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Florida – Emergency Medicine – A Patient With Diabetes Presents With Hyperglycemia, Nausea, Vomiting, And A Bicarbonate Level
On 4/28/2015, a 69-year-old female presented to the emergency department with complaints of nausea and vomiting, which had persisted for two to three days.
The patient reported that members of her family had recently experienced similar symptoms.
The patient presented with a history of diabetes and high blood pressure.
An ED physician ordered a general chemistry lab. The patient’s lab work revealed a high blood glucose level of 383 with a reference range of 65-99. The patient’s lab work also showed that her bicarbonate level was low at 15 with a reference range of 21-32. The low bicarbonate level indicated possible acidosis.
The ED physician treated the patient with insulin and antinausea medications and discharged her. The ED physician did not further investigate the patient’s low bicarbonate level. The ED physician did not assess the patient for diabetic ketoacidosis.
On 4/29/2015, the patient returned to the emergency department with recurrent nausea, vomiting, and worsening shortness of breath.
The patient was diagnosed with diabetic ketoacidosis and severe sepsis.
The patient’s condition deteriorated and she expired in the hospital on 5/4/2015.
The Board judged the ED physician’s conduct to be below the minimal standard of competence given that he failed to further investigate a low bicarbonate level by ordering additional laboratory studies such as a serum ketone, serum beta-hydroxybutyrate, or serum pH.
It was requested that the Board 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 Board deemed appropriate.
State: Florida
Date: October 2017
Specialty: Emergency Medicine
Symptom: Nausea Or Vomiting, Shortness of Breath
Medical Error: Failure to order appropriate diagnostic test
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF
Florida – Internal Medicine – Daily Dose Of 1200 Milligrams Of Gabapentin For Patient With End Stage Renal Disease
On 5/8/2014, a 74-year-old female presented to an internist for the purpose of establishing care. The patient had multiple medical problems, including diabetes, end-stage renal disease, and recurrent C. difficile infections.
At all times pertinent to this complaint, the patient was undergoing chronic hemodialysis treatment.
On 6/10/2014, the patient presented to the internist for a follow-up visit. The internist prescribed 600 mg tablets of gabapentin to the patient to treat her diabetic neuropathy. The patient’s prescription directed her to take the 600 mg of gabapentin twice daily, totalling 1200 mg of gabapentin per day.
On 6/14/2014, after taking her prescribed dosage of gabapentin, the patient lost control of her leg muscles and fell, resulting in a fracture of the T12 vertebrae in her back.
The prevailing professional standard of care required the internist to prescribe the patient a dosage of gabapentin not to exceed 150 mg per day, due to her end-stage renal disease. The internist prescribed the patient an inappropriate and/or excessive dosage of gabapentin.
According to the internist, he verbally instructed the patient and/or her family members to modify the gabapentin prescription.
The internist failed to document and/or accurately document the alleged verbal instruction to the patient and/or her family members to modify the patient’s gabapentin prescription.
The Board issued a letter of concern against the internist’s license. The Board ordered that the internist pay a fine of $5,000 against his license and pay reimbursement costs for the case at a minimum of $30,433.57 and not to exceed $32,433.57. The Board also ordered that the internist complete a medical records course and complete five hours of continuing medical education in clinical pharmacology and drug dosing.
State: Florida
Date: June 2017
Specialty: Internal Medicine, Nephrology
Symptom: Weakness/Fatigue
Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Diabetes, Neurological Disease, Spinal Injury Or Disorder, Renal Disease, Fracture(s)
Medical Error: Improper medication management, Accidental Medication Error, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Emergency Medicine – Pelvic Pain And Vaginal Bleeding With Urinalysis Revealing A Glucose Level >1000
On 8/21/2014, a patient presented with complaints of pelvic pain and vaginal bleeding. The patient was examined by a physician assistant supervised by an ED physician.
The physician assistant ordered laboratory evaluation for the patient, which included bloodwork, cervical/vaginal swabs, pelvic ultrasound, and urinalysis.
The urinalysis revealed the patient’s glucose level to be >1000, which was so high that it could not be measured.
The physician assistant gave the patient a prescription for Flagyl, an antibiotic, gave her education materials on uterine bleeding, bacterial vaginosis, dehydration, and ovarian cysts, and instructed her to follow up with her primary care physician and gynecologist. The physician assistant discussed the patient’s case with the ED physician and the ED physician agreed with the plan of care.
The ED physician did not perform or order a finger stick glucose test or a basic metabolic panel.
The ED physician did not discuss and/or did not order the physician assistant to discuss the patient’s glucose level in relation to her possible new onset of diabetes and did not recommend or order the physician assistant to recommend further evaluation and treatment of her elevated glucose levels.
The ED physician did not administer or order the administration of intravenous fluid and insulin.
On 8/26/2014, the patient expired due to diabetic ketoacidosis.
The Medical Board of Florida judged the ED physician’s conduct to be below the minimal standard of competence give that she failed to administer or order the administration of a finger stick glucose test or basic metabolic panel, discuss or instruct the physician assistant to discuss the patient’s glucose levels in relation to her possible new onset of diabetes and recommend further evaluation and/or treatment of her elevated glucose levels, and failed to administer or order the administration of intravenous fluid and insulin.
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 her 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: April 2017
Specialty: Emergency Medicine, Endocrinology, Physician Assistant
Symptom: Pelvic/Groin Pain, Abnormal Vaginal Bleeding
Diagnosis: Diabetes
Medical Error: Failure to follow up, Failure to order appropriate diagnostic test, Failure of communication with other providers, Improper supervision, Improper medication management
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF
California – Family Practice – Elevated Glucose Levels In A Patient On Aripiprazole, Asenapine, Quetiapine, And Olanzapine
On 11/6/2007, a family practitioner first began treating a patient and continued treating the patient until at least 6/9/2014.
On 12/21/2009, the family practitioner noted in the patient’s medical records that the patient was diabetic, writing “Lab-Spot glucose 242.” A level of 200 mg/dL or higher often means one has diabetes.
On 1/11/2010, the next exam noted in the patient’s records, the family practitioner noted a refill was needed for glipizide. However, there is no record that the patient was ever prescribed glipizide prior to this date.
During the course of treatment from the family practitioner, the patient was also prescribed aripiprazole, quetiapine, asenapine, and olanzapine for bipolar disorder. Aripiprazole, asenapine, and olanzapine can cause or worsen diabetes. According to medical notes, on 6/13/2011, the family practitioner was treating the patient with both aripiprazole and olanzapine as well as glipizide, which was to control diabetes.
On 7/11/2011, the patient’s blood sugars were noted to be in the 400 range, while 100 to 110 is considered to be the normal range for blood sugars in an individual. The family practitioner started the patient on insulin glargine to address diabetes on a daily basis.
In an interview that occurred on 10/1/2015, the family practitioner admitted that the family practitioner had no idea if the patient was taking the prescribed medications while under his care.
The Board judged the family practitioner’s conduct as having fallen below the standard of care for multiple patients given failure to record a physical exam in the progress notes, failure to revise and update assessments or plans for those patients, and failure to include a problem list or medication list in his progress notes. In addition, the family practitioner’s repeated, excessive and/or inappropriate prescribing of large doses of multiple strong antipsychotic medication and antidepressants to the patient with no regard or concern for drug interactions constituted a lack of knowledge and/or unprofessional conduct.
The family practitioner was placed on probation for 5 years with the stipulations of completing 40 hours annually of continuing medical education in the areas of deficient practice, a prescribing practices course at the Physician Assessment and Clinical Education Program, a medical record keeping course, an ethics course, a clinical training program equivalent to the Physician Assessment and Clinical Education Program, and undergo clinical practice monitoring.
State: California
Date: November 2016
Specialty: Family Medicine, Internal Medicine, Psychiatry
Symptom: N/A
Diagnosis: Diabetes, Psychiatric Disorder
Medical Error: Improper medication management, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
Washington – Endocrinology – Lack Of Communication Of Blood Test Results With Patient
On 7/16/2014, a patient saw an endocrinologist after being referred by her gynecologist for concerns about “not feeling well” and for questions about whether her hypothyroidism needed additional evaluation and management.
The patient described how the endocrinologist told her to throw out her other medications prescribed by her trusted long-term gynecologist, go on an antidepressant, and see a therapist. This advice was upsetting to the patient.
At the close of the visit, the patient went to the laboratory and gave a blood sample for testing. When the patient did not hear of the test results from the clinic after about 10 days, she contacted the clinic and was told that the results could not be found.
In a response to the complaint by the patient that she did not receive timely test results from the endocrinologist, the endocrinologist stated, through her lawyer, that the results were available through a patient electronic record portal called eCare. However, the patient had not enrolled in eCare and thus did not have access to the test results. The endocrinologist stated she planned to disclose and review the test results with the patient at a return visit in 3 months. The patient eventually established care with another endocrinologist.
The endocrinologist’s treatment of the patient fell below the standard of care when the endocrinologist failed to timely communicate the test results which showed the patient’s Hemoglobin A1C was at 6.1%. This test result is within a range that can be characterized as “prediabetes,” signifying that a patient may develop a diagnosis of diabetes within 10 years. A diagnosis of diabetes requires a test result of 6.5% or higher.
The Commission stipulated the endocrinologist reimburse costs to the Commission, complete a course on how to maintain and improve communication between physician and patient, and write and submit a paper of at least 1000 words, with annotated bibliography, on the importance of timely communication of laboratory results to patients and others with a need to know.
State: Washington
Date: October 2016
Specialty: Endocrinology
Symptom: N/A
Diagnosis: Diabetes
Medical Error: Failure of communication with patient or patient relations
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
California – Emergency Medicine – Abdominal Pain In An Alcoholic Improved With Fluids And Narcotics
On 8/9/2011 at 3:55 a.m., a 35-year-old non-English speaking, unemployed male presented to the emergency department complaining of 3 days of abdominal pain, nausea, and vomiting with anorexia and was seen by an ED physician. The patient had no documented prior similar episodes, but had a history of heavy alcohol consumption. Vital signs included a temperature of 98 F and a pulse of 86 bpm. Physical examination indicated normal bowel sounds and mild periumbilical tenderness, and distension. Rebound or guarding was not addressed. The nurse’s notes indicated that the last alcohol consumption was 1 day prior to admission, and abdominal pain had persisted for 3 days. 4/10 pain level was noted.
At 4:06 a.m., the patient’s treatment began with 2 L wide-open normal IV saline, GI cocktail, 5 mg morphine IV, and 4 mg Zofran IV. Laboratory results revealed a mildly elevated WBC count of 13.2 with a left shift. Blood glucose was markedly elevated at 260 mg/dL (normal fasting 70-100 mg/Dl; normal non-fasting 125 mg/dL or less; at >200 mg/dL, diabetes is presumed) without evidence of acidosis. Lipase level was below normal, and liver function tests were elevated. No alcohol was detected in the blood sample.
At 6:15 a.m., the patient was noted to be resting comfortably with a pain rating of 1/10. Vital signs included a temperature of 99.1 F and a heart rate of 93 bpm. The patient’s temperature and heart rate had risen despite fluid IV and pain medication. The ED physician approved the patient to be discharged home at 6:30 a.m. with oral instructions given through an interpreter to return if worse.
The patient was returned by ambulance to the emergency department at 10:40 a.m. again complaining of abdominal pain, this time at a level of 10/10. Physical examination noted abdominal tenderness and distention without rebound or guarding. The patient’s temperature was now 100.4 F and a pulse rate was 95 bpm. Laboratory findings noted the opiates administered at the previous visit, but also barbiturates of unclear source. WBC count was markedly low at 6.4, and a blood glucose level was now 421 mg/dL. Further, the patient reported experiencing increased thirst and urination for the last 3 days. A CT scan revealed a possible appendicitis with free fluid and inflammatory mass in the right lower quadrant. The patient was taken to surgery at 5:00 p.m., where appendicitis was confirmed. The patient was also admitted with a diagnosis of diabetes mellitus and treated with insulin drip to control blood sugar.
The Medical Board of California judged that the ED physician’s conduct departed from the standard of care because he failed to obtain an appropriate history and laboratory studies to rule out life-threatening illness. The ED physician had not elicited information concerning recurrent abdominal pains under similar circumstances without a surgical cause, and yet he presumed that the patient’s alcohol use was the overriding factor in his abdominal pain. The ED physician failed to order a urinalysis, a valuable test in the work-up of abdominal pain.
The ED physician’s final diagnosis did not follow from the history, physical, and work-up of the patient. The patient had WBC count and liver function abnormalities and had a history of heavy alcohol consumption, so the ED physician’s diagnosis of alcoholic gastritis was a reasonable differential diagnosis, but the ED physician did not consider and rule out possible causes of the pain, such as appendicitis and gallbladder disease, which would require surgical intervention. The ED physician ignored the patient’s high WBC count, which could have been an indication for appendicitis.
The observation period for the patient was inadequate. The ED physician did not allow enough time to adequately assess the patient’s condition and the risk of serious decline. The ED physician did not wait until the narcotic pain medication wore off to reexamine the patient over time for a possible surgical abdomen. The duration of morphine analgesia in 4 to 5 hours, and it was appropriate to relieve pain during the work-up, but repeat examination reporting that the patient was comfortable during the duration of analgesia was inadequate to fully appreciate the course of the illness.
The ED physician failed to record a history for the patient’s high blood glucose level and perform tests to determine the nature and severity of the abnormal finding. The blood glucose level of 260 mg/dL was suggestive of diabetes, and this was not previously diagnosed and required further history and laboratory studies. Ketones were not tested for in either blood or urine, but serum CO2 level was normal.
The ED physician’s discharge plan was inappropriate. The patient was given instructions in Spanish at discharge, and he did not record these instructions, but indicated that he would have instructed the patient to return if worse. No information was given concerning the elevated blood glucose. The ED physician failed to identify and ensure appropriate follow-up for a remarkably elevated blood glucose level.
For this case and others, the Medical Board of California placed the ED physician on probation for 5 years and ordered the ED physician to complete a medical record keeping course, an education course (at least 40 hours per 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. The ED physician was assigned a practice monitor and prohibited from supervising physician assistants.
State: California
Date: September 2016
Specialty: Emergency Medicine
Symptom: Abdominal Pain, GI Symptoms (GERD, Abdominal Distention, Dysphagia), Nausea Or Vomiting, Urinary Problems
Diagnosis: Acute Abdomen, Diabetes
Medical Error: Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Failure to follow up, Improper treatment, Lack of proper documentation
Significant Outcome: Hospital Bounce Back
Case Rating: 4
Link to Original Case File: Download PDF
Washington – Internal Medicine – Lack Of Follow-Up On Elevated Blood Glucose Followed By Foot Pain And Swelling
Between September 2000, and July 2013, an internist served as a patient’s primary care provider. The patient suffered from hypertension, chronic back pain from a herniated disc, morbid obesity, and strabismus which impaired her vision. The patient was also uninsured and unemployed. The internist was aware the patient could not afford to pay for multiple office visits. The internist arranged for the clinic’s charity foundation to pay for the patient’s medications.
Over a ten year period, the patient had three urinalysis screenings in which results revealed elevated glucose levels, a strong indication of diabetes. Elevated glucose levels require monitoring and additional lab work, particularly with the patient’s obesity and hypertension. There was no documentation to reflect the internist’s review of the patient urinalysis screens or consideration of a possible diabetes diagnosis.
In November 2011, the patient presented with complaints of right foot pain. The internist diagnosed foot cellulitis with erythema and prescribed an antibiotic and a pain reliever.
By February 2012, the patient complained of nausea, fever, and persistent pain with swelling related to her right foot. She also had a new complaint about her left foot where an ulcer formed over the top of the foot and over a bunion. The internist changed the antibiotic but continued the patient’s medication regimen without documenting consideration of other possible conditions.
In March 2012, the patient presented to the emergency department with extensive erythema with swelling and black tissue in her left foot consistent with wound infection. The hospital’s lab work showed a blood sugar level of 570 and a hemoglobin A1C of 12, compatible with a likely diagnosis of diabetes mellitus.
The hospital physician diagnosed the patient with osteomyelitis and diabetes mellitus with peripheral neuropathy. The physician performed an emergency debridement of the gangrenous left foot, but this did not resolve the infection in the foot and ankle. The patient then underwent a below-the-knee amputation of her left foot.
The Commission stipulated the internist reimburse costs to the Commission, allow a representative of the Commission to annually review his patient records, complete 6 hours of continuing education on the subject of screening for and treating diabetes in adults, write and submit a paper of at least 2500 words discussing what he learned in the continuing education course, how he will apply it in his practice, and how he will assure that this standard of care would be upheld despite a patient’s financial limitations. The internist will also present this paper to staff and colleagues at his workplace.
State: Washington
Date: March 2016
Specialty: Internal Medicine
Symptom: Extremity Pain, Fever, Swelling
Diagnosis: Diabetes
Medical Error: Diagnostic error, Failure to follow up
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 4
Link to Original Case File: Download PDF
California – Obstetrics – High-Risk Pregnancy Complicated By Diabetes, Previous Cesarean Sections, Obesity, High Blood Pressure, Proteinuria, Abdominal Pain, And Abnormal Discharge
On 5/12/2011, a patient presented to an obstetrician for prenatal care as a new obstetric patient. The patient’s last menstrual period was on 3/17/2011, and her expected delivery date was confirmed by ultrasound to be 12/22/2011. Although this was a new pregnancy, the patient had been known to the obstetrician since the age of 15 because the obstetrician had treated the patient for at least two other prior pregnancies, and the obstetrician had known about the patient’s medical history and prior Cesarean sections.
Since the patient’s first delivery, the patient has had two additional Cesarean sections as well as an early miscarriage. Despite knowing the patient’s medical history, the obstetrician reported no significant past medical history, but elevated blood pressures were documented outside of pregnancy, and the obstetrician documented that the patient was obese. The history of a prior classical Cesarean delivery was not recorded on the ACOG flow sheets in this pregnancy or in the 2010 pregnancy for which the obstetrician also provide care. The diagnosis of insulin-requiring gestational diabetes and preeclampsia in the patient’s 2010 pregnancy was also not documented.
On 5/12/2011, the patient’s first prenatal care, 2+ proteinuria was documented. Although the patient’s protein levels fluctuated and rose throughout her pregnancy, records show that the obstetrician merely instructed the patient to drink more water, but did not show that the obstetrician referred the patient to a specialist to treat the proteinuria. The patient failed her one-hour glucose tolerance test, which was elevated at 213. There was no record that a diagnostic three-hour test was performed. On 9/15/2011 (25 weeks) and 9/26/2011 (27 weeks), the patient complained of pressure and spotting. Progress notes did not document a speculum exam, digital cervical exam, or ultrasound. No record was found of any ultrasound besides the ultrasound performed on the initial visit.
On 7/15/2011, an elevated blood pressure was first detected at 17+ weeks of gestation. Blood pressure was again increased on 10/26/2011 at 142/82 (at 31 5/7 weeks of gestation). No note was made of this in the visit summary, and the patient was scheduled to return in two weeks.
On 11/10/2011 (34 weeks pregnant), the patient complained of pain/cramping, and the patient’s proteinuria was 4+. The abdominal exam was listed as “normal.” No fetal heart rate was documented. The patient was given a prescription for a narcotic pain reliever and terbutaline. The obstetrician continued to follow the expected delivery date, which was scheduled for 12/15/2011.
On 11/17/2011, the patient presented to the hospital complaining of abdominal pain, vaginal bleeding, and having passed a large blood clot. The patient was noted to be contracting irregularly. Her blood pressure was elevated and proteinuria was again present. After nursing staff communicated these findings to the obstetrician, he treated the patient by phone and ordered one liter IV hydration, a one-time dose of methyldopa (Aldomet), and IV butorphanol (Stadol). A verbal order was also given to discharge the patient if the pain resolved. The obstetrician did not examine the patient in person.
The obstetrician did not see the patient again until 11/29/2011, 19 days after her prior office visit. The patient’s blood pressure was 152/85 and 4+ proteinuria was noted. The patient’s weight also increased 8 pounds in two weeks to 210 pounds. No fetal heart rate was documented. The patient complained of increased swelling, off and on headaches, and a pink vaginal discharge. The patient was given a prescription for Aldomet and instructed to rest. The visit summary documented a plan for a follow-up appointment in one week.
At 3:50 p.m. on 11/29/2011, the patient presented to the labor and delivery department of the hospital complaining of severe abdominal pain and no fetal activity for one-hour. The nurses placed the patient in her bed but could not document a fetal heart rate. The obstetrician was called at 3:56 p.m. and arrived at 4:02 p.m. The obstetrician documented a very slow fetal heart rate by ultrasound. An emergency Cesarean section was performed. A uterine rupture and complete abruption of the placenta occurred, and the fetus was not alive when evacuated from the uterus.
Proteinuria on a subsequent formal UA was 2+. The obstetrician did not mention a diagnosis of preeclampsia in his notes, nor did he order magnesium sulfate for seizure prophylaxis. The blood pressure was noted to be 147/85 on post-operative day one. The patient was discharged on post-operative day two. The patient was seen for a post-operative visit for staple removal on 12/5/2011. The patient had lost 25 pounds in five days, and her blood pressure was 169/94 at that time. This was not mentioned in the visit summary. There was no documentation that the patient was questioned about symptoms of preeclampsia or that any additional evaluation was ordered. The patient was scheduled to return in five weeks.
The Medical Board of California judged that the obstetrician committed gross negligence in his care and treatment of the patient given that he failed to properly manage a high-risk pregnancy with a prior classical Cesarean section, diagnose and manage a pregnant woman with chronic hypertension, chronic proteinuria, and suspected preeclampsia and gestational diabetes, maintain and/or document the patient’s medical/surgical history as well as the care and procedures provided during patient visits, and deliver the baby earlier despite signs of fetal distress, which were evident before 11/29/2011 and the previously scheduled expected delivery date of 12/15/2011. The obstetrician also allowed a 19-day interval between the last two patient visits in a high-risk patient as well as failed to follow up on an elevated one-hour glucose, document any laboratory evaluation of proteinuria, document any sonograms, non-stress test, or biophysical profiles, and evaluate vaginal bleeding notes at 25 and 27 weeks gestation.
The Medical Board of California ordered that the obstetrician complete an education course, medical record keeping course, and clinical training program equivalent to the courses offered at the University of California San Diego School of Medicine (Program).
State: California
Date: October 2015
Specialty: Obstetrics
Symptom: Abnormal Vaginal Bleeding, Abnormal Vaginal Discharge, Headache, Abdominal Pain
Diagnosis: Preeclampsia, Diabetes
Medical Error: Failure to examine or evaluate patient properly, Underestimation of likelihood or severity, Failure to follow up, Improper treatment, Lack of proper documentation
Significant Outcome: Death
Case Rating: 3
Link to Original Case File: Download PDF
Kansas – Obstetrics – Poor Control Of Diabetes And Hypertension Results In Obstetrical Complications
A female patient began to see an obstetrician for her prenatal care on 12/6/2010. The patient had one previous pregnancy resulting in one live birth. The obstetrician documented that the patient had a history of diabetes, hypertension, and preeclampsia.
The patient was treated between 12/11/2010 and 3/18/2011 by a physician at an OB/GYN health facility. The OB/GYN records were faxed to the obstetrician on 4/5/2011 and were present in the obstetrician’s medical record for the patient.
On 3/15/2011 the patient’s gestational diabetes screen was elevated.
On 4/5/2011, the obstetrician observed the patient at a medical center for contractions and back pain. The obstetrician documented a history and physical/discharge summary for the patient, incorrectly noting the patient was a primigravida and failing to mention the patient’s glucose or history of hypertension and diabetes.
The obstetrician saw the patient on 5/12/2011 and documented the patient’s sugar was 169. The obstetrician documented a plan to perform nonstress tests at each visit and deliver the baby at 39 weeks.
The obstetrician saw the patient on 5/26/2011 and noted the patient had swollen feet and had not been taking her medications as prescribed. He scheduled an induction for 6/14/2011.
The obstetrician saw the patient on 6/2/2011 and noted the patient reported her feet were getting very swollen and she felt very tired. The patient’s Hgb was 8.7. The obstetrician failed to document a plan to address the patient’s anemia.
On 6/2/2011, the patient’s blood pressure was severely elevated at 161/88. The obstetrician failed to recheck the patient’s blood pressure or otherwise address the hypertension as possible preeclampsia in his plan for the patient.
The patient’s blood sugar logs were scanned into the obstetrician’s medical record and showed poor control of her diabetes. The obstetrician failed to make any adjustments to the patient’s medications.
Infants of a diabetic mother are known to be at risk of macrosomia and shoulder dystocia. This is most elevated in the setting of poorly controlled diabetes. There is no documentation in the obstetrician’s medical record that he discussed the possibility of these complications with the patient.
The obstetrician failed to make any effort to follow the growth of the infant with serial ultrasounds. The obstetrician failed to document any discussion with the patient regarding the desirability of such testing and failed to document the patient’s refusal of such testing.
The patient was admitted to a medical center for induction of labor on 6/14/2014.
The obstetrician initiated Pitocin at approximately 6:00 a.m. The Pitocin was increased at intervals to 16 milliunits/min until it was discontinued at 12:23 p.m.
The patient was documented as having severely elevated blood pressures, headache, and lower extremity edema during her induction. The patient was also given magnesium sulfate during her induction, suggesting she was suffering from severe preeclampsia.
The patient was complete at 12:23 p.m., and the obstetrician arrived at 12:40 p.m. The patient pushed for approximately 15 minutes before the obstetrician made a diagnosis of maternal exhaustion and documented “poor pushing effort.” The obstetrician failed to document any extenuating circumstances to support his premature discontinuation of the patient’s second stage of labor. There was no indication of fetal distress.
The obstetrician applied vacuum suction. There is no indication in the record that the obstetrician discussed options with the patient prior to attempting vacuum extraction of the fetus. There is no indication in the record that the patient was provided an explanation of risks and benefits regarding the use of vacuum extraction. There is no indication in the record that the obstetrician offered the patient the option for a Cesarean section.
The baby’s head was delivered at 12:58 p.m. The infant then sustained shoulder dystocia that the obstetrician was unable to resolve.
A labor and delivery emergency was then called, bringing several physicians and others to assist.
The 10 lb 5 oz infant was born six to seven minutes after the head was delivered. The infant had Apgars of 1,4 and 6. A neonatal consult was obtained, and the infant was diagnosed with multiple issues including bilateral brachial plexus injury. The infant was then transferred to Children’s Mercy Hospital.
The Board judged the obstetrician’s conduct to be below the minimum standard of competence given his failure to attempt to adjust the patient’s medication despite the fact that she had a known history of diabetes and her blood sugar logs indicated she had poor control over it. The obstetrician failed to document any attempt to educate the patient regarding the risks associated with a poorly controlled blood sugar, including but not limited to macrosomia and shoulder dystocia. Also, the obstetrician failed to monitor the growth of the infant in utero. He failed to perform appropriate weekly antenatal testing which would be indicated in a poorly controlled diabetic starting from 32 weeks. The obstetrician failed to appropriately evaluate and treat for preeclampsia in the face of severely elevated blood pressure in a patient with a known history of preeclampsia. The patient was administered Methergine, not as a last resort, but as the first medication after oxytocin and before cytotec, putting the patient at risk of a stroke in the postpartum period.
The Board ordered that the gynecologist change his licensure status from active to inactive and that he should not perform any type of surgical procedure including gynecological surgeries or provide obstetric care.
State: Kansas
Date: October 2015
Specialty: Obstetrics
Diagnosis: Preeclampsia, Diabetes
Medical Error: Improper medication management, Failure of communication with patient or patient relations, Failure to properly monitor patient, Lack of proper documentation, Procedural error
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 4
Link to Original Case File: Download PDF
Washington – Internal Medicine – Incidental Finding Of Glucose Level Of 283 mg/dl Without Fasting
On 2/11/2011, a 76-year-old man saw an internist in a clinic to address the patient’s report of a wound on his head that was not healing, hand lesions, diarrhea and white stools, gassiness, and having to go to the bathroom more frequently than normal. The internist was the patient’s primary care provider and ordered a complete blood count (CBC) and complete metabolic panel. The lab work identified that the patient had worsening renal function and a blood glucose level of 132 mg/dl (non-fasting). The internist asked the patient to return in one month for a follow-up basic metabolic panel.
On 3/13/2011, the patient’s follow-up lab work identified improved kidney function; however, the patient’s blood glucose level increased to 283 mg/dl, indicative of diabetes even if the patient had not fasted prior to the lab test. Medical staff documented that the clinic’s physician assistant called and spoke with the patient’s wife regarding the improved kidney results only. The patient’s high glucose level was not identified as an issue and the staff did not raise it with his wife. The internist did not see or speak to the patient following the lab results for the next ten months.
The internist saw the patient on 11/20/2011 to address the patient’s wife’s concerns about changes in the patient’s mentation, including a time when he got lost coming home. The internist administered the Mini-Mental State Exam, on which the patient scored 28/30. The internist did not order any lab tests. The internist failed to discuss the March lab results and failed to review the patient’s significantly increased blood glucose level from February to March 2011. The internist’s notes indicated that he reviewed medications, allergies, and past medical history as reported during the February 2011 visit, and social history as reported during a December 2009 visit. The internist’s notes did not indicate that he reviewed the February 2011 lab results or the March 2011 lab results.
On 12/27/2011, the patient called the clinic to request a fasting blood sugar test because he reported he had lost seven pounds in a week and was thirsty all the time. When his glucose level tested at 655 mg/dl, the clinic staff called the patient and directed him to be seen immediately, either at the clinic or at the emergency department (ED). The patient was seen in the clinic and was diagnosed with Diabetes Mellitus Type 2. Due to his altered mental state, the patient was directed to go to the ED for insulin and IV fluids.
The patient was diagnosed with acute renal injury secondary to dehydration. The patient’s A1C test result indicated that he had had elevated blood sugars at least over the past three months. The patient was discharged the following day without evidence of diabetic ketoacidosis or a hyperosmolar state.
The Commission stipulated the internist reimburse costs to the Commission and develop and submit a protocol which will ensure that the internist reviews the results of any lab work or tests he orders, follows up on forwarded reports and pertinent test results, documents his review of all lab work, test results and reports, and follows up in a timely manner with patients about test results or missed tests which had been ordered.
State: Washington
Date: September 2015
Specialty: Internal Medicine, Family Medicine
Symptom: Urinary Problems, Confusion, Diarrhea
Diagnosis: Diabetes, Renal Disease
Medical Error: Diagnostic error, Failure to follow up
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF