Found 17 Results Sorted by Case Date
Page 1 of 2

California – Emergency Medicine – Spontaneous Movement And Loss Of Sensation Of The Left Arm



On 6/1/2015, a 65-year-old male with a history of hypertension, atrial fibrillation, hyperlipidemia, depression, and anxiety, visited his primary care physician (PCP) complaining of spontaneous movement and loss of sensation in his left arm.  On physical examination of this patient, his PCP identified a loss of coordination and sensation in the upper left extremities.  Three years prior, this patient had undergone a surgical C4 partial corpectomy and fusion of cervical level C4 and C5 for cervical cord compression with impaired gait.  On 6/1/2015, his PCP diagnosed intermittent left limb ataxia and transferred the patient to the emergency department of the Veterans Administration Medical Center.

In the emergency department, ED physician A diagnosed upper extremity neuropraxia after obtaining a CT scan of the cervical spine.  ED physician A also ordered an MRI for 6/4/2015 before discharging the patient.

On 6/2/2015, the patient returned to the emergency department.  The patient described to a triage nurse and a direct care nurse symptoms of worsening left arm numbness, light flashes, a change in depth perception, imbalance and overall feeling “a lot worse.”  Thereafter, ED physician B, who was the on-duty emergency physician, saw the patient.  ED physician B documented that the patient had recurrent loss of left upper extremity control and paresthesias and that the patient expressed fear that he was having a stroke and might die.  ED physician B’s medical note further stated that the patient had no vision changes and that his sense and strength were grossly intact.  ED physician B informed the patient that he would have to wait for his cervical MRI until 6/4/2015, and ED Physician B did not appear to complete a brain MRI for the patient.  ED physician B found the patient’s primary diagnosis to be anxiety.

After the patient’s discharge from the emergency department, he continued to have persistence of his symptoms.  The patient was ultimately referred to a neurologist who ordered a brain MRI on 7/27/2015, which showed right cerebral sub-acute watershed infarcts and an occluded right internal carotid artery.  The patient was transferred to a specialty stroke center for additional evaluation and treatment.

According to the Board, when ED Physician B undertook the care and treatment of the patient, a worried patient with substantial risk factors who returned to the emergency department less than 24 hours for progressing complex neurological symptoms, and failed to obtain an accurate history and review of systems.

In addition, the Board judged ED Physician B’s conduct of the patient to be below the minimal standard of care given his failure to perform an effective neurological examination of the patient, failure to perform indicated imaging studies, and failure to obtain a neurology consult.  The Board deemed ED physician B’s failures to collectively constitute an extreme departure from the standard of care.

The Board issued a public reprimand with stipulations to complete a continuing medical education course on the topic of patient communication and a course on medical record keeping.

State: California


Date: May 2017


Specialty: Emergency Medicine


Symptom: Numbness, Vision Problems, Weakness/Fatigue


Diagnosis: Ischemic Stroke


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


Significant Outcome: Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Emergency Medicine – Patient With Disorientation And Speech Difficulties Discharged After CT Scan Shows No Abnormalities



On 12/2/2013, a 42-year-old female presented to the hospital with complaints of disorientation and speech difficulties.

An ED physician examined the patient and ordered labs and a CT scan of the brain.  He also documented aphasia in the patient’s chart.  He discharged the patient after the CT scan revealed no abnormalities.

Several hours later, the patient experienced difficulty in chewing and swallowing while attempting to eat and subsequently presented to the emergency department.

The patient was diagnosed with having suffered a stroke.  The ED physician did not diagnose the patient with a possible transient ischemic attack (TIA).  He also did not administer aspirin to the patient.  He did not hospitalize the patient for further evaluation and treatment.

The Medical Board of Florida issued a letter of concern against the ED physician’s license.  The Medical Board of Florida ordered that the ED physician pay a fine against his license for the amount of $5,000 and pay reimbursement costs for the case for a minimum of $6,650.86 and a maximum of $8,650.86.  The Medical Board of Florida also ordered that the ED physician complete five hours of continuing medical education in diagnosing and/or treating stroke patients and five hours of continuing medical education in “risk management.”

State: Florida


Date: April 2017


Specialty: Emergency Medicine


Symptom: Confusion


Diagnosis: Ischemic Stroke


Medical Error: Diagnostic error, Improper medication management


Significant Outcome: Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



California – Interventional Radiology – Radiologist Uses Profanity And Hits Patient’s Hand In Anger During Procedure



On 5/4/2015, between 6:00 p.m. and 6:45 p.m., an interventional radiologist entered the hospital’s Room 9 to perform a cerebral angiogram.  The interventional radiologist intended to perform a procedure on the patient, a 99-year-old patient who had just suffered a stroke.  The cerebral angiogram procedure involves the practitioner gaining access to the patient’s femoral artery, near the patient’s groin, by inserting and threading a catheter from the patient’s femoral artery to the brain.  The catheter absorbs and/or extracts any blood clots and can control bleeding in the patient’s brain.

Previously, between 5:30 p.m. and 5:50 p.m., three female ancillary staff, namely Registered Nurse (RN) A, Technician A, and Registered Nurse B, prepared both Room 9 and the equipment in Room 9 for the medical procedure.  In addition, ancillary staff prepared the patient by restraining the patient’s head and hands to the surgical table, as well as covering portions of her body with drapes.  When the interventional radiologist entered the room, he was immediately upset that the ultrasound machine was not fully ready and had not been placed by the patient’s head.  The interventional radiologist yelled, using profanity, at Technician A, regarding the fact that the ultrasound machine was not ready.

As the procedure began, the interventional radiologist started to gain access to the femoral artery to insert a guide wire into the femoral artery, near the patient’s groin, while the patient was lying on a table with her head taped to the table and her right arm was restrained to a board.  At that time, the patient managed to move or wriggle her hand toward her groin, a sterile field where the interventional radiologist was trying to insert the guide wire.  The interventional radiologist immediately grabbed the patient’s right arm with his hands and yelled at the patient, “God Damn It!  Don’t F—— Move!  I Said Don’t Move.”  The interventional radiologist was standing to the side of the patient when he then took the patient’s right hand and hit it with his closed fist hard.  The patient was not yet sedated and she cried out in pain.  The interventional radiologist then yelled at Technician A, “Look at what you made me do!  This is all your fault.”

After the hitting incident occurred, but during the procedure, a charge nurse came into the room to make her observations.  As the charge nurse was Technician A’s supervisor, Technician A wrote on a piece of paper, “He hit the patient” and gave the note to the charge nurse.  The charge nurse then left the room.  This note exchange occurred approximately between 6:45 p.m. and 6:55 p.m.

Once the procedure was completed, the interventional radiologist requested to look at the patient’s right hand.  Staff removed the drape over the hand and observed that the hand was bleeding and bruised.  The interventional radiologist ordered that the hand be x-rayed.  Later, the interventional radiologist returned to the room and told staff that he had informed the son how his mother had received the injury.  However, the interventional radiologist’s version as told to the son was that he had grabbed the patient’s hand and not that he hit her hand with a fist.  The interventional radiologist never documented in the patient’s chart that the bruising and bleeding of the hand occurred at all nor how it occurred.

The interventional radiologist’s conduct of swearing at the patient when she moved her hand constituted an extreme departure from the standard of care.  The interventional radiologist’s act of hitting the patient’s right hand with his closed fist also constituted an extreme departure from the standard of care.

The Board issued a public reprimand against the interventional radiologist.  Stipulations included enrolling in a course on anger management and a course on professionalism.

State: California


Date: February 2017


Specialty: Interventional Radiology


Symptom: N/A


Diagnosis: Ischemic Stroke


Medical Error: Ethics violation, Failure of communication with patient or patient relations


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Family Medicine – Weakness Of The Left Hand And Slurred Speech For Three Weeks



On 8/14/2014, a 54-year-old male presented to an urgent care clinic with complaints of weakness in his hands and slurred speech for three weeks.

The patient was initially seen by a triage nurse who noted weakness in the left hand, affected speech, and feeling “stroke-like symptoms.”

The patient’s checklist listed “stroke symptoms” as a concern to be addressed by the family practitioner.

The family practitioner reportedly did a complete neurological exam of the patient with the family practitioner noting weakness as the only finding.

There was a later note by the family practitioner that the neurological exam was normal.

The family practitioner diagnosed the patient with a transient ischemic attack (“TIA”).

The family practitioner also diagnosed the patient with an allergic reaction and increased blood pressure.

The family practitioner treated the patient for the allergic reaction and increased blood pressure but never treated the patient for the TIA.

The next morning, the patient went to an emergency room due to inability to walk.

The patient was diagnosed with a massive cerebral infarction.

The patient became severely incapacitated and had to reside at an assisted living facility.

The Medical Board of Florida judged the family practitioner’s conduct to be below the minimal standard of competence given that he failed to treat the TIA and/or make an urgent referral to a facility for further evaluation including neuroimaging, cervical cephalic vasculature imaging, cardiac evaluation, statin medication, and blood pressure management.

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

State: Florida


Date: February 2017


Specialty: Family Medicine, Internal Medicine


Symptom: Weakness/Fatigue


Diagnosis: Ischemic Stroke


Medical Error: Underestimation of likelihood or severity, Referral failure to hospital or specialist


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 3


Link to Original Case File: Download PDF



California – Vascular Surgery – Second CEA Finds Neointimal Hyperplasia And Results In Complications



An 80-year-old male patient first presented to a vascular surgeon on 3/4/2010 for a consultation.  He had a previous history of stroke and left CEA eight years prior. The patient did not report any transient ischemic attacks, syncope, or new weaknesses.  The patient had residual weakness in his right arm, but otherwise functioned well.

A CDUS on 2/11/2010 revealed 50% to 69% stenosis of the right internal carotid artery and 80% to 90% restenosis of the left internal carotid artery, with peak velocities over 600 cm/sec.  The vascular surgeon noted that he discussed the option of carotid stenting with the patient, but that the patient wanted to have a second CEA. The vascular surgeon did not obtain any additional imaging studies.

On 3/19/2010, the vascular surgeon performed a “re-do” left CEA on the patient.  He noted that it was a long and difficult operation. Instead of plaque, which can be removed, the vascular surgeon found neointimal hyperplasia, which cannot.  A classic CEA was therefore not performed; instead, the vascular surgeon widened the artery using a patch angioplasty.

There was no indication in the patient’s medical record that an assistant was present for surgery.  The vascular surgeon did not obtain a complete study following the procedure. At 10:30 p.m., the vascular surgeon made the first post-operative note containing status information, such as that the procedure was a left CEA re-do, with a Dacron patch repair with no complications.  He also noted that the patient’s right arm was slightly weaker than his left from an old stroke, and that “this is his baseline.” At 11:30 p.m., approximately one hour after the surgery, the vascular surgeon noted that the patient was slow to wake in the recovery room; had occasional left arm and leg movement, but the right side was quiet; that he was not yet responding to verbal commands; and that he had an interrupted breathing pattern.  These observations were consistent with a stroke. The vascular surgeon testified that he consulted with a neurologist and intensivist (the physician assigned to the intensive care unit, or ICU) in the early morning hours, and it was decided that the patient would remain in the ICU and receive intravenous heparin (a blood thinner) with the hope of dissolving the clot that was blocking the flow to the brain and preventing further clot formation.  The vascular surgeon, however, did not document a treatment plan and made no further chart notes until the following day.

Another physician ordered a CT imaging study at 4:35 a.m., the next morning, which showed an occluded left carotid artery.  A CDUS taken 3/20/2010 showed complete occlusion of the left common and internal carotid arteries. A CT scan of the patient’s head on 3/21/2010 showed a massive stroke.  The patient died on 3/23/2010. The vascular surgeon’s operative report stated that it was dictated on 4/7/2010.

The vascular surgeon committed gross negligence and the failure to maintain adequate and accurate records in the following respects: he did not obtain appropriate imaging studies, such as a CT angiogram, prior to performing the CEA; he did not provide proper counseling to the patient prior to surgery; intraoperatively, the vascular surgeon failed to obtain and document a completion imaging study in the operating room at the conclusion of the operation; postoperatively, when it was observed that the patient had neurologic deficits, the vascular surgeon failed to properly evaluate, diagnose, or exclude a technical problem, and the standard of care is to manage the problem immediately, with either urgent carotid duplex study or re-exploration of the carotid; and his failure to dictate his operative report in a timely manner, his failure to document the presence of an assistant during the procedure, his failure to document a completion study, and his failure to document a treatment plan when neurological deficits were observed constituted unprofessional conduct.

For this allegation as well as others, the Medical Board of California ordered that the vascular surgeon’s license be revoked and be placed on probation for five years. During this time, he was to attend a PACE program, a medical record keeping course, a CME education course, be assigned a practice monitor, and was prohibited from engaging in the solo practice of medicine as well as supervising physician assistants.

State: California


Date: December 2016


Specialty: Vascular Surgery


Symptom: Weakness/Fatigue


Diagnosis: Ischemic Stroke, Post-operative/Operative Complication


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


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



California – Vascular Surgery – Patient Undergoes Left CEA And Then Right CEA Resulting In Complications



A 66-year-old woman saw a vascular surgeon for a consultation in 2010.  She had a prior history of stroke. On 8/13/2010, the vascular surgeon performed a left CEA.  On 10/5/2010, he performed an abdominal aortic and bilateral iliac balloon angioplasty. The patient was a continuing patient of the vascular surgeon, and he asserted that he knew her well.

On 12/16/2010, the patient saw the vascular surgeon for a follow-up examination, and a CDUS taken on 12/10/2010 was discussed.  The report showed 70-80% stenosis in the patient’s right internal carotid artery. The vascular surgeon wrote to the patient’s physician that the report showed “progressive stenosis of the right side, now approaching 80%.”  She was asymptomatic. He recommended a right CEA, and the patient agreed.

The vascular surgeon performed a right CEA on 1/31/2011-2/1/2011.  In one operative report, in the Indication section, the vascular surgeon wrote that the patient had multiple cardiovascular problems, including bilateral carotid disease.  She had a previous stroke that involved weakness of her left arm and leg. Symptoms mostly had resolved over the years. She more recently had a left carotid endarterectomy for severe internal carotid artery stenosis and now was brought in for elective right carotid endarterectomy for a greater than 80% right internal carotid artery stenosis.  The procedure went well, but postoperatively, the patient evidenced a neurological deficit. A CDUS was obtained that showed compromised flow. The vascular surgeon undertook a re-exploration that was very difficult. He found the patient’s artery to be “friable;” it was very fragile, thin, and falling apart. He used a saphenous vein from her left ankle to replace a segment of the artery and inserted a self-expanding stent.

The vascular surgeon did not obtain a completion study after the procedure.  In another operative report in the Indications section, the vascular surgeon wrote that the patient experienced a good post-operative result from the left CEA and that “She also now has a progressing, now about 80%, right carotid stenosis.”  On 2/2/2011, the patient died following a stroke. In a death summary, the vascular surgeon wrote that the patient had “progressive stenosis now of the right side….”

The vascular surgeon’s care of the patient constituted gross negligence, and the failure to maintain adequate and accurate records in the following respects: he inaccurately and inconsistently reported the patient’s carotid duplex results, including the degree of stenosis; he inaccurately reported that the patient’s carotid duplex showed progressive stenosis of the right carotid artery; and postoperatively, the vascular surgeon failed to obtain a completion imaging study in the operating room at the conclusion of the second operation, which is an extreme departure from the standard of care.

For this allegation as well as others, the Medical Board of California ordered that the vascular surgeon’s license be revoked and be placed on probation for five years. During this time, he was to attend a PACE program, a medical record keeping course, a CME education course, be assigned a practice monitor, and was prohibited from engaging in the solo practice of medicine as well as supervising physician assistants.

State: California


Date: December 2016


Specialty: Vascular Surgery


Symptom: Weakness/Fatigue


Diagnosis: Ischemic Stroke, Post-operative/Operative Complication


Medical Error: Procedural error, Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Lack of proper documentation


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Family Medicine – Patient With Blood Coagulation Disorder Has Anticoagulation Improperly Managed For A Dental Procedure



A patient was diagnosed with a hypercoagulable disorder and was on Coumadin prior to being treated by a family practitioner.

On 1/12/2015, the patient had his INR level checked.  It was noted to be subtherapeutic.  The patient’s Coumadin dosage was increased.  He was advised to have it rechecked in two weeks.

On 1/21/2015, the patient’s dentist requested medical clearance from the family practitioner for dental surgery.  The family practitioner indicated to the dentist that it was acceptable to stop Coumadin six days before surgery, and the patient was given medical clearance.

On 1/29/2015, the patient went to the family practitioner ahead of dental surgery.  The family practitioner discovered that the patient had not yet stopped the Coumadin, even though it should have been stopped two days previously for the upcoming 2/2/2016 scheduled surgery.  The family practitioner then advised the patient to restart the Coumadin the day of the surgery.

The family practitioner never reviewed the patient’s INR levels before the surgery, especially once he knew the Coumadin had not been stopped in time.  The family practitioner never provided bridging therapy, before or after the surgery.

On 2/2/2015, the patient had the dental surgery.  The patient restarted Coumadin on the instructions of the family practitioner.

That afternoon, the patient had bihemispheric strokes resulting in encephalopathy, seizures, and respiratory failure, ultimately leading to death.

An INR level taken in the hospital that evening indicated a non-therapeutic level for a blood clotting disorder.

The Medical Board of Florida judged the family practitioner’s conduct to be below the minimal standard of competence given that he failed to check the INR levels more closely and provide bridging therapy for the blood coagulation disorder.

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

State: Florida


Date: September 2016


Specialty: Family Medicine, Internal Medicine


Symptom: N/A


Diagnosis: Ischemic Stroke, Hematological Disease


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


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



California – Cardiology – Confusion, Fever, And Worsening Procedural Site After Right Femoral Artery Graft



On 12/21/2012, a 57-year-old male had a stent procedure.  Complications arose, and on 12/27/2012, the patient returned to the emergency department with complaints of right lower extremity pain, numbness, and increasing inability to move his right lower extremity.  An on-call cardiologist diagnosed a blood clot in the patient’s femoral artery of the right leg and took the patient to surgery in order to place a graft to open the artery to give the leg circulation. During the surgery, the cardiologist also performed a right femoral artery exploration, a right common femoral endarterectomy and patch, and a right femoral to above knee popliteal artery bypass.

On the fourth post-surgical day, 12/31/2012, the patient was noted to be confused and had an atrial fibrillation rhythm, by telemetry, which then returned to a normal rhythm the next day.  On 1/1/2013, the patient had a swollen surgery site and complained of sweats and shakes. A low-grade fever was noted in the record. On 1/2/2013, there was documentation of increased erythema and drainage from the right groin wound.  Wound cultures were obtained, which demonstrated large numbers of gram-negative species present. The patient was again suffering from confusion, which combined with the bacterial culture result, were clues to the patient suffering from systemic and graft infection.

On 1/5/2013, the patient was combative.  A CT scan was performed, which identified fluid collection with bubbles.  On 1/5/2012, the nurse notes documented a worsening wound. On 1/6/2013, the patient had a stroke while attempting to access the bathroom in his hospital room.  Thereafter, from 1/9/2013 through 1/13/2012, the wound continued to worsen without any action by the cardiologist to remove the graft. On 1/14/2013, the patient was transferred to a rehabilitation center, but he had a fever, was delirious, and had an infected site.  The patient had to be transferred back to the hospital on 1/16/2013 because of uncontrollable bleeding from the wound. On 1/17/2013, another vascular surgeon removed the graft from the patient and performed a right Sartorius myoplasty in order to address the infection.

The Medical Board of California judged that the cardiologist’s conduct departed from the standard of care because he failed to recognize and diagnose the signs of serious infection, adequately treat the patient’s graft infection, and remove the graft during the patient’s first hospital stay.

The Medical Board of California placed the cardiac surgeon on probation for 2 years and ordered the cardiac surgeon to complete an education course for at least 40 hours in the first year of probation.

State: California


Date: August 2016


Specialty: Cardiology


Symptom: Numbness, Confusion, Fever, Extremity Pain, Swelling, Weakness/Fatigue, Wound Drainage


Diagnosis: Procedural Site Infection, Acute Ischemic Limb, Cardiac Arrhythmia, Ischemic Stroke


Medical Error: Diagnostic error, Failure to examine or evaluate patient properly, Improper treatment


Significant Outcome: Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



Arizona – Neurosurgery – Carotid Endarterectomy Complicated By Ulcerative Plaque Eroding Through Posterior Wall Of Carotid Artery



A 65-year-old woman was admitted to the hospital after presenting with symptoms consistent with a stroke.  She was found to have significant carotid disease and incidental aneurysms.

On 02/06/2014, the neurosurgeon performed a carotid endarterectomy.  The operative note reported ulcerative plaque eroding through the posterior wall of the carotid artery, which the neurosurgeon was unable to repair.  Consequently, the neurosurgeon surgically occluded the carotid artery.  The woman sustained a significant stroke and resultant hemiplegia.  The Medical Consultant of the Board opined that other methods could have been attempted, such as a patch graft or some form of an interposition graft.

State: Arizona


Date: December 2015


Specialty: Neurosurgery


Symptom: N/A


Diagnosis: Post-operative/Operative Complication, Ischemic Stroke


Medical Error: Improper treatment, Procedural error


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 2


Link to Original Case File: Download PDF



Arizona – Neurosurgery – Endovascular Treatment Of Aneurysm In Elderly Patient



An 81-year old-woman presented on 12/21/2013 with a subarachnoid hemorrhage.  She was found to be in a critical neurologic state and was intubated.  Initially, the neurosurgeon elected to treat the patient with expectant management.  However, the patient improved neurologically, and the neurosurgeon elected to endovascularly treat the aneurysm.

On 12/25/2013, the procedure was performed and was complicated by a thrombus in the carotid artery extending to the middle cerebral artery and anterior cerebral artery.  As a result, the patient sustained a major stroke.

On 12/27/2013, the patient expired.

The Medical Consultant of the Board stated that the neurosurgeon should not have first angiographically studied the non-ruptured aneurysm, which subjected the patient to a lengthier procedure with increased risk of stroke.  The Medical Consultant also stated that the neurosurgeon’s overall daily notes were not detailed with respect to the plan and discussion with the patient’s family.

In addition, the Board judged the neurosurgeon’s conduct to be below the minimum standard of competence given treatment of an elderly patient with aneurysmal subarachnoid hemorrhage as they have a mortality rate of greater than 60%.

State: Arizona


Date: December 2015


Specialty: Neurosurgery


Symptom: N/A


Diagnosis: Post-operative/Operative Complication, Intracranial Hemorrhage, Ischemic Stroke


Medical Error: Improper treatment, Lack of proper documentation, Procedural error


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



Page 1 of 2