Found 13 Results Sorted by Case Date
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Vermont – Emergency Medicine – Suspected Ventricular Tachycardia Not Addressed In A Patient With Respiratory Distress, Fever, And An Elevated Heart Rate



On 2/6/2013 a patient’s father contacted EMS (emergency medical services) because his son had respiratory distress, fever, and an elevated heart rate.

EMS documented a heart rate of 278 and performed a pre-hospital EKG because ventricular tachycardia (VTach) was a concern.  EMS contacted the hospital to report vital signs and their impression of VTach.

The patient presented to the emergency department at 11:29 p.m.  The patient was triaged at 11:42 p.m. and a pulse of 245, blood pressure of 53/39, and a temperature of 101.02 were recorded.  An EKG was performed at 11:43 p.m.  The results were shown to the ED physician at 11:47 p.m.

The ED physician’s notes state that at 12:13 a.m. the patient was examined.  It was documented that the ED physician suspected the patient was in VTach, but no therapy was administered.

The ED physician then contacted the on-call cardiologist, who advised the ED physician to treat the patient for probable sepsis with fluids and Tylenol.  The ED physician then ordered IV antibiotics and spoke to a critical care physician about transfer of the patient.

At 12:29 a.m. the patient had a ventricular fibrillation cardiac arrest.  He was treated with various medications but no shock was given.  At 12:45 a.m. the patient was pronounced dead.

The Board concluded that the ED physician be reprimanded, complete 15 hours of continuing education on Advanced Cardiac Life Support, and pay a fine of $1000.

State: Vermont


Date: September 2017


Specialty: Emergency Medicine, Cardiology


Symptom: Shortness of Breath, Fever, Palpitations


Diagnosis: Cardiac Arrhythmia


Medical Error: Improper treatment, Delay in proper treatment


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Anesthesiology – Improper Dosing Of Epinephrine And Atropine For Bradycardic Patient During Anesthesia For Colonoscopy



On 8/7/2015, a 51-year-old male presented to a surgical center for an outpatient esophagogastroduodenoscopy (EGD) and colonoscopy.

The patient had a history of bipolar disease, schizophrenia, obstructive sleep apnea on continuous positive airway pressure (CPAP), smoking, and morbid obesity.

The patient underwent EGD and colonoscopy via monitored anesthesia care with intravenous propofol.

During the patient’s colonoscopy, he became bradycardic, was mask ventilated, turned supine, and was given atropine, ephedrine, and epinephrine.

Specifically, the patient received two doses of 0.2 mg of epinephrine ten minutes apart.  These doses of epinephrine are not standard advanced cardiovascular life support (ACLS) resuscitation doses for a cardiac arrest.

The patient also received a 0.2 mg dose of atropine followed by a 0.4 mg dose.  The doses of atropine were inadequate for the patient’s size and considering that the patient was experiencing a bradycardic event.

The patient subsequently received cardiopulmonary resuscitation (CPR) and was transferred to a hospital for emergent care.  Shortly after arriving at the hospital, the patient passed away.

Prior to performing the procedures, the anesthesiologist failed to document a complete preoperative history and physical examination for the patient.

During the intraoperative course, the anesthesiologist failed to utilize and/or failed to document utilizing end-tidal CO2 (ETCO2) monitoring usage.

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


Specialty: Anesthesiology


Symptom: N/A


Diagnosis: Post-operative/Operative Complication, Cardiac Arrhythmia


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


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Internal Medicine – Patient Presents With Chest Pain That Started To Radiate To His Arms



From 2/22/2010 through 11/2/2011, a patient presented to an internist for medical assessment and/or treatment.

The patient presented to the internist with chest pain, unknown family medical history, several comorbid medical problems related to possible heart disease, and possible reflux esophagitis.

On 6/22/2011, during a medical evaluation, the internist noted that the chest pain changed in characteristic and began to radiate to his arms.

Despite the change in chest pain noted by the internist on 6/22/2011, he did not recommend a cardiologic evaluation and continued to treat the patient for possible reflux esophagitis.

On 10/4/2011, during a medical evaluation, the internist noted no complaints of heartburn but continued complaints of chest pain.

Between 6/22/2011 and 12/3/2011, the internist failed to refer the patient for cardiological evaluation.

On 12/3/2011, the patient died from a cardiac arrest.

The Medical Board of Florida issued a letter of concern against the internist’s license.  The Medical Board of Florida ordered that the internist pay a fine of $7,500 against his license and pay reimbursement costs for the case at a minimum of $3,458.14 and not to exceed $5,458.14.  The Medical Board of Florida ordered that the internist complete ten hours of continuing medical education in cardiovascular medicine and five hours of continuing medical education in “risk management.”

State: Florida


Date: April 2017


Specialty: Internal Medicine


Symptom: Chest Pain


Diagnosis: Acute Myocardial Infarction, Cardiac Arrhythmia


Medical Error: Referral failure to hospital or specialist


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Florida – Internal Medicine – History Of Atrial Fibrillation On Warfarin With INR Of 4.3 Started On Levofloxacin



On 3/26/2013, an 80-year-old female presented to a medical center with complaints of epigastric and right upper quadrant pain related to acute diverticulitis.

Upon the patient’s admission to the medical center, her medical records noted a history of atrial fibrillation and seizure disorder.  The records also indicated that she was on warfarin.

On 3/26/2013, the patient’s INR (admission INR) was recorded in the therapeutic range between 2.0 and 3.0.

On 3/26/2013, an internist improperly assessed the daily amount of warfarin that the patient was receiving prior to her admission to the medical center.  The internist increased the amount of the patient’s daily warfarin dosage.

The internist also prescribed Levaquin, an antibiotic, to treat the patient’s diverticulitis.  Levaquin can increase the anticoagulant effect of Warfarin.  On 3/28/2013, the patient’s INR was recorded as 4.3  On 3/29/2013, the patient’s INR was recorded as 8.9.

The administration of vitamin K and/or fresh frozen plasma is associated with anticoagulant reversal or moderation.  On 3/29/2013, the internist facilitated the oral administration of vitamin K to the patient.  Parenteral administration of vitamin K is indicated over oral administration in treating acute coagulopathy of the nature then-exhibited by the patient.

On 4/1/2013, the patient suffered an intracranial hemorrhage.

The internist did not facilitate the administration of fresh frozen plasma until 4/1/2013, after the patient exhibited neurologic change.  He did not facilitate the parenteral administration of vitamin K until 4/2/2013.

On 4/9/2013, the patient died from an intracranial hemorrhage due to Coumadin coagulopathy.

The Medical Board of Florida judged the internists conduct to be below the minimal standard of competence given that he failed to accurately assess the amount of warfarin that the patient was receiving prior to admission and treat with appropriate dosages accordingly.  The internist failed to recognize that the patient’s treatment for an acute infection, ingestion of Levaquin, and age put her at increased risk for acute coagulopathy, and treat accordingly.  He also failed to treat earlier for acute coagulopathy and with more aggressive methods, especially including earlier parenteral vitamin K and/or fresh frozen plasma.

It was requested that the Medical Board of Florida order one or more of the following penalties for the internist: 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: March 2017


Specialty: Internal Medicine


Symptom: Abdominal Pain


Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Cardiac Arrhythmia, Acute Abdomen


Medical Error: Improper medication management, Delay in proper treatment


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Florida – Family Medicine – Discontinuation Of Aspirin And Propafenone For A Patient With Arrhythmia After Repair For A Tibial Fracture



On 9/1/2012, a patient suffered a tibial fracture in her left leg after falling during a seizure.  In the aftermath of the fracture, the patient underwent left comminuted tibial open reduction internal fixation (“ORIF”) surgery.

During the patient’s discharge, she was prescribed aspirin and propafenone (Rythmol).  The aspirin was intended to help prevent post-surgical pulmonary embolism.  The propafenone was intended to control the patient’s atrial fibrillation.

On 9/14/2012, the patient was transferred to a rehabilitation facility for post-surgical rehabilitation.

Throughout her post-surgical rehabilitation, the patient was at an increased risk of pulmonary embolism.

Initially, the patient was continued on aspirin and propafenone at the rehabilitation center.

On 9/28/2012, the physician’s orders for October 2012 included a stop order on the administration of the patient’s aspirin and propafenone, effective 10/13/2012 and 10/14/2012.

In late September and early October 2012, a family practitioner electronically signed, approved, and executed the aforementioned physician’s orders.

On 10/18/2012, the patient suffered shortness of breath and decreased oxygen saturation.  Although the family practitioner transferred the patient for treatment at an emergency room, the patient passed away several hours later.

According to the medical examiner, the cause of the patient’s death was pulmonary embolism.

The Medical Board of Florida judged the family practitioners conduct to be below the minimal standard of competence given that he should have facilitated the long-term continuation of aspirin and/or propafenone to the patient.  Also, the family practitioner should not have signed, approved, and/or otherwise have executed physician’s orders that were in conflict with the physician’s intended course of prescribing/treatment for the patient.

The Medical Board of Florida issued a letter of concern against the family practitioner’s license.  The Medical Board of Florida ordered that the family practitioner pay a fine of $7,500 against his license and pay reimbursement costs for the case at a minimum of $1,708.35 and not to exceed $3,798.35.  The Medical Board of Florida also ordered that the family practitioner complete five hours of continuing medical education in “risk management.”

State: Florida


Date: February 2017


Specialty: Family Medicine, Internal Medicine


Symptom: Shortness of Breath


Diagnosis: Cardiac Arrhythmia, Pulmonary Embolism


Medical Error: Accidental Medication Error


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



California – Vascular Surgery – CEA Performed On A 91-Year-Old Patient With Intermittent Syncopal Episodes



On 10/7/2010, a vascular surgeon saw a 91-year-old male patient for an evaluation of left internal carotid artery stenosis.  He lived independently and was quite physically active. An echocardiogram was taken in 2007 that confirmed the patient had atrial fibrillation.  He complained of intermittent syncopal episodes for 1-2 years. A CDUS taken 7/2/2010 revealed 10% narrowing of the proximal right internal carotid artery and 60% of the left.

The vascular surgeon wrote to one of the patient’s physicians that the CDUS showed “an irregular 60-69% stenosis.”  He also wrote “[Patient] is neurologically intact. He does describe though syncopal episodes whenever he lifts his left arm over his head.  He has a strong radial pulse and no blood pressure discrepancy between the left and right arm and I cannot elicit any vertebral steal syndrome, but he states that this has happened 6 or 7 times this year and with the known carotid artery stenosis, I am recommending that he undergo a carotid endarterectomy.”

The patient chose to have a CEA.  In his preoperative history and physical, the vascular surgeon reported that the July CDUS showed “50-69% left internal carotid artery stenosis.  With this being a borderline stenosis, he was followed but since the symptoms are so dramatic and so consistent he was then referred for vascular surgical evaluation and recommended for admission and surgery at the time.”

The vascular surgeon performed left CEA on 10/29/2010.  He noted the same preoperative and post-operative diagnoses: “Symptomatic left internal carotid artery stenosis.”  The procedure went well, and the patient was discharged on 10/31/2010.

The vascular surgeon’s care of the patient constituted gross negligence and the failure to maintain adequate records in the following aspects: he inaccurately and inconsistently reported the patient’s carotid duplex results, which constituted inadequate and inaccurate medical records; his performance of a carotid endarterectomy on the patient was not indicated given that he was 91 years old, had medical comorbidities, had moderate carotid artery stenosis, and was asymptomatic; and the vascular surgeon’s attribution of the patient’s syncopal events to carotid artery stenosis without obtaining a full workup or evaluation of his syncopal events was below the standard of care.

For this allegation as well as others, the Medical Board of California ordered that the vascular surgeon’s license be revoked and be placed on probation for five years. During this time, he was to attend a PACE program, a medical record keeping course, a CME education course, be assigned a practice monitor, and was prohibited from engaging in the solo practice of medicine as well as supervising physician assistants.

State: California


Date: December 2016


Specialty: Vascular Surgery


Symptom: Syncope


Diagnosis: Cardiac Arrhythmia


Medical Error: Unnecessary or excessive treatment or surgery, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Cardiology – Confusion, Fever, And Worsening Procedural Site After Right Femoral Artery Graft



On 12/21/2012, a 57-year-old male had a stent procedure.  Complications arose, and on 12/27/2012, the patient returned to the emergency department with complaints of right lower extremity pain, numbness, and increasing inability to move his right lower extremity.  An on-call cardiologist diagnosed a blood clot in the patient’s femoral artery of the right leg and took the patient to surgery in order to place a graft to open the artery to give the leg circulation. During the surgery, the cardiologist also performed a right femoral artery exploration, a right common femoral endarterectomy and patch, and a right femoral to above knee popliteal artery bypass.

On the fourth post-surgical day, 12/31/2012, the patient was noted to be confused and had an atrial fibrillation rhythm, by telemetry, which then returned to a normal rhythm the next day.  On 1/1/2013, the patient had a swollen surgery site and complained of sweats and shakes. A low-grade fever was noted in the record. On 1/2/2013, there was documentation of increased erythema and drainage from the right groin wound.  Wound cultures were obtained, which demonstrated large numbers of gram-negative species present. The patient was again suffering from confusion, which combined with the bacterial culture result, were clues to the patient suffering from systemic and graft infection.

On 1/5/2013, the patient was combative.  A CT scan was performed, which identified fluid collection with bubbles.  On 1/5/2012, the nurse notes documented a worsening wound. On 1/6/2013, the patient had a stroke while attempting to access the bathroom in his hospital room.  Thereafter, from 1/9/2013 through 1/13/2012, the wound continued to worsen without any action by the cardiologist to remove the graft. On 1/14/2013, the patient was transferred to a rehabilitation center, but he had a fever, was delirious, and had an infected site.  The patient had to be transferred back to the hospital on 1/16/2013 because of uncontrollable bleeding from the wound. On 1/17/2013, another vascular surgeon removed the graft from the patient and performed a right Sartorius myoplasty in order to address the infection.

The Medical Board of California judged that the cardiologist’s conduct departed from the standard of care because he failed to recognize and diagnose the signs of serious infection, adequately treat the patient’s graft infection, and remove the graft during the patient’s first hospital stay.

The Medical Board of California placed the cardiac surgeon on probation for 2 years and ordered the cardiac surgeon to complete an education course for at least 40 hours in the first year of probation.

State: California


Date: August 2016


Specialty: Cardiology


Symptom: Numbness, Confusion, Fever, Extremity Pain, Swelling, Weakness/Fatigue, Wound Drainage


Diagnosis: Procedural Site Infection, Acute Ischemic Limb, Cardiac Arrhythmia, Ischemic Stroke


Medical Error: Diagnostic error, Failure to examine or evaluate patient properly, Improper treatment


Significant Outcome: Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



California – Anesthesiology – Hypotension During Epicardial Lead Placement



On 4/17/2014, a 79-year-old patient was scheduled for placement of an epicardial lead on the surface of the left ventricle by a cardiothoracic surgeon.  An anesthesiologist assigned to the procedure documented seeing the patient on 4/17/2014 at 4:05 p.m. in his per-operative note. The anesthesiologist submitted his note at 5 p.m. and signed his noted 5:06 p.m.  He indicated that the patient had medical problems, including atrial fibrillation, arthritis, gout, cardiomyopathy, skin cancer, peripheral artery disease, congestive heart failure, and acute renal failure. The anesthesiologist did not record performing a heart or lung exam and the patient’s last solid food intake or risk for aspiration.  The anesthesiologist also did not document the patient’s most recent lab work prior to surgery or comment regarding the lab values from the day of surgery.

The anesthesiologist did not place a transesophageal echo probe, and he did not place a biventricular pacer.  The anesthesiologist did not check arterial blood gas or electrolytes during surgery. During surgery, the patient’s blood pressure dropped, as a large left pleural effusion was evacuated, to a systolic of 50.  The anesthesiologist provided multiple doses of phenylephrine, ephedrine, and epinephrine. The anesthesiologist increased the dobutamine infusion. The epicardial lead was placed, and the surgeon closed the patient’s chest with resultant hypotension.  Surgery ended at 5:11 p.m.

The Medical Board of California judged that the anesthesiologist departed from the standard of care because he did not perform a heart or lung exam, did not document the patient’s last solid food intake or aspiration risk, and did not document the patient’s most recent lab work prior to surgery or comment on the patient being hyponatremic at a serum sodium level of 128 mEq/L, which increases the risk for severe arrhythmias and hypotension.  The anesthesiologist also did not utilize additional methods or techniques to manage intraoperative hypotension or ask for assistance from the proctoring cardiac trained anesthesiologist.

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: N/A


Diagnosis: Cardiovascular Disease, Cardiac Arrhythmia, Heart Failure


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


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



North Carolina – Internal Medicine – A Patient Treated For Hyperkalemia With Subsequent Hypokalemia



The Board was notified of a professional liability payment made on 06/15/2015.

A patient presented to the hospital for treatment of sepsis secondary to septic arthritis and associated with bacteremia.  The patient also suffered from a urinary tract infection, heart murmur, and lower back pain.  She was immunocompromised from daily prednisone use for severe rheumatoid arthritis.

When the patient was admitted to the hospital, her potassium level was elevated.  Another physician ordered medications to lower the patient’s potassium level.  The medications had the desired effect.  When a hospitalist assumed care, the patient’s potassium level was within the normal range.  The hospitalist cared for the patient over the next six days.

The following day, while under the care of another physician, the patient developed a cardiac arrhythmia, and her potassium level was found to be low.  The patient died from a cardiac arrhythmia, which may have been caused by the patient’s potassium deficiency.

The hospitalist acknowledged that he should have but did not monitor the patient’s potassium level during his care of her.

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: April 2016


Specialty: Internal Medicine


Symptom: N/A


Diagnosis: Cardiac Arrhythmia, Septic Arthritis


Medical Error: Failure to properly monitor patient


Significant Outcome: Death


Case Rating: 2


Link to Original Case File: Download PDF



California – General Surgery – Acute Abdominal Pain And Tachycardia In An Immunosuppressed Male



On 5/22/2010, a 60-year-old immunosuppressed male presented to the emergency department with acute onset of abdominal pain and tachycardia.  A CT scan revealed that the patient had a perforated diverticulitis and pneumoperitoneum.  The admitting physicians evaluated and determined that the patient would likely need surgery after his condition was optimized.  The patient was managed with antibiotics and IV fluids and seen daily be General Surgeon A and other physicians through 5/25/2010.  On that date, General Surgeon A noted that the patient had improved and signed off from the case.  Also on that day, the patient’s heart rate had increased from normal to the low 100’s, and the patient’s lab work revealed concern regarding ongoing severe infection.  However, General Surgeon A documented in his notes that the patient appeared much better and that he believed the patient’s perforation had sealed.  General Surgeon A didn’t see the patient again until he became progressively unstable.

The patient’s condition worsened on 5/26/2010, including the development of atrial fibrillation, persistent tachycardia, worsening renal function, and other conditions consistent with ongoing sepsis.  A second CT scan was ordered on 5/27/2010 but was not performed until the next day.  It revealed worsening peritonitis from the known perforation.  General Surgeon A was informed of the patient’s condition and the CT results at 10 a.m. on 5/28/2010, but the patient was not seen by a surgeon until 1:30 p.m. that day by General Surgeon B who was covering for General Surgeon A. General Surgeon B took the patient to surgery for a laparotomy and sigmoid resection with colostomy for perforated diverticulitis with fecal peritonitis.  The patient remained critically unstable in the ICU on maximum support with respiratory failure, ongoing sepsis, cardiac ischemia with acute myocardial infarction.  The patient ultimately died from fatal ventricular arrhythmia.

On the day General Surgeon A signed off of the case indicating the patient was so improved that his surgical services were no longer needed, there was indication of ongoing significant infection in spite of ongoing aggressive medical therapy.  General Surgeon A failed to recognize the significance of the clinical picture.  It was not until the patient’s condition worsened further that an additional CT scan was ordered and performed on 5/28/2010.

Although General Surgeon A was informed of the need for the additional CT scan, it was General Surgeon B who became involved and promptly took the patient into surgery, but the surgery was too late to save the patient.  Because of the delay in recognition of the need for urgent surgical intervention, the patient experienced ongoing sepsis resulting in acute cardiac insult and progressive hemodynamic and metabolic instability.

General Surgeon A should have recognized that the patient’s immunocompromised condition would not only interfere with the patient’s ability to seal off the perforation and control the intraperitoneal sepsis but also compromise the patient’s ability to mount an effective response to the associated systemic sepsis syndrome.  General Surgeon A did not appreciate the gravity of the signs of ongoing infection in this patient warranting urgent surgical intervention.

The Medical Board of California judged that General Surgeon A’s conduct was grossly negligent in the care and treatment of the patient because he delayed recognizing the need for urgent surgical intervention and didn’t appreciate the gravity of the signs of ongoing infection in this patient warranting urgent surgical intervention.

For this case and others, the Medical Board of California ordered General Surgeon A to surrender his license.

State: California


Date: March 2015


Specialty: General Surgery


Symptom: Abdominal Pain


Diagnosis: Sepsis, Acute Myocardial Infarction, Cardiac Arrhythmia, Acute Abdomen, Pulmonary Disease


Medical Error: Underestimation of likelihood or severity, Delay in proper treatment, Failure to follow up


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



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