Found 115 Results Sorted by Case Date
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California – Interventional Radiology – Pain And Cold Foot After Arteriogram, Angioplasty, And Atherectomy



On 6/26/2015, a patient presented to an interventional radiologist’s outpatient clinic for a left lower extremity arteriogram and intervention for a thrombosed left lower extremity bypass graft, originally placed in 2007.  The patient had an extensive medical history including a renal transplant, diabetes, right leg amputation, and multiple revascularization procedures, including prior thrombectomies of the left lower extremity graft.

The patient reportedly had pain both at rest and with activity, and had a cold left leg prior to and immediately before the procedure.  In order to improve blood flow in the patient’s left leg, the interventional radiologist performed an arteriogram, angioplasty, tPA administration, atherectomy, and stent placement within the left lower extremity, including an attempt to revascularize the native superficial femoral artery.

Images show an initially thrombosed femoral artery to popliteal bypass graft and deep femoral artery.  Further images show balloons inflated in various parts of the graft and native arteries.  Final images show flow through a patent common femoral artery (CFA), bypass graft, and peroneal and anterior tibial arteries.  The deep femoral artery appeared occluded shortly beyond its origin.

After the procedure, a nurse noted the patient’s foot was cold.  The interventional radiologist also assessed the patient post-procedure and found the foot to be cold, both two (2) and four (4) hours post-procedure.  The interventional radiologist recommended to the patient that she travel to the emergency department of a university hospital.

The patient was then driven by her companion two hours to the emergency department, where she was assessed by an ED physician and a vascular surgeon.  She was taken to the operating room where she underwent surgery, which included a left leg above-the-knee amputation and a deep femoral artery thrombectomy.

The Board stated that the standard of care for an interventional radiologist when performing an intervention is to recognize complications and to take appropriate steps to manage them.  Although the patient’s foot was reportedly cold and painful immediately post-procedure, it can take some time for the foot to warm, and pain could be caused by reperfusion.  However, it is clear that two to four hours after the procedure, the interventional radiologist recognized that the patient’s leg had not improved and was worsening and that further care was needed.  Thus, when it became clear to the interventional radiologist that the foot was not improving, he recommended that the patient seek more treatment.

The records of the interventional radiologist’s care of the patient were inadequate in that they do not state whether the patient’s clinical status post-procedure was worse than before the procedure.  A post-procedure pulse examination was lacking which would have helped in determining the patient’s clinical status.

The patient reported to the ED physician that the pain began after the procedure and steadily worsened, which indicates that the patient rethrombosed her bypass graft and deep femoral artery (source of collateral flow) immediately.  This event should have been recognized by the interventional radiologist.

However, the interventional radiologist’s documentation for this patient was inadequate and sparse.  The medical records lacked documentation of the change in the patient’s status post-procedure, the discussion with the patient leading up to the discharge from his center, and the patient’s disposition.  The interventional radiologist discharged the patient to her own care directly from his clinic instead of calling Emergency Medical Services (EMS), which indicates that the interventional radiologist failed to recognize the gravity of what was occurring.

His conduct did not ensure that the patient would be attended continuously until definitive treatment was given.  The patient arrived at the emergency department at approximately 8:00 p.m., two hours after the patient was discharged from the interventional radiologist’s clinic.

Had the process of discharge and transfer occurred earlier, it is possible that the outcome could have been different.  The interventional radiologist failed to communicate with the ED physician ahead of the patient’s arrival.  The interventional radiologist gave the patient a CD of the procedure, a copy of the medical records, and his phone number, as an attempt of communicating with the emergency department personnel regarding the events that occurred at the interventional radiologist’s clinic.

However, the interventional radiologist failed to telephone the ED physicians at the emergency department to give a verbal report on the patient and to provide a more informative transition and preparation for continued care.  In expecting the practitioners at the emergency department to call the interventional radiologist to gain more information, the interventional radiologist improperly sought to shift his responsibility to provide needed information about the patient to the staff at the emergency department.

The interventional radiologist failed to maintain documentation regarding the change in the patient’s status post-procedure, the discussion leading up to the discharge from his center, and the patient’s disposition.  He stated that he was not sure if he documented these events, and if he did, he sent them with the patient.  Documentation sent with the patient has since been lost.  Documentation of a change in the patient’s clinical status was lacking.  The medical records lacked documentation of what was discussed regarding the patient’s disposition and where she was told to go for further care.

The Board judged the interventional radiologist’s conduct to have fallen below the standard of care for the following reasons:

1) The interventional radiologist failed to offer to transport the patient by ambulance or EMS services to ensure that she would be attended continuously until definitive treatment was given. His failure to do so indicates that he failed to understand the gravity of the situation which was occurring.

2) The interventional radiologist failed to adequately communicate with the emergency department, to call ahead of time to inform them that the patient was in transit, and to inform them of the circumstances.

3) The interventional radiologist failed to maintain adequate and accurate records.

The Board issued a public reprimand.

State: California


Date: December 2017


Specialty: Interventional Radiology, Vascular Surgery


Symptom: Extremity Pain


Diagnosis: Acute Ischemic Limb, Post-operative/Operative Complication


Medical Error: Diagnostic error, Delay in proper treatment, Underestimation of likelihood or severity, Failure of communication with other providers, Lack of proper documentation


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Emergency Medicine – Patient With Chest Pain Radiating To The Neck, Throat, And Back Discharged With Instructions To Follow up In 3-5 Days



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

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

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

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

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

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

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

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

State: Florida


Date: December 2017


Specialty: Emergency Medicine


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


Diagnosis: Aneurysm


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


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Florida – Internal Medicine – Patient With Worsening Chronic Kidney Disease Presents With Arm Pain, Numbness, And Shortness Of Breath



From 2009 until 2014, an internist served as the patient’s primary care physician.

In 2009, the internist referred the patient to Cardiologist A for a cardiology evaluation.  The results of the 2009 cardiology evaluation revealed that the patient’s electrocardiogram and stress test were both abnormal.

At this time, Cardiologist A recommended that the internist increase the patient’s medication as needed in order to get the patient’s cholesterol to below seventy.

The patient was evaluated by Cardiologist A again in June 2010.

The June 2010 cardiac evaluation revealed that the patient had shortness of breath on exertion at times, possibly related to hypertension and subclinical congestive heart failure.

On 7/17/2013, the patient underwent lab work, the results which showed that his glomerular filtration rate (GFR) was thirty-four.  The internist staged the patient’s chronic kidney disease (CKD) at a stage III/IV.

The patient’s next set of lab work was conducted on 11/18/2013, the results of which showed that his GFR was twenty-two.  The internist wrote in a progress note that the patient’s CKD was a stage III/IV.

On 1/13/2014, the patient had lab work done again, the results which showed that his GFR was twenty-six.  In his progress note he wrote that the patient’s CKD was now a stage IV.

Despite a dramatic decline in the patient’s GFR levels indicative of worsening CKD, the internist did not refer the patient to a nephrologist.

On 1/13/2014, the patient presented to the internist complaining of left arm pain, numbness radiating to both hands, and shortness of breath.  The internist ordered an EKG, chest x-ray, and lab work.  His assessment of the patient at this time was dyspnea on exertion, questionable coronary artery disease, questionable pulmonary disease, and questionable anxiety.

On 1/14/2014, the patient returned to the office for an echocardiogram.  After the echocardiogram, the internist referred the patient to Cardiologist B for a consult.  The patient could not obtain an appointment with Cardiologist B until 2/3/2014.

The internist ordered that a stress test be conducted prior to the patient’s visit with Cardiologist B, and advised that the patient bring the results of the stress test to his appointment with Cardiologist B.

On 1/23/2014, the stress test was performed and the results were abnormal.

The Medical Board of Florida judged that the internist failed to adequately evaluate the patient’s symptoms and recognize the patient’s worsening coronary artery disease, development of congestive heart failure, and worsening chronic kidney disease.  He failed to refer the patient to a nephrologist for further evaluation upon seeing a dramatic decline in the patient’s GFR levels.  He also failed to send the patient to the emergency department for treatment when the patient presented to him with exhibiting cardiac symptoms and had a known history of heart disease.

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 $2,500 against his license and pay reimbursement costs for the case at a minimum of $5,756.36 and not to exceed $7,756.36.  The Medical Board of Florida also ordered that the internist complete five hours of continuing medical education in the treatment of patients with chronic kidney disease and chronic heart disease.

State: Florida


Date: December 2017


Specialty: Internal Medicine


Symptom: Extremity Pain, Numbness, Shortness of Breath


Diagnosis: Heart Failure, Cardiovascular Disease, Renal Disease


Medical Error: Failure to examine or evaluate patient properly, Referral failure to hospital or specialist


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Internal Medicine – Worsening Chronic Kidney Disease, Abnormal Stress Test, And Cardiac Symptoms



From 2009 until 2014, an internist served as a patient’s primary care physician.

In 2009, the internist referred the patient to Cardiologist A for a cardiology evaluation.  The results of the 2009 cardiology evaluation revealed that the patient’s electrocardiogram and stress test were both abnormal.  At this time Cardiologist A recommended that the internist increase the patient’s medication as needed in order to get the patient’s LDL cholesterol below seventy.

The patient was evaluated by Cardiologist A again in June 2010.  The June 2010 cardiac evaluation revealed that the patient had shortness of breath on exertion at times, possibly related to hypertension and subclinical congestive heart failure.

On 7/17/2013, the patient underwent lab work, the results which showed that his glomerular filtration rate (“GFR”) was thirty-four.  The internist stated the patient’s chronic kidney disease (“CKD”) as stage III/IV.

The patient’s next set of lab work was conducted on 11/18/2013, the results of which showed that his GFR was twenty-two.  The internist wrote in a progress note that the patient’s CKD was stage III/IV.

The patient had lab work done again on 1/13/2014, the results of which showed that his GFR was twenty-six.  In a progress noted created on 1/13/2014, the internist wrote that the patient’s CKD was now at stage IV.

Despite the dramatic decline in the patient’s GFR levels indicative of worsening CKD, the internist did not refer the patient to a nephrologist.

On 1/13/2014, the patient presented to the internist complaining of left arm pain, numbness radiating to both hands, and shortness of breath.  The internist ordered an EKG, chest x-ray, and lab work.  The internist’s assessment of the patient at this time was dyspnea on exertion, questionable coronary artery disease, questionable pulmonary issue, and questionable anxiety.

The internist had the patient return to the office on 1/14/2014 for an echocardiogram.  After the echocardiogram, the internist referred the patient to Cardiologist B for a consult.

The patient could not obtain an appointment with Cardiologist B until 2/3/2014.

The internist ordered that a stress test be conducted prior to the patient’s visit to Cardiologist B, and advised that the patient bring the results of the stress test to his appointment with Cardiologist B.  The stress test was performed on 1/23/2014, and the results were abnormal.

The Board judged the internist’s conduct to be below the minimum standard of competence given that the internist failed to adequately evaluate the patient’s symptoms and recognize the patient’s worsening coronary artery disease, development of congestive heart failure, and worsening of chronic kidney disease.  The internist should have referred the patient to a nephrologist for further evaluation upon seeing a dramatic decline in the patient’s GFR levels. When the patient, with a known history of cardiac disease, presented with cardiac symptoms, the internist should have should have sent the patient to an emergency department for treatment.

The Board ordered that the internist pay a fine of $2,000 imposed against his license.  The Board also ordered that the internist pay reimbursement costs of a minimum of $5,756.36 and not to exceed $7,756.36.  The internist was ordered to complete five hours of continuing medical education in the treatment of patients with chronic kidney disease and five hours of continuing medical education in the treatment of patients with chronic heart disease.

State: Florida


Date: December 2017


Specialty: Internal Medicine


Symptom: Extremity Pain, Numbness, Shortness of Breath


Diagnosis: Renal Disease, Cardiovascular Disease


Medical Error: Referral failure to hospital or specialist


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Emergency Medicine – Sharp Chest Pain After Intercourse



On 4/4/2015, a 47-year-old male presented to the emergency department with sharp chest pain after intercourse.

The RN on duty noted taking the patient’s vitals and performing an EKG, chest radiograph, and labs.

In his physician note, the ED physician documented the following: the patient did not take his medication for hypertension or dyslipidemia despite having a history of hypertension and homelessness;  the patient reported a history of coronary artery disease and possible coronary artery stent placement; and the patient reported chest discomfort and dyspnea for the week prior to presentation as well as a history of tobacco use.

The ED physician recorded a differential diagnosis including acute myocardial infarction, non-ST segment elevation myocardial infarction (“NSTEMI”), angina, and acute coronary syndrome.

The ED physician did not diagnose the patient with possible cardiac etiology of chest discomfort.  He also did not contact the on-call cardiologist.  The ED physician did not perform provocative testing or cardiac catheterization.  He also did not admit the patient for hospitalization and cardiology consultation.  The ED physician discharged the patient without requiring any further evaluation/treatment or serial EKG/troponin.  He did not arrange for close outpatient follow-up prior to discharge.

The Board issued a letter of concern against the ED physician’s license and ordered that he pay a fine, reimburse costs for the proceedings, and complete 5 hours of continuing education in risk management.

State: Florida


Date: November 2017


Specialty: Emergency Medicine


Symptom: Chest Pain


Diagnosis: Cardiovascular Disease


Medical Error: Failure to order appropriate diagnostic test, Referral failure to hospital or specialist, Failure to follow up


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Family Medicine – Recurrent Chest Pain Diagnosed As Esophageal Spasm



On 8/27/2012 a 47-year-old female presented with complaints of hypertension, possible hyperlipidemia, and pain in her foot.  A family practitioner assessed the patient and diagnosed her with poor control of her hypertension and reinforced medical advice for the patient to increase her lisinopril.  Additionally, the family practitioner waited for the results of the previous laboratory work and recommended conservative management and stretching for the foot and ankle.

On 4/1/2013, the patient again presented to the family practitioner to address difficulties with concurrent chest pain.  The patient stated the chest pains were very severe and “stopped her in her tracks at times.”  The patient stated that she felt she was having a heart attack, although she reportedly realized that that was not the case.  The family practitioner deemed the chest pain was likely an esophageal spasm, for which he prescribed the patient Librax (chlordiazepoxide/clidinium) and recommended that she see a gastroenterologist for an endoscopy if the medication failed to provide relief.  The family practitioner also assessed the patient for hypertension and instructed the patient to stop taking hydrochlorothiazide.  The family practitioner provided the patient with a trial of Dyrenium (triamterene).

On 4/12/2013, the patient complained of chest pain and suffered a cardiac arrest.  Upon EMS arrival, the patient was unstable and unresponsive.  The patient was transported to a hospital where she was later pronounced deceased.

The Board judged the family practitioners conduct to be below the minimal standard of competence given that he failed to conduct an adequate history, which included a risk factor assessment for a patient complaining of chest pain, to order or perform an EKG on a patient complaining of chest pain, and send a patient complaining of chest pain to an emergency room or an expedited outpatient facility for a chest pain evaluation.

The Board ordered that the family practitioner pay a fine of $5,000 against his license and pay reimbursement costs for a minimum of $2,122.00 and not to exceed $4,122.00.  The Board also ordered that the family practitioner complete ten hours of continuing medical education in diagnosis in cardiology and five hours of continuing medical education in “Risk Management.”

State: Florida


Date: November 2017


Specialty: Family Medicine


Symptom: Chest Pain, Extremity Pain


Diagnosis: Cardiovascular Disease


Medical Error: Diagnostic error, Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Referral failure to hospital or specialist


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Interventional Radiology – Assigning A Diagnosis To The Wrong Patient Leads To Cardiac Catheterization Performed On The Wrong Patient



On 1/28/2015, Patient A, a 47-year-old male, presented to the hospital with chest pain and was admitted for treatment.  A radiological technician was ordered to complete a CT angiogram of the heart for Patient A.

On 1/29/2015, a radiologist received Patient A’s angiogram images to review, as well as heart images for another Patient B.  The radiologist assigned a diagnosis of sixty to seventy percent stenosis to Patient A.

The diagnosis of sixty to seventy percent stenosis was intended for Patient B, not Patient A, who did not have any noticeable blockage or stenosis.

On 1/29/2015, subsequent to the radiologist assigning the diagnosis of sixty to seventy percent stenosis to Patient A, Patient A underwent an unnecessary cardiac catheterization without further incident.

On 1/30/2015, the radiologist conducted a corrected review and diagnosis of Patient A’s angiogram.

On 2/3/2015, the radiologist informed Patient A of the error.

The Board judged the radiologist’s conduct to be below the minimal standard of competence given that he assigned a diagnosis to the wrong patient, which resulted in the patient undergoing a medically unnecessary procedure, a cardiac catheterization.

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

State: Florida


Date: October 2017


Specialty: Interventional Radiology


Symptom: Chest Pain


Diagnosis: Cardiovascular Disease


Medical Error: Accidental error, False positive, Unnecessary or excessive treatment or surgery


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Vascular Surgery – Arteriogram Performed On A Patient’s Right Leg Instead Of The Left Leg



On 8/15/2016, a patient presented to a vascular surgeon with peripheral vascular disease, a non-healing ulcer on his left third toe tip, and diminished arterial blood flow in both legs.

Based on his initial evaluation, the vascular surgeon determined that a left leg arteriogram was necessary.

On 8/18/2016, the patient’s family consented to a left leg arteriogram and the vascular surgeon pre-operatively marked the patient’s left and correctly performed a timeout.

After the vascular surgeon performed the timeout, he performed a right leg arteriogram instead of the planned left leg arteriogram.

The Board judged the vascular surgeon’s conduct to be below the minimal standard of competence given that he performed a wrong-site procedure by performing an arteriogram on the patient’s right leg (wrong site) instead of the patient’s left leg (correct site).

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

State: Florida


Date: October 2017


Specialty: Vascular Surgery


Symptom: N/A


Diagnosis: Cardiovascular Disease


Medical Error: Wrong site procedure


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



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



Virginia – Emergency Medicine – Chest Pain Radiating To The Neck, Throat, And Back



On 11/15/2013, a patient presented to the emergency department complaining of chest pain with radiation to the neck, throat, and back.  The patient expired the next day due to cardiac arrest.  The ED physician failed to perform a CT scan of the patient’s chest and failed to admit the patient for observation.  The ED physician discharged the patient with the diagnosis of “musculoskeletal chest pain.”

He was ordered a fine and to complete 5 hours of continuing medical education in each of the topics of medical record keeping and risk management.

State: Virginia


Date: August 2017


Specialty: Emergency Medicine


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


Diagnosis: Cardiovascular Disease


Medical Error: Diagnostic error


Significant Outcome: Death


Case Rating: 1


Link to Original Case File: Download PDF



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