Found 8 Results Sorted by Case Date
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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



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



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

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

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

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

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

For this case and others, the Medical Board of California placed the ED physician on probation for 5 years and ordered the ED physician to complete a medical record keeping course, an education course (at least 40 hours per year of probation), and a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.  The ED physician was assigned a practice monitor and prohibited from supervising physician assistants.

State: California


Date: September 2016


Specialty: Emergency Medicine


Symptom: Chest Pain, Back Pain, Joint Pain


Diagnosis: Pneumothorax, Trauma Injury, Fracture(s)


Medical Error: False negative, Improper medication management


Significant Outcome: Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



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



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

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

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

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

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

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

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

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

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

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

For this case and others, the Medical Board of California placed the ED physician on probation for 5 years and ordered the ED physician to complete a medical record keeping course, an education course (at least 40 hours per year of probation), and a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.  The ED physician was assigned a practice monitor and prohibited from supervising physician assistants.

State: California


Date: September 2016


Specialty: Emergency Medicine


Symptom: Chest Pain, Fever, Extremity Pain


Diagnosis: Fracture(s), Pneumothorax


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


Significant Outcome: Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



California – General Surgery – Patient With Abdominal Pain And Pneumoperitoneum Following Treatment Of Pneumonia and Pleural Effusion With Chest Tube Placement



On 1/5/2011, a 45-year-old male was admitted to the hospital where he presented with chest pain, cough, fever, and shortness of breath.  The patient’s chest x-ray indicated a right lower lobe pneumonia and concomitant right loculated pleural effusion. The patient was placed on antibiotics, and a general surgeon was consulted the next day for a right tube thoracostomy (placement of chest tube) to address the pleural effusion.  The general surgeon placed the chest tube in the patient without complication. Despite his treatment, the patient’s condition worsened, and he was transferred to the ICU.

On 1/10/2011, the patient developed abdominal distension and abdominal pain.  The patient was noted to have a spontaneous collapse of the right lung and pneumoperitoneum.  Over the next few days, the patient had increased abdominal discomfort, which warranted a tomography scan of the patient’s abdomen and pelvis.  The tomography scan resulted in a finding of free air, free fluid, and thickening of the rectosigmoid region of the colon.

On 1/17/2011, the general surgeon performed an exploratory laparotomy on the patient, where he observed and noted inflammation, food particles, and left colon abnormalities.  The general surgeon was unable to locate any overt perforation. An appendectomy was performed, and the surgical procedure was terminated after placement of drains. On 1/21/2011, the patient was transferred to another hospital.  On 1/22/2011, the patient underwent another exploratory laparotomy, which was performed by another general surgeon. During this procedure, significant fecal contamination was encountered and a perforated sigmoid colon was located.  A resection and diverted colostomy was performed to address the perforation.

The Medical Board of California judged that the general surgeon’s conduct departed from the standard of care because he failed to perform a left colon resection and end colostomy (Hartmann procedure) on the patient, which was warranted given intraoperative findings consistent with an intestinal perforation and significant intra-abdominal contamination, and he failed to consider and/or rule out an abdominal source at the time of the initial indication of pneumoperitoneum in the patient.

The Medical Board of California placed the general surgeon on probation for 7 years and ordered the general surgeon to complete an education course (at least 40 hours per year for each year of probation) and clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California


Date: May 2015


Specialty: General Surgery


Symptom: Chest Pain, Cough, Fever, GI Symptoms (GERD, Abdominal Distention, Dysphagia), Abdominal Pain, Shortness of Breath


Diagnosis: Acute Abdomen, Pneumonia, Pulmonary Disease, Pneumothorax


Medical Error: Diagnostic error, Improper treatment


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



North Carolina – Radiology – Decreased Breath Sounds After Liposuction



In February 2011, a 50-year-old female was undergoing liposuction under general anesthesia.  The anesthesiologist involved in the liposuction noted decreased breath sounds in the patient’s right chest and ordered a portable chest x-ray to rule out atelectasis versus pneumothorax.  The x-ray films were taken and sent to the radiologist.  The radiologist reviewed the x-ray and mentioned a modest infiltrate in the right lower lung, but the radiologist did not comment on the presence or absence of a pneumothorax.

The patient received treatment for atelectasis but later presented to an emergency facility with right chest pain and shortness of breath.  A CT scan was performed that revealed a pneumothorax.  The patient received a chest tube and recovered uneventfully.

The Board expressed concern that the radiologist’s conduct may have fallen below the standard of care given failure to correctly interpret the chest x-ray, which may have caused a delay in the proper management of the patient’s condition.

The Board issued a public letter of concern, which was reported to the Federation of State Medical Boards, and which may have been reported to the National Practitioner Data Bank.

State: North Carolina


Date: March 2015


Specialty: Radiology


Symptom: Chest Pain


Diagnosis: Pneumothorax


Medical Error: Diagnostic error


Significant Outcome: Death


Case Rating: 1


Link to Original Case File: Download PDF



Colorado/California – Pulmonology – Reading A STAT Portable Chest Radiograph For Respiratory Decompensation Under Pressure



A patient was admitted to the hospital in February 2011 with shortness of breath, hypoxemia, and progressive bilateral interstitial lung infiltrates.  A pulmonologist performed a diagnostic bronchoscopy, a broncho-alveolar lavage in the patient’s right middle lobe, and a trans-bronchial biopsy in the left lower lobe.  The patient developed respiratory decompensation after the procedure, and as an iatrogenic pneumothorax was suspected.

The pulmonologist ordered a STAT portable chest radiograph.  The radiographic image was unavailable for transmission to the bronchoscopy suite and the radiologist’s reading station.  The pulmonologist left the patient in the care of a respiratory therapist and nurse, ran to another floor where the plate reader was located, and hastily reviewed the 90 degree rotated image.  The pulmonologist misread the side of the pneumothorax displayed on the chest radiograph, and as a result, he incorrectly placed a chest tube on the left side. The patient did not improve with the insertion of the chest tube, and another portable chest radiograph was requested.  The second radiograph image was loaded onto the hospital network, and the radiologist called to report that the chest tube was on the side away from the pneumothorax. The pulmonologist placed a right-sided chest tube, and the patient stabilized. The pulmonologist did not request assistance from a radiologist to read the radiograph initially, but left the patient to read the image himself at a time when the patient was unstable.  A delay in correctly placing the chest tube resulted.

The Medical Board of Colorado revoked the pulmonologist’s license.  The Medical Board of California ordered the pulmonologist to surrender his license.

State: Colorado, California


Date: January 2014


Specialty: Pulmonology


Symptom: Shortness of Breath


Diagnosis: Pneumothorax, Pulmonary Disease


Medical Error: Accidental error, Diagnostic error, Procedural error


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Plastic Surgery – Respiratory Arrest During Breast Augmentation And Abdominoplasty Procedure



A plastic surgeon provided medical care and treatment to a 34-year-old patient between October and December 2010.

On 10/25/2010, the patient presented to the plastic surgeon for a consultation regarding a breast lift with implants and a buttock augmentation procedure.  During her consultation, the patient agreed to have 500 ml saline breast implants placed, submuscularly, via an inframammary approach. She also agreed to a breast reduction procedure (mastopexy) and a buttock augmentation procedure.  Although not noted in the consult, the patient obtained a quote for liposuction to the abdominal area.

The patient returned to the plastic surgeon on 12/7/2010 for a pre-operative visit.  The plastic surgeon noted that the patient was going to have a buttock augmentation and a breast augmentation with a lift, but was now requesting an abdominoplasty or tummy tuck procedure.  The plan was for her to have surgery in 1 week.

The patient returned 2 days later on 12/9/2010 to discuss her surgery change from a buttock augmentation to abdominoplasty with the plastic surgeon.  The only note in the plastic surgeon’s chart from this date states: “Plan: Tummy tuck and breast augmentation with reduction and lift.” The billing quote of 12/9/2010, however, states that a liposuction to the back and a fat transfer plus liposuction were also contemplated.

The patient presented to the plastic surgeon’s surgery center on 12/17/2010 for surgery.  Prior to arriving at his surgery center, the patient had taken Ativan and clonidine as prescribed by the plastic surgeon. The surgery was to have been performed under conscious sedation.  In addition to the pre-operative oral sedatives, the patient was given intravenous Versed 5 mg, propofol 165 mg, ketamine 100 mg, and fentanyl 150 mcg. This combination of drugs and in the doses administered were sufficient to induce deep sedation to the patient.

The anesthesia record was inconsistent and incomplete.  There was no record of the type and quantity of local anesthetic utilized. The operative note indicated that the tumescent solutions were placed into the abdominal area; tumescent solution is usually made with lidocaine, with a maximum dose of 45-55 mg/kg.  Lidocaine toxicity may have played a role in the patient’s respiratory arrest. Further, the dose of propofol was incorrectly listed in the anesthesia record as 150 mg. However, the individual entries noted that 15 ml were given at 8:30 a.m. followed by a 10 ml bolus at 11:40 a.m.  Importantly, there was no “level of consciousness” noted anywhere in the anesthesia record. There was no record of blood loss, urine loss, or of the total amount of intravenous fluid administered during the 3-hour procedure.

The plastic surgeon performed the abdominoplasty on the patient by removing 900 ml of fat.  He then began the breast augmentation procedure. While working on the left breast, the patient went into respiratory arrest, after a bolus of propofol was given to combat restlessness.  Repositioning of the patient’s airway, as well as insertion of a nasal and oral airway did not alleviate the respiratory distress. The plastic surgeon attempted to intubate the patient, but did not appreciate that his effort was unsuccessful and the patient’s oxygen levels continued to drop.  The staff called 911. The plastic surgeon then attempted a tracheotomy; however, he performed a cricothyroidotomy which allowed the patient to be ventilated. The poorly performed cricothyroidotomy resulted in a tracheal laceration, pneumomediastinum, bilateral pneumothoraces, and pneumoperitoneum.

The plastic surgeon quickly closed the breast incisions and in his haste he left a breast fill-tube inside the wound.  When the EMTs arrived, the tracheal tube had dislodged and the patient was orally intubated by the EMT. The patient was taken to an emergency department.  In addition to the tracheal, lung, and peritoneal injuries, the patient’s breast wounds were noted to have asymmetry in nipple position with the right nipple placed at the superior border of the vertical incision line and the left nipple placed in the mid-portion of the vertical line.  The implants were removed as the patient was considered to be at high risk for infection. The breast wounds were closed by a plastic surgeon who attempted to attain as much symmetry as possible. The patient remained at the hospital for approximately 2 weeks.

The standard of care when performing outpatient cosmetic surgery calls for the presence of two surgical personnel, one of whom must have Advanced Cardiac Life Support Certification.  When medications are given to achieve sedation for the surgical procedure, the provider of the medications must know how to properly administer the drugs, as well as the potential side effects and treatment of the side effects.  There must also be appropriate safety equipment for emergencies, and the surgical personnel must know how to use the emergency equipment for resuscitation.

The standard of care calls for a physician to know the distinction between conscious sedation and deep sedation.  Advanced airway skills are required when a patient is placed in a state of deep sedation by drug choice and drug dose.

When using propofol as an anesthetic agent, the standard of care usually restricts its use to those health care providers trained in anesthesia, such as anesthesiologists or certified registered nurse anesthetists (CRNA).  These specialists have expertise in airway management and knowledge of the acute vital sign monitoring that is necessary when this sedative is administered. The dose of propofol administered to the patient alone, without any other medication, was sufficient enough to induce deep sedation.

The standard of care requires a physician to fully advise a patient’s HIPAA designated representative of all complications that may have arisen during an untoward event during surgery.  The plastic surgeon’s care and treatment of the patient as set forth includes the following acts and omissions which constitute extreme departures from the standard of practice: the failure to appropriately administer conscious sedation medications to the patient; placing the patient in a state of deep sedation through a combination of multi-pharmaco use consisting of Ativan, clonidine, propofol, Versed, ketamine, and fentanyl; failure to recognize the difference between conscious sedation and deep sedation; the inappropriate use of propofol; failure to have staff on hand familiar with advanced airway management in the event of respiratory arrest; the plastic surgeon’s failure to readily appreciate that he did not properly intubate the patient and the failure to attempt a re-intubation procedure to ventilate the patient; negligently performing a cricothyroidotomy instead of a tracheotomy and causing numerous complications; leaving a foreign body (implant fill-tube) within the patient’s breast; and the failure to advise the patient’s husband that he performed a cricothyroidotmy on the patient in order to establish an airway.

For the allegations in this case and others, the Medical Board Of California ordered that the plastic surgeon lose all his rights and privileges as a physician and surgeon in California. His license was revoked.

State: California


Date: October 2013


Specialty: Plastic Surgery


Symptom: N/A


Diagnosis: Post-operative/Operative Complication, Pneumothorax


Medical Error: Procedural error, Failure of communication with patient or patient relations, Improper supervision, Improper medication management, Lack of proper documentation, Retained foreign body after surgery


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Virginia – Internal Medicine – Intubated With Central Venous Catheter Placed Leading To Complication



On 3/9/1998, a 76-year-old female with a history of chronic obstructive pulmonary disease was admitted with complaints of weakness, dizziness, and progressive shortness of breath with a diagnosis of possible gastrointestinal bleeding.

On 3/13/1998, the patient underwent partial gastrectomy with Billroth II anastomosis, during which she was intubated and a central venous catheter was placed.

On 3/14/1998, a CXR was ordered for the following morning.  On 3/15/1998, the progress note failed to mention the chest x-ray.  However, the x-ray indicated a large pneumothorax.

After a careful review of the records of his care regarding multiple patients and other information provided, and following a discussion with the nephrologist, the Committee found that he had no violations.  The physician provided evidence that in July 1999 after a six-month review of his medical records found no deficiencies, he was granted full staff privileges at a hospital.  Based on the foregoing, the Committee voted unanimously to dismiss this matter with no action.

State: Virginia


Date: June 1999


Specialty: Internal Medicine


Symptom: Shortness of Breath, Dizziness, Weakness/Fatigue


Diagnosis: Pneumothorax


Medical Error: No error found


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



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