oxygen administration, his ongoing scleroderma renal crisis which necessitated hemodialysis, his persistent interstitial lung disease, and his frequent bleeding and cauterizations for GAVE, his condition was not stable, and elective procedures at this time were contraindicated.  The patient’s classification was clearly ASA level 4, which denotes an individual with severe, incapacitating disease, poorly controlled or end-stage, at risk for death due to organ failure.

5) The gastroenterologist failed to provide for an anesthesiology consultation, given the patient’s unstable and life-threatening condition, and instead elected to provide conscious sedation directed by the gastroenterologist and administered by a registered nurse.  The level of sedation administered to the patient during the upper endoscopy procedure was relatively large for an individual with so many co-morbid conditions, and an anesthesiologist or nurse anesthetist should have been in attendance.

6) Since both procedures were elective, the gastroenterologist failed to reschedule the procedures for a time when the patient was stable and able to tolerate conscious sedation directed by the gastroenterologist and administered by a nurse.

7) The patient had a very unstable post-procedure course in the recovery room.  He was unresponsive to verbal and painful stimuli and oxygen saturation was below 90%.  Reversal medications had to be administered before the patient became responsive.  When the patient became responsive, the gastroenterologist performed the esophageal manometry in the recovery room.  This procedure was unnecessary to determine the need for a PEG and further endangered the health of the patient.

8) The respondent approved sending the patient home with instructions after his oxygen saturation was above 93% for 30 minutes.  The patient was a very high-risk patient for elective procedures and had had a very unstable post-procedure course in the recovery room, including the development or exacerbation of pneumonia.  Under these circumstances, in conjunction with his numerous co-morbidities, it was unsafe to send the patient home.  There was no record found of the patient leaving the clinic AMA.

The Board issued a public reprimand against the gastroenterologist.  Stipulations included continuing medical education in the topics of pre-operative patient evaluation, informed consent, sedation, and medical record keeping.

State: California

Date: May 2017

Specialty: Gastroenterology, Hospitalist, Internal Medicine

Symptom: GI Symptoms (GERD, Abdominal Distention, Dysphagia), Cough, Shortness of Breath, Weight Loss

Diagnosis: Gastrointestinal Disease, Pneumonia, Pulmonary Disease

Medical Error: Unnecessary or excessive treatment or surgery, Failure of communication with other providers, Lack of proper documentation

Significant Outcome: Death, Hospital Bounce Back

Case Rating: 5

Link to Original Case File: Download PDF

California – Pediatrics – Fourteen-Year-Old Male With A Hemoglobin Of 8.2

On 7/30/2013, a 14-year-old male was seen by a pediatrician for a well-child assessment.  The pediatrician reviewed the patient’s height, weight, temperature, and blood pressure and administered hearing and vision tests.  She reviewed the patient’s development, including body image, home situation, education, school progress, risk-taking behaviors, sexuality, and mental health.  A complete physical examination was performed.

On 7/30/2013, the patient received a routine HPV immunization.  Routine diagnostic laboratory tests were ordered, including urinalysis.  A hemoglobin test by finger stick was performed.  The patient’s urinalysis test result was normal, but his hemoglobin result of 8.2 was significantly lower than normal.  The pediatrician repeated the hemoglobin test by finger stick but did not order a complete blood count by venipuncture.  The patient’s hemoglobin result was again 8.2.  The pediatrician started the patient on iron supplement therapy and instructed him to follow up in three months.  No additional diagnostic tests were done during this visit.

On 8/18/2013, the clinic received a report that the patient was experiencing shortness of breath and chest pain.  The patient was instructed to go to an emergency room.

At the emergency room, the patient experienced a full cardiac arrest.  His complete blood count revealed severe anemia, with a hemoglobin result of 7.5, a hematocrit of 21, 99 atypical lymphocytes, and a critically low platelet count of 39,000.  The patient’s cause of death was acute lymphoblastic leukemia/lymphoma.

The Board deemed the pediatrician’s level of conduct to be below the standard of care given failure to order a complete blood count by venipuncture for the follow-up blood test, failure to schedule a visit and lab check at an earlier date, and failure to consider other diagnoses in addition to iron deficiency anemia.

The Board issued a public reprimand against the pediatrician.  Stipulations included performing sixty hours of free services to a community or a non-profit organization, conducting 40 hours of continuing medical education, enrolling in a professionalism program, and undergoing a clinical competency assessment program.

State: California

Date: May 2017

Specialty: Pediatrics, Hematology

Symptom: Shortness of Breath, Chest Pain

Diagnosis: Cancer, Hematological Disease

Medical Error: Failure to order appropriate diagnostic test, Delay in proper treatment

Significant Outcome: Death

Case Rating: 5

Link to Original Case File: Download PDF

Virginia – Gastroenterology – Colonoscopy With Significant Amount Of Liquid Stool In Bowel

On 2/5/2015, a 50-year-old female underwent a colonoscopy conducted by a gastroenterologist.

Although the gastroenterologist noted a significant amount of liquid stool remaining in the bowel and hard stool adhering to mucosa, he continued the procedure and repeatedly injected saline and air into the bowel in an effort to clear the visual field.

Although the gastroenterologist knew that the suction button on the colonoscopy was continually sticking, thus making the necessary suctioning difficult and/or impossible, the gastroenterologist continued the procedure.

After approximately 31 minutes, the gastroenterologist stopped the procedure when he noted that the patient’s abdomen was distended.  He then ordered x-rays and requested an immediate surgical consultation.

The x-rays revealed free air in the abdomen.  The patient underwent emergency surgery to repair a baro-rupture of her cecum.  Subsequently, the patient developed sepsis and multi-organ failure and died on 2/12/2015.

The gastroenterologist was permanently restricted from performing invasive procedures.

State: Virginia

Date: April 2017

Specialty: Gastroenterology

Symptom: N/A

Diagnosis: Post-operative/Operative Complication, Acute Abdomen

Medical Error: Procedural error

Significant Outcome: Death

Case Rating: 5

Link to Original Case File: Download PDF

California – Cardiology – CT Coronary Angiogram On Hemodynamically Compromised Patient For Chest Pain, Abnormal Electrocardiogram, Right Atrial Enlargement, And Elevated Cardiac Enzymes

On 4/16/2012, a 23-year-old female presented to the emergency department with chest pain, acute nausea, vomiting, and diarrhea.  The patient had a history of pulmonary hypertension. Laboratory measurements were taken that revealed a hemoglobin of 17.2, hematocrit of 49.9, an acidotic pH of 7.12, an elevated WBC count of 15,900, potassium of 6.6, BUN of 31, and creatinine level of 1.4.  These measurements were consistent with mild renal insufficiency. An electrocardiogram test revealed sinus tachycardia, which was consistent with the findings of an electrocardiogram performed on the patient approximately 1 year earlier.

On 4/17/2012, the patient was admitted to the hospital.  The patient was initially treated with sodium bicarbonate to treat her lactic acidosis and IV fluids for dehydration.  The patient also received a dialysis catheter in her right femoral artery due to the increase in the BUN/creatinine measurements.  However, this catheter was never used.

On 4/17/2012, a cardiologist performed a telephonic cardiology consult with the hospitalist and ordered a CT coronary angiogram due to the patient’s chest pain, abnormal electrocardiogram, right atrial enlargement, and elevated cardiac enzymes (troponin).  The cardiologist also ordered 100 ml of ionic contrast to facilitate the CT angiogram despite the patient’s continued elevated BUN and creatinine levels. The cardiologist also ordered 50 mg of metoprolol orally and 5 mg intravenously to improve visualization on the CT angiogram despite the patient’s clinical condition.  The cardiologist did not perform a physical examination of the patient, measure the patient’s pulmonary pressure, or review the patient’s diagnostic or laboratory tests prior to ordering ionic contrast, CT angiogram, or administering metoprolol.

On 4/17/2012, the patient deteriorated and became hypotensive approximately 90 minutes after the CT angiogram and administration of metoprolol.  At approximately 8:00 p.m., the patient expired due to cardiac arrest.

The Medical Board of California judged that the obstetrician’s conduct departed from the standard of care because he failed to physically examine the patient prior to ordering a potentially dangerous procedure and drugs, review the patient’s previous diagnostic testing and laboratory testing prior to ordering a potentially dangerous procedure and drugs, and order a pulmonary artery catheter to measure pulmonary pressure in a hemodynamically compromised patient.

The Medical Board of California placed the cardiologist on probation for 3 years and ordered the cardiologist to complete a medical record keeping course and an education course (at least 40 hours per year for each year of probation).  The cardiologist was also assigned a practice monitor.

State: California

Date: March 2017

Specialty: Cardiology

Symptom: Chest Pain, Diarrhea, Nausea Or Vomiting

Diagnosis: Cardiovascular Disease, Renal Disease, Sepsis

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

Significant Outcome: Death

Case Rating: 5

Link to Original Case File: Download PDF

Wisconsin – Physician Assistant – 25-Year-Old Man With Cough, Fever, Chills, And Night Sweats

On 12/15/2003, a 25-year-old non-smoking man presented to a clinic with 10 days of cough, fever, chills, and night sweats.  He was noted to have a heart rate of 142 and a respiratory rate of 24.  He was on amoxicillin, doxycycline, and prescription cough medication.

Physician Assistant A switched him to a different cough medication.  He reported that he had re-checked the heart rate, but there was no documentation of the re-check.  He recommended that the patient continue with amoxicillin and doxycycline.  A TB skin test was ordered.  Physician A was supervising Physician Assistant A.  She reviewed and signed the note sometime after 2/13/2004.

On 12/18/2003, the patient returned to the clinic to have his TB test read.  At that time, he was doing worse.  He saw Physician Assistant B, who was also being supervised by Physician A.  Physician Assistant B reviewed Physician Assistant A’s notes and documented that “his cough seems to be worse” and that the antibiotics “do not seem to be helping.”  His temperature was noted to be 101.3, respiratory rate 32, and on physical exam, it was noted that he was coughing, the coughing intensified when he was reclined, he had a headache with coughing, he had bilateral lower pleuritic pain, and he had “decreased breath sounds to the right base.”   The TB test was negative.  He was diagnosed with “probable pneumonia.”

She recommended a chest x-ray and a CBC, but the patient declined due to cost.  Antibiotics were changed to gatifloxacin 400 mg daily.  It was recommended that he increase fluid intake.  On 12/19/2003, Physician Assistant B dictated the note for the patient visit from the prior day.  The note contained her signature, but not the date.  The medical records reflected that Physician A reviewed and signed the note, but did not reflect when she reviewed or signed it.  On review of the chart, oxygen saturation was not documented.  Physician A did not contact the patient or direct Physician Assistant B to contact the patient, in order to obtain an updated oxygen saturation.

On 12/23/2003, the patient was admitted to the ICU.  Oxygen saturation was at 71%.  On 12/26/2003, he was placed on a mechanical ventilator.  On 1/1/2004, the patient suffered cardiac arrest and could not be resuscitated.

The cause of death was noted to be acute respiratory distress syndrome secondary to pneumonia due to blastomycosis.  On 10/2/2009, a jury concluded that Physician A was negligent in her supervision of Physician Assistant A and B.  The jury attributed 35% of the total causal negligence to Physician A.

The Board addressed the issue of whether Physician A should have sought to obtain an oxygen saturation level.  The Board ultimately decided that Physician A was within the standard of care.

Physician Assistant B’s conduct in her treatment of the patient was below the minimum standards for the profession in the following respects: she failed to document in the patient’s chart that the chest x-ray and CBC were not done “against medical advice”; failed to recommend admission for the patient; failed to consult with her supervising physician; and failed to request a pulmonary consult.

The Board ordered Physician Assistant B be reprimanded, complete 4 hours of continuing medical education in the areas of evaluation and treatment of pneumonia and respiratory distress, and pay the costs of the proceeding.

State: Wisconsin

Date: January 2017

Specialty: Physician Assistant, Internal Medicine

Symptom: Cough, Fever, Headache, Chest Pain, Shortness of Breath

Diagnosis: Pneumonia

Medical Error: Improper treatment, Failure to order appropriate diagnostic test, Failure of communication with other providers, Referral failure to hospital or specialist, Improper supervision, Lack of proper documentation

Significant Outcome: Death, Hospital Bounce Back

Case Rating: 5

Link to Original Case File: Download PDF

Washington – General Surgery – Right Upper Quadrant Mass And Abdominal Pain With Suspicion For Hernia In Obese Patient With Thrombocytopenia

A patient’s primary care physician (PCP) referred her to a general surgeon for a right upper quadrant mass after suspecting a hernia.  In his written referral to the general surgeon, the PCP stated that the patient’s present illness was “Abdominal pain in RUQ from hernia…Refer to surgeon to evaluate RUQ mass/pain.”

In October 2008, the general surgeon examined the patient and noted that the patient presented with “a painful bulge in the R lateral abdominal wall,” she was 75 years old, 5’4” tall, 240 pounds, and suffered from hypertension.  The pre-operative note also indicated that the patient would not accept a blood transfusion.  This is significant considering that the patient’s pre-operative laboratory report showed a low platelet count of 84,000.

Although the patient had been experiencing significant pain and her PCP had suspected and noted the likelihood of a hernia, the general surgeon believed the abdominal mass to be a lipoma.  The general surgeon did not obtain any pre-operative image studies.  Instead, the general surgeon scheduled the patient for surgery at an outpatient, ambulatory surgery center, where he works.  The general surgeon did not take into account that complex hernia repairs that require bowel repair or resection are not appropriate for same day surgical procedures and outpatient centers are not equipped for such procedures.  At a minimum, without a preoperative image study, the general surgeon should have scheduled the patient for surgery at the hospital so that whatever issue was encountered could be properly addressed.

In November 2008, the general surgeon attempted surgery on the patient at the ambulatory surgery center.  The general surgeon used the subcostal approach and discovered that in fact, the patient had a hernia and not the lipoma he had anticipated.  A hernia was stuck to the undersurface of the abdominal area where the general surgeon found dense adhesions.

The surgery had to be stopped 25 minutes after its start because the surgery center lacked the instrumentation and equipment for hernia surgery.  As a result of the more difficult and involved surgery required, the conscious sedation started by the anesthesiologist was insufficient to control the patient’s discomfort, and a laryngeal mask airway was needed and provided.  The patient was immediately transferred by ambulance to the hospital.

The surgery center’s anesthesiologist’s report stated that the patient had a “likely bowel perforation.” If the anesthesiologist’s note is correct, the requisite delay in repairing the perforation could potentially expose the patient to an increased risk of wound infection.  A bowel perforation requires emergent repair, and any delay poses serious consequences.

The general surgeon denied perforating the patient’s bowel during the surgery at the surgery center but his own hospital admission report states that the patient had “a probable perforation of the hepatic flexure.”  The hospital’s report also contains a contradicting note where the general surgeon states that the patient had begun outpatient surgery to remove a right-sided abdominal mass which “ended up perforating bowel.”  This hospital’s report further acknowledged that the patient was admitted for “bowel resection as this could not be done at the surgery center.”

At the hospital, the general surgeon undertook the more extensive surgery which confirmed that the bowel was perforated.  The general surgeon performed this second surgery with a subcostal retroperitoneal approach despite his recognition of dense adhesions and presumed bowel injury, as well as the earlier difficulty in exposing the large hernia in the morbidly obese patient.

The general surgeon’s discharge summary states that the patient had experienced purulent drainage from her incision.  However, the general surgeon did not document his evaluation of the patient’s wound prior to discharging the patient from the hospital, nor did the general surgeon document the patient’s complaint of pain.  The general surgeon discharged the patient to a rehabilitation center.

Within 24 hours of discharge, the patient immediately returned to the hospital by ambulance with a grossly infected wound.  The patient appeared septic, experienced constant, intense pain, with fever, chills and brown, bilious-colored material draining from her surgical incision.

A CT scan showed draining fecal matter in her right abdomen.  The patient stated that her abdominal pain and wound drainage began three days prior to discharge from the hospital.  The scan also revealed the patient had a significant intra-abdominal process that likely festered for some time.  This fact raises the possibility that the drainage in the abdominal wound was the continuum of a process that was occurring intra-abdominally.

The patient returned for a third surgery.  The general surgeon again performed the surgery, this time using a midline incision.  The general surgeon described the surgery as mildly bloody.  During this surgery, in a purulent area in the right side of the abdomen, the general surgeon identified a perforation in the patient’s colon which was leaking air.  The general surgeon resected the patient’s colon and broke down some hard adhesions.  Because of the extensive peritonitis that had developed, the patient had to have a colostomy.  The patient’s health rapidly declined following the third surgery.

The patient died less than thirty days after the general surgeon’s initial surgery.  The general surgeon prepared the death certificate, and he failed to accurately reflect that the patient died of multi-organ system failure as a consequence of a bowel perforation that occurred from his abdominal surgery to repair a hernia.  There was no mention for reason of organ failure and the only pathology mentioned were various organ system failures that occurred just before death.  A death certificate should accurately reflect the course of events leading up to a patient’s demise.  The general surgeon neglected to properly document the actual cause of the patient’s death.

The Commission stipulated the general surgeon reimburse costs to the Commission, arrange for the manager of the Quality Review Committee at all facilities where he provides patient care to submit quarterly reports addressing whether any surgical cases involving the general surgeon were discussed at the Quality Review Committee meetings,  and write and submit a paper of at least 1500 words, with annotated bibliography, discussing the Communication and Resolution Program (CRP) principles and the importance of integrating these principles into practice.

State: Washington

Date: January 2017

Specialty: General Surgery

Symptom: Abdominal Pain

Diagnosis: Post-operative/Operative Complication, Sepsis, Procedural Site Infection

Medical Error: Underestimation of likelihood or severity, Failure to examine or evaluate patient properly, Lack of proper documentation, Procedural error

Significant Outcome: Death, Hospital Bounce Back

Case Rating: 5

Link to Original Case File: Download PDF

North Carolina – General Surgery – Alcohol Based Solution For Surgical Prep And Electrocautery Device Causes Complications During Lipoma Removal

The Board was notified of a professional liability payment made on 7/17/2015.

In preparation for the removal of a lipoma on a patient’s posterior neck, the surgery area and the hairline were treated with an alcohol based antibacterial solution called DuraPrep.  Although the manufacturer’s recommended drying time is two to three minutes, the general surgeon allowed the DuraPrep to dry for approximately ten minutes.  The general surgeon also blotted the patient’s neckline with a sponge.  Seeing no visible residue on the blotting sponge, the patient’s head was covered with a drape.  During the procedure, which was performed using open oxygen under monitored anesthesia care, strands of the patient’s hair covered with DuraPrep solution residue were ignited from the electrocautery.  The oxygen, which had accumulated under the drapes, served as a fire accelerant.  The patient was transferred by air with an endotracheal intubation to a burn center for flash burns to the midface, nose, mouth, eyelids, and right ear.

The Board believed the general surgeon responded appropriately to the intraoperative emergency and noted that the general surgeon sustained second degree burns to his hand trying to extinguish the flame.  The Board also acknowledged the general surgeon and his operating team’s rapid response minimized harm to the patient.

The cause of the fire was multifactorial; however, the Board believed the surgeon was ultimately responsible for the patient’s safety during the operation.  They recommended that in similar cases, the general surgeon should use a non-alcohol based skin prep, allow additional drying time, or use a non-sparking cautery, minimize the use of open oxygen, and use draping techniques that would allow adequate ventilation when open oxygen is used.  The Board acknowledged that the general surgeon received additional training in surgical fire prevention and safety.

The Board issued a public letter of concern, which was reported to the Federation of State Medical Boards.  It was not reported to the National Practitioner Data Bank.

State: North Carolina

Date: October 2016

Specialty: General Surgery

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

Diagnosis: Post-operative/Operative Complication

Medical Error: Procedural error

Significant Outcome: N/A

Case Rating: 5

Link to Original Case File: Download PDF

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