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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

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

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

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Virginia – Neurosurgery – All-Terrain Vehicle Rollover Accident Causes L1 Compression Fracture

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

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

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

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

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

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

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

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

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