Found 114 Results Sorted by Case Date
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California – Family Practice – Providing Medical Clearance For A Tummy Tuck Procedure



A family practitioner cleared a patient for a tummy tuck procedures.  The patient had a history of sickle cell anemia and a respiratory infection.

The Board judged the family practitioner’s conduct as having fallen below the minimum level of competence given failure to address the status of the patient’s sickle cell anemia and failure to assess the patient’s respiratory infection.

The Board issued a public letter of reprimand.

State: California


Date: October 2017


Specialty: Family Medicine, Internal Medicine


Symptom: N/A


Diagnosis: Hematological Disease, Infectious Disease


Medical Error: Improper treatment


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



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


Diagnosis: Diabetes, Sepsis


Medical Error: Failure to order appropriate diagnostic test


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Florida – Physician Assistant – Diflucan For Yeast Infection Given With Tacrolimus



A patient received a heart transplant and was on a long-term tacrolimus regimen.

On 10/7/2011, the patient presented to a physician assistant with complaints of an oral yeast infection.  The physician assistant prescribed the patient a two-week course of Diflucan and advised him to return for follow-up three weeks after the 10/7/2011 appointment.

Diflucan is known to potentiate tacrolimus, which causes the tacrolimus to reach toxic levels.

The standard of care required that the physician assistant perform serial monitoring of the patient’s drug levels to ensure that they did not reach a toxic level, starting immediately after the physician assistant prescribed Diflucan.

The physician assistant did not schedule blood testing to monitor the patient’s drug levels and advised the patient to return for a follow-up appointment three weeks after the initial appointment.

The physician assistant voluntarily relinquished his license.

State: Florida


Date: August 2017


Specialty: Physician Assistant


Symptom: N/A


Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Infectious Disease


Medical Error: Improper medication management, Failure to properly monitor patient


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Pediatrics – Cough, Post-Tussive Emesis, Fever, Elevated Heart Rate, And Elevated Respiratory Rate



On 6/8/2012, a 16-year-old female presented with complaints of tactile fever for the previous four days, coughing, and one incident of post-tussive emesis.

A pediatrician performed an examination and documented that the patient’s temperature was 98.3, her heart rate was 98, and her respiratory rate was 22.  The patient’s weight was also documented to be 209 pounds.

The pediatrician assessed the patient was suffering from an upper respiratory infection (URI) and recommended that she continue over-the-counter medication to manage her symptoms.

On 6/9/2012, the patient again presented to the pediatrician.  She presented with the same complaints of fever and coughing, but additionally complained of a sore throat.

The pediatrician performed an examination and documented that the patient’s heart rate was 106 and her respiratory rate was 32.  She was also running a temperature of 100.8.

The pediatrician assessed that the patient had a URI and pharyngitis.  The pediatrician provided the patient with respiratory instruction and advised that she should return in two days if her temperature persisted.

Despite the increase in the patient’s heart rate and respiratory rate from the 6/8/2012 and 6/9/2012 visit, the pediatrician did not order a STAT chest x-ray for the patient. Despite the increase in the patient’s heart rate and respiratory rate from the 6/8/2012 and 6/9/2012 visit, the pediatrician did not check the patient’s oxygen saturation.

On 6/10/2012, the patient expired in her home.  The medical examiner documented the patient’s cause of death as pneumonia with sepsis due to haemophilus influenzae.

The Medical Board of Florida judged the obstetrician’s conduct to be below the minimal standard of competence given that he failed to order a STAT chest x-ray and check the patient’s oxygen saturation.

The Medical Board of Florida issued a letter of concern against the pediatrician’s license.  The Medical Board of Florida ordered that the pediatrician pay a fine of $5,000 against his license and pay reimbursement cost at a minimum of $1,408.03 and a maximum of $3,408.03.  The Medical Board of Florida ordered that the pediatrician complete five hours of continuing medical education in pediatric medicine and complete three hours of continuing medical education in diagnosis and treatment of pneumonia.

State: Florida


Date: August 2017


Specialty: Pediatrics, Emergency Medicine, Family Medicine, Internal Medicine


Symptom: Fever, Cough, Nausea Or Vomiting


Diagnosis: Pneumonia


Medical Error: Failure to order appropriate diagnostic test


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Nebraska – Family Medicine – Excessive X-Rays And Antibiotics For Sinus Infection And Pneumonia



A family practitioner treated a 32-year-old female, for approximately 10 years.  The patient had a mechanical mitral valve and was on Coumadin therapy.  The family practitioner diagnosed her with sinus infections and pneumonia repeatedly.  He ordered nine sinus x-rays, eight chest x-rays, and 29 prothrombin time tests, the majority of which were subtherapeutic, during a one-year period.  The patient was a chronic smoker, and there was nothing in the chart to indicate smoking cessation counseling was tried.  The patient was treated with Biaxin (from one to four weeks at a time), 13 Rocephin injections, Levaquin for three weeks, Bactrim for one month, Keflex for two days and 10 days and Diflucan, Levaquin and Rocephin treatments simultaneously.

The family practitioner’s use of repeated sinus x-rays for the patient, which have questionable medical value under these circumstances, constituted substandard medical care.

Also, the family practitioner’s use of antibiotic therapy for the patient, there being no evidence that such therapy has a recognized medical benefit under the circumstances, constituted substandard medical care.

Finally, the family practitioner’s failure to refer the patient for pulmonary evaluations, after repeated visits with the same symptoms, constituted substandard of medical care.

For these allegations and others, the Board judged that the family practitioner’s methodology of practice overall and the specific negligent acts of his practice constituted negligence.  The Board ordered that the family practitioner have his license censured, have a practice monitor to review his practice on a quarterly basis for one year, pay a fine, and complete review courses on the following subjects: Eye, Nose, and Throat practice and referral, Endocrinology, Immunology and Immune Systems, indications for the need of radiographs and the appropriate use of radiology consultations.

State: Nebraska


Date: July 2017


Specialty: Family Medicine


Symptom: N/A


Diagnosis: Pneumonia, Infectious Disease


Medical Error: Improper medication management, Unnecessary or excessive diagnostic tests, Failure of communication with other providers, Unnecessary or excessive treatment or surgery


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Physician Assistant – Patient With Animal Bite Wound Treated With Sutures Only



On 7/13/2011, a 47-year-old female presented to a physician assistant with an animal bite wound.  The physician assistant treated the patient’s animal bite wound with sutures.

The physician assistant discussed this wound with an orthopedic specialist, who recommended IV antibiotics and an antibiotic prescription for home.

The physician assistant did not order or administer antibiotics to the patient while the patient was in the hospital.  The physician assistant did not order or administer antibiotics to the patient at the time of discharge.

The Board judged the physician assistant’s conduct to be below the minimal standard of competence given that she failed to prescribe antibiotics when assessing and/or treating a patient with the following presentation.

The Board issued a letter of concern against the physician assistant’s license. The Board ordered that the physician assistant pay a fine of $2,000 against her license and pay reimbursement costs for the case at a minimum of $3,867.71 but not to exceed $5,867.71.  The Board also ordered that the physician assistant complete five hours of continuing medical education in diagnosing and/or treating patients with wounds and five hours of continuing medical education in “risk management.”

State: Florida


Date: July 2017


Specialty: Physician Assistant


Symptom: N/A


Diagnosis: Trauma Injury, Infectious Disease


Medical Error: Improper treatment


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Pediatrics – Deep Laceration Of The Right Knee Treated With Debridement, Irrigation, And Suturing



On 12/7/2011, an 8-year-old male presented to a medical emergency department with a deep laceration to his right knee.  The laceration was a full thickness cut with visualization of the capsule.  An x-ray revealed air in the knee joint.

A pediatrician examined the patient’s knee and performed debridement, cleaning by irrigation, and suturing of the laceration.  Bacitracin and dressing were applied to the patient’s knee.

On 12/10/2011, the patient returned to the emergency department with complaints of right knee swelling, redness, and pain.  The patient was admitted to the pediatric floor.

Further examination revealed septic arthritis in the patient’s right knee, which required two operations and the introduction of a PICC line for long-term antibiotic therapy.  The patient sustained cartilage damage as a result of the septic arthritis and suffered from significant knee pain.

The Board judged the pediatrician’s conduct to be below the minimal standard of competence given that he failed to refer the patient to an orthopedic surgeon and to fully wash out the patient’s joint by performing an open debridement under anesthesia.

The Board issued a letter of concern against the pediatrician’s license.  The Board ordered the pediatrician to pay a fine of $10,000 against his license and pay reimbursement costs at a minimum of $5,496.59 and not to exceed $7,496.59.  The Board also ordered that the pediatrician complete ten hours continuing medical education in pediatric orthopedic diagnosis and treatment and complete five hours of continuing medical education in “risk management.”

State: Florida


Date: June 2017


Specialty: Pediatrics, Orthopedic Surgery


Symptom: Joint Pain, Swelling


Diagnosis: Trauma Injury, Septic Arthritis


Medical Error: Improper treatment, Referral failure to hospital or specialist


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 4


Link to Original Case File: Download PDF



Florida – Physician Assistant – Cardiac Catheterization Ordered In The Wrong Patient



On 10/11/2015, Patient A, an 89-year-old male presented to the emergency department with complaints of chest congestion, weakness, and chest pressure.

Lab results revealed that Patient A had elevated troponin levels, and he was admitted and referred for a cardiology consultation.

On 10/11/2015, the patient saw a cardiologist for the cardiology consultation.  The cardiologist documented that the patient had an upper respiratory infection and recommended that the patient continue antibiotics, gentle diuresis, and outpatient medical therapy.

At around the same time, on the same date, the cardiologist saw Patient B for a cardiology consultation.  Sometime after the cardiac consultations of Patient A and Patient B, the cardiologist contacted a physician assistant and instructed him to order a cardiac catheterization for Patient B.

The physician assistant placed an entry in Patient A’s medical chart instead of Patient B’s chart, ordering the cardiac catheterization.  The physician assistant failed to review Patient A’s available medical records, including labs, notes, and imaging studies, before placing the cardiac catheterization order in his chart.

The following morning, cardiac catheterization was unnecessarily performed on Patient A.

The Board judged the physician assistant’s conduct to be below the minimal standard of competence given that he failed to review the patient’s available medical records, including labs, notes, and images studies, before placing the cardiac catheterization order in his chart.

The Board issued a letter of concern against the physician assistant’s license.  The Board ordered that the physician assistant pay a fine of $2,000 against his license and pay reimbursement costs for the case at a minimum of $2,611.86 and not to exceed $3,111.86.  The Board also ordered that the physician assistant complete five hours of continuing medical education in “risk management.”

State: Florida


Date: June 2017


Specialty: Physician Assistant, Cardiology


Symptom: Weakness/Fatigue


Diagnosis: Infectious Disease


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


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Gastroenterology – Fevers And Chills After Endoscopic Retrograde Cholangiopancreatography (ERCP)



On 6/22/2010, Gastroenterologist A provided a consultation for a patient after an abdominal ultrasound showed that the patient had cholelithiasis and choledocholithiasis.  The patient’s elevated liver enzymes and dilated bile duct indicated a moderate to high probability of the possibility of stones and warranted a preoperative ERCP and sphincterotomy.  The purpose of the consultation was to remove a suspected common bile duct stone prior to a cholecystectomy.

On 6/28/2010, Gastroenterologist A performed an ERCP with sphincterotomy and balloon sweeping of the common bile duct.  He was unable to determine if he had successfully removed the suspected common bile duct stone from the patient’s dilated bile duct and placed an 8.5-French 5 cm stent into the common bile duct.

In the patient’s chart, Gastroenterologist A noted: “will pull the stent out in 2 months.”

On 11/24/2010, Gastroenterologist A next saw the patient in his office.  A second ERCP was scheduled for 2/10/2011 to remove the stent.  The patient’s medical chart contains no record of instructions given to the patient or his family members regarding the removal of the stent.  The patient’s medical chart contains no explanation for the passage of time between the placement of the stent on 6/28/2010 and the removal of the stent on 2/10/2011.  The Board noted that stents can be expected to occlude after six months and form a nidus for the formation of other stones, mud, and debris.

At 8:30 a.m. on 2/10/2011, Gastroenterologist A performed a second ERCP on the patient and removed the stent.  During the second ERCP, Gastroenterologist A performed a balloon sweep.  The patient’s medical chart contains no clear documentation that all ducts were swept.  No antibiotics were prescribed or administered to the patient immediately before, during, or after the second ERCP.  After the second ERCP, the patient was discharged from the endoscopy facility.  Several hours later, the patient’s wife called Gastroenterologist A’s office to report that the patient was experiencing chills and pain in his back and stomach.  Gastroenterologist A and/or his staff advised that the patient should be brought to Gastroenterologist A’s office right away.

At 6:00 p.m., after efforts to convince the patient’s wife to bring the patient to his office had been unsuccessful, Gastroenterologist A noted in the patient’s chart that he advised the patient’s wife to bring the patient to the office the following morning if the pain were to continue.

Thereafter, Gastroenterologist A prescribed amoxicillin 500 mg to be taken three times a day for the patient.

The following morning, the patient’s condition had not improved.  Further conversations took place between Gastroenterologist A and/or his office staff and the patient’s wife.

At noon on 2/11/2011, the patient arrived at the hospital.

On 10/7/2014, Gastroenterologist A testified that there had been several telephone calls between his office and the patient’s wife on 2/10/2011 and 2/11/2011.  Further, he stated that he and/or his staff had impressed upon the patient’s wife the severity of the patient’s condition and that it was matter of life and death that the patient receive urgent medical attention, but that patient’s wife apparently failed to understand and/or take Gastroenterologist A’s comments seriously.

However, Gastroenterologist A did not document in the cart for the patient.  He did not document the frequency of the conversations, the information given to the patient’s wife, or his wife’s failure or refusal to understand the information.

At 1:30 p.m. on 2/11/2011, the patient was admitted to a hospital and was found to be critically ill with severe sepsis.

Gastroenterologist A consulted Gastroenterologist B, who performed an ERCP on the patient on 2/12/2011.  Gastroenterologist B found “clear evidence of a biliary obstruction as evidenced by darkly pigmented bile and extensive amounts of bloody liquid and sand-like material concerning for hemobilia.”  Gastroenterologist B diagnosed “biliary obstruction resulting in ascending cholangitis and sepsis” and placed a stent in the common bile duct.

On 2/12/2011, the patient passed away.

On 2/16/2011, Gastroenterologist A completed a two-page note in the patient’s medical chart entitled “Death Summary” and marked “Final Report, ” in which he made the following comments.

“Endoscopic retrograde cholangiopancreatography was performed 2 or 3 months ago … for common bile stone retrieval with stenting of the common bile duct … His condition continued to deteriorate.  During the night, his oxygen saturation began to deteriorate, suggesting acute respiratory distress syndrome.  He was intubated and put on the machine.  The blood pressure was kept on Dopamine and Neo-Synephrine.  But, in spite of this, on 2/12/2011 after all the resources have [sic] been pulled out, I have a hunch that he would not make it because of multiorgan [sic] failure.  Therefore, I called the family and explained the grave situation as best that I could.  The patient finally expired on 2/12/2011.”

Gastroenterologist A listed the final diagnosis as “septic shock, death.”

Gastroenterologist’s “Death Summary” for the patient contained no mention of the third ERCP, performed on 2/12/2011, or Gastroenterologist’s B diagnosis of biliary obstruction.

After a hearing, the State Medical Board concluded that Gastroenterologist A committed repeated negligent acts given failure to ensure timely removal of the temporary stent, failure to ensure that the patient had a clear understanding of the importance of timely removal of the temporary stent, failure to ensure that the patient had an understanding of the risks associated with performing the second ERCP and the possible warning signs to monitor after the procedure, and failure to maintain appropriate documentation of his care and treatment of the patient.

The State Medical Board placed Gastroenterologist A on probation with stipulations to complete a professionalism program, complete a medical record keeping course, complete 40 hours annually of continuing medical education for each year of probation, and undergo clinical practice monitoring with an emphasis on medical record keeping.  During probation, Gastroenterologist A was prohibited from performing ERCP procedures.

State: California


Date: May 2017


Specialty: Gastroenterology, Internal Medicine


Symptom: Fever


Diagnosis: Sepsis


Medical Error: Physician concern overridden, Delay in proper treatment, Failure of communication with patient or patient relations, Lack of proper documentation


Significant Outcome: Death, Hospital Bounce Back


Case Rating: 4


Link to Original Case File: Download PDF



California – Gastroenterology – Endoscopy In High Risk Patient With Esophageal Scleroderma Results In Complications



A 69-year-old male with diffuse systemic sclerosis, interstitial lung disease, end stage renal disease on hemodialysis, anemia, hypertension, hypoalbuminemia, secondary hypothyroidism, and gastric antral vascular ectasia (“GAVE”) had been referred to a gastroenterology clinic for evaluation of recurrent problems with weight loss and dysphagia.  It was assumed that the patient’s disease had progressed to esophageal scleroderma and that a percutaneous endoscopic gastrostomy (“PEG”) would be necessary to bypass his esophagus and would allow him to take in adequate nutrition without swallowing.  The patient was referred to the gastroenterology clinic for evaluation and a PEG.

On 6/25/2012, the gastroenterologist ordered a PEG, and she scheduled an esophagogastroduodenoscopy (“EGD” or upper endoscopy) and esophageal manometry for the afternoon of 6/25/2012, both elective, non-emergent diagnostic procedures, scheduled to be done on an outpatient basis.  On 6/23/2012 or 6/24/2012, the patient had been discharged from the hospital on antibiotics with home oxygen administration after treatment for aspiration pneumonia.

The gastroenterologist performed a pre-endoscopy history and physical examination in the early afternoon of 6/25/2012 and noted that the patient had active diffuse scleroderma complicated by renal crisis, diffuse systemic sclerosis, interstitial lung disease, GAVE with multiple cauterizations, and end stage kidney disease.  In past medical history, she listed “scleroderma renal crisis, “Started dialysis December 30, 2011,” and “Pneumonia. Admitted to er 6/24/12.”  She noted that the patient had had multiple upper endoscopies for gastrointestinal bleeding prior to this EGD.  Her physical examination listed “Lungs: Clear Auscultation. Clear percussion and Normal Symmetry and Expansion.”  She noted that she, not an anesthesiologist, was ordering sedation.

Sedation was to be administered by a registered nurse.  The gastroenterologist listed Airway as Class 2 and ASA Level (American Society of Anesthesiologists physical status classification system) as 3 (severe systemic disease).

On 6/25/2012 at 2:48 p.m. and ending at approximately 3:15 p.m., the gastroenterologist performed an upper endoscopy on the patient and took biopsies.  Nursing records indicate that sedation consisted of midazolam, 7 mg, administered over the 22 minutes; fentanyl, 175 mcg administered over the 22 minutes, and Cetacaine spray applied to the throat prior to the procedure.

The patient was transferred from the endoscopy procedure room to the recovery area under the care of a registered nurse.  The nurse noted that the patient was unresponsive to verbal and painful stimuli, with blood pressure 108/70, heart rate 86, and O2 saturation 89% on 2 liters delivered by nasal cannula.  A face mask was applied at 10 liters O2 and oxygen saturation went up to 97%.  When the gastroenterologist was notified, she ordered reversal medications: flumazenil 0.25 mg IVP over 15 seconds and Narcan 0.4 mg IVP at 3:40 p.m., and the patient was still unresponsive.  A second dose of flumazenil 0.25 mg IVP was given at 3:43 p.m., and the patient became responsive at 3:44 p.m.  Once the patient was responsive, the gastroenterologist performed the esophageal manometry procedure.  No time is entered in the medical record for this procedure although the gastroenterologist acknowledges that it was done and the results are recorded.

The gastroenterologist was later notified by nursing staff of concerns with the patient’s breath sounds, and the gastroenterologist noted stridor at 4:26 p.m.  She was notified at 5:19 p.m. that the patient’s oxygen saturation was 89% on 5 liters oxygen delivered by nasal cannula.  At 5:20 p.m., the gastroenterologist ordered a chest x-ray due to the inability to wean the patient off oxygen after the endoscopy.  A face mask was applied at 10 liters oxygen at 5:21 p.m., and oxygen saturation went up to 93%.  The chest x-ray indicated “a dense retrocardiac opacity and a left pleural effusion” and a “volume loss in the left lung with mild shift of the mediastinum towards the left.”

After the manometry procedure in the recovery room, the patient’s oxygen saturation was monitored, and when the oxygen saturation remained above 90% for 30 minutes on room air, the patient met endoscopy discharge criteria.  The patient was discharged home with instructions concerning any complications that might arise.

The gastroenterologist states that she arranged to admit the patient to the hospital, but the patient left against medical advice (AMA).  Neither notation of this nor a signed AMA release was found in the record.  Pathology results revealed gastritis and the manometry procedure revealed a condition consistent with esophageal scleroderma.

On 6/27/2012, the patient presented to the emergency department with shortness of breath and cough.  Chest x-ray showed new right lung patchy opacities, and the patient was cachectic.  He was admitted to the intensive care unit for treatment of pneumonia.  The admission diagnosis was “most likely persistent pneumonia, likely aspiration due to esophageal dysmotility.”  The patient failed to improve despite intensive hospital care.  Although the gastroenterologist had scheduled a PEG for 7/2/2012, it was decided that the patient would not go through with the procedure.  Instead, it was decided that the medical team would provide palliative care for the patient.

On 7/4/2012, the patient died with the cause of death listed as aspiration pneumonia due to esophageal dysmotility and end-stage scleroderma with severe malnutrition as a contributing factor.

The Board deemed the gastroenterologist’s conduct as falling below the standard of care for the following reasons:

1) The gastroenterologist failed to provide an accurate analysis of the patient’s suitability for the endoscopic and manometry procedures.

2) She classified the patient as an ASA Level 3, which denotes an individual with stable multiple system disease that limits daily activity without immediate danger of death.

3) At the time of the EGD and manometry done by the gastroenterologist, the patient had just been released from another hospital, where he had been treated for aspiration pneumonia and discharged on antibiotics and home oxygen.

4) By reason of the patient’s recent aspiration pneumonia and the necessity for home oxygen administration, his ongoing scleroderma renal crisis which necessitated hemodialysis, his persistent interstitial lung disease, and his frequent bleeding and cauterizations for GAVE, his condition was not stable, and elective procedures at this time were contraindicated.  The patient’s classification was clearly ASA level 4, which denotes an individual with severe, incapacitating disease, poorly controlled or end-stage, at risk for death due to organ failure.

5) The gastroenterologist failed to provide for an anesthesiology consultation, given the patient’s unstable and life-threatening condition, and instead elected to provide conscious sedation directed by the gastroenterologist and administered by a registered nurse.  The level of sedation administered to the patient during the upper endoscopy procedure was relatively large for an individual with so many co-morbid conditions, and an anesthesiologist or nurse anesthetist should have been in attendance.

6) Since both procedures were elective, the gastroenterologist failed to reschedule the procedures for a time when the patient was stable and able to tolerate conscious sedation directed by the gastroenterologist and administered by a nurse.

7) The patient had a very unstable post-procedure course in the recovery room.  He was unresponsive to verbal and painful stimuli and oxygen saturation was below 90%.  Reversal medications had to be administered before the patient became responsive.  When the patient became responsive, the gastroenterologist performed the esophageal manometry in the recovery room.  This procedure was unnecessary to determine the need for a PEG and further endangered the health of the patient.

8) The respondent approved sending the patient home with instructions after his oxygen saturation was above 93% for 30 minutes.  The patient was a very high-risk patient for elective procedures and had had a very unstable post-procedure course in the recovery room, including the development or exacerbation of pneumonia.  Under these circumstances, in conjunction with his numerous co-morbidities, it was unsafe to send the patient home.  There was no record found of the patient leaving the clinic AMA.

The Board issued a public reprimand against the gastroenterologist.  Stipulations included continuing medical education in the topics of pre-operative patient evaluation, informed consent, sedation, and medical record keeping.

State: California


Date: May 2017


Specialty: Gastroenterology, Hospitalist, Internal Medicine


Symptom: GI Symptoms (GERD, Abdominal Distention, Dysphagia), Cough, Shortness of Breath, Weight Loss


Diagnosis: Gastrointestinal Disease, Pneumonia, Pulmonary Disease


Medical Error: Unnecessary or excessive treatment or surgery, Failure of communication with other providers, Lack of proper documentation


Significant Outcome: Death, Hospital Bounce Back


Case Rating: 5


Link to Original Case File: Download PDF



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