Found 176 Results Sorted by Case Date
Page 3 of 18

Florida – Radiology – Failure To Diagnose Subdural Hematoma From Radiology Report



On 10/27/2015, a patient presented to the emergency department after suffering a fall.

An emergency department physician ordered a computerized tomography (CT) scan of the patient’s head.

Radiologist A reviewed the CT scan.  Radiologist A failed to recognize or failed to report the presence of a significant subdural hematoma.  Radiologist A erroneously reported that the CT scan showed no acute intracranial abnormalities.

The patient’s wounds from the fall were treated, and the patient was discharged home.  That night, the patient became unresponsive at home and was transported back to the hospital.

A second CT scan was performed and was reviewed by Radiologist B.  Radiologist B compared the second CT scan to the first CT scan performed earlier that day.

Radiologist B noted that the first CT scan showed a 6 mm hematoma.  He reported that the second CT scan showed that the hematoma had markedly increased in size to 28 mm since the first scan taken approximately six hours before.

The patient expired the morning of 10/28/2015, due to complications from an acute subdural hematoma.

The Board judged Radiologist A’s conduct to be below the minimal standard of competence given that she failed to recognize and report any significant abnormalities present on a patient’s CT scan.

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

State: Florida


Date: June 2017


Specialty: Radiology


Symptom: N/A


Diagnosis: Intracranial Hemorrhage, Trauma Injury


Medical Error: False negative


Significant Outcome: Death, Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Family Medicine – Failure Of Pain Management In A Patient With Cervical Discogenic Disease, Lumbar Discogenic Disease, And Myofascial Pain Syndrome



From 8/11/2011 to 8/12/2013, a family practitioner treated a 48-year-old female, with a prior history and diagnosis of cervical discogenic disease, lumbar discogenic disease, and myofascial pain syndrome.

During the treatment period, the family practitioner carried these diagnoses from the patient’s prior healthcare provider without obtaining, or did not document obtaining, a complete medical history and/or physical examination for the patient to support these diagnoses.

The family practitioner did not perform, or did not document performing, diagnostic testing and imaging studies, such as MRIs, x-rays, and CT scans of the cervical spine and/or lumbar spine in support of the continued diagnosis of cervical discogenic disease, lumbar discogenic disease, and myofascial pain syndrome for the patient.

The family practitioner prescribed the controlled substances Duragesic, Roxicodone, and Xanax to the patient on one or more occasions.  He did not obtain, or document obtaining a history of substance abuse including illicit substances from the patient before prescribing Duragesic, Roxicodone, and Xanax.

The family practitioner did not adequately assess the patient’s complaints and symptoms.  He did not document the nature and intensity of the patient’s pain, current and past treatments of the pain, as well as any underlying or coexisting disease or conditions that affected the pain on the physical and psychological function of the patient.  He also did not perform a complete physical examination specific to the areas of the patient’s complaints.  The family practitioner did not document the location, duration, frequency or character of the patient’s pain, including alleviating and/or aggravating symptoms.

The family practitioner did not maintain complete and accurate records of the patient’s medical history, physical examinations, diagnostic therapeutic testing, evaluations, consultations, treatment objectives and/or treatments.  He did not evaluate, or document evaluating the effectiveness of his treatment plan for the patient.

The family practitioner did not adequately monitor the patient’s medication use to prevent noncompliance, dependence, addiction, or diversion of controlled substances.

The family practitioner failed to maintain thorough and accurate records which would have helped identify the patient as a violator of the controlled substance program, and at being high risk for diversion of pain medication and controlled substances.  He also did not perform, or document performing, frequent urine drug screenings for the patient after she violated the terms of the controlled substances contract on one or more occasions.

The family practitioner did not refer, or document referring, the patient to a pain management physician for proper evaluation after she violated the terms of the controlled substance contract on one or more occasions.

On 4/12/2013, the family practitioner wrote the patient prescriptions for Duragesic, Roxicodone, and Xanax without having evaluated, and/or documented seeing or evaluating the patient.  The patient died from an overdose.  An autopsy performed on the patient revealed the case of death as “fentanyl toxicity.”

The Board judged the family practitioners conduct to be below the minimal standard of competence given that he failed to obtain a complete medical history and/or physical examination from the patient’s prior healthcare provider(s) to support his diagnoses of cervical discogenic disease, lumbar discogenic disease, and myofascial pain syndrome.  He also failed to perform additional diagnostic testing such as MRIs, x-rays, and CT scans, of the patient cervical spine and/or lumbar spine to support the history, physical examination, and the patient’s prior diagnosis of cervical discogenic disease, lumbar discogenic disease, and myofascial pain syndrome.  He failed to obtain a history of substance abuse, including illicit substances before prescribing Duragesic, Roxicodone, Xanax on one or more occasions.  The family practitioner did not assess the patient’s complaints and symptoms and perform a complete physical examination specific to the areas of the complaint.  He did not perform a physical examination to support his treatment and evaluate the effectiveness of his treatment plan for the patient.  The family practitioner should have written prescriptions for the patient only after seeing and evaluating her.  He also should have adequately monitored the patient’s medication use to prevent noncompliance, dependence, addiction, or diversion of controlled substances and perform frequent urine drug screens for the patient after she violated the terms of the controlled substances contract on one or more occasions. He should have referred the patient to a pain management physician for proper evaluation after the patient violated the terms of the controlled substance contract on one or more occasions.

It was requested that the Board 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 Board deemed appropriate.

State: Florida


Date: June 2017


Specialty: Family Medicine, Internal Medicine


Symptom: Pain


Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Drug Addiction, Spinal Injury Or Disorder


Medical Error: Improper medication management, Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Referral failure to hospital or specialist, Failure to properly monitor patient, Lack of proper documentation


Significant Outcome: Death


Case Rating: 2


Link to Original Case File: Download PDF



California – Neurology – Diagnostic Errors When Evaluating Neck Pain, Back Pain, And Headaches After A Motor Vehicle Accident



On 2/28/2012, a 27-year-old male presented to a neurologist with chief complaints of neck, lower back, and headache following a motor vehicle accident that occurred approximately 3 weeks earlier.  The patient denied any loss of consciousness in the accident and gave no history of suffering a head trauma. The patient’s neurological examination was normal except for mild reflex asymmetry in the upper and lower extremities and a slow gait.  The neurologist noted moderate tenderness on palpation of the cervical paraspinal musculature with full range of motion, but no neck stiffness. The neurologist listed his diagnoses of the patient as: post-concussive headache/migraine syndrome; status post MVA and head injury; cervical spasm; lumbar spasm; and the neurologist wanted to rule out cervical and lumbar radiculopathy.

On this initial visit, the neurologist performed an in-office EEG for the patient’s headaches and “head injury,” but the patient never reported suffering a head injury in the accident, or any loss of consciousness or any seizure activity that would justify this study at this time.  The EEG was normal. The neurologist also performed an in-office EMG and NCV of both bilateral upper and lower extremities, testing 68 muscles, which the neurologist stated took approximately 1 hour. During the study, the neurologist obtained no response of bilateral tibial H-Reflexes.  The neurologist’s impression of the NCV was that the patient suffered from “right sided mild carpal tunnel syndrome” in the “bilateral upper extremities.” The test results, however, did not support the neurologist’s impression as the patient did not have the electrophysiological features for carpal tunnel syndrome.  The neurologist’s further impression was that the patient “possible S1 radiculopathy,” however, the test results did not establish a diagnosis of S1 radiculopathy.

The neurologist also ordered an MRI of the patient’s brain, cervical spine, and lumbar spine.  The neurologist also advised the patient to obtain physical therapy/occupational therapy or chiropractic treatment, but the neurologist failed to write a prescription for physical or occupational therapy and failed to refer the patient to a facility where he could obtain such treatments.

On this visit, the neurologist billed $550 for the office visit, $4,320 for the NCV, $380 for he H-Reflex amp study, $640 for the needle EMG, and $1,125 for the EEG, for a total single visit charge of $7,015.

On 3/6/2012, the patient returned for a follow-up visit complaining of increased neck, shoulder, and low back pain.  The neurologist’s list of diagnoses remained the same as the previous visit and appeared to be cut and pasted into the new chart note.  During this visit, the neurologist performed “Cervical and Lumbar trigger points” injections, but there was no report documenting this procedure in the certified chart, and the neurologist’s billing summary did not reflect a charge for this procedure on this date.

On 4/19/2012, the patient underwent an MRI of his brain and lumbar spine at an outside facility, which were interpreted as normal.  The cervical MRI, however, revealed a 3 to 4 mm left paramedian disc protrusion at C7-T1, degenerative changes at C2 to C6, and a 13 mm x 6 mm lesion in the left lobe of the thyroid gland consistent with thyroid adenoma or colloid cyst.

On 4/30/2012, the patient returned for a follow-up visit complaining of neck and shoulder pain.  The neurologist noted moderate tenderness on palpation of the cervical paraspinal musculature at C6 to C7, but the patient’s range of movement was within normal limits.  The neurologist’s diagnoses were post-concussive headache syndrome, status post MVA, and cervical and lumbar spasm.

The neurologist performed “Cervical Trigger point” injections at 6 different points, but there was no report documenting this procedure in the certified chart.  The neurologist also had the patient undergo an in-office carotid artery duplex scan even though the patient had no carotid bruits on examination, had no clinical evidence or history of vascular pathology involving the anterior circulation, nor any evidence or history of transient ischemic attack or other similar medical conditions, which would justify the scan.  The scan was completely normals. The neurologist charted that he asked the patient to go to “intense physical therapy” and told the patient that his symptoms were mostly due to spasm due to “cervical acute disc herniation.” The patient, however, did not have a herniated cervical disc.

On this visit, the neurologist billed $1,350 for the in-office carotid artery duplex scan, $950 for the trigger point injections with ultrasound guidance (for which there was no procedure report), $415 for interpreting the outside MRI of the spinal canal, and $415 for interpreting the MRI of the brain, which had been reported by the outside facility to be normal.

On 5/2/2012, the patient returned for another follow-up visit complaining of pain with spasm in his neck and shoulder area.  The neurologist charted that the patient stated the injections from 2 days earlier and the new medication helped relieve his pain, but it returned last night.  The neurologist noted neck pain and spasm in the midscapular area with “back pain/spasm but less.” The neurologist, however, did not explain how the patient’s back pain was less since on the prior visit, 2 days earlier, the patient had no back complaints.  The neurologist’s list of diagnoses were identical to those listed on the patient’s initial visit on 2/28/2012, including the status post “head injury” and ruling out “cervical and lumbar Radiculopathy,” which appeared to be copied and pasted from the February note.

On 5/18/2012, the patient returned for another follow-up visit complaining of severe neck pain.  The neurologist noted moderate tenderness in the cervical paraspinal muscles at C4 to C7, and moderate tenderness in the paraspinal muscles at L2 to S1, but the patient had no back complaints on this visit.  The neurologist’s list of “current” diagnoses were identical to those listed on the patient’s initial visit on 2/28/2012, including the status post “head injury,” “lumbar spasm,” and ruling out of “lumbar Radiculopathy,” which appeared to be cut and pasted from the initial visit in February.  In his unsigned cervical injection procedure report, the neurologist listed the patient’s diagnoses as cervical radiculopathy, cervical spinal stenosis, intractable migraine, post concussion headache, and cervical muscle spasm, but here was no evidence in the certified chart that the patient suffered from all these conditions.

On 5/30/2012, the patient returned for a further follow-up visit complaining of neck pain radiating into his left shoulder.  The neurologist’s review of systems was identical to that of the previous visit, including the misspelling, and appeared to have been copied and pasted from the prior note.  The neurologist noted back pain and spasms even though the patient had no back complaints on this visit and no tenderness was found upon examination.

The neurologist performed another NCV/EMG of the patient’s bilateral upper extremities, but there had been no significant change in the patient’s condition to justify repeating this test.  The neurologist’s impression was that the patient had bilateral cervical radiculopathy at C5-C7, inter alia, but the test results did not support the neurologist’s impression for radiculopathy.

For all the previous appointments, the neurologist’s plan was to order physical therapy for the patient, but there as no prescription or order found in the certified chart indicating that the neurologist ordered or prescribed physical therapy on this visit.

On 6/13/2012, the patient returned for another follow-up visit complaining of increased neck pain radiating into his left shoulder.  The neurologist’s review of systems was identical to the previous visit, including the misspelling, and noted back pain and spasms even though the patient had no back complaints on this visit.  In his unsigned procedure note, the neurologist performed a cervical thoracic facet steroid injection, under ultrasound guidance, but the corresponding ultrasound images listed a date of 6/14/2012.  The consent for the procedure was not signed by the patient, and there was no explanation in the certified chart indicating why someone else signed the consent for the patient, who was alert and talking with the neurologist during the visit.  On this visit, the neurologist wrote a prescription for the patient to receive physical or occupational therapy.

On 6/27/2012, the patient returned for another follow-up visit with improved neck pain, but now complained of back pain and spasm.  The neurologist’s review of systems was identical to the previous visit, including the misspelling, and it appeared to have been copied and pasted from the prior note.  The neurologist noted moderate tenderness in the paraspinal musculature at L2-S1, but the patient’s range of motion was normal. The neurologist also recorded ankle jerks upon examination.  The neurologist performed another NCV/EMG of the patient’s bilateral extremities, which the neurologist interpreted as showing bilateral radiculopathy at L5 and S1, but the test results did not support a diagnosis of radiculopathy.  The neurologist again obtained no responses of the bilateral tibial II-Reflexes, demonstrating improper placement of the electrodes or that these areas were not tested.

Throughout these appointments, the neurologist failed to order additional tests or studies concerning the thyroid lesion identified on the cervical MRI, and failed to refer the patient to an endocrinologist or other appropriate specialist for further evaluation and treatment of the thyroid lesion.

The patient ordered a repeat MRI of the patient’s lumbar spine and continued physical therapy, but there was no documentation in the certified chart that the patient was actually receiving physical therapy at this time.  This appeared to be the last time the patient saw the neurologist, but there was a LabCorp lab request form in the certified chart indicating that labs were collected on 6/13/2014 at 3:48 p.m., but there was no corresponding chart notes reflecting a patient visit on this date

The Medical Board of California judged that the neurologist’s conduct departed from the standard of care because he failed to accurately analyze and interpret the repeat in-office EMG/NCV studies performed, appropriately evaluate the large lesion identified on the cervical MRI and/or refer the patient to an endocrinologist or other appropriate professional for its evaluation and treatment, fully evaluate and initially treat the patient’s neck and back pain and headaches with conservative care and non-interventional treatment, initially order physical therapy for the patient while repeatedly performing invasive treatments, and overall fully, properly, and appropriately evaluate and treat the patient’s complaints.

For this case and others, the Medical Board of California revoked the neurologist’s license.

State: California


Date: June 2017


Specialty: Neurology


Symptom: Head/Neck Pain, Headache, Back Pain, Joint Pain


Diagnosis: Spinal Injury Or Disorder


Medical Error: Unnecessary or excessive diagnostic tests, Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, False positive, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Pain Management – Contrast And Steroid Injected Into The Intrathecal Space Instead Of The Epidural Space



Between February 2006 and September 2012, a patient presented to a pain specialist with complaints of chronic low back pain.

On one or more occasions between February 2006 and September 2012, the pain specialist assessed the patient with, among other things, low back pain, lumbago, osteoarthritis, lumbar failed back surgery syndrome, lumbar radiculopathy, and lumbar muscle spasms.

On 9/28/2012, the patient presented to the pain specialist in order for him to perform a lumbar transforaminal epidural steroid injection with catheter and fluoroscopy.  Epidural administration is a medical route of administration in which a drug or contrast agent is injected into the epidural space of the spinal cord.

During the procedure, the pain specialist inserted the tip of the catheter through the patient’s epidural space and into the patient’s intrathecal space.  Intrathecal administration is a medical route of administration in which a drug or contrast agent is injected into the spinal canal, or into the subarachnoid space so that it reaches the cerebrospinal fluid.

During the procedure, the pain specialist injected contrast and injectate into the patient’s intrathecal space instead of the patient’s epidural space.

The pain specialist did not obtain an intra-injection lateral view epidurogram to confirm the location of the catheter tip and/or the dispersal pattern of the contrast and injectate.

The pain specialist did not obtain a post-injection lateral view epidurogram to confirm the location of the catheter tip and/or the dispersal pattern of the contrast and injectate.

The pain specialist did not recognize that he had performed an intrathecal injection instead of an epidural injection.

After the procedure, the patient complained of bilateral hip and leg pain, numbness, and paralysis.

The patient was transferred to a hospital where she was ultimately diagnosed with conus medullaris syndrome.

It was requested that the Medical Board of Florida order one or more of the following penalties for the pain specialist: 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: June 2017


Specialty: Pain Management, Anesthesiology


Symptom: Back Pain, Numbness, Extremity Pain, Pelvic/Groin Pain, Weakness/Fatigue


Diagnosis: Post-operative/Operative Complication, Spinal Injury Or Disorder


Medical Error: Wrong site procedure, Lack of proper documentation, Procedural error


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 3


Link to Original Case File: Download PDF



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



Arizona – Internal Medicine – Managing A Patient Using Alternative Medicine As Opposed To Allopathic Medicine



In November 2009, an 87-year-old man, who was Physician A’s family member, began seeing Physician A for hypotension, autonomic dysfunction syndrome, osteoarthritis, hypothyroidism, and “hormonal imbalance.”  Physician A prescribed over-the-counter herbs and supplements, prescription strength hormonal replacement therapy, and acupuncture treatments.

On 02/20/2011, the patient suffered a right frontal hemorrhagic stroke with residual left hemiplegia. Physician A took the patient to the hospital after 12 hours of initial symptoms.  Physician A said that no neurologist was available at the local hospital and the weather made it hazardous for him to drive at that time.

On 09/22/2014, an osteopathic provider Physician B saw the patient.  He advised that the patient take his blood pressure medications on a regular basis as opposed to as needed as recommended by the Physician A.  Physician B recommended albuterol for dyspnea and a follow up spirometry.  He also recommended tamsulosin in addition to saw palmetto for benign prostatic hypertrophy.

In August 2016, Physician A was removed as the patient’s primary medical provider.

The Board judged Physician A’s conduct to be below the minimum standard of competence given failure to obtain written consent regarding the treatment plan, which involved over-the counter medicines, herbs, and an absence of allopathic treatment.

Physician A did not monitor the patient’s TSH.  He prescribed magnesium when the patient had chronic kidney disease and did not monitor the patient’s magnesium levels.  He prescribed iron supplements when there was no documentation that the patient suffered from iron deficiency.  He prescribed Natto and other supplements which had blood thinning effects and could have lead to the hemorrhagic stroke along with uncontrolled hypertension.

He prescribed testosterone when the patient had an elevated PSA level and uncontrolled hypertension.

The Board issued a Decree of Censure and placed Physician A on probation for 1 year.  He was ordered to complete the Professional/Problem-Based Ethics program offered by the Center of Personalized Education for Physicians for Ethics and Boundaries.

State: Arizona


Date: May 2017


Specialty: Internal Medicine


Symptom: N/A


Diagnosis: Intracranial Hemorrhage


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


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 1


Link to Original Case File: Download PDF



New York – Internal Medicine – Chronic Fatigue, Disturbed Sleep, Joint Pains, Nausea, Diarrhea, And An Abnormal MRI Diagnosed As Chronic Fatigue Syndrome



From 10/15/1998 to 3/7/2008, Physician A treated a 38-year-old female who presented with complaints of severe fatigue, disturbed sleep, irritability, joint pains, frequent sore throats, nausea, and diarrhea.  At her initial visit, the patient reported that 9 years earlier she had been told she had a borderline Lyme test and was treated with antibiotics.  In the past 5 years, she had frequent bouts of fatigue and was diagnosed with Chronic Fatigue Syndrome.

In December 1998, the patient was seen by a neurologist who, based on an abnormal MRI, recommended a lumbar puncture but one was not done.  In June 1999, the patient had an abnormal brain SPECT.  In January 2002, the patient had her first and only physical examination at Physician A’s practice.  In January 2008, ten years after the initial MRI, the patient had a second MRI, which was again abnormal.  A neurologist performed a lumbar puncture.

The results of the lumbar puncture were negative for Lyme disease but revealed positive oligoclonal band proteins which are consistent with the diagnosis of multiple sclerosis.

The Board judged Physician A’s conduct to have fallen below the standard of care given failure to take an adequate history of present illness, failure to obtain prior medical records, failure to perform a physical examination, failure to construct a differential diagnosis, failure of prescribing medications without appropriate medical conditions, failure to perform a lumbar puncture, and failure to timely diagnose the patient’s multiple sclerosis.

The Board charged Physician A with professional incompetence and gross negligence.

State: New York


Date: April 2017


Specialty: Internal Medicine, Family Medicine, Neurology


Symptom: Weakness/Fatigue, Nausea Or Vomiting, Joint Pain


Diagnosis: Neurological Disease, Autoimmune Disease


Medical Error: Diagnostic error


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Internal Medicine – Tissue Plasminogen Activator Administered To A Patient With A History Of Intracranial Hemorrhage



On 3/12/2014, a 78-year-old male presented to the medical center.  Upon admission, a brain CT revealed a history of intracranial hemorrhage.

On 3/15/2014, a stroke alert was called due to the belief that the patient had suffered a stroke, setting in motion a hospital protocol to check for stroke.

A stat CT scan revealed subacute or chronic left suboccipital stroke, which did not correspond with the patient’s acute symptoms.

An internist ordered a neuro consult and gave a history that did not include intracranial hemorrhage.  He ordered and confirmed tissue plasminogen activator (“tPA”) to be administered to the patient, which is contraindicated for patients with a history of intracranial hemorrhage.  He did not obtain an MRI of the brain.

The Medical Board of Florida judged the internists conduct to be below the minimal standard of competence given that he did not order an MRI of the brain since symptoms and the stat CT did not correspond.  He ordered tPA for a patient with a history of intracranial hemorrhage.  He also failed to give an accurate history of intracranial hemorrhage to the neurologist.

It was requested that the Medical Board of Florida order one or more of the following penalties for the internist: 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: April 2017


Specialty: Internal Medicine, Neurology


Symptom: N/A


Diagnosis: Neurological Disease


Medical Error: Improper medication management, Failure to order appropriate diagnostic test, Failure of communication with other providers


Significant Outcome: N/A


Case Rating: 2


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



Kansas – Physician Assistant – High Dosing Regimen Of Amitriptyline For A Pediatric Patient With Headache, Vomiting, And Incontinence



On 11/19/2015, a patient presented to a physician assistant at a family care clinic with chief complaints of headache, vomiting, and incontinence since 11/17/2015.  The patient’s father reported, in addition to the severe headache, the patient was experiencing involuntary arm jerking.  Furthermore, the night prior, the patient experienced hearing voices.

The patient had a history of respiratory problems, was noted to have “poor” functional status, and was noted to be in preschool.

The physician assistant did not complete a neurological examination; however, he diagnosed the patient with pediatric migraine and ordered thirty 10 mg tablets of amitriptyline with instructions for the patient to take one tablet three times daily and the patient was to have one refill.  The physician assistant did not perform a thorough workup to include additional studies or tests prior to prescribing amitriptyline.

On 2/3/2016, the Board received a response from the physician assistant wherein he indicated, “I recall little about the episode, except possibly after reviewing his chart and the nurses [sic] report, in investigating his headache and cyclic vomiting and physical exam in UpToDate that the treatment I initiated would have been per the UpToDate recommendations.”

UpToDate is an online website claiming to be an evidence-based, physician-authored clinical decision support resource.

The physician assistant inappropriately prescribed amitriptyline due to the excessive dose and age of the patient.

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

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

State: Kansas


Date: April 2017


Specialty: Physician Assistant, Family Medicine, Pediatrics


Symptom: Headache, Nausea Or Vomiting, Psychiatric Symptoms, Urinary Problems


Diagnosis: Neurological Disease


Medical Error: Improper medication management, Accidental Medication Error, Failure to examine or evaluate patient properly


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Page 3 of 18