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Kansas – Physician Assistant – Lovenox Prescribed For DVT In A Patient With A History Of GI Bleeding
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
Florida – Family Medicine – Discontinuation Of Aspirin And Propafenone For A Patient With Arrhythmia After Repair For A Tibial Fracture
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
Arizona – Internal Medicine – Left Pleuritic Pain With Small Pulmonary Embolism Seen On CT Scan
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
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
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
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
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
Wisconsin – General Surgery – Hernia Repair For An Obese Patient With An Upper Respiratory Infection
On 02/15/2008, a 58-year-old obese woman was referred to the general surgeon for an endoscopy and a colonoscopy, during which the general surgeon found a large right lower quadrant incisional hernia. A large segment of the right colon was in the hernia sac, but the patient was only occasional symptomatic.
On 05/16/2008, the patient returned to see the general surgeon to arrange for a repair, which was scheduled on 06/19/2008.
On 06/12/2008, the patient phone her primary care physician to report a sinus infection with yellow drainage. Her primary care physician prescribed doxycycline 100 mg twice a day. On 06/16/2008, the patient went to her primary care physician wondering if she should cancel the surgery given worsening sinus congestion, drainage, and fullness. She was prescribed azithromycin for an upper respiratory tract infection and told to inform the general surgeon if she did not improve within 48 hours. The patient did not contact the general surgeon prior to 06/19/2008, the date of the elective surgery.
On 06/19/2008, the patient reported for surgery. The intake nurse’s note indicates that the patient was getting over a sinus infection. The general surgeon documented that the patient’s head, ears, eyes, nose, and throat were within normal limits on exam. The nurse anesthetist noted that the patient had sinusitis. Labs were normal and the patient was afebrile.
The general surgeon performed incisional hernia repair with mesh, after which the patient went home. That evening, the patient fell off the edge of a bed and became unresponsive momentarily. She went to the emergency department where she was diagnosed with syncope secondary to nausea and vomiting. The general surgeon was notified of this admission, but he did not treat her during it.
On 06/22/2008, the patient was discharged and prescribed amoxicillin/clavulanate 875 mg twice a day for 10 days for acute sinusitis.
On 07/03/2008, the patient presented to the general surgeon for follow up and reported pain after eating. The general surgeon performed an ultrasound of the gallbladder.
On 07/10/2008, the general surgeon saw the patient, who reported persistent lethargy and lightheadedness. Abdominal exam revealed an obvious subcutaneous fluid collection in the area of the patient’s previous hernia.
On 07/11/2008, a CT abdomen was ordered, and the radiologist’s report noted the following: “Large 5×10 cm fluid collection subcutaneous tissues right side lower abdomen. Within the intra-abdominal wall, more ill-defined 5x5cm focus containing multiple air bubbles. Conceivably this could represent an abscess.”
On 07/14/2008, the patient was admitted to the hospital by the general surgeon for post-operative abscess. The general surgeon’s admitting history and physical stated the following:
The patient underwent a CT scan of the abdomen last Friday, which showed fluid collection felt to possibly represent postoperative infectious process versus seroma. The patient was started on a Z-Pak for treatment of chronic sinusitis and this was felt to potentially cover any postoperative infectious process and decision was made in conjunction with the patient to see how she did on the oral antibiotics. Over the weekend, the pain has grown progressively worse with right-sided abdominal swelling near her previous incision, increased abdominal pain, fevers and shaking chills…”
The general surgeon ordered IV metronidazole and IV piperacillin/tazobactam. Deep vein thrombosis prophylaxis was not ordered. The general surgeon ordered drain placement, which was performed by the interventional radiologist.
On 07/15/2008, the general surgeon ordered a CT scan. The radiologist noted: “When compared to the previous study on July 11, the size of the superficial fluid collection has increased, although there is a drainage catheter in place…” The radiologist also documented:
IMPRESSION: Significant inflammation both deep and superficially at the ventral hernia repair site in the right lower quadrant as detailed above, with a large complex fluid collection superficially containing an indwelling drainage catheter; the deeper inflammatory process containing a small amount of fluid but more significantly containing fat and air without a definite or significant drainable component. Communication between the two is indeterminate at this time.
On 07/16/2008, the general surgeon incised and drained the superficial fluid collection in the patient’s hospital room.
On 07/17/2008, CT scan revealed an anterior fluid collection (which went from 17.7 cm x 5.8 cm to 14.3 cm x 3.1 cm in size) and an internal abdominal fluid collection (which went from 6.2 cm to 6.1 cm in length).
On 07/18/2008, the general surgeon removed the mesh, which was found to be infected. Intraoperatively, the anesthesiologist had difficulty ventilating the patient. After surgery, the patient was placed on sequential compression devices for deep vein thrombosis. She was continued on the mechanical ventilator given concern for respiratory failure secondary to residual sedative effects from perioperative medications, morbid obesity, and effects of the surgery.
On 07/19/2008, the patient self-extubated and was initiated on enoxaparin for deep vein thrombosis by another physician.
On 07/21/2008, enoxaparin was discontinued when heparin-induced thrombocytopenia was suspected. Lepirudin was initiated for anticoagulation. The patient appeared to improve, but on the following day, she died from pulmonary embolism after being repositioned in bed.
The Board judged care to have fallen below minimum standards of competence given that the general surgeon failed to defer elective surgery given the sinus infection and failed to order deep vein thrombosis prophylaxis on admission.
In June 2012, the general surgeon attended a conference called “Abdominal Wall Reconstruction” sponsored by Georgetown University Hospital for 8.5 hours of continuing medical education credit. He was reprimanded by the Board and ordered to pay a fine.
State: Wisconsin
Date: August 2012
Specialty: General Surgery, Family Medicine, Hematology, Hospitalist, Internal Medicine
Symptom: Dizziness, Weakness/Fatigue
Diagnosis: Acute Abdomen, Hematological Disease, Pulmonary Embolism
Medical Error: Improper treatment
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF
Washington – Family Medicine – Leg Swelling And Shortness Of Breath After Back Surgery
A 45-year-old woman had been a family practitioner’s patient for over 25 years.
On 12/9/2010, the patient had back surgery.
On 12/23/2010, the patient called the family practitioner’s office and complained of swollen legs. Before the family practitioner’s nurse could return the call that day, when she planned to suggest a Doppler study, the patient called again and said she attributed the swelling to her being able to use her legs again and move as she had not been able to in some years. The patient said she would continue to monitor her legs’ condition, and would call the office right away if she saw an increase in swelling. No one from the family practitioner’s office called the patient to follow up.
The patient presented to the family practitioner’s office on 1/14/2011, after having twisted her right ankle falling down a short flight of stairs. The patient was in pain and severely short of breath. The family practitioner’s chart notes indicated the patient was worried she had had disturbed a surgical repair to her foot, although the patient’s medical records did not reflect that she had had a recent surgical repair of her foot. Surgery on the patient’s right foot was planned for the following July.
The patient arrived at the family practitioner’s office with her husband. The patient was in a hurry, did not have an appointment, and arrived just before the family practitioner’s staff left for lunch. The family practitioner stated her staff were unable to locate the patient’s chart before they left for lunch.
The family practitioner was concerned that the patient may have injured her back after her recent surgery, not just her ankle, and asked her to come to an examining room. The family practitioner stated that the patient requested that family practitioner only refer her for an x-ray of her ankle. The family practitioner stated that the patient said she did not want an appointment for an exam, as the patient’s husband did not want to her to go to the doctor’s office at all, was not supportive, and believed nothing was wrong with her ankle. The patient said she was in a hurry, refused to take off her ankle boot, and refused an examination of her foot and ankle. The family practitioner stated that the patient denied any problems with her legs, and denied low back pain or chest pain.
The family practitioner stated that because of the patient’s shortness of breath, she listened to the patient’s lungs as she stood in the examining room. She heard mild wheezing, which was consistent with the patient’s history of asthma. She did not hear any other abnormal sounds. She administered a breathing treatment to the patient, which eliminated the wheezing and brought the patient’s respiration rate down to 18 breaths per minute. She stated that the patient attributed her tachypnea to her pain and anxiety. The family practitioner had treated the patient for anxiety and stress for many years. She did no additional physical exam. The family practitioner provided the patient a referral for an x-ray of her ankle and directed her to follow up with her surgeon.
The next day the patient died of a pulmonary embolism after collapsing at home.
The Commission stipulated the family practitioner reimburse costs to the Commission, have her license be placed on probation for a period of three years, complete a continuing education course on medical record-keeping, complete at least 5 continuing education hours on deep vein thrombosis, write and submit a paper of at least 1000 words on the topic of deep vein thrombosis and pulmonary embolisms, dictate or type her progress notes and use the SOAP charting format, implement a practice policy for each patient that includes chart reviews, documentation of vital signs, and evaluation of each patient, and allow a representative of the Commission to conduct annual visits to her practice to review patient charts and interview staff.
State: Washington
Date: June 2012
Specialty: Family Medicine, Internal Medicine
Symptom: Swelling, Shortness of Breath
Diagnosis: Pulmonary Embolism
Medical Error: Diagnostic error
Significant Outcome: Death
Case Rating: 5
Link to Original Case File: Download PDF