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On 8/12/2011, a patient was admitted to a medical center for post-operative care after a right thyroid lobectomy.

The patient presented with multiple risk factors for coronary artery disease, including obesity and tobacco use.  She had a prolonged and difficult time with extubation after the surgery and complained of shortness of breath.

An internist was consulted for medical management.  The internist diagnosed the patient with questionable and mild pulmonary edema.  The internist’s plan of care for the patient was to admit her to the hospital, obtain ventilation/perfusion (V/Q) scan, perform cardiology and deep vein thrombosis evaluations, and perform peptic ulcer disease prophylaxis.  The internist did not order telemetry monitoring for the patient.

On 8/12/2011, the patient was found slumped over the left side of her hospital bed and unresponsive. Staff initiated resuscitative efforts but they were unsuccessful and the patient expired.

The Board judged the internists conduct to be below the minimum standard of competence given that he failed to order telemetry monitoring for her upon her admission to the medical center.

The Board ordered that the internist pay a fine of $5,000 against his license and pay reimbursement costs for the case for a minimum of $2,378.85 and not to exceed $4,378.85.  The Board also ordered that the internist complete five hours of continuing medical education in “Risk Management” and complete a one hour lecture/seminar on “Risk Management.”

State: Florida

Date: November 2017

Specialty: Internal Medicine

Symptom: Shortness of Breath

Diagnosis: Pulmonary Disease

Medical Error: Failure to properly monitor patient

Significant Outcome: Death

Case Rating: 1

Link to Original Case File: Download PDF

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

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

On 11/19/2015, a patient presented to a family care clinic with complaints of swelling and pain in the right lower extremity (“RLE”).

The patient was seen by the APRN who documented the patient’s history of GI bleeding, noting the patient had experienced a RLE deep vein thrombosis (“DVT”) and pulmonary embolism (“PE”) on October 2015, that had been treated with an IVC filter in a medical center.

The APRN further documented in the patient’s chart, “No [sic] on anticoagulants due to GI Bleed,” and “Recent [history] GI bleed.”

The patient was referred to cardiology for the management of his anticoagulation.  He was to follow up on the morning of 11/20/2015 to have a complete blood count (“CBC”) drawn.

On 11/20/2015, the patient presented to a physician assistant with right leg and foot swelling with new onset pain rated a 1/10.  The physician assistant did not document a patient history and did not review the APRN’s notes from 11/19/2015.  The physician assistant diagnosed the patient with DVT of the right popliteal vein and mild anemia.  The physician assistant improperly prescribed Lovenox 60 mg SQ twice a day for one week with a follow-up to confirm dissolution of the clot.

On 11/23/2015, the patient awoke during the night with chest pain and was transported via ambulance to the emergency department where it was determined the patient had a GI bleed.  The patient’s hemoglobin (“HGB”) dropped abnormally low to 7.7, and his hematocrit (“HCT”) was also abnormally low at 27.4%.

The physician assistant’s response, received by the Board on 3/29/2016, noted, “There was no indication in the note from the previous day, nor in any clinic note that he was not a candidate for anticoagulation therapy.”  However, the original notes received by the Board on 10/6/2016 from the hospital indicated that the patient had a history of GI bleed and no anticoagulants should have been prescribed.

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

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, Emergency Medicine, Internal Medicine

Symptom: Blood in Stool, Extremity Pain, Swelling

Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Deep Vein Thrombosis/Intracardiac Thrombus, Pulmonary Embolism

Medical Error: Improper medication management, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

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

On 9/1/2012, a patient suffered a tibial fracture in her left leg after falling during a seizure.  In the aftermath of the fracture, the patient underwent left comminuted tibial open reduction internal fixation (“ORIF”) surgery.

During the patient’s discharge, she was prescribed aspirin and propafenone (Rythmol).  The aspirin was intended to help prevent post-surgical pulmonary embolism.  The propafenone was intended to control the patient’s atrial fibrillation.

On 9/14/2012, the patient was transferred to a rehabilitation facility for post-surgical rehabilitation.

Throughout her post-surgical rehabilitation, the patient was at an increased risk of pulmonary embolism.

Initially, the patient was continued on aspirin and propafenone at the rehabilitation center.

On 9/28/2012, the physician’s orders for October 2012 included a stop order on the administration of the patient’s aspirin and propafenone, effective 10/13/2012 and 10/14/2012.

In late September and early October 2012, a family practitioner electronically signed, approved, and executed the aforementioned physician’s orders.

On 10/18/2012, the patient suffered shortness of breath and decreased oxygen saturation.  Although the family practitioner transferred the patient for treatment at an emergency room, the patient passed away several hours later.

According to the medical examiner, the cause of the patient’s death was pulmonary embolism.

The Medical Board of Florida judged the family practitioners conduct to be below the minimal standard of competence given that he should have facilitated the long-term continuation of aspirin and/or propafenone to the patient.  Also, the family practitioner should not have signed, approved, and/or otherwise have executed physician’s orders that were in conflict with the physician’s intended course of prescribing/treatment for the patient.

The Medical Board of Florida issued a letter of concern against the family practitioner’s license.  The Medical Board of Florida ordered that the family practitioner pay a fine of $7,500 against his license and pay reimbursement costs for the case at a minimum of $1,708.35 and not to exceed $3,798.35.  The Medical Board of Florida also ordered that the family practitioner complete five hours of continuing medical education in “risk management.”

State: Florida

Date: February 2017

Specialty: Family Medicine, Internal Medicine

Symptom: Shortness of Breath

Diagnosis: Cardiac Arrhythmia, Pulmonary Embolism

Medical Error: Accidental Medication Error

Significant Outcome: Death

Case Rating: 3

Link to Original Case File: Download PDF

On 08/04/2014, a 75-year-old man with a history of benign prostatic hyperplasia, osteoarthritis, and congenital deafness, reestablished care with an internist whom he had previously seen at a prior practice.  The patient reported that he had visited the emergency department the month prior for left-sided pleuritic chest pain.  Workup was normal, and he was given a prescription for oxycodone.

On 08/11/2014, the patient was again seen by a nurse practitioner in the internist’s practice with complaints of chest pain.

On 08/13/2014, the patient followed up with the internist and complained of increasing left pleuritic chest pain.  The internist requested the patient’s emergency department records.  He ordered an EKG, echocardiogram, and labs.  An empiric trial of colchicine was prescribed for the possibility of pericarditis.  The EKG showed a borderline 1st degree AV block and nonspecific T wave changes to the septal leads not present on the prior EKG.

On 08/18/2014, a CT angiogram ordered by the internist revealed a small focal pulmonary embolism to the left lower lobe pulmonary artery with no other findings.  The internist instructed the patient to follow up in a week.

On 08/28/2014, the patient was seen by a different provider who worked at the same practice as the internist.  He was seen to undergo a hypercoagulable work up.  At the time of this appointment, the patient was not on any medications for pulmonary embolism.  The provider ordered anticoagulation to treat the pulmonary embolism.  He ordered labs to assess for a hypercoagulable state and ordered ASAP lower extremity venous Doppler studies.  The studies revealed a non-occlusive deep vein thrombosis involving the right popliteal, posterior tibial, and peroneal veins.  There was also deep veno-occlusive disease involving the left peroneal veins.

During a hearing, the internist testified that when he obtained the results of the chest CT, he had discussed the finding with the interpreting radiologist, who agreed that the patient likely had a resolving pulmonary embolus.  The internist testified that based on this discussion, he believed the patient did not need to be anticoagulated.  The Board noted that the internist did not have the results of the Doppler studies at the time he decided against anticoagulation therapy.

The Board judged internist’s conduct to be below the minimum standard of competence given failure to immediately treat the patient’s symptomatic pulmonary embolism.

On 04/2016, an interim order was issued for the internist to complete a competency evaluation.  The internist appealed.  On 08/04/2016, the Board denied the internist’s appeal of the interim order.  The provider submitted his intention to retire.  Given concern that the internist had also performed below the standard of care in a multitude of cases, the Board elected to restrict his practice and prohibited from practicing medicine in the state of Arizona.  They ordered that he complete and pass a competency evaluation in order to reverse the practice restriction.

State: Arizona

Date: January 2017

Specialty: Internal Medicine

Symptom: Chest Pain

Diagnosis: Pulmonary Embolism

Medical Error: Improper treatment

Significant Outcome: N/A

Case Rating: 3

Link to Original Case File: Download PDF

On 2/19/2013, a 17-month-old male presented to a pediatrician’s office for his fifteen-month check.  The pediatrician documented a past medical history of transposition of great vessels at three weeks and open heart surgery.  During the appointment, the pediatrician failed to document family history entirely.  The pediatrician’s section is word-for-word the same information as in other patient records.  The pediatrician failed to provide a detail of treatment plan unique to the patient

On 4/10/2013, the patient presented with a chief complaint of progressively worsening cough with concerns for respiratory syncytial virus, and bronchiolitis.  The review of systems documented ENT evaluation and did not assess the heart. No pulse oximetry was performed.  The physical assessment did not document any GI, musculoskeletal, or skin assessments.

On 5/2/2013, the patient presented for nasal congestion and cough for the last two to three days.  No review of systems was documented.  No oximetry was performed.  It is unclear whether budesonide and albuterol were prescribed, although the pediatrician indicated treatments of budesonide and albuterol in his plan.

On 5/13/2013, the patient presented for coughing coupled with wheezing and rales in the chest.  No pulse oximetry was performed.  The pediatrician signed the patient’s record electronically ten days following the patient visit.

On 6/13/2013, the patient presented with chief complaints of croupy cough, very phlegmy, audible wheezing, rales in the chest, and low-grade fever.  No pulse oximetry was performed.  The pediatrician failed to document his impression regarding why the patient has had the same symptoms since 4/10/2013.

The pediatrician signed the patient record electronically on 7/9/2014.

The pediatrician eventually administered Rocephin and IV methylprednisolone, which was identified as being inappropriate.

The Board judged the pediatrician’s conduct to be below the minimum standard of competence given his failure to keep written medical records and given his failure to prescribe appropriate medications for the patient’s diagnosis.

The Board ordered that the pediatrician attend and successfully complete the Medical Record Keeping Seminar at Center for Personalized Education for Physicians (“CPEP”). Also, the Board ordered that the pediatrician hire a medical scribe. Finally, the Board ordered that the pediatrician have another pediatrician monitor his work.

State: Kansas

Date: October 2016

Specialty: Pediatrics

Symptom: Cough, Fever

Diagnosis: Pulmonary Disease

Medical Error: Improper medication management, Failure to order appropriate diagnostic test, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

On 2/4/2013 a 7-year-old female presented to a pediatrician and saw the advanced practice registered nurse (“APRN”).  The patient presented with chief complaints of allergies, congestion, and diarrhea.  The patient was prescribed albuterol, Qvar 40 mcg, Bactrim, and triamcinolone.  The Bactrim was prescribed inappropriately for diarrhea.  The pediatrician agreed but thought that he had perhaps forgotten to document otitis media.

On 2/19/2013, the pediatrician saw the patient for a follow-up appointment.  The pediatrician documented that the patient was there for a follow-up for her asthma, even though the patient previously presented with reactive airway disease.  The pediatrician did not document his thought process in how reactive airway disease developed in asthma.  The pediatrician did not electronically sign the record until 4/11/2013.

On 6/11/2013, the patient presented to the pediatrician for a school physical.  The pediatrician failed to document the patient’s asthma.  In the school health examination, the pediatrician stamped signature appears on the form with the date 6/11/2013.  The pediatrician stamped the document “No” to the question, “Is this student subject to any condition which might cause a possible classroom emergency such as seizures, fainting, diarrhea, diabetes, asthma, allergies, etc.”

The Board judged the pediatrician’s conduct to be below the minimum standard of competence given his failure to keep written medical records, and inappropriately prescribing a medication.

The Board ordered that the pediatrician attend and successfully complete the Medical Record Keeping Seminar at Center for Personalized Education for Physicians (“CPEP”). Also, the Board ordered that the pediatrician hire a medical scribe. Finally, the Board ordered that the pediatrician have a pediatrician monitor his work.

State: Kansas

Date: October 2016

Specialty: Pediatrics

Symptom: Allergic Reaction Symptoms, Diarrhea

Diagnosis: Asthma

Medical Error: Lack of proper documentation, Improper medication management

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

A 56-year-old male presented to a hematologist-oncologist with a 6-month history of a left neck mass and 3 years of progressive back pain in July 2013.  Later that month, the patient was diagnosed with Stage III Hodgkin’s lymphoma, nodular sclerosis. The hematologist-oncologist started the patient on a standard chemotherapy protocol on 7/24/2013 with adriamycin, bleomycin, vinblastine, and dacarbazine.  The hematologist-oncologist did not document obtaining informed consent from the patient for the chemotherapy, including the use of bleomycin and its attendant risks of lung injury. Bleomycin is a key component of curative chemotherapy regimens used to treat curable cancers, such as Hodgkin’s lymphoma.  Its use may cause bleomycin-induced lung injury, including life-threatening interstitial pulmonary fibrosis in up to 10% of patients receiving the drug.

The hematologist-oncologist noted that the patient complained of new symptoms on his 9/30/2010 visits, including a persistent cough for 2 weeks.  The patient received another cycle of chemotherapy, including bleomycin, on 10/4/2013.

The patient was admitted from 10/18/2013 until 10/21/2013 and was treated for presumptive pneumonia.  A progress note entered by the hematologist-oncologist on 10/21/2013 stated that a chest x-ray and a CT scan revealed changes in the patient’s radiologic appearance.  A chest x-ray taken on 10/18/2013 showed bibasilar airspace disease, and a high-resolution CT scan taken on 10/20/2013 showed interstitial fibrosis with areas of patchy ground glass density consistent with bleomycin toxicity.

The patient returned home and had gradual progressive shortness of breath and an increased dry cough.  He presented to the emergency department on 10/28/2013 with dyspnea. He was found to be tachypneic but not hypoxic.  A chest x-ray showed low lung volumes and extensive bilateral lung opacities, indicating worsening interstitial fibrosis, consistent with bleomycin toxicity.  The patient was admitted to the ICU for further treatment. His condition continued to deteriorate, and he died on 11/19/2013. The Death Summary reported that the patient had bleomycin lung toxicity with severe acute respiratory distress syndrome.

The Medical Board of California judged that the hematologist-oncologist’s conduct departed from the standard of care because he ignored signs of possible pulmonary toxicity from bleomycin that warranted further evaluation with pulmonary function tests, high-resolution CT scans, and/or pulmonary consultation.  Instead, the hematologist-oncologist proceeded to administer an additional dose of bleomycin.  The hematologist-oncologist also did not order a pulmonary function test or a chest x-ray to rule out bleomycin toxicity before proceeding with an additional chemotherapy treatment on 10/4/2013 even though a PET/CT exam taken on 10/2/2013 was abnormal and showed mild diffuse lung uptake, which was not present on a prior July 2013 PET/CT exam, and which was suggestive of new lung toxicities.  Also, after the high-resolution CT scan on 10/20/2013 demonstrated interstitial fibrosis with areas of patchy ground glass density consistent with bleomycin toxicity, the hematologist-oncologist failed to consider and carry out a therapy directed at bleomycin toxicity. The patient should have been promptly started on steroids. Corticosteroids have been the mainstay of intervention for bleomycin toxicity and have been found to be more successful earlier in the evolution of the process.  The hematologist-oncologist additionally failed to inform the patient of the dangerous risks of his chemotherapy treatment.

The Medical Board of California issued a public reprimand and ordered the hematologist-oncologist to complete a medical record keeping course.

State: California

Date: October 2016

Specialty: Oncology

Symptom: Cough, Mass (Breast Mass, Lump, etc.), Back Pain, Shortness of Breath

Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Cancer, Pulmonary Disease

Medical Error: Improper medication management, Diagnostic error, Failure to order appropriate diagnostic test, Failure of communication with patient or patient relations, Improper treatment

Significant Outcome: Death, Hospital Bounce Back

Case Rating: 4

Link to Original Case File: Download PDF