Found 38 Results Sorted by Case Date
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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



California – General Surgery – Acute Abdominal Pain And Tachycardia In An Immunosuppressed Male



On 5/22/2010, a 60-year-old immunosuppressed male presented to the emergency department with acute onset of abdominal pain and tachycardia.  A CT scan revealed that the patient had a perforated diverticulitis and pneumoperitoneum.  The admitting physicians evaluated and determined that the patient would likely need surgery after his condition was optimized.  The patient was managed with antibiotics and IV fluids and seen daily be General Surgeon A and other physicians through 5/25/2010.  On that date, General Surgeon A noted that the patient had improved and signed off from the case.  Also on that day, the patient’s heart rate had increased from normal to the low 100’s, and the patient’s lab work revealed concern regarding ongoing severe infection.  However, General Surgeon A documented in his notes that the patient appeared much better and that he believed the patient’s perforation had sealed.  General Surgeon A didn’t see the patient again until he became progressively unstable.

The patient’s condition worsened on 5/26/2010, including the development of atrial fibrillation, persistent tachycardia, worsening renal function, and other conditions consistent with ongoing sepsis.  A second CT scan was ordered on 5/27/2010 but was not performed until the next day.  It revealed worsening peritonitis from the known perforation.  General Surgeon A was informed of the patient’s condition and the CT results at 10 a.m. on 5/28/2010, but the patient was not seen by a surgeon until 1:30 p.m. that day by General Surgeon B who was covering for General Surgeon A. General Surgeon B took the patient to surgery for a laparotomy and sigmoid resection with colostomy for perforated diverticulitis with fecal peritonitis.  The patient remained critically unstable in the ICU on maximum support with respiratory failure, ongoing sepsis, cardiac ischemia with acute myocardial infarction.  The patient ultimately died from fatal ventricular arrhythmia.

On the day General Surgeon A signed off of the case indicating the patient was so improved that his surgical services were no longer needed, there was indication of ongoing significant infection in spite of ongoing aggressive medical therapy.  General Surgeon A failed to recognize the significance of the clinical picture.  It was not until the patient’s condition worsened further that an additional CT scan was ordered and performed on 5/28/2010.

Although General Surgeon A was informed of the need for the additional CT scan, it was General Surgeon B who became involved and promptly took the patient into surgery, but the surgery was too late to save the patient.  Because of the delay in recognition of the need for urgent surgical intervention, the patient experienced ongoing sepsis resulting in acute cardiac insult and progressive hemodynamic and metabolic instability.

General Surgeon A should have recognized that the patient’s immunocompromised condition would not only interfere with the patient’s ability to seal off the perforation and control the intraperitoneal sepsis but also compromise the patient’s ability to mount an effective response to the associated systemic sepsis syndrome.  General Surgeon A did not appreciate the gravity of the signs of ongoing infection in this patient warranting urgent surgical intervention.

The Medical Board of California judged that General Surgeon A’s conduct was grossly negligent in the care and treatment of the patient because he delayed recognizing the need for urgent surgical intervention and didn’t appreciate the gravity of the signs of ongoing infection in this patient warranting urgent surgical intervention.

For this case and others, the Medical Board of California ordered General Surgeon A to surrender his license.

State: California


Date: March 2015


Specialty: General Surgery


Symptom: Abdominal Pain


Diagnosis: Sepsis, Acute Myocardial Infarction, Cardiac Arrhythmia, Acute Abdomen, Pulmonary Disease


Medical Error: Underestimation of likelihood or severity, Delay in proper treatment, Failure to follow up


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



California – Gynecology – Robotic-Assisted Laparoscopic Myomectomy And Ovarian Cystectomy Performed Based On Wrong Ultrasound



On 10/7/2008, a 48-year-old patient was under the care of her primary care physician, who performed a pelvic exam, which was described as normal.  During that exam, a pap smear test was performed. The interpretation of the patient’s pap smear test was abnormal, showing atypical glandular cells of endocervical origin.  The patient’s primary care physician referred her to a gynecologist.

On 11/17/2008, the patient had her first appointment with the gynecologist, who performed a colposcopy, cervical biopsy, and endocervical curettage.  The results of the tests were described on pathology reports as benign without evidence of atypical glandular cells. A human papilloma virus screen was negative, and the gynecologist’s impression was a finding of nabothian cysts of the cervix.  On 3/19/2009, the patient returned to see the gynecologist for a repeat pap smear test. The test was interpreted as atypical squamous cells of undetermined significance. On 9/10/2009, the gynecologist ordered a pelvic ultrasound study, which was performed on 9/18/2009.  The patient’s medical record did not mention a complaint of pelvic pain.

On the morning of 9/24/2009, the result of the pelvic ultrasound study was faxed to the gynecologist in preparation of the patient’s return visit.  At that visit, the patient saw the gynecologist for a repeat pap smear test and to discuss her pelvic ultrasound study. The pap smear test was normal, but the ultrasound report indicated that the patient had an enlarged uterus and six fibroids, including three large intramural uterine fibroids.  The ultrasound report was dated 9/18/2009, but the interpretation of that study was dated 7/1/2009. The gynecologist signed off on the ultrasound report, but failed to recognize that the 7/1/2009 report could not have been the report on the patient’s 9/18/2009 ultrasound test. Although the patient’s medical record does not mention a complaint of pelvic pain or vaginal bleeding, the gynecologist recorded that he discussed uterine artery embolization and total laparoscopic hysterectomy with the patient.

Also on the morning of 9/24/2009, a second pelvic ultrasound report was faxed to the gynecologist that correctly identified the patient and the correct date of service.  The gynecologist also signed off on the second ultrasound report, which reflected that the patient suffered from a smaller, single focal, intramural myoma, and a right unilocular anechoic cyst on the right ovary.  In the second correct report, the radiologist described the patient’s changes as consistent with mild, diffuse adenomyosis. The radiologist’s advice with respect to the ovarian cyst was to obtain a follow-up pelvic ultrasound to confirm stability of the cyst, as warranted.  However, no further imaging studies were ordered prior to surgery.

On 10/10/2009, an MRI study was performed at the gynecologist’s order, which reported findings similar to the second, correct iteration of the ultrasound report dated 9/18/2009.  On 12/7/2009, the patient again saw the gynecologist, at which time the gynecologist noted the discrepancy between the results of the first ultrasound, which demonstrated six fibroids, and the MRI, which revealed only a single small, intramural myoma.  The gynecologist scheduled the patient for robotic-assisted laparoscopic myomectomy and ovarian cystectomy. On 1/14/2010, the patient saw the gynecologist for a pre-operative history and physical. The patient’s medical record of that visit did not show that a pelvic examination was performed and did not mention any complaint of pain by the patient.  The gynecologist’s dictated notes only included the results of the first, incorrect ultrasound report.

On 1/19/2010, the gynecologist performed surgery on the patient, and no fibroids were found.  During surgery, the gynecologist removed a small, right ovarian cyst, which was later confirmed to be benign.  The patient remained in the hospital until 1/22/2010, at which time she was discharged. On 1/23/2010, the patient returned to the emergency department complaining of shortness of breath, dizziness, and weakness.  A CT scan of her chest confirmed bilateral pleural effusions, and she was treated.

On 2/3/2010, the gynecologist performed a post-surgical examination of the patient, who was experiencing a new symptom of tenderness in her left pelvis.  On 3/3/2010, the gynecologist performed the second post-surgical examination of the patient and recorded a limited physical examination, making no entries about the incision or the uterus.  He noted that the vagina was well-healed and without infection, even though no vaginal surgery had been performed on the patient. He noted the adnexa to be palpably normal and assessed the patient as stable and doing well.

On 6/9/2010, the patient continued her post-operative care with a different physician, who documented symptoms of abdominal pain, left lower quadrant abdominal cramping, and a bulge at the umbilical incision site.  The patient had not been feeling well since her surgery. Upon examination, the new physician documented a tender supraumbilical hernia and tenderness in the left lower quadrant of the patient’s abdomen. An abdominal and pelvic CT examination confirmed that the patient had an incisional hernia, and she was referred to a general surgeon for its repair.

The Medical Board of California judged that the gynecologist’s conduct departed from the standard of care because he failed to appropriately manage the patient’s uterine myoma, removed the patient’s asymptomatic, benign-appearing right ovarian cyst, and failed to document any complaint of abdominal or pelvic pain in the patient’s medical records.

The Medical Board of California placed the gynecologist on probation for 3 years and ordered the gynecologist to complete a medical record-keeping course 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: March 2015


Specialty: Gynecology


Symptom: Abdominal Pain, Dizziness, Shortness of Breath, Weakness/Fatigue


Diagnosis: Post-operative/Operative Complication, Pulmonary Disease


Medical Error: Unnecessary or excessive treatment or surgery, Accidental error, Failure to follow up, Lack of proper documentation


Significant Outcome: Hospital Bounce Back


Case Rating: 4


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



California – Internal Medicine – Improper Treatment For Patient With Chest Pain On Exertion, Shortness Of Breath, Abnormal Blood Pressure, And Vomiting



A 71-year-old white female patient saw an internist 5 times between 2000 and 11/24/2008.  During a 3/16/2007 visit, COPD with shortness of breath and chest pain on exertion were noted.  An ordered electrocardiogram and physical were recorded as normal.

During the 11/3/2008 visit, the internist noted that the patient was on medication for mild hypertension and that she was a long time smoker.  The internist noted that the patient had hypothyroidism, COPD, and osteoporosis. There was no documentation of a review of systems, past medical history, social history, or family history.

The patient next returned on 11/24/2008.  The internist made a note to follow up on labs, a DEXA scan, and chest x-ray results.  Again, no clearly documented physical examination results were noted, and there was no documentation of a review of systems, past medical history, social history, or family history.

The internist saw the patient again on 11/25/2008.  Again, a single-page written progress record was utilized.  The patient’s temperature was 97.1, her pulse was 72, respirations were 24, and her blood pressure was 80/60 mm Hg in the left arm, but there was no analysis of what this abnormal blood pressure might mean.  The patient complained of shortness of breath since midnight of that day. She also complained of vomiting three times during the previous night. The patient also complained of chest pain from her epigastrium to sternal notch and that the pain was worse when lying down.

The internist noted during this visit that the patient had been having heartburn for three days and had been “taking turns” with some improvement.  The internist reported that the patient had no left or right chest pain, shoulder pain, or arm pain. Her EKG was reviewed and was noted to be largely unchanged.  She was noted to have a history of COPD and a very strong tobacco smell. The internist diagnosed GERD, COPD, and prescribed Prilosec and Zantac/Reglan. He indicated in his notes that the patient should follow up in 4 to 5 days or go to the emergency room as needed.

The patient went home and was still feeling quite unwell.  By the middle of the day, she continued to feel worse. The patient’s daughter stated that she heard a loud thud in the patient’s room.  She found the patient on the floor unresponsive. 9-1-1 was called. The paramedics found the patient pulseless, apneic, and unresponsive.  She was defibrillated in the field, and a spontaneous pulse was brought back. She never regained any cerebral function and a diagnosis of anoxic encephalopathy was made.  The patient remained in a persistent vegetative state. She was terminally extubated on 12/4/2008, and subsequently expired rapidly.

The failure to properly assess the patient on 11/25/2008, the failure to adequately and accurately document her medical condition and treatment during her visits, and to properly treat the patient’s symptoms were each extreme departures from the standard of care.

The Medical Board of California ordered that the internist complete two courses in diagnosing a disease, with at least one emphasizing cardiac issues.  Upon successful completion thereof, a public letter of reprimand shall be issued by the Board to the internist.

State: California


Date: January 2014


Specialty: Internal Medicine


Symptom: Shortness of Breath, GI Symptoms (GERD, Abdominal Distention, Dysphagia), Nausea Or Vomiting, Chest Pain


Diagnosis: Pulmonary Disease, Endocrine Disease, Musculoskeletal Disease


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


Significant Outcome: Death


Case Rating: 4


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



Colorado – Anesthesiology – Insertion Of Catheter At The Wrong Angle Causes Spinal Lesion



On 5/25/2007, an anesthesiologist improperly performed a procedure to place a permanent spinal catheter in the patient’s spine.  The patient had complications.  A general surgeon ordered a Doppler ultrasound, because he was concerned about the patient getting venous clots.  The anesthesiologist cancelled the Doppler ultrasound.  The patient experienced deep venous thrombosis and a pulmonary embolism, which may have been avoided had the anesthesiologist not cancelled the ultrasound.  The anesthesiologist inserted the patient’s catheter too high and at the wrong angle which also caused a lesion on the patient’s spine.

The Board ordered the anesthesiologist’s license be put on indefinite probation.  The Board also put a restriction for the anesthesiologist to be a solo practitioner in any practice environment or setting.  The anesthesiologist was required to complete continuing medical education on professional/problem based ethics program and enroll in the Center for Personalized Education for Physicians.  The Board ordered that the anesthesiologist pay a fine of $5,000.

State: Colorado


Date: July 2013


Specialty: Anesthesiology


Symptom: N/A


Diagnosis: Deep Vein Thrombosis/Intracardiac Thrombus, Spinal Injury Or Disorder, Pulmonary Embolism


Medical Error: Procedural error, Failure to order appropriate diagnostic test


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Kansas – Physician Assistant – Improper Documentation While Treating A Patient And His Relatives For Various Conditions



On 10/2/2009, a physician assistant prescribed a patient Phenergan 25 mg for complaints of watery diarrhea and vomiting.

On 1/6/2010, the physician assistant prescribed the patient an inhaler due to the fact it was empty. It was after normal operating hours of his primary care physician’s (PCP’s) office, and he was experiencing shortness of air and wheezing.

On 1/18/2010, the physician assistant prescribed the patient Zofran 4 mg oral for nausea, vomiting, and gastroenteritis.

On 7/13/2010, the physician assistant prescribed the patient ciprofloxacin for “frequent urination, dysuria, etc.”

On 7/26/2010, the physician assistant prescribed the patient’s son-in-law Bactrim DS after reviewing pictures sent via cellular phone of a large abscess/cellulitis.

On 8/14/2010, the physician assistant prescribed the patient’s grandson Bactrim to treat cellulitis of the right knee.

On 8/23/2010, the physician assistant prescribed ciprofloxacin for the patient due to complaints of continued prostate problems, dysuria, and erectile dysfunction.  The physician assistant testified that she provided the prescription because the patient did not have time to go to his PCP.  She also testified that she referred him to his urologist and his PCP for another repeat CT, as recommended by the CT report and the PCP several months prior.

On 9/3/2010, the physician assistant prescribed the patient’s son Bactrim to treat an upper respiratory infection and a skin infection that the patient’s son told described to her via a phone call and text.

On 9/16/2010,  the physician assistant prescribed the patient’s grandson Bactrim SS after the patient grandson’s mother called the physician assistant describing the patient’s grandson’s complaint of an abscess on the calf.

The physician assistant had a personal dating relationship with the patient from August 2008 to 9/25/2010.  This personal dating relationship did not initiate from a preexisting patient/physician assistant relationship.

The Board judged the physician assistant’s conduct to be below the minimal standard of competence given her failure to properly document her patient encounters with the above patients.

The Board ordered the physician assistant complete continuing medical education course for Effective and Efficient Methods of Documenting Patient Care, by The Center for Personalized Education for Physicians.

State: Kansas


Date: June 2013


Specialty: Physician Assistant


Symptom: Diarrhea, Nausea Or Vomiting, Shortness of Breath, Urinary Problems


Diagnosis: Gastrointestinal Disease, Infectious Disease, Asthma, Urological Disease


Medical Error: Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Washington – Internal Medicine – Recurrent Shortness Of Breath, Cough, And Wheezing



An internist began treating a patient in November 2004.  On 6/18/2006, the patient presented with shortness of breath, a non-productive cough, and wheezing.  The internist diagnosed her with asthma and bronchitis.  She was prescribed an Advair inhaler.  The internist did not order an x-ray.

On 7/9/2007, the patient followed up regarding her cough.  The internist noted that the patient’s asthma was improved and her lung exam was clear, and he directed her to continue the Advair inhaler.

On 2/26/2008, the patient presented with coughing and a rattle in her chest that had been going on for about one week.  The internist noted bilateral wheezing, and diagnosed atypical pneumonia and asthma.  The internist prescribed an albuterol inhaler and oral prednisone.  He did not believe that a chest x-ray was indicated.

On 3/4/2008, the patient followed up with the internist.  Her cough ceased, but she complained of shortness of breath.  On exam, the internist again noted that the patient had bilateral wheezing in her lungs.  He concluded that the patient’s asthma was exacerbated.  He directed her to continue her medications, and he scheduled a follow-up in two weeks.  He did not believe that a chest x-ray was indicated.  On 3/17/2008, the patient again followed up with the internist and reported that she was doing much better.

More than a year passed before the patient revisited the internist.  On 4/27/2009, the patient complained of heart flutter and shortness of breath.  The internist performed an electrocardiogram, a pulmonary function test, and blood work.  Blood work showed abnormal liver enzyme levels and an elevated sedimentation rate; however, the internist did not believe that a chest x-ray was indicated.  He again diagnosed asthma or bronchitis.

On 5/4/2009, the patient reported to the internist that she was still experiencing shortness of breath.  The internist increased her dosage of Advair inhaler and scheduled a follow-up appointment.  On 6/1/2009, the patient reported that she was feeling better.  The internist repeated laboratory testing, including liver enzyme and sedimentation rate.  Blood work testing again showed abnormal liver enzyme levels and an elevated sedimentation rate.  The patient was contacted by the internist’s office and a follow-up was scheduled; however, the patient subsequently canceled the appointment.

On 2/16/2010, the patient was examined at an urgent care clinic for shortness of breath and referred to the emergency center because a chest x-ray revealed that her lungs were “whited out.”  The patient was evaluated at the emergency center and another chest x-ray was taken.  The patient was diagnosed with chronic lung disease most suggestive of severe sarcoidosis, which had likely been going on for a long time.

The Commission stipulated the internist reimburse costs to the Commission, complete 6 hours of continuing education on the diagnosis of chest complaints, including pulmonary sarcoidosis, write and submit a paper of at least 1000 words, plus bibliography, on the diagnosis and treatment of pulmonary sarcoidosis, and allow a representative of the Commission to make yearly visits to the internist’s practice to review his assessment and treatment of patients who complain of shortness of breath.

State: Washington


Date: May 2013


Specialty: Internal Medicine


Symptom: Shortness of Breath, Cough


Diagnosis: Pulmonary Disease


Medical Error: Failure to order appropriate diagnostic test


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



California – Family Medicine – Failure Of Diagnosis In Patient With Altered Mental Status, Shortness Of Breath, And Chest Pain



A long-term patient saw a family practitioner at a prison on an emergency basis on 2/10/2006.  The patient was 59-years-old with a history of a splenectomy, serologic evidence of hepatitis B and C, and oxygen-dependent chronic obstructive pulmonary disease.  On the afternoon of 2/9/2006, the patient complained of “compressing chest pain” and was taken to the emergency room. The patient was attended to by the on-call physician that day.  The physician noted that the patient had a history of substernal chest pain and shortness of breath and had been out of inhalers for the previous month. The patient’s oxygen saturation was 91%.  The patient was given “breathing treatments” with bronchodilators. The physician determined the patient should be seen at a fully equipped emergency room and had the patient transported by ambulance to the emergency room.

The patient was evaluated at the hospital and told the doctor there that he had no chest pain and “felt better.”  His oxygen saturation was 97%. The doctor wanted to admit him to the hospital but the patient refused all medical treatment and left against medical advice. He arrived back at the prison in the early evening on the same day and stated he had no pain.  He was given Levaquin tablets, 500 mg for 10 days and had blood drawn for lab work. He was told to return to the “MD line” for further evaluation.

The family practitioner was the on-call doctor on 2/10/2006.  The patient came into the emergency room at 8:05 p.m. The notation on the “flow sheet” showed a chief complaint of “hard to arouse.”  The medical technician noted that the patient was “unresponsive to verbal stimuli, responds to sternal rub and answers questions appropriately.”  The Glasgow Coma Scale rating showed the patient was oriented. His pupils were norms, and showed “brisk” response. His blood pressure was 117/60 and his oxygen saturation was 88% on room air.

The family practitioner examined the patient at 9:38 p.m.  He noted the patient was “sleepy.” The patient’s blood pressure was 117/60.  The patient’s lungs were clear and his oxygen saturation had risen to 94% after having been given oxygen by nasal cannula.  The family practitioner charted that the patient’s lungs were “clear to auscultation” and there were no heart murmurs. The family practitioner found the patient’s blood sugar level to be normal.  The family practitioner noted the patient had “skin dehydration” and “throat secretions in mouth.” He assessed the patient as having dehydration and his plan was to give him 1 liter of saline solution intravenously at the rate of 100 ml per hour.  The family practitioner next saw the patient at 11:24 p.m. He noted that the oxygen saturation had risen to 96% and blood pressure was 121/78. He increased the saline drip rate to 200 ml per hour and made the following chart entry, “RTC when infusion of saline completed and VS O2 WNL.”  An issue that arose was the meaning of “RTC” in this context. The Board’s reviewer and expert both read this as meaning “return to custody.” In a summary that the family practitioner prepared 2 weeks before the hearing, the family practitioner agreed RTC meant that the patient was to return to his “housing.”  However, at trial, the family practitioner testified RTC meant “return to clinic.”

The emergency care flow sheet showed that at 1:30 a.m., the patient was still in the emergency room and received albuterol on a metered-dose inhaler.  At 3:00 a.m., the “interdisciplinary progress notes” showed the patient’s vital signs had deteriorated. His oxygen saturation dropped to 80% and his blood pressure dropped to 80/50.  These vital signs could not have been taken in the prisoner’s housing, and the progress notes were the type that are recorded in a medical facility; the inference was that the patient was in the treatment and triage area at this time.  The patient was noted to have an unsteady gait and said he felt “cold” but “okay.”

The family practitioner saw the patient for the last time at 4:30 a.m.  He noted that the patient had been “sent back to ER.” There was no clear indication as to where the patient was between 3:00 a.m. and 4:30 a.m.  It was unlikely that a patient known to be in distress would have been sent back to his housing unit. Since 3:00 a.m. the patient’s vital signs were not within normal limits, and the family practitioner had ordered that the patient not be returned to custody until his vital signs were normal, the reasonable inference to be drawn was that the patient remained in the treatment and triage area until he was seen by the family practitioner for the last time.  When he saw the patient at 4:30 a.m. he noted the low vital signs and ordered oxygen and an intravenous saline line to be kept open. He then ordered that the patient be transferred to the emergency room. The patient was transported and admitted for treatment. He died on 3/8/2006. The cause of death was cardiopulmonary arrest, due to multi-organ failure, due to disseminated coccidioidomycosis commonly known as “valley fever,” a fungal-based lung infection.

The family practitioner was grossly negligent in his care and treatment of the patient for his failure to properly evaluate and treat a patient with “altered mental status” by not conducting a neurological or cardiovascular examination, not performing an adequate pulmonary examination, and not ordering screening laboratory tests.

For this allegation, the Medical Board of California issued the surrender of the family practitioner’s license.

State: California


Date: April 2013


Specialty: Family Medicine, Internal Medicine


Symptom: Chest Pain, Psychiatric Symptoms, Shortness of Breath


Diagnosis: Infectious Disease, Pulmonary Disease


Medical Error: Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test


Significant Outcome: Death, Hospital Bounce Back


Case Rating: 5


Link to Original Case File: Download PDF



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