Found 38 Results Sorted by Case Date
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Virginia – Neurosurgery – All-Terrain Vehicle Rollover Accident Causes L1 Compression Fracture



On 1/19/2008, a 32-year-old man suffered an L1 compression fracture following an all-terrain vehicle rollover accident.  He saw a neurosurgeon who placed him in a rigid back brace and prescribed pain medications.  The patient’s fracture appeared to be clinically stable and appeared to be improving.  The Board deemed the long-term risk of developing a kyphotic deformity low in this patient.

On 3/7/2008,  the neurosurgeon performed a kyphoplasty of the spine the patient.  During the kyphoplasty, the vertebral body was too dense to accept the cement.  As a consequence, the cement extruded out of the fracture plans into the epidural space.

The neurosurgeon addressed this complication by performing a posterior laminectomy and decompression of the thecal sac.  The Board stated that the laminectomy procedure subjected the patient to a far greater risk for development of kyphosis than had existed prior to the kyphoplasty.

The Board considered the surgery unwarranted and issued a reprimand.  The neurosurgeon was ordered to complete 10 hours of continuing medical education in the subject of patient selection for spinal surgery.

State: Virginia


Date: November 2017


Specialty: Neurosurgery


Symptom: Back Pain


Diagnosis: Spinal Injury Or Disorder, Fracture(s)


Medical Error: Unnecessary or excessive treatment or surgery, Procedural error


Significant Outcome: N/A


Case Rating: 5


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 – Radiology – Motor Vehicle Accident With Missed Diagnosis After Review Of The CT Scan



On 8/14/2013, a 63-year-old female patient presented to a hospital with trauma sustained in a car accident.

X-rays of the patient’s chest and ankle were performed.  CT scans of the patient’s head, face, cervical spine, chest, abdomen, and pelvis were performed.  A radiologist read the x-rays and CT scans performed on the patient.  The radiologist recognized several transverse process fractures in the patient’s lumbar spine.  The radiologist failed to diagnose an L4 vertebral body fracture that was present on one or more CT images.  The radiologist failed to order further CT or MRI scans of the patient’s lumbar spine.

The Board judged the radiologist’s standard of care to be below the minimum standard of competence given his failure to recognize and diagnose the L4 vertebral body fracture present on one or more CT images for the patient and order further CT or MRI scans of the lumbar spine.

The Board ordered that the radiologist pay a fine of $7,500 against his license and that the radiologist pay reimbursement costs from a minimum of $3,004.65 to a maximum of $5,004.65.  The Board also ordered that the radiologist complete six hours of continuing medical education in radiological studies/interpretation.

State: Florida


Date: June 2017


Specialty: Radiology


Symptom: N/A


Diagnosis: Fracture(s), Spinal Injury Or Disorder


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


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Emergency Medicine – Delayed Response In Spine Immobilization And Ordering X-Rays And CT Scan In Patient With Lumbar Spine Fractures



On 6/22/2012 at 12:30 a.m., a patient was an unrestrained back seat passenger of a taxicab when it was involved in a motor vehicle accident.  The patient was intoxicated at the time of the accident.

EMT-Paramedics were dispatched to the scene of the accident and documented that the patient was moving all extremities and had a pulse, motor, and sensation in all four extremities.  The EMT-Paramedics transported the patient to the emergency department without back-board or spinal immobilization precautions.

At 12:58 a.m., the patient arrived at the hospital.

At 1:32 a.m., an ED physician performed an exam of the patient’s back and documented equivocal lumbar back tenderness.  The ED physician performed an exam of the patient’s pelvis and documented equivocal pelvic tenderness.  He also performed a neurologic exam and documented no movement of the patient’s toes or leg muscles.  The ED physician performed a rectal exam and documented that the patient exhibited an absence of anal sphincter tone.

AT 1:48 a.m., the ED physician ordered x-rays of the patient’s lumbosacral spine and pelvis.  The lumbosacral spine x-ray results showed a comminuted fracture dislocation at T12-L1.

At 2:58 a.m., the ED physician ordered a computed tomography scan of the patient’s lumbar spine.  The CT scan of the patient’s lumbar spine also showed a comminuted fracture dislocation at T12-L1.

At 3:17 a.m., the ED physician ordered that the patient be placed on a backboard.

At 4:20 a.m., the patient was transferred by ambulance to a level 1 Trauma Center.

The patient was ultimately diagnosed with paraplegia.  A medical malpractice lawsuit was filed against the physician.

The Board judged the ED physician’s conduct to be below the minimal standard of competence given that he failed to immediately perform a full trauma evaluation, immediately immobilize the patient’s spine, immediately order an x-ray of the patient’s chest, immediately order a CT scan of the patient’s abdomen, and immediately order a CT scan of the patient’s pelvis.

The Board issued a letter of concern against the ED physician’s license.  The Board ordered that the ED physician pay a fine of $5,000 against his license and pay reimbursement costs for the case at a minimum of $6,452.58 and not to exceed $8,452.58.  The Board also ordered that the ED physician complete five hours of continuing medical education of emergency medicine and five hours of continuing medical education in “risk management.”

State: Florida


Date: June 2017


Specialty: Emergency Medicine, Trauma Surgery


Symptom: N/A


Diagnosis: Fracture(s), Spinal Injury Or Disorder


Medical Error: Failure to examine or evaluate patient properly, Delay in proper treatment


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 4


Link to Original Case File: Download PDF



Florida – Interventional Radiology – Kyphoplasty Performed On T11 Instead Of T12 Site For T12 Fracture After A Fall



On 10/13/2015, a 70-year-old male was transported to the emergency department after a fall from a hammock when the rope broke.

A CT scan of the lumbar spine was done and a 20% anterior wedge compression fracture on the T12 section was found.  An MRI of the lumbar spine, on the same day, showed an acute T12 compression fracture.  An MRI of the thoracic spine was done, on the same day, and showed an acute T12 compression fracture with bone marrow edema.

The patient was admitted to the hospital and recommended for T12 kyphoplasty.

On 10/14/2015, an interventional radiologist performed a kyphoplasty on the patient’s T11 vertebrae (wrong site), instead of the T12 vertebrae.

The patient was discharged on 10/19/2015 and began having progressively more pain.

On 10/22/2015, the patient was readmitted to the hospital by ambulance with progressively worsening pain.

On 10/23/2015, a two-view x-ray of the lumbar spine revealed that a T12 compression fracture had remained unchanged despite the 10/12/2015 surgery, and that the T11 vertebrae had been unnecessarily operated upon.

The patient was discharged to a rehabilitation center for two weeks to recover.

The Board issued a letter of concern against the interventional radiologist’s license.  The Board ordered that the interventional radiologist pay a fine of $4,000 against his license and pay reimbursement costs for the case at a minimum of $2,009.04 and not to exceed $4,009.04.  The Board also ordered that the interventional radiologist complete five hours of continuing medical education in “risk management” and complete a one-hour lecture/seminar on wrong site surgeries.

State: Florida


Date: June 2017


Specialty: Interventional Radiology


Symptom: Pain


Diagnosis: Fracture(s), Spinal Injury Or Disorder


Medical Error: Wrong site procedure


Significant Outcome: Hospital Bounce Back


Case Rating: 2


Link to Original Case File: Download PDF



Washington – Orthopedic Surgery – Complex Wrist Fracture After A Fall With A Screw Within The Radiocarpal Joint



On 5/26/2012, a patient presented to an emergency department after falling and fracturing the distal radius, at his right wrist.  The operating room was unavailable so the orthopedic surgeon opted for a non-surgical (closed reduction) procedure, aligning the patient’s wrist and arm into a splint until he could return for surgery the following week

On 6/1/2012, the patient presented to the orthopedic surgeon for open reduction surgery and internal fixation.  This type of surgery involves surgically aligning the broken bones and using items like plates and screws to hold broken bones together to encourage healing in the correct position.  The orthopedic surgeon positioned a plate adjacent to the fracture and secured the plate to the fracture area with screws.

On 6/13/2012, the patient returned to the orthopedic surgeon for a follow-up.  Imaging found one of the plate’s screws appeared to be within the patient’s radiocarpal joint (where the wrist and palm meet).  The orthopedic surgeon told the patient of the potential for hardware to intrude into the joint.  The orthopedic surgeon noted that if the positioning of the hardware continued to remain a concern, then further imaging and hardware removal would be discussed.

On 7/11/2012, the orthopedic surgeon contacted the patient to discuss the findings of a CT scan performed two days prior.  He assessed the patient’s wrist to be healing nicely, but the CT scan confirmed one of the screws was protruding through the radiocarpal joint.  The orthopedic surgeon decided to go forward with removing the screws and hardware.

On 7/26/2012, the orthopedic surgeon performed his second open surgery on the patient’s wrist, this time removing all of the hardware.  A significant amount of scar tissue and new bone formation had to be cleared in order to reach the hardware.  The orthopedic surgeon found the fracture reasonably stable with gentle flexion-extension movements.  The fracture itself seemed to move as a single unit when doing this, and he felt no further hardware was necessary.

On 8/28/2012, the patient returned to the orthopedic surgeon.  The orthopedic surgeon found the patient’s distal radius had healed abnormally with some displacement of the wrist joint.  The orthopedic surgeon proposed the patient get a specialist’s opinion regarding feasibility for further constructive work.

On 9/27/2012, the patient saw a hand specialist for a second opinion.  The patient described having diminished nerve sensation near the wound area.  The specialist discovered that the patient’s July 2012 CT scan showed the plate had partially dislodged itself.  Upon examination, the specialist noted a displacement deformity at the hand on the forearm.  The patient’s wrist had healed improperly, leaving a significant dorsal prominence of the joint surface and the remaining part of his wrist displaced at the palm.  The patient’s right wrist had limited motion.

The Commission stipulated the orthopedic surgeon reimburse costs to the Commission and write and submit a paper of at least 1000 words, with an annotated bibliography, on knowing his limitations, especially with complex wrist fractures, and complete a continuing education course on complex wrist fractures.

State: Washington


Date: April 2017


Specialty: Orthopedic Surgery


Symptom: N/A


Diagnosis: Fracture(s)


Medical Error: Procedural error


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 2


Link to Original Case File: Download PDF



North Carolina – Orthopedic Surgery – Radiology Report Diagnoses Medial Supracondylar Fracture



The Board was notified of a professional liability payment made on 01/05/2016.

In April 2014, a six-year-old male was referred to an orthopedic surgeon for a follow-up of an elbow injury.  The emergency department radiology report stated that the patient’s injury was a “medial supracondylar fracture.”  The orthopedic surgeon took subsequent x-rays of the patient and continued closed treatment of the patient for what was thought to be a “medial supracondylar fracture.

The patient continued to suffer pain and popping at the fracture area during treatment.  While the patient was out-of-state, he sought treatment with another orthopedic surgeon, who correctly diagnose the patient’s fracture as a “displaced lateral condyle fracture with non-union” and referred him to another physician for surgical treatment.

The Board obtained the patient’s records and sent them to a qualified independent medical expert for review.  The independent medical expert judged the orthopedic surgeon’s conduct to be below the minimum standard of competence given failure to properly diagnose the patient’s “displaced lateral condyle fracture with non-union.”

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: January 2017


Specialty: Orthopedic Surgery


Symptom: Extremity Pain


Diagnosis: Fracture(s)


Medical Error: Diagnostic error


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Family Medicine – Left Hip Pain With X-Ray Interpreted As Showing No Acute Process



On 9/22/2010, a woman in her forties fell at work, striking her forehead and injuring her left hip.  She was transported to a hospital and evaluated by a family practitioner working in occupational medicine.  The patient denied any headache, but complained of left hip pain and fatigue.  The family practitioner’s examination did not note any acute findings.  The family practitioner obtained a left hip x-ray and interpreted the films as showing “no acute process.”  The family practitioner diagnosed the patient with left hip strain and superficial abrasion.  The family practitioner noted her prior history of ankylosing spondylitis, sciatica, and multiple extremity arthroplasties, including a prior hip replacement.  The family practitioner prescribed physical therapy as well as two days off duty then return to work.

On 9/23/2010, the patient’s hip x-rays were interpreted by a radiologist to show a possible fracture in the inferior pubic ramus inferior to the acetabulum.  The radiology report stated, “an acute fracture is not excluded.”  The report was transmitted to the family practitioner via facsimile.

On 10/19/201, the patient presented to the family practitioner for follow-up.  The family practitioner documented left hip complaints but failed to document any review of the radiology report.  The family practitioner ordered more physical therapy and return to work.

On 11/22/2010, the patient presented again to the family practitioner.  She continued to have left hip complaints, and the family practitioner documented decreased range of motion of the left hip.

The family practitioner made an orthopedic referral but did not refer the patient for any further radiological study, and the family practitioner continued to fail to document any review of the prior left hip x-ray report.  The family practitioner’s orthopedic referral was made on a routine (not emergent or stat) basis, and the orthopedic appointment was scheduled for 1/11/2011.

On 12/20/2010, the patient presented again to the family practitioner, now complaining of a “pop” with increased hip pain and shortening of the left leg.  The family practitioner ordered new left hip x-rays, which he interpreted as showing “no acute findings.”

On 12/21/2010, this second set of x-rays were interpreted by a radiologist to show “more deformity” in the left hip than prior films, and “healing fractures.”  The family practitioner documented review of these findings on 12/22/2010.  However, the family practitioner failed to order stat orthopedic referral, failed to inform the patient of the findings, and failed to order any additional diagnostic studies.

On 1/11/2011, the patient was seen by an orthopedic surgeon who reviewed the x-ray films previously obtained by the family practitioner.  The orthopedic surgeon diagnosed femoral neck fracture, ordered additional tests, took the patient off duty from work, and recommended no weight bearing until surgery.  Ultimately, the patient underwent reconstructive hip surgery.

The Board judged the family practitioner’s care of the patient to be below the minimum level of competence given failure to review the radiologist’s hip x-ray findings when they were sent to him on 9/23/2010; failure to review these findings when the patient presented for follow-up on 10/19/2010, 11/22/2010, and 12/20/2010; and failure to refer the patient for treatment in a timely fashion either to an orthopedic surgeon or to the emergency department.

Based on this case and others, the Board revoked the family practitioner’s license.  The family practitioner was placed on probation for three years with stipulations to complete 40 hours annually in the areas of deficient practice, complete an education program equivalent to the Physician Assessment and Clinical Education Program, and undergo clinical monitoring.

State: California


Date: October 2016


Specialty: Family Medicine, Orthopedic Surgery


Symptom: Joint Pain


Diagnosis: Fracture(s)


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


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Emergency Medicine – 8-Foot Fall Off Ladder Onto A Concrete Service With Right Chest Wall And Right Elbow Tenderness



On 9/10/2012 at 5:00 p.m., a 64-year-old male was brought into the emergency department by ambulance on a backboard with cervical spine precautions taken after he fell 8 feet off of a ladder onto a concrete surface.  The patient complained of pain in the chest, right elbow, and back. Medical history was significant for a mechanical heart valve requiring anti-coagulation with warfarin. Vital signs included a normal temperature, pulse rate 57 bpm, respiratory rate 22, and pulse oximetry 96% on room air.  Pain level was listed as 10/10. Tenderness was noted on the right chest and right elbow. A right laceration was noted on one finger. The right elbow had limited range-of-motion (ROM). The ED physician noted a palpable fracture on the right chest and ecchymosis. Breath sounds were marked as questionable/decreased.  Blood work was ordered. CBC and chemistry were unremarkable, and PT/INR indicated anti-coagulation. The ED physician noted no fractures on examining a series of rib x-rays ordered on the patient. The CT scan of the head was negative for bleeding. Lumbosacral (LS) spine x-rays were also read by the ED physician as negative.

The ED physician ordered an intramuscular (IM) injection of 10 mg of morphine given at 5:15 p.m., and he ordered a second dose of 10 mg morphine given at 5:36 p.m.  The ED physician’s last note was entered at 7:09 p.m. indicating that the patient was improved and that a posterior splint was applied. At 7:20 p.m., the patient could not walk due to pain in his tailbone.  At 8:40 p.m., the patient was discharged home with a supply of Norco, and vital signs before discharge included normal temperature, pulse rate 66 bpm, respiratory rate 18, blood pressure 112/73, and pulse oximetry down to 94%.

The following morning, the radiologist noted in the x-rays a 30% pneumothorax and a sixth-rib fracture and informed the ED physician.  The ED physician called the patient back to the hospital, and he was admitted and treated with a chest tube.

The Medical Board of California judged that the ED physician’s conduct departed from the standard of care because he failed to detect a large pneumothorax apparent on x-rays ordered and read by the ED physician on the patient’s initial emergency department visit. Traumatic rib fractures present a known risk of life-threatening pneumothorax.  The patient had experienced a significant mechanism of injury with an 8-foot fall onto concrete, clinical evidence of rib fracture, and falling pulse oximetry readings.

The ED physician ordered and had administered 2 large doses of IM morphine approximately 21 minutes apart.  The onset of IM narcotic medication is between 10-30 minutes with analgesia peaking between 30-60 minutes and of 4-5 hours duration.  The administration of 2 doses of IM morphine 10 mg, so close together before the first dose had a chance to take effect was virtually the same as giving one dose of 20 mg morphine, an excessive amount.  The ED physician documented no reason for the patient needing the back-to-back administration and noted no results for either injection. Furthermore, despite an aggressive initial approach to pain management, no additional pain medications were given to the patient 2 hours later when the patient was unable to walk due to tailbone pain.  The ED physician did not appreciate the onset, peak, and duration of the narcotic medications given to the patient.

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: Chest Pain, Back Pain, Joint Pain


Diagnosis: Pneumothorax, Trauma Injury, Fracture(s)


Medical Error: False negative, Improper medication management


Significant Outcome: Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



California – Emergency Medicine – Patient With Chest Pain After Severe Motor Vehicle Accident Discharged And Readmitted The Next Day



On 6/18/2012, a 55-year-old female was brought to the emergency department by ambulance after a single-vehicle rollover accident on a local highway.  She was injured, but had walked a distance before someone stopped to help her and called an ambulance. The patient was alert with intact memory of the incident.  On arrival at the emergency department, the patient complained of right chest pain and left hand pain. The patient’s temperature was 97.2 F, pulse rate was 91 bpm, respiratory rate of 14, and blood pressure of 137/89.  Physical examination was positive for tender right chest and tender left hand on the ulnar aspect. The neck was non-tender and full range of motion, so no cervical spine x-ray was deemed necessary. A thoracic spine x-ray indicated 10% wedging of the T-11 and T-12 vertebrae of uncertain age.  This was noted by the radiologist, but not mentioned by the ED physician. An x-ray of the right ribs revealed a single sixth rib fracture without pneumothorax. Another x-ray was positive for left fifth metacarpal fracture.

Laboratory studies revealed an elevated WBC count of 14.8 with a segmented count of 91.  Hemoglobin and hematocrit were normal. Troponin was negative for cardiac injury. Chemistry panel was normal.  Liver function tests (LFTs) were mildly elevated with AST of 73 and ALT of 80. ECG revealed abnormalities, including anterior lateral ST-T wave depressions consistent with ischemia with no old ECG consulted for comparison.  The ED physician ordered a urinalysis, but the Ed physician did not document or address the results in the patient chart. The test was positive for blood and nitrates.

At 4:40 a.m., the patient received 10 mg of IV morphine and 10 mg of IV Zofran.  At 6:00 a.m., the patient was remedicated with IV morphine 10 mg and 37 minutes later, the ED physician documented a repeat examination of the patient and described the patient as “drowsy with meds.”  TDaP vaccine was ordered, and the patient was cleared for discharge, but due to a delay in obtaining the TDaP vaccine, the discharge order was not given until 8:30 a.m. The patient was discharged at 8:48 a.m. with a pulse rate of 82 bpm, respiratory rate of 16, blood pressure of 119/75, and pulse oximetry of 96%.  The patient was discharged with instructions to see an orthopedist for her hand, and she was given a prescription for pain medication and a work release note for approximately 3 weeks.

The patient returned the following day.  She was brought in by paramedics with fever and chest pain, apparently without severe shortness of breath.  The patient had not yet filled her pain prescription. A follow-up x-ray showed bibasilar atelectasis. A CT scan showed a 10% pneumothorax with mild right pulmonary effusion.  An incidental upper lobe pulmonary arteriovenous malformation was noted. Treatment for UTI detected by the urinalysis ordered the day before but not addressed, was provided. It was unclear whether the patient’s fever was caused by the atelectasis or the UTI.

The Medical Board of California judged that the ED physician’s conduct departed from the standard of care because he failed to admit the patient to the hospital for observation.  The patient had been in a motor vehicle accident with a high risk of intra-thoracic and intra-abdominal injury. Her car had rolled over 3 times, and she had at least 2 known fracture, blood in urine, elevated LFT’s, and evidence of cardiac ischemia on the ECG.  The patient had a significant mechanism of injury, evidence of extensive damage, and other unresolved medical problems that should have been addressed through hospital observation to determine the extent of the injuries involved.

The ED physician’s medical evaluation of the patient was inappropriately limited.  He should have done further investigation of the abnormalities with CT scans and other diagnostic mechanisms.  The ED physician also failed to document significant abnormalities or did not address those which were documented.  The ED physician failed to adequately examine the patient and document findings pertinent to the patient’s presentation after a potentially fatal automobile accident.

The ED physician failed to address the ECG abnormalities consistent with ischemia.  The patient’s ECG showed signs of ischemia in the setting of an accident that could have caused cardiac injury.  The ED physician had no previous ECG of the patient to compare, so it must be assumed that the ischemic changes were new.  The patient should have been admitted for this finding alone. A low initial troponin does not rule out cardiac injury.

The ED physician observation period for the patient was inadequate.  In his examination and treatment of the patient, he failed to allow enough time to adequately assess the patient’s condition and risk of serious decline.  The patient had been in an accident with a severe mechanism of injury, multiple fractures, and evidence of internal injury in 3 different systems, and the ED physician ordered 2 large doses of intravenous morphine close together and then precipitously discharged the patient with further reexamination or treatment.  The ED physician also did not appreciate the onset, peak, and duration of narcotic medications given when he reassessed the patient’s pain level.

The ED physician failed to perform and record an adequate back examination and order additional testing as indicated.  Thoracic spine x-rays were ordered, but the ED physician failed to perform or to document a back examination for back tenderness, and this finding was only noted on the patient’s second visit to the emergency department.

The ED physician failed to document or act upon significant abnormal findings.  The patient’s urinalysis was ordered, but the ED physician did not document the results in the patient record.  He did not document evidence of blunt kidney trauma and/or infection. He did not document the significance of an abnormal ECG.  The ED physician either failed to review the abnormalities, and so did not act upon them or he reviewed them, failed to document them, and then failed to appreciate the significance of the abnormalities.  Although he had evidence that the patient had a UTI, the ED physician failed to address the illness, which, left untreated, could have progressed to a serious illness, such as pyelonephritis or sepsis. He failed to adequately examine and document findings pertinent to the patient’s presentation.

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: Chest Pain, Fever, Extremity Pain


Diagnosis: Fracture(s), Pneumothorax


Medical Error: Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Failure to follow up, Improper treatment, Improper medication management, Lack of proper documentation


Significant Outcome: Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



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