Found 7 Results Sorted by Case Date
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New York – Internal Medicine – Pain Associated With PICC Line



From 7/8/2008 to August 2008, Physician A treated a 46-year-old woman with a history of Parkinson’s disease diagnosed in May 2008.  At her initial visit, she reported that in early May 2008, she had a tick bite with subsequent bull’s eye rash.  She had been treated with antibiotics and intramuscular injections for approximately seven weeks.

Physician A ordered a PICC line for the administration of parenteral antibiotics, which was placed on 7/17/2008.  One week later, the patient complained of pain in her neck and shoulder.  On 7/31/2008, the patient reported extreme pain.  The patient had a venous Doppler study, which indicated deep vein thrombosis.  The patient was admitted to the hospital where the PICC line was removed, and the patient was placed on anticoagulant therapy.

The Board judged Physician A’s conduct as having fallen below the minimum level of competence given failure to take an appropriate history, failed to perform a physical exam, failure to construct a differential diagnosis, and failure to evaluate her pain in a timely fashion.

State: New York


Date: April 2017


Specialty: Internal Medicine, Family Medicine


Symptom: Extremity Pain, Head/Neck Pain


Diagnosis: Deep Vein Thrombosis/Intracardiac Thrombus


Medical Error: Diagnostic error


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Kansas – Physician Assistant – Lovenox Prescribed For DVT In A Patient With A History Of GI Bleeding



On 11/19/2015, a patient presented to a family care clinic with complaints of swelling and pain in the right lower extremity (“RLE”).

The patient was seen by the APRN who documented the patient’s history of GI bleeding, noting the patient had experienced a RLE deep vein thrombosis (“DVT”) and pulmonary embolism (“PE”) on October 2015, that had been treated with an IVC filter in a medical center.

The APRN further documented in the patient’s chart, “No [sic] on anticoagulants due to GI Bleed,” and “Recent [history] GI bleed.”

The patient was referred to cardiology for the management of his anticoagulation.  He was to follow up on the morning of 11/20/2015 to have a complete blood count (“CBC”) drawn.

On 11/20/2015, the patient presented to a physician assistant with right leg and foot swelling with new onset pain rated a 1/10.  The physician assistant did not document a patient history and did not review the APRN’s notes from 11/19/2015.  The physician assistant diagnosed the patient with DVT of the right popliteal vein and mild anemia.  The physician assistant improperly prescribed Lovenox 60 mg SQ twice a day for one week with a follow-up to confirm dissolution of the clot.

On 11/23/2015, the patient awoke during the night with chest pain and was transported via ambulance to the emergency department where it was determined the patient had a GI bleed.  The patient’s hemoglobin (“HGB”) dropped abnormally low to 7.7, and his hematocrit (“HCT”) was also abnormally low at 27.4%.

The physician assistant’s response, received by the Board on 3/29/2016, noted, “There was no indication in the note from the previous day, nor in any clinic note that he was not a candidate for anticoagulation therapy.”  However, the original notes received by the Board on 10/6/2016 from the hospital indicated that the patient had a history of GI bleed and no anticoagulants should have been prescribed.

The Board judged the physician assistant’s conduct to be below the minimum standard of competence given his inappropriate prescribing of Lovenox.

For this allegation and others, the Board ordered the physician assistant to contact The Center for Personalized Education for Physicians, (“CPEP”) for a competence assessment, follow all recommendations of the CPEP assessment, and complete a medical record keeping seminar.

State: Kansas


Date: April 2017


Specialty: Physician Assistant, Emergency Medicine, Internal Medicine


Symptom: Blood in Stool, Extremity Pain, Swelling


Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Deep Vein Thrombosis/Intracardiac Thrombus, Pulmonary Embolism


Medical Error: Improper medication management, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Arizona – Emergency Medicine – Right Leg Pain, Shortness Of Breath, And History Of A Deep Vein Thrombosis



The Board received a complaint regarding the care and treatment of a 71-year-old woman.

On 12/03/2015, a patient presented to the hospital complaining of right leg pain and shortness of breath.  She disclosed having a history of deep vein thrombosis.  The ED physician ordered labs, an ultrasound of the right leg, a chest x-ray, an ECG, and a CT angiogram.

The CT angiogram noted central, segmental, and subsegmental pulmonary emboli bilaterally and ground glass opacity at the right lung apex.  The ED physician reviewed the CT angiogram but failed to diagnose the patient with multiple pulmonary emboli.  Prior to the patient’s discharge, the ED physician re-examined her and told her to follow up with a cardiologist and pulmonologist.

On 12/5/2015, the patient presented to a different hospital with worsening complaints of shortness of breath.  The CT angiogram from the first hospital was reviewed.  A repeat CT angiogram was performed revealing the same findings of multiple bilateral pulmonary emboli.  The patient underwent ultrasounds on both legs which revealed deep vein thrombosis of the left leg and superficial vein thrombosis of the right leg.  An ECG did not show signs of right heart strain.  The patient was discharged on enoxaparin and coumadin.

State: Arizona


Date: October 2016


Specialty: Emergency Medicine


Symptom: Shortness of Breath, Extremity Pain


Diagnosis: Pulmonary Embolism, Deep Vein Thrombosis/Intracardiac Thrombus


Medical Error: Diagnostic error


Significant Outcome: Hospital Bounce Back


Case Rating: 2


Link to Original Case File: Download PDF



California – General Surgery – Laparoscopic Left Colectomy For Nausea, Vomiting, And Abdominal Pain With A Diagnosis Of Crohn’s Disease



On 4/26/2012, a general surgeon treated a 72-year-old female who was admitted to the hospital via the emergency department on the same day.  The patient presented with nausea, vomiting, and severe abdominal pain with a duration of 6 days, and no fever. The location of the pain was the right lower quadrant and the left lower quadrant.  The patient had multiple previous admissions for large bowel obstruction, which were all treated conservatively. The patient had a CT scan, labs, and colonoscopy, which were non-diagnostic, and the etiology of her current problem was unclear.

On 4/26/2012, the general surgeon performed a laparoscopic left colectomy.  The pathology was diagnostic for Crohn’s disease. During the surgery, the general surgeon performed a proximal diverting ileostomy procedure for fear of an anastomosis leak.  An enterocutaneous fistula developed at the site of the 7 cm band assisted site. Despite pathology and the enterocutaneous fistula, the general surgeon failed to treat the patient for Crohn’s disease.  The patient was discharged and sent home on 5/6/2012.

The patient was seen for office visits weekly until 5/24/2012.  The patient had a diverting ileostomy and had at least 500 ml of stool out per day even though she still had occasional bowel movements.  The patient was subsequently readmitted to the hospital after her initial surgery to treat the wound infection and also for bilateral lower extremity deep venous thrombosis.

On 6/11/2012, the general surgeon saw the patient and noted she was not on any medication for Crohn’s disease.  The general surgeon’s plan did not address the patient’s Crohn’s disease. The patient was readmitted on 9/4/2012, and the general surgeon performed an ileostomy takedown and definitive redo left colectomy to address the enterocutaneous fistula.  The general surgeon still had not treated the patient for Crohn’s disease. On 9/5/2012, the patient had an open laparotomy with her left colon removed and her ileostomy taken down. Pathology from the ileostomy site showed active Crohn’s disease.  The general surgeon discharged the patient home on 9/13/2012 without any medications for Crohn’s disease.

The Medical Board of California judged that the general surgeon’s conduct departed from the standard of care because he failed to treat the patient’s Crohn’s disease.

The Medical Board of California ordered the general surgeon to surrender his license.

State: California


Date: September 2016


Specialty: General Surgery


Symptom: Nausea Or Vomiting, Abdominal Pain


Diagnosis: Gastrointestinal Disease, Deep Vein Thrombosis/Intracardiac Thrombus, Procedural Site Infection


Medical Error: Improper treatment


Significant Outcome: Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



California – Obstetrics – History Of Coagulopathy And Long Distance Driving After Cesarean Section



On 4/18/2007, a 28-year-old married female presented to an obstetrician for her first prenatal visit.  She was Gravida 2, Para 0 (G2 P0); she had two pregnancies, but no live births. The patient’s last menstrual period was on 2/28/2007.  Her menses were irregular, and she had a history of infertility. The patient’s past medical history was subsequently noted as negative.  The obstetrician had previously treated the patient. The obstetrician had documented a diagnosis of polycystic ovary syndrome (PCOS) in the patient in 2000, presenting as androgen excess, hirsutism, anovulation, weight gain, and infertility.

The obstetrician treated the patient with metformin and recommended fertility treatment with Clomid when she was ready to conceive.  On 11/30/2006, the obstetrician referred the patient to a reproductive endocrinologist. Lab work on the patient dated 1/31/2007 reflected elevated testosterone and DHEAS, low progesterone, and the patient being heterozygous for the MTHFR mutation.  Anti-phospholipid antibody results were not obtained because the patient had no risk factors for thrombosis according to the obstetrician’s testification.

On 4/26/2007, the patient presented to the emergency department complaining of pelvic pain.  The emergency department records documented that the patient’s medications included 40 mg SQ Lovenox, baby ASA, folic acid, and progesterone.  An intrauterine pregnancy showing 2 gestational sacs with fetal poles was identified. A past history of coagulopathy resulting in a “hypercoagulable” state was listed.  The physical exam was negative. An ultrasound confirmed a twin gestation at 7 weeks 4 days with fluid in the gestational sacs. The final diagnosis was threatened abortion with a ruptured ovarian cyst.

On 4/30/2007, the patient was referred to a perinatologist (a maternal and fetal medicine specialist).  On 5/22/2007, the patient received an ultrasound with the perinatologist. It revealed “no obvious problems in either fetus.”  The plan was to await biochemistry results. He documented that it was an in vitro fertilization pregnancy. The patient had no history of pregnancy losses or DVT.  However, the perinatologist noted there was a family history of coagulopathies. The perinatologist recommended continuing aspirin alone without metformin or Lovenox but noted that complete blood work was not available for review.  He noted that the patient was at increased risk for gestational diabetes, given her history of PCOS, twins, and maternal obesity. On 5/22/2007, the patient also received genetic counseling, where risk factors were reviewed. The patient reported that her sister had lupus, anti-phospholipid syndrome, positive anti-cardiolipins, a history of fetal demise, MTHFR mutation, and a child with autism.  On that basis, the perinatologist recommended that the patient undergo further testing. The risks of progesterone, Lovenox, and ASA administration during pregnancy were reviewed.

The patient was allergic to sulfa.  The patient’s family history was noted as positive for breast cancer and heart disease.  The obstetrician made no reference in the ACOG records, or any medical records, of the patient’s family history of coagulopathy.  Genetic screening was checked off as all negative, including no blood disorders, no recurrent pregnancy loss, no current medications, and no over-the-counter drugs or supplements.  The obstetrician made no reference in the ACOG records, or any other medical records, of the patient’s current medications, progesterone, ASA or Lovenox, and he did not evaluate their use.  The obstetrician made no reference to the patient’s fertility problems, or that she had achieved the current pregnancy through in vitro fertilization, in the ACOG records, or any other medical records, of the patient, to any consultation with the reproductive endocrinologist seen by the patient.  The circumstances of the IVF were not considered.

On 5/31/2007, the patient’s physical examination was remarkable for a 14 to 16-week size uterus and “narrow pelvis.”  Two cold sores were noted. The patient was given an expected date of delivery of 12/5/2007. In June 2007, at 16-week gestation, as indicated by the obstetrician’s medical records, the patient called the obstetrician’s office and was anxious in light of her sister’s history of incompetent cervix resulting in a miscarriage at 25 weeks.  On 8/2/2007, a follow-up ultrasound was performed for the perinatologist. It revealed a normal twin pregnancy at 22 weeks. The patient’s cervical length was normal. The patient was advised to reduce activity by 50%.

On 8/13/2007, the patient was admitted to the hospital in premature labor.  Her cervical length was shortened with funneling. The patient was treated with magnesium sulfate and bed rest. Labor was successfully stopped.  The patient remained in the hospital on bedrest. The obstetrician treated the patient during her hospital stay. On 8/21/2007, sequential suppression boots (thromboguards) were ordered for the patient.

On 9/25/2007, the patient was discharged from the hospital to home care.  Upon discharge, an ultrasound identified a 23-week twin gestation with no fluid around twin A.  The patient was documented as having reported leakage over the past few days. After having been discharged, the patient was readmitted to the hospital with preterm premature rupture of membrane and treated with “rescue” steroids, IV antibiotics, and “not aggressive” tocolysis.  The patient complained of sharp pain in her left groin area unrelated to uterine contractions. The obstetrician’s partner was notified. The patient’s pain resolved in a few hours. The patient was observed on bedrest for the remainder of her pregnancy under the obstetrician’s care.  During her hospital stay, the patient was noted to have edema, and the patient complained of left inguinal pain.

On 11/9/2007, at 36-weeks gestation, the obstetrician performed an elective Cesarean section on the patient without complications.  The patient gave birth to a healthy baby girl and a healthy baby boy. The twin babies did well. On 11/12/2007, the patient was discharged from the hospital.  The patient’s hemoglobin was 8.6, which was out of range. The patient was taking Repliva, an iron supplement, and hydrocodone, a narcotic pain-reliever. On 11/20/2007, the patient had a regular follow-up appointment with the obstetrician to review any complaints she had and to check her incision, consistent with his custom and practice.  The obstetrician documented no complaints and noted the incision was healing well. Aside from referencing the incision, no physical exam or discussion with the obstetrician was described. Family members of the patient reported that, at the time, the patient had a slight fever, an irritating cough, was complaining of painful swelling in her legs and ankles, and she urinated frequently, 2-3 times per day.  Lactation was difficult, as she produced little milk. She stated she felt cold all of the time. The patient was concerned she was having post-partum depression.

On 12/4/2007, the patient had her final appointment with the obstetrician.  The obstetrician documented that she complained of depression, weakness, and a cough.  The obstetrician documented that the patient’s lungs were clear to auscultation and documented prescribing the patient a cough suppressant and an antidepressant, and ordered lab work.  The obstetrician ordered a CBC and thyroid studies. The obstetrician knew that the patient’s family planned to move to Idaho and would be driving there soon. The obstetrician gave the patient no directives and made no recommendations to the patient about the driving trip to move to Idaho or any subsequent treatment.  The obstetrician had no concerns about her driving aside from the usual situation when people are driving any distance when they are pregnant or in the post-partum period, notwithstanding the risks for the patient developing thrombosis.

On 12/6/2007, the patient and her family began their drive to Idaho.  On 12/7/2007 at 4:30 p.m., the patient and her family arrived at the home of relatives in Idaho.  The patient visited with immediate and extended family. Less than 2 hours later, the patient lifted a bag, climbed the stairs of her family’s home, collapsed, and lost consciousness.  Relatives called 911 and summoned an ambulance. An ambulance arrived, but emergency medical personnel were unable to revive the patient. They drove her to a hospital where she was officially pronounced dead.

The Medical Board of California judged that the obstetrician’s conduct departed from the standard of care because he initiated obstetric care of the patient without first obtaining a complete history of her then current pregnancy, list of her then current medications, and family history, failed to recognize the patient’s risk of thrombosis, and failed to anticoagulate the patient in the weeks following her Cesarean section.

For this case and others, the Medical Board of California placed the obstetrician on probation for 7 years and ordered the obstetrician to complete a medical record-keeping course, an education course (at least 40 hours for each year of probation), a professionalism program (ethics course), 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: April 2015


Specialty: Obstetrics


Symptom: Pelvic/Groin Pain, Cough, Fever, Abnormal Vaginal Discharge, Psychiatric Symptoms, Swelling, Urinary Problems, Weakness/Fatigue


Diagnosis: Deep Vein Thrombosis/Intracardiac Thrombus


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


Significant Outcome: Death


Case Rating: 5


Link to Original Case File: Download PDF



Colorado – Anesthesiology – Insertion Of Catheter At The Wrong Angle Causes Spinal Lesion



On 5/25/2007, an anesthesiologist improperly performed a procedure to place a permanent spinal catheter in the patient’s spine.  The patient had complications.  A general surgeon ordered a Doppler ultrasound, because he was concerned about the patient getting venous clots.  The anesthesiologist cancelled the Doppler ultrasound.  The patient experienced deep venous thrombosis and a pulmonary embolism, which may have been avoided had the anesthesiologist not cancelled the ultrasound.  The anesthesiologist inserted the patient’s catheter too high and at the wrong angle which also caused a lesion on the patient’s spine.

The Board ordered the anesthesiologist’s license be put on indefinite probation.  The Board also put a restriction for the anesthesiologist to be a solo practitioner in any practice environment or setting.  The anesthesiologist was required to complete continuing medical education on professional/problem based ethics program and enroll in the Center for Personalized Education for Physicians.  The Board ordered that the anesthesiologist pay a fine of $5,000.

State: Colorado


Date: July 2013


Specialty: Anesthesiology


Symptom: N/A


Diagnosis: Deep Vein Thrombosis/Intracardiac Thrombus, Spinal Injury Or Disorder, Pulmonary Embolism


Medical Error: Procedural error, Failure to order appropriate diagnostic test


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



New York – Emergency Medicine – Neck Swelling With An Indwelling Subclavian Catheter



On 09/02/2002, a patient with a history of right sided mastectomy secondary to breast cancer and an indwelling subclavian catheter presented to the emergency department with right sided neck swelling for three days.  The ED physician diagnosed the patient with supraclavicular soft tissue swelling of unknown etiology and discharged her home.

On 09/03/2002, the patient was admitted for treatment of a superior vena cava thrombosis secondary to the indwelling subclavian catheter.

The Board judged the ED physician’s conduct as failing to meet the standard of care given failure to correctly diagnose the patient and failure to maintain an adequate medical record for the patient.

He was ordered to complete an educational program in medical recordkeeping, to only practice medicine when monitored by a licensed physician, and to maintain medical malpractice insurance coverage with limits no less than $2 million per occurrence and $6 million per policy year.

State: New York


Date: October 2007


Specialty: Emergency Medicine


Symptom: Swelling


Diagnosis: Deep Vein Thrombosis/Intracardiac Thrombus


Medical Error: Diagnostic error


Significant Outcome: Hospital Bounce Back


Case Rating: 2


Link to Original Case File: Download PDF



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