Found 4 Results Sorted by Case Date
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California – Pediatrics – Long Term Regimen Of Compounded Dexamethasone Cough Syrup For Pneumonia And Asthma



On 1/13/2015, a pediatrician saw a child just short of her second birthday.  She had been diagnosed with asthma and was maintained on corticosteroid and albuterol inhalers.  The patient presented with fever, coughing, and loss of appetite.  Although she had taken an antibiotic prior to this visit, it is not noted in the pediatrician’s chart notes.  The pediatrician diagnosed pneumonia, laryngotracheobronchitis (croup), and asthma and prescribed a different antibiotic for her.

The pediatrician stated that she followed up with the patient by telephone on 1/14/2015 and 1/15/2015.  Based on these follow-up calls, the pediatrician prescribed compounded cough syrup at a daily dose containing 0.55 mg dexamethasone, a corticosteroid.  She prescribed a sufficient amount of the medication to last a month and when the patient’s mother said that she was afraid that the patient would begin to cough again because her entire family had caught the cold, the pediatrician called in a partial refill for the medication.  None of this information was included in the pediatrician’s chart notes for the patient.

The pediatrician’s chart notes for the patient’s follow-up visits on 1/20/2015 and 2/20/2015 did not make reference to the compounded cough medication, instructions on how to take the medication, or to the advice she gave the patient’s mother concerning weaning the patient off the medication.  Although the pediatrician stated that she was concerned about the patient’s reduced “immunity” and recommended an over the counter immune pediatric supplement for the patient on 2/20/2015, this concern was not documented in the patient’s chart notes.

The Board judged the pediatrician’s conduct to have fallen below the standard of care given failure to appropriately prescribe dexamethasone to the patient and given failure to document the follow-up telephone calls, the fact that she had prescribed the compounded cough medication to the patient, instructions for the patient to wean off the dexamethasone, concern for the patient’s reduced “immunity,” and the fact that the patient had taken antibiotics prior to her first visit with the patient.

A public reprimand was issued against the patient with stipulations to take a medical record keeping course.

State: California


Date: May 2017


Specialty: Pediatrics


Symptom: Cough, Fever


Diagnosis: Pneumonia, Asthma


Medical Error: Improper medication management, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Kansas – Pediatrics – Improper Documentation For Reactive Airway Disease And Improper Use of Bactrim



On 2/4/2013 a 7-year-old female presented to a pediatrician and saw the advanced practice registered nurse (“APRN”).  The patient presented with chief complaints of allergies, congestion, and diarrhea.  The patient was prescribed albuterol, Qvar 40 mcg, Bactrim, and triamcinolone.  The Bactrim was prescribed inappropriately for diarrhea.  The pediatrician agreed but thought that he had perhaps forgotten to document otitis media.

On 2/19/2013, the pediatrician saw the patient for a follow-up appointment.  The pediatrician documented that the patient was there for a follow-up for her asthma, even though the patient previously presented with reactive airway disease.  The pediatrician did not document his thought process in how reactive airway disease developed in asthma.  The pediatrician did not electronically sign the record until 4/11/2013.

On 6/11/2013, the patient presented to the pediatrician for a school physical.  The pediatrician failed to document the patient’s asthma.  In the school health examination, the pediatrician stamped signature appears on the form with the date 6/11/2013.  The pediatrician stamped the document “No” to the question, “Is this student subject to any condition which might cause a possible classroom emergency such as seizures, fainting, diarrhea, diabetes, asthma, allergies, etc.”

The Board judged the pediatrician’s conduct to be below the minimum standard of competence given his failure to keep written medical records, and inappropriately prescribing a medication.

The Board ordered that the pediatrician attend and successfully complete the Medical Record Keeping Seminar at Center for Personalized Education for Physicians (“CPEP”). Also, the Board ordered that the pediatrician hire a medical scribe. Finally, the Board ordered that the pediatrician have a pediatrician monitor his work.

State: Kansas


Date: October 2016


Specialty: Pediatrics


Symptom: Allergic Reaction Symptoms, Diarrhea


Diagnosis: Asthma


Medical Error: Lack of proper documentation, Improper medication management


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Anesthesiology – Arteriovenous Fistulogram On Obese Patient With Renal Disease, Asthma, Cardiovascular Disease, Diabetes, And Sleep Apnea



On 3/5/2014, a 55-year-old, 5’3”, and 109 kg (BMI 44.2) female was scheduled for a left arm arteriovenous fistulogram and possible revision of her dialysis fistula to prevent re-bleeding.  An anesthesiologist assumed the anesthesia care of this patient prior to the start of surgery. The patient suffered from a history of end-stage renal disease, had been on dialysis for 15 years, suffered from obesity, asthma, rheumatoid arthritis, diabetes, and sleep apnea, and used home oxygen at night.  The patient also had a history of atrial fibrillation, cardiomyopathy with an ejection fraction of 28%, moderate-severe aortic insufficiency and stenosis, coronary artery disease with stents placed in 2013, and chronic congestive heart failure. The patient had begun to experience bleeding from the AV fistula five days prior to admission.

In his pre-operative note, the anesthesiologist documented that the patient was 100 kg, had chronic renal failure, had coronary disease with stents, had a left bundle branch block, and suffered from occasional gastric reflux.  The anesthesiologist did not note that the patient suffered from sleep apnea, cardiomyopathy, chronic heart failure, atrial fibrillation, aortic valve disease, or diabetes. The anesthesiologist’s note did not document the last time the patient had received dialysis.   The anesthesiologist’s pre-operative note showed that he saw the patient at 3:40 p.m. Anesthesia start time was noted at 3:49 p.m. The note was filed at 4:24 p.m. and signed at 5:18 p.m.

The patient’s vital signs were charted at 3:55 p.m. and were listed as followed: blood pressure of 160/70, pulse of 78/min sinus rhythm, respiratory rate of 20, and 100% oxygen saturation on the 10 L mask.  At 3:50 p.m., the anesthesiologist administered 1 mg of midazolam and 50 mcg of fentanyl and began a propofol infusion. The dose of propofol was not charted. At 4:05 p.m., the anesthesiologist administered 1 mg of midazolam and 50 mcg of fentanyl.  Just prior to the surgeon injecting local anesthetic, the anesthesiologist administered 30 mg propofol, but did not chart the dosage. The anesthesiologist attached the pulse oximeter trace distal to the blood pressure cuff on the same limb. The anesthesiologist also had the patient wear a non-rebreathing oxygen mask.  At 4:20 p.m., the surgery began. During the surgery, the surgeon noticed the patient’s blood had turned dark and that the patient was cyanotic. At 4:28 p.m., it was noted that the surgeon could not feel a pulse, and a code was called.

The anesthesiologist provided 0.4 mg of atropine and 1 mg of epinephrine.  The patient’s blood pressure was 90/40. The anesthesiologist provided a second dose of epinephrine.  The code blue team note began at 4:28 p.m. The patient was intubated at 4:29 p.m. Compressions began at 4:31 p.m.  The code blue team provided one amp of bicarbonate. The patient’s pulse was obtained. Then the patient’s pulse could not be felt a second time.  A second code was called at 4:50 p.m. Further work was done of the patient. The patient was transferred to the ICU, where she remained unresponsive.  She was converted to comfort care and expired that evening.

The Medical Board of California judged that the anesthesiologist departed from the standard of care because he administered doses of sedation to an obese patient with a history of sleep apnea, who was sensitive to the effects of respiratory depressants.  The anesthesiologist was not vigilant during the time that she developed hypoventilation and obstruction. Prior to the surgeon realizing that the patient had no pulse, the anesthesiologist failed to promptly and adequately rescue her.  Once the code was called, the anesthesiologist failed to take an active role in the resuscitation of the patient. The anesthesiologist also failed to recognize and treat respiratory depression, bradycardia, and pulseless arrest. The anesthesiologist’s failure to recognize the patient’s condition led to intubation and airway rescue being delayed, only occurring after the code team had arrived.  The pre-operative note was written and submitted after the patient received IV sedation and signed after she coded a second time. The anesthesiologist did not create a summary note of the code blue events that occurred in the operating room or of the patient’s subsequent death. The anesthesiologist failed to document this intraoperative sentinel event.

The Medical Board of California placed the anesthesiologist on probation for 4 years and ordered him to complete a medical record-keeping course, an education course for at least 20 hours for the first 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.

State: California


Date: May 2016


Specialty: Anesthesiology


Symptom: Bleeding


Diagnosis: Cardiovascular Disease, Asthma, Pulmonary Disease


Medical Error: Failure to examine or evaluate patient properly, Improper treatment, Improper medication management, Lack of proper documentation


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Kansas – Physician Assistant – Improper Documentation While Treating A Patient And His Relatives For Various Conditions



On 10/2/2009, a physician assistant prescribed a patient Phenergan 25 mg for complaints of watery diarrhea and vomiting.

On 1/6/2010, the physician assistant prescribed the patient an inhaler due to the fact it was empty. It was after normal operating hours of his primary care physician’s (PCP’s) office, and he was experiencing shortness of air and wheezing.

On 1/18/2010, the physician assistant prescribed the patient Zofran 4 mg oral for nausea, vomiting, and gastroenteritis.

On 7/13/2010, the physician assistant prescribed the patient ciprofloxacin for “frequent urination, dysuria, etc.”

On 7/26/2010, the physician assistant prescribed the patient’s son-in-law Bactrim DS after reviewing pictures sent via cellular phone of a large abscess/cellulitis.

On 8/14/2010, the physician assistant prescribed the patient’s grandson Bactrim to treat cellulitis of the right knee.

On 8/23/2010, the physician assistant prescribed ciprofloxacin for the patient due to complaints of continued prostate problems, dysuria, and erectile dysfunction.  The physician assistant testified that she provided the prescription because the patient did not have time to go to his PCP.  She also testified that she referred him to his urologist and his PCP for another repeat CT, as recommended by the CT report and the PCP several months prior.

On 9/3/2010, the physician assistant prescribed the patient’s son Bactrim to treat an upper respiratory infection and a skin infection that the patient’s son told described to her via a phone call and text.

On 9/16/2010,  the physician assistant prescribed the patient’s grandson Bactrim SS after the patient grandson’s mother called the physician assistant describing the patient’s grandson’s complaint of an abscess on the calf.

The physician assistant had a personal dating relationship with the patient from August 2008 to 9/25/2010.  This personal dating relationship did not initiate from a preexisting patient/physician assistant relationship.

The Board judged the physician assistant’s conduct to be below the minimal standard of competence given her failure to properly document her patient encounters with the above patients.

The Board ordered the physician assistant complete continuing medical education course for Effective and Efficient Methods of Documenting Patient Care, by The Center for Personalized Education for Physicians.

State: Kansas


Date: June 2013


Specialty: Physician Assistant


Symptom: Diarrhea, Nausea Or Vomiting, Shortness of Breath, Urinary Problems


Diagnosis: Gastrointestinal Disease, Infectious Disease, Asthma, Urological Disease


Medical Error: Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



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