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Florida – Internal Medicine – Patient With Worsening Chronic Kidney Disease Presents With Arm Pain, Numbness, And Shortness Of Breath
From 2009 until 2014, an internist served as the patient’s primary care physician.
In 2009, the internist referred the patient to Cardiologist A for a cardiology evaluation. The results of the 2009 cardiology evaluation revealed that the patient’s electrocardiogram and stress test were both abnormal.
At this time, Cardiologist A recommended that the internist increase the patient’s medication as needed in order to get the patient’s cholesterol to below seventy.
The patient was evaluated by Cardiologist A again in June 2010.
The June 2010 cardiac evaluation revealed that the patient had shortness of breath on exertion at times, possibly related to hypertension and subclinical congestive heart failure.
On 7/17/2013, the patient underwent lab work, the results which showed that his glomerular filtration rate (GFR) was thirty-four. The internist staged the patient’s chronic kidney disease (CKD) at a stage III/IV.
The patient’s next set of lab work was conducted on 11/18/2013, the results of which showed that his GFR was twenty-two. The internist wrote in a progress note that the patient’s CKD was a stage III/IV.
On 1/13/2014, the patient had lab work done again, the results which showed that his GFR was twenty-six. In his progress note he wrote that the patient’s CKD was now a stage IV.
Despite a dramatic decline in the patient’s GFR levels indicative of worsening CKD, the internist did not refer the patient to a nephrologist.
On 1/13/2014, the patient presented to the internist complaining of left arm pain, numbness radiating to both hands, and shortness of breath. The internist ordered an EKG, chest x-ray, and lab work. His assessment of the patient at this time was dyspnea on exertion, questionable coronary artery disease, questionable pulmonary disease, and questionable anxiety.
On 1/14/2014, the patient returned to the office for an echocardiogram. After the echocardiogram, the internist referred the patient to Cardiologist B for a consult. The patient could not obtain an appointment with Cardiologist B until 2/3/2014.
The internist ordered that a stress test be conducted prior to the patient’s visit with Cardiologist B, and advised that the patient bring the results of the stress test to his appointment with Cardiologist B.
On 1/23/2014, the stress test was performed and the results were abnormal.
The Medical Board of Florida judged that the internist failed to adequately evaluate the patient’s symptoms and recognize the patient’s worsening coronary artery disease, development of congestive heart failure, and worsening chronic kidney disease. He failed to refer the patient to a nephrologist for further evaluation upon seeing a dramatic decline in the patient’s GFR levels. He also failed to send the patient to the emergency department for treatment when the patient presented to him with exhibiting cardiac symptoms and had a known history of heart disease.
The Medical Board of Florida issued a letter of concern against the internist’s license. The Medical Board of Florida ordered that the internist pay a fine of $2,500 against his license and pay reimbursement costs for the case at a minimum of $5,756.36 and not to exceed $7,756.36. The Medical Board of Florida also ordered that the internist complete five hours of continuing medical education in the treatment of patients with chronic kidney disease and chronic heart disease.
State: Florida
Date: December 2017
Specialty: Internal Medicine
Symptom: Extremity Pain, Numbness, Shortness of Breath
Diagnosis: Heart Failure, Cardiovascular Disease, Renal Disease
Medical Error: Failure to examine or evaluate patient properly, Referral failure to hospital or specialist
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
Florida – Internal Medicine – Worsening Chronic Kidney Disease, Abnormal Stress Test, And Cardiac Symptoms
From 2009 until 2014, an internist served as a patient’s primary care physician.
In 2009, the internist referred the patient to Cardiologist A for a cardiology evaluation. The results of the 2009 cardiology evaluation revealed that the patient’s electrocardiogram and stress test were both abnormal. At this time Cardiologist A recommended that the internist increase the patient’s medication as needed in order to get the patient’s LDL cholesterol below seventy.
The patient was evaluated by Cardiologist A again in June 2010. The June 2010 cardiac evaluation revealed that the patient had shortness of breath on exertion at times, possibly related to hypertension and subclinical congestive heart failure.
On 7/17/2013, the patient underwent lab work, the results which showed that his glomerular filtration rate (“GFR”) was thirty-four. The internist stated the patient’s chronic kidney disease (“CKD”) as stage III/IV.
The patient’s next set of lab work was conducted on 11/18/2013, the results of which showed that his GFR was twenty-two. The internist wrote in a progress note that the patient’s CKD was stage III/IV.
The patient had lab work done again on 1/13/2014, the results of which showed that his GFR was twenty-six. In a progress noted created on 1/13/2014, the internist wrote that the patient’s CKD was now at stage IV.
Despite the dramatic decline in the patient’s GFR levels indicative of worsening CKD, the internist did not refer the patient to a nephrologist.
On 1/13/2014, the patient presented to the internist complaining of left arm pain, numbness radiating to both hands, and shortness of breath. The internist ordered an EKG, chest x-ray, and lab work. The internist’s assessment of the patient at this time was dyspnea on exertion, questionable coronary artery disease, questionable pulmonary issue, and questionable anxiety.
The internist had the patient return to the office on 1/14/2014 for an echocardiogram. After the echocardiogram, the internist referred the patient to Cardiologist B for a consult.
The patient could not obtain an appointment with Cardiologist B until 2/3/2014.
The internist ordered that a stress test be conducted prior to the patient’s visit to Cardiologist B, and advised that the patient bring the results of the stress test to his appointment with Cardiologist B. The stress test was performed on 1/23/2014, and the results were abnormal.
The Board judged the internist’s conduct to be below the minimum standard of competence given that the internist failed to adequately evaluate the patient’s symptoms and recognize the patient’s worsening coronary artery disease, development of congestive heart failure, and worsening of chronic kidney disease. The internist should have referred the patient to a nephrologist for further evaluation upon seeing a dramatic decline in the patient’s GFR levels. When the patient, with a known history of cardiac disease, presented with cardiac symptoms, the internist should have should have sent the patient to an emergency department for treatment.
The Board ordered that the internist pay a fine of $2,000 imposed against his license. The Board also ordered that the internist pay reimbursement costs of a minimum of $5,756.36 and not to exceed $7,756.36. The internist was ordered to complete five hours of continuing medical education in the treatment of patients with chronic kidney disease and five hours of continuing medical education in the treatment of patients with chronic heart disease.
State: Florida
Date: December 2017
Specialty: Internal Medicine
Symptom: Extremity Pain, Numbness, Shortness of Breath
Diagnosis: Renal Disease, Cardiovascular Disease
Medical Error: Referral failure to hospital or specialist
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
Florida – Family Medicine – Patient With Kidney Stone Started On Morphine Along With Fluoxetine And Promethazine
A 27-year-old female was a patient of a family practitioner. On 2/11/2014, the patient started complaining to the family practitioner about a potential kidney stone.
The family practitioner had records indicating that the patient was being treated with tramadol, Percocet, fluoxetine, and promethazine.
On 5/12/2014, the family practitioner prescribed morphine 60 mg, extended release, to the patient, to be taken twice a day, but the family practitioner never adequately documented medical justification for the prescription. The standard starting dose for morphine is 15 mg every eight to twelve hours.
The patient was also taking fluoxetine and promethazine and the family practitioner signed a CVS form indicating the patient could start morphine despite possible contraindications.
The family practitioner did not take additional precautions to monitor the patient, despite her taking fluoxetine and promethazine in combination with morphine.
At 5:25 p.m. on 5/14/2014, the patient’s husband found her unresponsive in the bedroom and 911 was called immediately.
The patient ultimately was transported to a hospital and diagnosed with poisoning by opiates and related narcotics.
The Board judged the family practitioners conduct to be below the minimum standard of competence given his failure to prescribe morphine for medically justified reasons. The family practitioner failed to start with an initial dose of morphine at 15 mg every eight to twelve hours. The family practitioner failed to take additional precautions regarding monitoring for central nervous system or respiratory depression when the morphine was prescribed with the fluoxetine and promethazine. The Board judged that the family practitioner failed to adequately create or maintain medical records that justified the course of treatment for the patient.
The Board ordered that the family practitioner have a reprimand against his license. The Board ordered that the family physician pay a fine against his license of $7,500 and that the family practitioner pay reimbursement costs for the case between a minimum of $820.04 and a maximum of $2,820.04. The Board ordered that the family practitioner complete a drug prescribing course and a medical records course and that the family practitioner complete five hours of continuing medical education in nephrology.
State: Florida
Date: November 2017
Specialty: Family Medicine, Internal Medicine
Symptom: Abdominal Pain
Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Renal Disease
Medical Error: Improper medication management, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Internal Medicine – Retained Guide Wire Found After Replacement Of Dialysis Catheter
On 3/19/2015, a patient presented to a hospital with complaints of chest pain, history of acute stent thrombosis, and renal failure.
On 3/21/2015, a physician referred the patient to an internist for replacement of temporary dialysis catheter to address her acute kidney failure. The internist placed a double-lumen dialysis catheter in the patient’s left subclavian vein.
Due to the catheter not functioning properly, another physician performed a catheter exchange procedure on the patient on 3/23/2015. After the procedure, the inspection of the catheter revealed that the guide wire remained in one of the lumens of the catheter.
Neither the internist nor his staff removed the guide wire from the catheter prior to the insertion of the catheter into the patient’s left subclavian vein.
The Board judged the internist’s conduct to be below the minimum standard of competence given that he left a foreign body in a patient.
The Board ordered that the internist pay a fine of $3,500 against his license and pay reimbursement costs for the case for a minimum of $3,419.35 and not to exceed $5,419.35. The Board also ordered that the internist complete five hours of continuing education in “Risk Management” and complete a lecture/seminar on retained foreign body objects to medical staff.
State: Florida
Date: November 2017
Specialty: Internal Medicine, Nephrology
Symptom: Chest Pain
Diagnosis: Renal Disease
Medical Error: Retained foreign body after surgery
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
Florida – Urology – Stent Placed For Kidney Stone Placed In Wrong Ureter
On 7/16/2016, a 50-year-old male presented to the medical center emergency department with abdominal pain.
The patient was diagnosed with renal kidney stones and admitted to the hospital.
The patient was taken to the operating room for a planned cystoscopy, right ureteroscopy, and placement of right ureteral stent.
Informed consent was obtained from the patient for the placement of the right ureteral stent.
On 7/20/2016, a urologist placed a stent in the patient’s left ureter (wrong site), rather than the right ureter (correct site). The patient was then discharged home.
On 7/25/2016, the patient returned to the hospital with complaints of abdominal pain.
A CT scan of the patient’s abdomen and pelvis revealed right distal ureteral stones with moderate right hydronephrosis. The CT scan also revealed a left ureteral without left hydronephrosis.
On 7/26/2016, the patient was informed by the Chief Medical Officer of the hospital that the surgery was performed on the wrong side.
On 7/26/2016, the patient underwent a second procedure to remove the foreign body (left stent) and right ureteroscopy with laser lithotripsy and placement of right ureteral stent.
The second surgery was performed without incident and the patient was discharged home on 7/27/2016.
It was requested that the Board order one or more of the following penalties for the urologist: permanent revocation or suspension of his license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Board deemed appropriate.
State: Florida
Date: August 2017
Specialty: Urology
Symptom: Abdominal Pain
Diagnosis: Renal Disease
Medical Error: Wrong site procedure
Significant Outcome: Hospital Bounce Back
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Urology – Failure to Follow-Up On Chest X-Rays Ordered In A Patient With Micro Hematuria And Stone Disease
A urologist treated a patient from 2/3/2011 to 3/4/2011.
On 2/3/2011, the patient first presented to the urologist with micro hematuria and stone disease.
On 2/9/2011, the urologist ordered pre-operative blood work and chest x-rays for the patient.
The radiology report of the chest x-ray dated 2/9/2011 revealed a “newly developed 2.5 cm irregular contoured nodule located in the right lower lobe” that was “suspicious for potential malignancy and chest CT correlation [was] recommended…”
The urologist did not review the 2/9/2011 chest x-ray or radiology report and subsequently did not notify the patient and the patient’s primary care physician of the radiology findings.
On July 2012, the patient’s primary care physician ordered a chest x-ray, which demonstrated a 5 cm mass with metastasis.
A medical malpractice lawsuit was filed against the urologist.
The Board judged the urologist conduct to be below the minimal standard of competence given that he failed to review the chest x-ray and radiology report that were ordered by his staff and inform the patient and the patient’s primary care physician of the findings of the chest x-ray.
It was requested that the Board order one or more of the following penalties for the urologist: permanent revocation or suspension of his license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Board deemed appropriate.
State: Florida
Date: July 2017
Specialty: Urology
Symptom: Urinary Problems
Diagnosis: Urological Disease, Cancer, Renal Disease
Medical Error: Failure to follow up
Significant Outcome: N/A
Case Rating: 4
Link to Original Case File: Download PDF
Florida – Internal Medicine – Daily Dose Of 1200 Milligrams Of Gabapentin For Patient With End Stage Renal Disease
On 5/8/2014, a 74-year-old female presented to an internist for the purpose of establishing care. The patient had multiple medical problems, including diabetes, end-stage renal disease, and recurrent C. difficile infections.
At all times pertinent to this complaint, the patient was undergoing chronic hemodialysis treatment.
On 6/10/2014, the patient presented to the internist for a follow-up visit. The internist prescribed 600 mg tablets of gabapentin to the patient to treat her diabetic neuropathy. The patient’s prescription directed her to take the 600 mg of gabapentin twice daily, totalling 1200 mg of gabapentin per day.
On 6/14/2014, after taking her prescribed dosage of gabapentin, the patient lost control of her leg muscles and fell, resulting in a fracture of the T12 vertebrae in her back.
The prevailing professional standard of care required the internist to prescribe the patient a dosage of gabapentin not to exceed 150 mg per day, due to her end-stage renal disease. The internist prescribed the patient an inappropriate and/or excessive dosage of gabapentin.
According to the internist, he verbally instructed the patient and/or her family members to modify the gabapentin prescription.
The internist failed to document and/or accurately document the alleged verbal instruction to the patient and/or her family members to modify the patient’s gabapentin prescription.
The Board issued a letter of concern against the internist’s license. The Board ordered that the internist pay a fine of $5,000 against his license and pay reimbursement costs for the case at a minimum of $30,433.57 and not to exceed $32,433.57. The Board also ordered that the internist complete a medical records course and complete five hours of continuing medical education in clinical pharmacology and drug dosing.
State: Florida
Date: June 2017
Specialty: Internal Medicine, Nephrology
Symptom: Weakness/Fatigue
Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Diabetes, Neurological Disease, Spinal Injury Or Disorder, Renal Disease, Fracture(s)
Medical Error: Improper medication management, Accidental Medication Error, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
California – Cardiology – CT Coronary Angiogram On Hemodynamically Compromised Patient For Chest Pain, Abnormal Electrocardiogram, Right Atrial Enlargement, And Elevated Cardiac Enzymes
On 4/16/2012, a 23-year-old female presented to the emergency department with chest pain, acute nausea, vomiting, and diarrhea. The patient had a history of pulmonary hypertension. Laboratory measurements were taken that revealed a hemoglobin of 17.2, hematocrit of 49.9, an acidotic pH of 7.12, an elevated WBC count of 15,900, potassium of 6.6, BUN of 31, and creatinine level of 1.4. These measurements were consistent with mild renal insufficiency. An electrocardiogram test revealed sinus tachycardia, which was consistent with the findings of an electrocardiogram performed on the patient approximately 1 year earlier.
On 4/17/2012, the patient was admitted to the hospital. The patient was initially treated with sodium bicarbonate to treat her lactic acidosis and IV fluids for dehydration. The patient also received a dialysis catheter in her right femoral artery due to the increase in the BUN/creatinine measurements. However, this catheter was never used.
On 4/17/2012, a cardiologist performed a telephonic cardiology consult with the hospitalist and ordered a CT coronary angiogram due to the patient’s chest pain, abnormal electrocardiogram, right atrial enlargement, and elevated cardiac enzymes (troponin). The cardiologist also ordered 100 ml of ionic contrast to facilitate the CT angiogram despite the patient’s continued elevated BUN and creatinine levels. The cardiologist also ordered 50 mg of metoprolol orally and 5 mg intravenously to improve visualization on the CT angiogram despite the patient’s clinical condition. The cardiologist did not perform a physical examination of the patient, measure the patient’s pulmonary pressure, or review the patient’s diagnostic or laboratory tests prior to ordering ionic contrast, CT angiogram, or administering metoprolol.
On 4/17/2012, the patient deteriorated and became hypotensive approximately 90 minutes after the CT angiogram and administration of metoprolol. At approximately 8:00 p.m., the patient expired due to cardiac arrest.
The Medical Board of California judged that the obstetrician’s conduct departed from the standard of care because he failed to physically examine the patient prior to ordering a potentially dangerous procedure and drugs, review the patient’s previous diagnostic testing and laboratory testing prior to ordering a potentially dangerous procedure and drugs, and order a pulmonary artery catheter to measure pulmonary pressure in a hemodynamically compromised patient.
The Medical Board of California placed the cardiologist on probation for 3 years and ordered the cardiologist to complete a medical record keeping course and an education course (at least 40 hours per year for each year of probation). The cardiologist was also assigned a practice monitor.
State: California
Date: March 2017
Specialty: Cardiology
Symptom: Chest Pain, Diarrhea, Nausea Or Vomiting
Diagnosis: Cardiovascular Disease, Renal Disease, Sepsis
Medical Error: Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Improper medication management
Significant Outcome: Death
Case Rating: 5
Link to Original Case File: Download PDF
Kansas – Cardiothoracic Surgery – Improper Surgical Procedure Of Abdominal Aortic Aneurysm Results In Anuria And Then Death
A 72-year-old male patient was admitted to a medical center with foot ulcer and foot pain. During the patient’s hospitalization, an ultrasound revealed an 8.5 cm large abdominal aortic aneurysm (AAA). The patient was subsequently scheduled for surgical repair.
On 10/24/2010, a cardiothoracic surgeon admitted the patient to a medical center and completed a history and physical. The cardiothoracic surgeon also signed pre-operative orders at that time.
On 10/25/2010, the cardiothoracic surgeon performed an endovascular AAA stent repair on the patient using an Endologix stent graft. After surgery, the cardiothoracic surgeon returned to Wichita, Kansas. The cardiothoracic surgeon’s first assistant an ARNP, signed the post-operative orders and monitored the patient’s recovery along with other hospital staff.
Post-surgery the patient began to have decreased urine output on 10/26/2010. The patient was oliguric and then anuric. The patient failed to respond to large doses of diuretics so a nephrologist was consulted for dialysis.
A CT scan on 10/26/2010 showed bilateral renal artery occlusion and segmental occlusion of the proximal superior mesenteric artery.
Eventually the patient was transferred to Wichita, Kansas for further care where he later died on 10/29/2010.
The Board judged the cardiothoracic surgeon’s conduct to be below the minimum standard of competence given his failure to perform proper endovascular surgery on the patient
The Board ordered that the cardiothoracic surgeon have a cardiac surgeon and/or radiologist with adequate experience in endovascular abdominal aortic aneurysm repair participate and assist the cardiothoracic surgeon on his next ten endovascular abdominal aortic aneurysm repair cases. Also, the Board ordered that the cardiothoracic surgeon complete at least eight hours of continuing medical education courses with emphasis on endovascular abdominal aortic aneurysm repair.
State: Kansas
Date: June 2016
Specialty: Cardiothoracic Surgery, Nephrology
Symptom: Pain
Diagnosis: Aneurysm, Renal Disease
Medical Error: Procedural error
Significant Outcome: Death
Case Rating: 2
Link to Original Case File: Download PDF
Washington – Emergency Medicine – End Stage Renal Disease Started On Levofloxacin 500 mg Oral Daily For 7 Days
On 1/21/2015, a man in his mid-50s came to the emergency department (ED) presenting with coughing, shortness of breath, and sounds in his lungs. The ED physician evaluated the patient and diagnosed him with asthmatic bronchitis with probably underlying viral influenza-like illness.
The patient’s ED records for the visit documented that the patient had end stage renal disease (ESRD). In spite of the patient’s ESRD, the ED physician chose to prescribe 500 mg of levofloxacin per day for seven days.
The patient’s creatinine clearance at the time of his visit was documented as 12 ml/min. The ED physician prescribed a standard dose of levofloxacin, not a renally adjusted dose based on the patient’s renal insufficiency.
The patient began to experience symptoms of severe bilateral Achilles tendinopathy, diagnosed subsequently by another physician as being due to the patient’s treatment with levofloxacin.
The Commission stipulated the ED physician reimburse costs to the Commission, complete 5 hours of continuing education covering the subject of appropriate medication choices and doses for patients with renal insufficiency, write and submit a paper of at least 1000 words, with references, regarding appropriate medication choices and doses for patients with renal insufficiency to the Commission and to all members of his former practice group.
State: Washington
Date: February 2016
Specialty: Emergency Medicine
Symptom: Cough, Shortness of Breath
Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Infectious Disease, Renal Disease
Medical Error: Improper medication management
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF