Found 16 Results Sorted by Case Date
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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



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



California – Pediatrics – Long Term Regimen Of Compounded Dexamethasone Cough Syrup For Pneumonia And Asthma



On 1/13/2015, a pediatrician saw a child just short of her second birthday.  She had been diagnosed with asthma and was maintained on corticosteroid and albuterol inhalers.  The patient presented with fever, coughing, and loss of appetite.  Although she had taken an antibiotic prior to this visit, it is not noted in the pediatrician’s chart notes.  The pediatrician diagnosed pneumonia, laryngotracheobronchitis (croup), and asthma and prescribed a different antibiotic for her.

The pediatrician stated that she followed up with the patient by telephone on 1/14/2015 and 1/15/2015.  Based on these follow-up calls, the pediatrician prescribed compounded cough syrup at a daily dose containing 0.55 mg dexamethasone, a corticosteroid.  She prescribed a sufficient amount of the medication to last a month and when the patient’s mother said that she was afraid that the patient would begin to cough again because her entire family had caught the cold, the pediatrician called in a partial refill for the medication.  None of this information was included in the pediatrician’s chart notes for the patient.

The pediatrician’s chart notes for the patient’s follow-up visits on 1/20/2015 and 2/20/2015 did not make reference to the compounded cough medication, instructions on how to take the medication, or to the advice she gave the patient’s mother concerning weaning the patient off the medication.  Although the pediatrician stated that she was concerned about the patient’s reduced “immunity” and recommended an over the counter immune pediatric supplement for the patient on 2/20/2015, this concern was not documented in the patient’s chart notes.

The Board judged the pediatrician’s conduct to have fallen below the standard of care given failure to appropriately prescribe dexamethasone to the patient and given failure to document the follow-up telephone calls, the fact that she had prescribed the compounded cough medication to the patient, instructions for the patient to wean off the dexamethasone, concern for the patient’s reduced “immunity,” and the fact that the patient had taken antibiotics prior to her first visit with the patient.

A public reprimand was issued against the patient with stipulations to take a medical record keeping course.

State: California


Date: May 2017


Specialty: Pediatrics


Symptom: Cough, Fever


Diagnosis: Pneumonia, Asthma


Medical Error: Improper medication management, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



North Carolina – Physician Assistant – 10-Year-Old With Cough, Fever, High Blood Pressure, and Sore Throat Diagnosed With Strep Throat



The Board was notified of a professional liability payment made on 1/28/2016.

A 10-year-old presented to a physician assistant with a chief complaint of cough, headache, sore throat, and fever.  The patient’s blood pressure was elevated, 140/190, and she had a fever of 103.2 degrees F.  According to the history, the patient denied nausea, vomiting, or diarrhea.  In the physical examination, it was documented a normal respiratory assessment.  The patient was diagnosed with strep throat, prescribed amoxicillin, and the patient was discharged home.

The patient died two days later from pneumonia secondary to influenza infection, which was not listed in the differential diagnosis.

The Board expressed concern that the physician assistant did not consider influenza in the differential diagnosis, prescribed an antibiotic without identifying the pathogen responsible for the infection, and did not perform a blood pressure recheck for the patient’s hypertension.  The Board noted a failure to document providing adequate follow up instructions to the patient’s family enumerating red flag signs and symptoms which would prompt the family to return the child to a health care facility.

The Board issued a public letter of concern, which was reported to the Federation of State Medical Boards.  It was not reported to the National Practitioner Data Bank.

State: North Carolina


Date: April 2017


Specialty: Physician Assistant, Emergency Medicine, Pediatrics


Symptom: Fever, Cough, Headache


Diagnosis: Pneumonia


Medical Error: Diagnostic error, Lack of proper documentation


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Emergency Medicine – Fever, Cough, Sore Throat, And Shortness Of Breath With An Oxygen Saturation Of 91%



On 1/30/2013, a 33-year-old female presented to an ED physician with complaints of fever, cough, and sore throat, which began three days prior.  The patient also complained of shortness of breath.

The ED physician obtained the patient’s vital signs and performed a physical exam.

The ED physician noted the patient’s pulse oximetry was 91%.  He interpreted the patient’s pulse oximetry as “mild desaturation.”

The ED physician noted the patient’s heart rate was 129.  On cardiac exam, he found the patient to be tachycardic.

The ED physician ordered lab work.  The patient’s white blood cell count was found to be elevated at 20.4.  The patient was also found to have bandemia.

The ED physician ordered a chest x-ray.  He interpreted the chest x-ray as showing no infiltrate and no acute disease.  However, the radiologist later reported the chest x-ray as showing right middle lobe infiltrate worrisome for pneumonia.

The patient was administered ketorolac, acetaminophen, and intravenous fluids.

On re-evaluation, the ED physician noted that the patient had diffuse wheezing.

The ED physician discharged the patient home with a diagnosis of viral syndrome, cough, febrile illness, leukocytosis, and tobacco abuse.

The patient’s presentation was consistent with possible septicemia.

On 2/2/2013, the patient returned to the emergency department with complaints of high fever, cough with sputum, and shortness of breath.

The patient was subsequently diagnosed with bilateral pneumonia, septic shock, acute kidney injury, acute respiratory failure, bilateral pleural effusions, and pneumothorax, requiring admission to the hospital, and later transfer to the ICU, for approximately twenty days.

The Medical Board of Florida judged the ED physician’s conduct to be below the minimal standard of competence given that he failed to evaluate, or failed to document evaluating the patient’s septicemia.  He also failed to check, or failed to document checking the patient’s lactate level.  He failed to obtain, or failed to document obtaining blood cultures for the patient.  He failed to treat, or failed to document treating the patient for septicemia.  The ED physician failed to administer, or failed to document administering, IV antibiotics for the patient.  He also failed to recheck, or failed to document rechecking the patient’s vital signs prior to discharging her home.  He failed to admit, or failed to document admitting the patient to the hospital.

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 of $5,500 against his license and pay reimbursement costs for the case at a minimum of $2,004.13 but not to exceed $4,004.13.  The Medical Board of Florida also ordered that the ED physician complete five hours of continuing medical education in diagnosis of septicemia and five hours of continuing medical education in “risk management.”

State: Florida


Date: February 2017


Specialty: Emergency Medicine


Symptom: Fever, Cough, Head/Neck Pain, Shortness of Breath


Diagnosis: Pneumonia, Sepsis, Pulmonary Disease, Pneumothorax


Medical Error: Diagnostic error, Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Referral failure to hospital or specialist, Lack of proper documentation


Significant Outcome: Hospital Bounce Back


Case Rating: 4


Link to Original Case File: Download PDF



Arizona – Emergency Medicine – 4-Year-Old Girl With Complex Congenital Heart Disease Presents With Headache, Shaking, And Vomiting



The Board received notification of a malpractice settlement regarding the care and treatment of a 4-year-old girl.

The patient was a product of triplet gestation.  Her past medical history included complex congenital heart disease.  She also had a history of asplenia, heterotaxy syndrome, hydrocephalus, and failure to thrive.  Her surgical history included multiple open cardiac surgeries, ventriculo-peritoneal shunt placement, and gastrostomy tube placement.

Before 9:00 a.m., on 01/03/2013, the patient presented to the outpatient registration area of a children’s hospital for a scheduled cardiac catheterization to assess her right superior vena cava shunt.  The patient’s parents reported that she had an upper respiratory tract infection during the prior 7 days.  Several days prior she had finished a course of amoxicillin.  Otherwise, she had been in her usual state of health.

Shortly after the patient presented to the hospital registration area, she was found to have a temperature of 103 degrees Fahrenheit.  She was complaining of a headache, “shaking,” and vomiting.  The parents remarked that at that time she appeared to be cyanotic around the mouth.  At 9:15 a.m., the rapid assessment team arrived.  It was recommended that she be immediately transferred to the pediatric emergency department for further evaluation.

At 9:35 a.m., the ED physician saw the patient and documented that the patient had a temperature of 36.7 degrees Celsius, a respiratory rate of 24, a blood pressure of 101/59, and a heart rate of 187.  The ED physician documented that the patient was “pale and mottled and looked unwell.”  His exam documented a capillary refill time of 2 seconds.

The ED physician ordered the placement of a peripheral intravenous line and lab tests including viral swabs and a nasopharyngeal swab for pertussis.  The patient was started on 40 ml/hour of normal saline and 1.5 mg of IV ondansetron for nausea.  No dextrose containing solutions were ordered and the patient did not receive a fluid bolus.

The patient was periodically reassessed by various nurses throughout her emergency department stay.  She remained persistently tachycardic despite fever control.  The patient’s scheduled cardiac catheterization was postponed.  The patient’s labs returned showing a mild elevation of her total white blood cell count with a left shift (neutrophils were at 90%) with no bandemia.  The patient had mild hemo-concentration with hemoglobin and hematocrit of 14.1 and 42.4 with platelets at 98 with clumping noted.

The patient’s total CO2 on the BMP was 20 with an increased BUN:creatinine ratio of 40:1, suggesting pre-renal azotemia.  The viral swabs were negative.  An MRI of the brain showed no evidence of interval change with respect to the ventricular size, ruling out shunt malfunction.  The chest x-ray was normal and her EKG showed sinus tachycardia.

At time of discharge, the patient remained tachycardic despite fever control.  It was documented that 20 minutes prior to the PIV removal, the patient had a heart rate of 180 and an increased respiratory rate at 40.  The patient was afebrile, but she was noted at that time to have a delay in her capillary refill at 4 seconds (all previous measurements were normal at 2 seconds).  The hospital records for the patient document more than once and by more than one provider that the parents wanted to take the patient home.

Approximately two hours after arriving home, the patient was tachycardic and tachypneic.  Emergency responders were called, and they found the patient in cardiac arrest.  She was flown to a tertiary care facility where the patient arrived in active cardiopulmonary arrest.  She was hypoglycemic and received a glucose bolus and 10 rounds of IV epinephrine.  She also received calcium and two rounds of rocuronium, the later of which was given for unsuccessful attempts at re-intubation.  Despite lifesaving efforts, the patient was pronounced dead at 5:29 p.m.  The blood culture eventually grew out streptococcus pneumonia the next day.

The Board judged ED physician’s conduct to be below the minimum standard of competence given failure to provide antibiotics in a patient without a spleen who was tachycardic, tachypneic, and febrile.

The Board ordered the physician to be reprimanded.

State: Arizona


Date: January 2017


Specialty: Emergency Medicine, Pediatrics


Symptom: Fever, Headache, Nausea Or Vomiting


Diagnosis: Pneumonia


Medical Error: Diagnostic error


Significant Outcome: Death, Hospital Bounce Back


Case Rating: 4


Link to Original Case File: Download PDF



Wisconsin – Physician Assistant – 25-Year-Old Man With Cough, Fever, Chills, And Night Sweats



On 12/15/2003, a 25-year-old non-smoking man presented to a clinic with 10 days of cough, fever, chills, and night sweats.  He was noted to have a heart rate of 142 and a respiratory rate of 24.  He was on amoxicillin, doxycycline, and prescription cough medication.

Physician Assistant A switched him to a different cough medication.  He reported that he had re-checked the heart rate, but there was no documentation of the re-check.  He recommended that the patient continue with amoxicillin and doxycycline.  A TB skin test was ordered.  Physician A was supervising Physician Assistant A.  She reviewed and signed the note sometime after 2/13/2004.

On 12/18/2003, the patient returned to the clinic to have his TB test read.  At that time, he was doing worse.  He saw Physician Assistant B, who was also being supervised by Physician A.  Physician Assistant B reviewed Physician Assistant A’s notes and documented that “his cough seems to be worse” and that the antibiotics “do not seem to be helping.”  His temperature was noted to be 101.3, respiratory rate 32, and on physical exam, it was noted that he was coughing, the coughing intensified when he was reclined, he had a headache with coughing, he had bilateral lower pleuritic pain, and he had “decreased breath sounds to the right base.”   The TB test was negative.  He was diagnosed with “probable pneumonia.”

She recommended a chest x-ray and a CBC, but the patient declined due to cost.  Antibiotics were changed to gatifloxacin 400 mg daily.  It was recommended that he increase fluid intake.  On 12/19/2003, Physician Assistant B dictated the note for the patient visit from the prior day.  The note contained her signature, but not the date.  The medical records reflected that Physician A reviewed and signed the note, but did not reflect when she reviewed or signed it.  On review of the chart, oxygen saturation was not documented.  Physician A did not contact the patient or direct Physician Assistant B to contact the patient, in order to obtain an updated oxygen saturation.

On 12/23/2003, the patient was admitted to the ICU.  Oxygen saturation was at 71%.  On 12/26/2003, he was placed on a mechanical ventilator.  On 1/1/2004, the patient suffered cardiac arrest and could not be resuscitated.

The cause of death was noted to be acute respiratory distress syndrome secondary to pneumonia due to blastomycosis.  On 10/2/2009, a jury concluded that Physician A was negligent in her supervision of Physician Assistant A and B.  The jury attributed 35% of the total causal negligence to Physician A.

The Board addressed the issue of whether Physician A should have sought to obtain an oxygen saturation level.  The Board ultimately decided that Physician A was within the standard of care.

Physician Assistant B’s conduct in her treatment of the patient was below the minimum standards for the profession in the following respects: she failed to document in the patient’s chart that the chest x-ray and CBC were not done “against medical advice”; failed to recommend admission for the patient; failed to consult with her supervising physician; and failed to request a pulmonary consult.

The Board ordered Physician Assistant B be reprimanded, complete 4 hours of continuing medical education in the areas of evaluation and treatment of pneumonia and respiratory distress, and pay the costs of the proceeding.

State: Wisconsin


Date: January 2017


Specialty: Physician Assistant, Internal Medicine


Symptom: Cough, Fever, Headache, Chest Pain, Shortness of Breath


Diagnosis: Pneumonia


Medical Error: Improper treatment, Failure to order appropriate diagnostic test, Failure of communication with other providers, Referral failure to hospital or specialist, Improper supervision, Lack of proper documentation


Significant Outcome: Death, Hospital Bounce Back


Case Rating: 5


Link to Original Case File: Download PDF



North Carolina – Family Practice – Evaluation Of A Patient With Persistent Symptoms of Pneumonia



In May 2015, a patient with a remote history of smoking presented to a family practitioner with symptoms of worsening cough of two months duration.

The patient was diagnosed with seasonal allergies and offered empiric treatment for chronic cough.  Per the Board, the initial treatment complied with the applicable standard of care.

In early August 2015, the patient returned to the office complaining of diarrhea and a cough that had started one month earlier.

The family practitioner ordered a chest x-ray, diagnosed the patient with pneumonia, and treated her accordingly.

By September 2015, the patient developed additional symptoms such as dyspnea on exertion, low-grade fevers, and weight loss. On examination, the family practitioner noted decreased breath sounds and ordered a repeat chest x-ray that showed interval worsening with consolidation.

The family practitioner also ordered a CT scan that revealed enlarged mediastinal and hilar lymph nodes or mass with effusion. These findings were consistent with an infectious etiology, but also raised significant concern for an underlying neoplasm.

The Board noted that the standard of care for a patient with the patient’s presentation – worsening symptoms, radiologic findings, and past history of smoking – would have been to further evaluate the patient for possible lung cancer through referral to a pulmonologist; instead, the family practitioner continued to treat pneumonia.

Though the patient returned to your office in early October 2015 reporting significant improvement in her symptoms, by late October, the patient demonstrated recurrent symptoms of pneumonia and presented with a tongue mass.

At that point, the family practitioner referred the patient to a pulmonologist for a second opinion. The patient underwent another CT scan on 11/09/2015 and saw a pulmonologist on 11/11/2015.

The patient was diagnosed with Stage IV lung cancer and ultimately died in April 2016.

The Board issued a public letter of concern, which was reported to the Federation of State Medical Boards.  It was not reported to the National Practitioner Data Bank.

State: North Carolina


Date: December 2016


Specialty: Family Medicine, Internal Medicine


Symptom: Shortness of Breath, Cough, Diarrhea, Fever


Diagnosis: Lung Cancer, Pneumonia


Medical Error: Diagnostic error


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Washington – Hospitalist – CT Scan Results Reveal A 3.3 cm Right Renal Mass Mentioned On Page Two Of The Report



On 8/2/2014, a patient presented to the hospital for shortness of breath.  A hospitalist assumed care of the patient and admitted him for inpatient treatment.  Based on the patient’s presentation, the hospitalist ordered multiple labs and radiology studies, including a chest computed tomography scan (CT) with contrast, to rule out serious lung conditions, such as pulmonary embolism.  The 8/2/2014 chest CT report was negative for pulmonary embolism, but did show a 3.3 cm right renal mass highly suggestive of malignancy.  No mention of the renal mass was noted in the hospitalist’s chart notes.  The hospitalist reviewed page one of the CT report which was negative for pulmonary embolism, eliminating the problem from the hospitalist’s differential diagnosis.  The right renal mass suggestive of malignancy was reported on page two of the report; however, the hospitalist was not aware there was a page two.

The hospitalist indicated in her statement to the Commission that she did review the CT report and focused on the findings that addressed the current lung complaints.  She indicated that because the patient did not have complaints suggestive of a renal or bladder issue, she did not order the CT to evaluate renal issues.

The hospitalist continued to follow the patient throughout the hospital admission and prepared the discharge summary.  On 8/6/2014, she discharged the patient.  The discharge diagnoses included bilateral pneumonia, sepsis, and exacerbation of chronic obstructive pulmonary disease (COPD).  The discharge summary recommended that the patient follow up with his primary care provider in one week.  No recommendations were documented regarding the renal mass.

On 8/25/2014, the patient followed up with his primary care provider.  Notes do not indicate that the primary care provider was notified of the renal mass.  The patient continued to follow up with multiple providers for various medical conditions between August 2014 and March 2015.  The patient indicated that on follow-up for psoriasis with a different provider, the renal mass was brought to his attention.  On 3/31/2015, the patient underwent a follow-up CT, which showed that the renal mass had increased in size.  Subsequently, the patient was confirmed to have renal carcinoma and underwent successful treatment.

The Commission stipulated the hospitalist reimburse costs to the Commission, develop and follow a written protocol for the clinic to ensure outside lab and other tests results are promptly reviewed, and write and submit a paper of at least 1000 words, plus bibliography, addressing the standard of care applicable to the ordering provider when reviewing lab/radiology reports and the ordering provider’s responsibility for arranging follow-up of abnormal results.

State: Washington


Date: September 2016


Specialty: Hospitalist, Emergency Medicine, Family Medicine, Internal Medicine, Oncology


Symptom: Shortness of Breath


Diagnosis: Cancer, Pneumonia, Sepsis


Medical Error: Failure to follow up, Diagnostic error


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



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