Found 38 Results Sorted by Case Date
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Arizona – Emergency Medicine – Right Leg Pain, Shortness Of Breath, And History Of A Deep Vein Thrombosis



The Board received a complaint regarding the care and treatment of a 71-year-old woman.

On 12/03/2015, a patient presented to the hospital complaining of right leg pain and shortness of breath.  She disclosed having a history of deep vein thrombosis.  The ED physician ordered labs, an ultrasound of the right leg, a chest x-ray, an ECG, and a CT angiogram.

The CT angiogram noted central, segmental, and subsegmental pulmonary emboli bilaterally and ground glass opacity at the right lung apex.  The ED physician reviewed the CT angiogram but failed to diagnose the patient with multiple pulmonary emboli.  Prior to the patient’s discharge, the ED physician re-examined her and told her to follow up with a cardiologist and pulmonologist.

On 12/5/2015, the patient presented to a different hospital with worsening complaints of shortness of breath.  The CT angiogram from the first hospital was reviewed.  A repeat CT angiogram was performed revealing the same findings of multiple bilateral pulmonary emboli.  The patient underwent ultrasounds on both legs which revealed deep vein thrombosis of the left leg and superficial vein thrombosis of the right leg.  An ECG did not show signs of right heart strain.  The patient was discharged on enoxaparin and coumadin.

State: Arizona


Date: October 2016


Specialty: Emergency Medicine


Symptom: Shortness of Breath, Extremity Pain


Diagnosis: Pulmonary Embolism, Deep Vein Thrombosis/Intracardiac Thrombus


Medical Error: Diagnostic error


Significant Outcome: Hospital Bounce Back


Case Rating: 2


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 – 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 – Anesthesiology – Arteriovenous Fistulogram On Obese Patient With Renal Disease, Asthma, Cardiovascular Disease, Diabetes, And Sleep Apnea



On 3/5/2014, a 55-year-old, 5’3”, and 109 kg (BMI 44.2) female was scheduled for a left arm arteriovenous fistulogram and possible revision of her dialysis fistula to prevent re-bleeding.  An anesthesiologist assumed the anesthesia care of this patient prior to the start of surgery. The patient suffered from a history of end-stage renal disease, had been on dialysis for 15 years, suffered from obesity, asthma, rheumatoid arthritis, diabetes, and sleep apnea, and used home oxygen at night.  The patient also had a history of atrial fibrillation, cardiomyopathy with an ejection fraction of 28%, moderate-severe aortic insufficiency and stenosis, coronary artery disease with stents placed in 2013, and chronic congestive heart failure. The patient had begun to experience bleeding from the AV fistula five days prior to admission.

In his pre-operative note, the anesthesiologist documented that the patient was 100 kg, had chronic renal failure, had coronary disease with stents, had a left bundle branch block, and suffered from occasional gastric reflux.  The anesthesiologist did not note that the patient suffered from sleep apnea, cardiomyopathy, chronic heart failure, atrial fibrillation, aortic valve disease, or diabetes. The anesthesiologist’s note did not document the last time the patient had received dialysis.   The anesthesiologist’s pre-operative note showed that he saw the patient at 3:40 p.m. Anesthesia start time was noted at 3:49 p.m. The note was filed at 4:24 p.m. and signed at 5:18 p.m.

The patient’s vital signs were charted at 3:55 p.m. and were listed as followed: blood pressure of 160/70, pulse of 78/min sinus rhythm, respiratory rate of 20, and 100% oxygen saturation on the 10 L mask.  At 3:50 p.m., the anesthesiologist administered 1 mg of midazolam and 50 mcg of fentanyl and began a propofol infusion. The dose of propofol was not charted. At 4:05 p.m., the anesthesiologist administered 1 mg of midazolam and 50 mcg of fentanyl.  Just prior to the surgeon injecting local anesthetic, the anesthesiologist administered 30 mg propofol, but did not chart the dosage. The anesthesiologist attached the pulse oximeter trace distal to the blood pressure cuff on the same limb. The anesthesiologist also had the patient wear a non-rebreathing oxygen mask.  At 4:20 p.m., the surgery began. During the surgery, the surgeon noticed the patient’s blood had turned dark and that the patient was cyanotic. At 4:28 p.m., it was noted that the surgeon could not feel a pulse, and a code was called.

The anesthesiologist provided 0.4 mg of atropine and 1 mg of epinephrine.  The patient’s blood pressure was 90/40. The anesthesiologist provided a second dose of epinephrine.  The code blue team note began at 4:28 p.m. The patient was intubated at 4:29 p.m. Compressions began at 4:31 p.m.  The code blue team provided one amp of bicarbonate. The patient’s pulse was obtained. Then the patient’s pulse could not be felt a second time.  A second code was called at 4:50 p.m. Further work was done of the patient. The patient was transferred to the ICU, where she remained unresponsive.  She was converted to comfort care and expired that evening.

The Medical Board of California judged that the anesthesiologist departed from the standard of care because he administered doses of sedation to an obese patient with a history of sleep apnea, who was sensitive to the effects of respiratory depressants.  The anesthesiologist was not vigilant during the time that she developed hypoventilation and obstruction. Prior to the surgeon realizing that the patient had no pulse, the anesthesiologist failed to promptly and adequately rescue her.  Once the code was called, the anesthesiologist failed to take an active role in the resuscitation of the patient. The anesthesiologist also failed to recognize and treat respiratory depression, bradycardia, and pulseless arrest. The anesthesiologist’s failure to recognize the patient’s condition led to intubation and airway rescue being delayed, only occurring after the code team had arrived.  The pre-operative note was written and submitted after the patient received IV sedation and signed after she coded a second time. The anesthesiologist did not create a summary note of the code blue events that occurred in the operating room or of the patient’s subsequent death. The anesthesiologist failed to document this intraoperative sentinel event.

The Medical Board of California placed the anesthesiologist on probation for 4 years and ordered him to complete a medical record-keeping course, an education course for at least 20 hours for the first 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.

State: California


Date: May 2016


Specialty: Anesthesiology


Symptom: Bleeding


Diagnosis: Cardiovascular Disease, Asthma, Pulmonary Disease


Medical Error: Failure to examine or evaluate patient properly, Improper treatment, Improper medication management, Lack of proper documentation


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Washington – Internal Medicine – Abnormal ECG, Elevated CPK, And Tachycardia Following A Fall



On 12/10/2014, a patient, a resident of an inpatient psychiatric facility, fell on his face during a fire drill.  Per ward staff, it appeared the patient had experienced a seizure.  An on-the-scene physician ordered labs for the next morning, checked the patient’s vital signs, performed a dental consult, and provided a dose of antibiotic and some Gatorade.

On 12/11/2014, the same physician examined the patient and noted his pulse to be 90-100, after an initial measurement of 113, and his blood pressure stable.  Soon after, a second physician performed an examination on the patient and noted that he was “feeling generally unwell, had a low grade temperature and some muscle pain.”  It appeared to the physician the patient had an upper respiratory infection.  Albuterol and a complete blood count were ordered.

On the afternoon of 12/11/2014, a third physician examined the patient.  The physician’s records showed the patient presented with a probable upper respiratory virus with asthmatic bronchitis.  The patient’s heart rate was 120.  The physician documented that the patient’s tachycardia was probably due to mild dehydration and medications.  The treatment plan for the patient included a chest x-ray and evaluation of creatine phosphokinase (CPK) levels.  It was reported that the patient’s chest x-ray “seemed negative.”  The patient denied having any chest pain.  The physician opined that the increased CPK level may have been caused by medications or a possible recent seizure.  The physician’s treatment plan included an electrocardiogram (ECG), rechecking labs, and oral hydration.

On 12/12/2014, an internist entered the patient’s medical room.  She ordered fluid monitoring every shift, continuation with vital signs every four hours, and repeat lab testing in the morning.  The ECG reported “probably abnormal ECG.”  The internist was notified of this reporting and informed an assisting physician.

The internist failed to review the patient’s previous medical records, which included chest x-rays and perpetuated the diagnosis of dehydration despite adequate hydration.  The internist failed to respond to abnormal vital signs and properly diagnose and treat the patient’s medical condition.  The internist also failed to transfer the patient to a higher level of care for additional work-up.

On 12/13/2014,  the patient’s treating psychiatrist received a call from the nursing staff informing her the patient was suffering from an elevated heart rate, and had an elevated, though declining, CPK level.  The patient continued to receive treatment from various physicians who noted the patient’s decline, which included symptoms of tachycardia and weakness.

On 12/14/2014, the patient was transported to a hospital by ambulance where diagnostic tests revealed “extensive bilateral pulmonary emboli and probably thrombus in the right atrium.” The patient was transported to a second hospital.  While in interventional radiology, the patient became pulseless and was later pronounced dead.

The Commission stipulated the internist reimburse costs to the Commission and write and submit a paper of at least 1000 words on how to appropriately evaluate patients with shortness of breath and tachycardia.  The paper should also discuss the proper review of ECG findings consistent with pulmonary embolisms.

State: Washington


Date: March 2016


Specialty: Internal Medicine


Symptom: Palpitations, Shortness of Breath, Weakness/Fatigue


Diagnosis: Pulmonary Embolism


Medical Error: Diagnostic error


Significant Outcome: Death


Case Rating: 5


Link to Original Case File: Download PDF



Washington – Emergency Medicine – COPD, Shortness Of Breath, And Tachycardia With Administration Of Adenosine



On 8/28/2013, a patient who had chronic obstructive pulmonary disease (COPD) was admitted to the emergency department (ED) with shortness of breath.  The patient was transferred to telemetry for COPD exacerbation and persistent tachycardia.  The ED physician conducted various tests and an EKG.  He identified the patient’s medical issue as acute COPD exacerbation secondary to acute bacterial bronchitis with sinus tachycardia.

The patient was admitted to an internist for COPD exacerbation.  The admitting internist misread the EKG as supraventricular tachycardia (SVT).  Based on this, the internist administered adenosine without first consulting a cardiologist.  The internist failed to understand that using adenosine can cause worsening bronchospasm and must be used with caution in COPD patients.  The internist misinterpreted the patient’s severe bronchospastic response to the adenosine as anxiety and gave the patient Ativan, which would be expected to exacerbate this patient’s problem.  Shortly after, the patient experienced respiratory arrest.  Fortunately, the patient was resuscitated successfully.

The patient’s cardiologist felt that the respiratory arrest had been a side effect of the adenosine.  Adenosine has a side effect of causing bronchospasm, which means adenosine is contraindicated in patients with bronchospasm and cautioned for use in any patient with a history of COPD.  The internist failed to identify that the patient may have been suffering from severe bronchospasm or severe COPD.

The internist’s practice fell below the standard of care in the following ways:

1)     The internist misread the EKG.

2)     The internist administered a contraindicated drug.

3)     The internist failed to recognize the expected adverse reaction of that drug.

4)     The internist gave the patient a different drug which potentially exacerbated the adverse reaction.

5)     The internist’s treatment in this case resulted in the patient arresting.

The Commission stipulated the internist reimburse costs to the Commission, allow a Commission representative to audit patient records and review practices related to the internist’s assessment and treatment of patients with COPD, complete 6 hours of continuing education in the area of interpretation and management of cardiac arrhythmias, and write and submit a paper of at least 1000 words, with bibliography, on the subject of arrhythmias and their treatment in COPD patients.

State: Washington


Date: January 2016


Specialty: Hospitalist, Cardiology, Emergency Medicine, Internal Medicine


Symptom: Shortness of Breath


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


Medical Error: Improper medication management


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



California – Infectious Disease – Patient With Chronic Cough, Shortness Of Breath, Hemoptysis, And Failure To Thrive



On 9/16/2011, an 81-year-old male with a history of chronic obstructive pulmonary disease, coronary artery disease status post stent placement, hypertension, atrial arrhythmia, Parkinson’s disease, and cachexia presented to an infectious disease specialist.

The patient’s primary care physician referred the patient to the infectious disease specialist to evaluate the patient’s pneumonia, which had not been responding to antibiotic therapy.  The infectious disease specialist noted that the patient complained of “easy fatigability, cough, shortness of breath, occasional hemoptysis, cachexia, anorexia and overall failure to thrive.”

The patient was “relegated to a wheelchair” and “very debilitated.”  A sputum culture, previously ordered by the patient’s pulmonologist, was reported to contain many Escherichia coli and many methicillin-sensitive Staphylococcus aureus.

The infectious disease specialist conducted a physical examination, which included a review of the patient’s general appearance, lungs, abdomen, extremities, and neurological condition.  There was no documentation of the patient’s temperature.

The infectious disease specialist’s impression was “staph aureus pneumonia and tracheobronchitis” with a notation that “[a]lthough E. Coli was discovered in the sputum, I suspect staph aureus is the pathogen here.”  The infectious disease specialist’s treatment plan included changing the patient’s medication to doxycycline 100 mg b.i.d., adding Marinol to stimulate appetite, and scheduling a two-week follow-up to check on the patient’s progress.

There was no documentation of any plan to reimage the patient’s lung.  At the time of this consultation, the patient’s most recent imaging study of the lungs was a chest CT performed one month earlier on 8/10/2011.

On 10/5/2011, the infectious disease specialist’s follow-up note indicated, among other things, that the patient was “doing much better [and] [h]is staph tracheabronchitis [sic] appears to be significantly improved.”  There were no specific details regarding the basis for this assessment.  The recorded physical examination was limited to the lungs, which were reported to be clear.  The treatment plan was “to observe carefully and have [patient] follow up in two months.”

On 12/21/2011, the patient had another outpatient follow up visit with the infectious disease specialist.  Per the Board, the progress note for this visit was confusing and contradictory and indicated, among other things, that the patient “appears to be improving” yet it also noted that “[t]he patient has severe tracheobronchitis and a recurrent urinary tract infection” with another part of the progress note stating “[t]he patient’s tracheobronchitis appears to be resolved.”  Another part of the note stated that “[h]e had a recent urinary tract infection secondary to e-coli, which has resolved, but the risk of recurrence is strong.”

The Board noted that the objective basis for any recurrent urinary tract infection was not mentioned in the progress note, and there was no reference to any urinalysis or urine culture to substantiate the basis for the urinary tract infection.  The progress note also indicated “I am going to be stopping the Levaquin and continuing long-term suppressive therapy with nitrofurantoin.”

The progress note did not reference any laboratory studies such as those to assess renal function, which, per the Board, would have been appropriate since nitrofurantoin is contraindicated in patients with renal insufficiency.  There was no documentation in the progress note of any temperature being taken, and the only organ system recorded as being examined were the lungs.

On 2/8/2012, the progress note indicated that the patient “is much improved” without specific details regarding the basis for this assessment.  The only organ system recorded as being examined were the lungs, which were reported as being “clear.”  There was neither mention of any imaging studies of the lungs nor of a urinalysis or urine culture in the progress note.

The infectious disease specialist’s treatment plan was to provide the patient with a prescription of Marinol 5 mg twice a day, “hold off on the antibiotics for now since the patient has experienced such a dramatic improvement,” and schedule a follow-up appointment in approximately 2 months.

On 3/2/2012, the infectious disease specialist’s progress note indicated the patient “has easy fatigability, myalgia, arthralgia and tracheobronchitis.”  The progress note stated that the infectious disease specialist was “starting him on some mycobacterium medication consisting of azithromycin and ethambutol” for treatment of a Mycobacterium avium complex (MAC) infection.  There was no written basis in the progress note for the clinical impression of MAC infection, such as any reference to imaging studies or any microbiological results.

On 4/3/2012, the progress note indicated that the plan was to continue treatment of the MAC infection with azithromycin and ethambutol with follow up in a month.

On 5/2/2012, the progress note indicated the patient was “experiencing severe symptoms of tracheobronchitis.”  The infectious disease specialist counseled the patient about smoking cessation, and the patient agreed to reduce his cigarettes from seven to four per day.

On 6/1/2012, the progress note indicated that the patient was “still having some difficulty breathing but [was] compliant with his medications.”  Risks and side effects of the azithromycin and ethambutol were reviewed along with “the new risk for azithromycin” that was recently published.  The infectious disease specialist “gave the patient reassurance and emphasized the need for adherence to his current medication” regimen with a follow-up scheduled for one month.

On 9/6/2012, the infectious disease specialist placed the patient on home ceftriaxone 1 g daily for a duration of seven days to treat a complex urinary tract infection.

On 9/13/2012, the progress note indicated that “[t]he patient [was] completing therapy for a complex urinary tract infection” and that “[h]e [was] also cachectic and had ongoing chronic lung problems, as demonstrated by tracheobronchitis.”  The plan was to continue IV antibiotic therapy with follow-up in approximately one month.

On 10/17/2012, the progress note indicated that the patient was “complaining of some suprapubic pain,” and the infectious disease specialist suspected “he ha[d] another urinary tract infection.”  The infectious disease specialist’s plan was to send off a urinalysis to confirm if the patient had a urinary tract infection.  If he had a urinary tract infection, the plan would be to begin another round of IV antibiotic therapy.

On 10/18/2012, a urine culture was ordered by infectious disease specialist which was reported to be positive for methicillin-resistant Staphylococcus aureus (MRSA) on 10/20/2012.  In response, the infectious disease specialist called in a prescription for doxycycline 100 mg by mouth twice daily and spoke with the patient’s caregiver about the prescription.

On 10/23/2012, the patient was admitted to the hospital.  The initial review of symptoms for the patient included lethargy, altered mental status, flank pain, and brownish urine.  Urinalysis was positive for blood and bacteria.

At 1:54 a.m. on 10/23/2012, blood cultures were collected.  The patient was admitted for presumed “bacteremia and sepsis.”

On 10/23/2012, the patient was seen by the infectious disease specialist in the Intensive Care Unit (ICU).  The infectious disease specialist noted that the patient had “a history of many chronic medical problems including cachexia and Parkinson’s disease.”  He also noted that the patient was “ill-appearing,” “not aware of his surroundings,” and “awake, but nonverbal.”  He further noted the patient “has been discovered to have methicillin-resistant Staph aureus in the blood.”

The infectious disease specialist’s impression was, among other things, that the patient had methicillin-resistant Staphylococcus Aureus (MRSA) urosepsis with MRSA bacteremia and “Right sided pleural effusion, possibly secondary to MRSA.”  In actuality, the blood culture of the specimen collected earlier in the morning at 1:54 a.m. did not reveal the presence of MRSA but instead revealed two different strains of coagulase-negative Staphylococcus: specifically, Staphylococcus hominis and Staphylococcus epidermi, which are typically the result of skin contamination of the blood culture bottle, not true bacteremia.  The microbiology report indicates that a second blood specimen was collected on 10/24/2009, at 4:07 a.m., which was cultured and had no growth after 5 days.

The infectious disease specialist recommended intravenous Vancomycin and reculturing the patient.  He noted that “this patient is likely septic.”  He further indicated that the patient was “cachectic, which renders him further immunocompromised [and] [h]e will likely require a long course of intravenous antibiotic therapy to address the septic process.”

On 10/24/2012, the infectious disease specialist’s handwritten progress note indicated that the patient was doing “much better,” that he was “aware” and “interactive.”  The patient was noted to be positive for “staph in blood” and “MRSA in urine.”  There was a notation that the patient had “staph sepsis.”  The plan was to continue with the intravenous Vancomycin and Zosyn.

On 10/29/2012, the infectious disease specialist’s handwritten note for this visit states that the patient “appear[ed] to be improving,” and he was “more alert and interactive.”  The “MRSA Urosepsis” was noted to be “much improved on Zosyn [and] Vancomycin.”  The infectious disease specialist’s plan was probable discharge to home or a skilled nursing facility later in the week and to “continue on IV Vancomycin thru Nov. 6th 2012.”  (On 11/5/2012, the IV antibiotic therapy was extended until 11/8/2012.)

On 10/31/2012, the patient was discharged from the hospital.  The discharge summary was prepared by the patient’s primary care physician who listed the discharge diagnoses as urosepsis, bacterial pneumonia, malnutrition, and Parkinson’s disease.  The discharge summary described the reason for the hospital stay and hospital course as follows:

“REASON FOR STAY: This is an 83-year-old male, very well known to me, who presents with hypotension, tachycardia, and altered mental status, was found to have a UTI and became bacteremic causing urosepsis and was also noted to have bilateral infiltrates bilaterally.

HOSPITAL COURSE: Initially, he was admitted to the ICU, and was under the care of me and Dr. [T] and [the infectious disease specialist].  He was started on Vanco and Zosyn IV for his urosepis (sic) and bilateral pneumonia.  Thoracentesis was done on his infiltrates.  It was negative for any acute malignancy.  There is some white blood cells there in the urine.

His repeat urine culture and blood cultures [were] negative, but in the initial, 1 did grow out MRSA in both the urine and the blood.  He responded well to treatment on IV vancomycin and Zosyn.  It was also thought that for his severe malnutrition, a PEG tube to be placed to start him on some additional tube feeds.  He does swallow appropriately on dysphagia diet.  PEG started on Pulmicort and then switch over to Jevity with bolus feeds, which was very well tolerated for patient.”

The future treatment plan included follow up with his physicians, including the infectious disease specialist, continuation of the IV vancomycin antibiotic therapy at 1250 mg daily until 11/6/2012 for MRSA urosepsis with MRSA bacterium (though, in fact, the patient did not have any MRSA bacteremia), bolus tube feeding every 6 hours to address malnutrition, and visitation from nurses and home physical therapy to assist with the patient’s recovery.

On 11/7/2012, the patient’s caretaker called the infectious disease specialist’s office to report that the patient was bedbound, “failing,” and could not be placed in a wheelchair to attend a previously scheduled appointment with the infectious disease specialist set for the next day.  The infectious disease specialist’s office manager reportedly informed the caretaker that the infectious disease specialist’s office could not handle a gurney due to space limitations and recommended that it would be more appropriate to call 911 if the patient was decompensating.

On 11/9/2012, the patient was readmitted to the hospital.  The patient was not feeling well and having increased shortness of breath.  A chest x-ray indicated right-sided pleural effusion, which had increased in size since the last hospital admission, and an elevated white blood cell count. The infectious disease specialist saw the patient for an infectious disease consultation.  The reason for the consultation was “[e]valuation of a possible recurrent MRSA infection.”  Broad spectrum antibiotic therapy was initiated.  The patient developed worsening hypoxia and shock.  Due to the patient’s overall poor prognosis, the patient was placed on comfort care measures, started on a morphine IV drip, and passed away on 11/10/2012.

The Board judged the infectious disease specialist’s conduct to be below the minimum level of competence given his failure to properly diagnose and manage the patient’s presumed pulmonary Mycobacterium avium complex.  He failed to obtain microbiologic confirmation prior to treatment.  He prescribed an inappropriately high dose of ethambutol.  He failed to obtain timely radiologic studies of the patient’s lungs at the time of the patient’s initial evaluation on 9/16/2011 and during subsequent follow-up visits for the diagnosis of Staphylococcus aureus pneumonia.  He failed to maintain adequate medical records.  He often failed to include the patient’s temperature, and many of his notes failed to include a physical examination.  He misinterpreted the patient’s blood culture from a blood specimen collected on 10/23/2012 at 1:54 a.m. as containing methicillin-resistant Staphylococcus aureus when it did not.

The Board issued a public reprimand with stipulations to complete a continuing medical education course on medical record keeping and to undergo the Physician Assessment and Clinical Education Program (PACE) offered at the University of California – San Diego School of Medicine.

State: California


Date: October 2015


Specialty: Infectious Disease, Hospitalist, Internal Medicine


Symptom: Shortness of Breath, Bleeding, Confusion, Cough, Weakness/Fatigue


Diagnosis: Infectious Disease, Pulmonary Disease


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


Significant Outcome: Death


Case Rating: 2


Link to Original Case File: Download PDF



California – Radiology – Coughing, Back Pain, And Breathing Problems With Chest CT Scan Revealing Pneumonia



On 1/6/2013 at 8:23 p.m., a patient was admitted to the emergency department with complaints of coughing, back pain, and breathing problems.  On 1/7/2013, the patient’s treating physician ordered a CT scan of the chest with contrast.  The CT scan of the chest acquired was of satisfactory quality and showed the presence of an obvious pulmonary embolism.  On the same day, a radiologist submitted a final report of the patient’s chest scan, which did document the presence or absence of a pulmonary embolism.  The report indicated the presence of pneumonia.  The patient was treated for pneumonia and discharged on 1/14/2013 without being treated for pulmonary embolism.

The Medical Board of California judged that the radiologist’s failure to recognize pulmonary embolism on the CT scan constituted an extreme departure from the standard of care.

For this case and others, the Medical Board of California ordered the radiologist to surrender his medical license.

State: California


Date: October 2015


Specialty: Radiology


Symptom: Shortness of Breath, Cough, Back Pain


Diagnosis: Pulmonary Embolism


Medical Error: Diagnostic error


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



North Carolina – Emergency Medicine – Discharging A Patient While Awaiting D-Dimer Results



The Board was notified of a professional liability payment.

On 04/05/2011, a patient presented to the emergency department with complaints of racing heart, chest tightness, and shortness of breath.  The patient had a history of deep vein thrombosis.  A series of tests were ordered, including a d-dimer test, to rule out the possibility of venous thrombosis or pulmonary embolism.

The patient was discharged prior to the result of the d-dimer test being available and thus prior to the ED physician reviewing it.  After the patient left the emergency department, the d-dimer results returned with a value of 12 (normal < 0.5).

Approximately 1.5 hours later, the patient became symptomatic again and was transported to another facility.  The patient underwent a CT angiography of the chest, which revealed a pulmonary embolism.  Several hours later the patient died of pulmonary emboli.

The Board judged the ED physician’s conduct to be below the minimum standard of competence given failure to wait for a test result to be completed prior to discharge the patient.  The Board noted that the admitting physician and internist at the second hospital delayed starting anticoagulation therapy, which may have decreased the chance of patient recovery.

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: July 2015


Specialty: Emergency Medicine


Symptom: Shortness of Breath, Chest Pain, Palpitations


Diagnosis: Pulmonary Embolism


Medical Error: Diagnostic error


Significant Outcome: Death, Hospital Bounce Back


Case Rating: 2


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



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