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On 12/22/2011, a patient was transported to the emergency department after suffering from vertigo.  While at the emergency department, he was having trouble urinating and was told he had a kidney infection.  A family practitioner admitted the patient to the hospital.

At the hospital, the family practitioner diagnosed the patient with an altered level of consciousness secondary to a urinary tract infection and severe cognitive impairment.  The records showed that the patient met the criteria for the diagnosis of sepsis due to urinary tract infection and showed ongoing unstable vital signs and alterations of his level of consciousness compared to baseline.

The patient was transferred to a skilled nursing facility based on recommendations from the family practitioner.  The patient was treated at the skilled nursing facility for five days.

On 12/27/2011, the patient was discharged from the skilled nursing facility and sent home.

On 1/9/2012, the patient presented again to the emergency department with a fever of 102.  The patient was admitted by the same family practitioner as before.

The patient was noted to have generalized weakness, mental status changes, a reported fever of 102, an elevated white blood count, and pyuria.

Abnormal laboratory test results included a low potassium, low calcium, low albumin, elevated brain natriuretic peptide, low and declining hemoglobin and hematocrit, abnormal chest x-ray, right bundle branch block on EKG, and hyperglycemia.  These findings were not addressed in the records by the family practitioner that admitted the patient.

On arrival to the to the hospital’s emergency department on 1/9/2012, the patient’s initial blood pressure was 146/76.  By midnight, his blood pressure was 86/48.  The ED physician on duty ordered 2 L of normal saline to be administered “wide open.”  The family practitioner in his initial admission orders ordered “normal saline” at 100 ml/hr.

At the time this order was written, the patient’s blood pressure was 88/44 with a heart rate of 50 after receiving 2 L of saline.  The family practitioner was aware of the patient’s prior medical records showing that the patient’s systolic blood pressure ranged from 100-136.

The family practitioner admitted the patient to a floor of the hospital and did not order cardiac monitoring.  The family practitioner ordered ceftriaxone and ciprofloxacin IV (initially IV and later changed to an oral dose).

On 1/10/2012, the patient remained hypotensive with blood pressure readings as low as 85/50.  On that day, the patient was transferred to the same skilled nursing facility at which he had previously resided, against the objections of the patient’s family.  The family practitioner did not actually meet with the spouse or family members of the patient.

Diastolic blood pressure was recorded as low as 42.  The patient also remained bradycardic with a heart rate in the 50’s and 40’s.  The ongoing hypotension was called to the family practitioner’s attention by other medical professionals who were concerned about the patient’s stability for transfer to the skilled nursing facility and the appropriateness of this transfer.  The family practitioner insisted that the patient was stable for transfer and ordered the transfer to proceed despite ongoing hypotension and bradycardia.

After he ordered the transfer to the skilled nursing facility, blood cultures turned positive for a gram-positive organism in all four blood cultures that were obtained.  He was aware of all four blood cultures being positive for a gram-positive organism before the patient left the hospital as he noted this fact on his short stay discharge summary.  Final identification and sensitivities were not reported until 1/12/2012.

On 1/11/2012 at 2:00 a.m., the patient was found to be unresponsive.  911 was called, and the patient was transported back to the emergency department in full cardiac arrest.  He was not able to be resuscitated.

The Board raised several concerns.  The Board noted that the patient met the diagnosis of sepsis based on hypotension and noted that elderly patients are sometimes unable to mount a significant temperature response.  The records indicate that the family practitioner did not consider the diagnosis of sepsis.

The family practitioner did not order broad-spectrum antibiotics for coverage of methicillin-resistant Staphylococcus aureus despite gram-positive bacteremia.  The family practitioner’s notes reflect that no consideration was given for coverage of resistant bacteria that may have been contracted in a healthcare setting.

The family practitioner’s medical records from 1/9/2011 to 1/11/2012 indicated that he referred to the previous admission as the basis for an abbreviated history and physical for this admission.

As such, he did not document a review of systems or document a new physical examination of the patient.  There was no documentation that he spoke with the patient’s wife or that she approved of her husband’s transfer to a “SNF for IV ABX.”

For this allegation and others, the Board ordered that the family practitioner be reprimanded, complete a medical record keeping course, and complete a clinical training program equivalent to the Physician Assessment and Clinical Education Program (PACE).

State: California

Date: February 2016

Specialty: Family Medicine, Internal Medicine

Symptom: Fever, Dizziness, Urinary Problems, Weakness/Fatigue

Diagnosis: Sepsis

Medical Error: Diagnostic error, Improper treatment, Lack of proper documentation

Significant Outcome: Death, Hospital Bounce Back

Case Rating: 3

Link to Original Case File: Download PDF

A female presented to a gynecologist on 5/10/2012 reporting a 4-week-long history of abnormal uterine bleeding.  The patient’s past medical history included chronic lung disease, morbid obesity, insulin-dependent diabetes, hypothyroidism, hypercholesterolemia, and hypertension.  She was 22 years post-menopausal and had previously been pregnant 5 times, one ending in a Cesarean delivery.

The gynecologist performed a pelvic exam and Pap cytologic smear at his office.  The gynecologist noted that the uterus was palpably enlarged. The patient had a CT scan of the abdomen and pelvis performed at a hospital on 5/8/2012.  That imaging study described an enlarged uterus, though the dimensions were not specified. A blood count demonstrated a mild anemia, a normal white count, and normal platelet count.

The gynecologist admitted the patient to a medical center on the evening of 5/10/2012 and performed a comprehensive pre-operative medical evaluation.  He further obtained a pre-operative cardiology consultation by a cardiologist. An echocardiogram on 5/19/2011 had shown a normal 82% cardiac ejection fraction.  The consent form for a dilation and curettage (D&C) was signed and witnessed at 7:00 p.m. on 5/10/2012. Pre-operative pelvic CT scan with contrast was ordered on 5/10/2012 at 6:00 p.m.  It was not done preoperatively, but instead was accomplished on the morning of the first post-operative day.

The medical records showed that the gynecologist did not perform a pelvic examination under anesthesia.  A pelvic examination under anesthesia would allow the gynecologist to better appreciate the actual degree of uterine enlargement prior to instrumenting the uterus.  The gynecologist dictated an operative report at 5:54 p.m. The operative report did not specifically mention the use of a sharp metal curette nor did that operative report indicate any suspicion of uterine perforation.

According to the subsequently dictated History and Physical at another medical center on 5/12/2012, the gynecologist indicated that he realized the possibility of a uterine perforation caused by the No. 6 suction cannula at the time of the D&C.  In that dictation, he stated that he realized the perforation, intraoperatively, upon placing the unknown device into the uterus. He continued “minimal amount of D&C was done.” However, his operative report, dictated immediately postoperatively, included no mention of any suspicion for uterine perforation.

The gynecologist obtained approximately 50 mL of clot and enough tissue to make a conclusive histopathologic diagnosis.  The histopathologic report from the D&C procedure gave no indication of any extra uterine tissue suctioned into the specimen.  If the gynecologist suspected uterine perforation intraoperatively, he should have left the offending instrument in place and should have immediately discontinued the procedure.

The gynecologist did not immediately begin prophylactic antibiotics.  Ceftriaxone was initiated only after the patient had spiked a temperature, postoperatively, in the ICU.  After determining there was excessive uterine bleeding, an immediate laparoscopic or open abdominal pelvic assessment was necessary.  The medical records described a large amount of blood with an estimated blood loss of 400 mL. Postoperatively, the patient was admitted to the ICU for closer observation in light of the excessive blood loss.  The handwritten operative note indicated that no complications were suspected or realized. However, the gynecologist’s post-operative report, dictated the following day, clearly suggested that he was aware of the perforation at the time of surgery.

At the gynecologist’s Subject Interview, he indicated that he was aware, or at minimum suspected, perforation of the uterus.  He also indicated that he did not give prophylactic antibiotics upon suspecting uterine perforation at the time of the D&C. The gynecologist suspected a uterine perforation had occurred but still curetted the uterine cavity.

Postoperatively, the patient continued to have ongoing vaginal bleeding, requiring that pads be changed every several hours.  A post-operative blood count showed an elevated white count and a significant and progressive anemia. These values represented marked changes when compared to the corresponding pre-operative values.

On the patient’s first post-operative day in the ICU, she experienced a generally declining trend in blood pressure, and no clear trend in pulse rate.  The gynecologist was called approximately 12 hours postoperatively because the patient was crying in pain. However, the records reflected that 2 hours later, she was sleeping soundly.  No indication of why this occurred was included in her chart. The morning of the first post-operative day, a CT of the pelvis demonstrated a 15 x 10 mesenteric abscess with free air in the abdominal cavity.  The gynecologist sought to consult with other general surgeons at the hospital, but they deferred his request.

Approximately 24 hours postoperatively, the patient’s temperature rose to 101.3 F, and blood cultures were drawn.  Ceftriaxone was begun in the evening of 5/12/2012. Also, that evening blood products were typed and crossed in preparation for a potential transfusion.  The gynecologist spend several hours trying to arrange transfer of the patient to the ICU, but they were at capacity. The gynecologist then contacted a medical center, where he had admitting privileges, to arrange for a transfer to their ICU.  Medical records were faxed to the medical center at 7:00 p.m. At 8:00 p.m., the patient was transferred to the medical center via ambulance.

The D&C Surgical Pathology Report demonstrated a malignant mixed Mullerian tumor.  Incidentally, that report gave no indication of extra uterine tissue having been suctioned into the specimen.

Upon arrival at the medical center, the patient was in septic shock and unresponsive.  The gynecologist contacted a gynecological oncologist and a general surgeon. The patient underwent an immediate hernia repair, hysterectomy, and omentectomy.  A critical care general surgeon served as the primary surgeon for this exploratory laparotomy procedure. At his Subject Interview, the gynecologist stated that he felt that it was unwise to take the patient to the OR so quickly at such time that she was suffering from severe diabetic ketoacidosis.

During the laparotomy, the uterine perforation was discovered.  The peritoneum contained 1500 mL of blood and clots. The blood in the peritoneal cavity was foul-smelling, suggesting infection from the perforated uterus.  The retroperitoneal space also contained a hematoma, and the surgical pathology report indicated an acutely-inflamed hernia sac. The uterine specimen, from the supracervical hysterectomy done by the gynecologist, featured acute and chronic endometritis, perforation, and a malignant mixed Mullerian tumor.  Abscess formation involved the adjacent ovary.

Postoperatively, the patient was noted to be severely acidemic.  Additionally, the patient’s troponin was elevated. The patient required intubation.  She went into diffuse intravascular coagulation and had multiple cardiac arrests. She was pronounced dead on 5/13/2012 at 11:15 p.m.  The preliminary cause of death was cardiac arrest secondary to severe sepsis.

The gynecologist’s medical records were often illegible and conflicting.  He dictated his pre-operative history and physical on 7/18/2012 for an admission on 5/10/2012, 2-months after the event.  His handwritten operative note of 5/11/2012 written at 6:00 p.m. was cursory and did not meet the basic requirements of a post-operative note.  The gynecologist’s dictated post-operative note reflected no suspicion or recognition of a uterine perforation. He dictated his Discharge Summary at a medical center reflecting an uncomplicated D&C and a normal brief post-operative course.  This representation was not consistent with the patient’s actual excessive bleeding at surgery and her complicated post-operative course in the ICU.

The Medical Board of California judged that the gynecologist’s conduct departed from the standard of care because he curetted the uterine cavity when he suspected a uterine perforation, failed to pursue an aggressive evaluation, either laparoscopy or laparotomy, when he suspected a uterine perforation, did not perform a pelvic examination under anesthesia before or during the procedure, did not immediately initiate prophylactic antibiotics when he suspected a uterine perforation, had a 2-month gap in time between his dictated pre-operative history and physical for an admission, and failed to maintain adequate 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 a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.  The gynecologist was assigned a practice monitor and was prohibited from supervising physician assistants. His license was later revoked.

State: California

Date: November 2015

Specialty: Gynecology

Symptom: Abnormal Vaginal Bleeding

Diagnosis: Post-operative/Operative Complication, Sepsis

Medical Error: Procedural error, Improper medication management, Lack of proper documentation

Significant Outcome: Death

Case Rating: 4

Link to Original Case File: Download PDF

On 11/14/2012 at 6:30 a.m., a 60-year-old female presented to the emergency department with a five-day history of intermittent abdominal pain located in the right lower quadrant, which was severe at time of presentation.  She also presented with chills without fever.  Two days prior, the patient had developed nausea and vomiting, which eventually became blood-streaked.  The patient was placed on morphine for the pain, and the pain eased.  The patient was prophylactically placed on intravenous antibiotics for suspected infection.  A CT scan of the abdomen and pelvis revealed a 5 mm kidney stone at the right ureterovesical junction (UVJ) with moderate hydronephrosis above it.  A urologist was called in on consult, and the patient was admitted to the hospital.

The urologist read the emergency department records and laboratory results and scan, examined the patient, and affirmed that she had a 5 mm obstructive UVJ ureteral stone, which was symptomatic with hydronephrosis and creatinine and glomerular filtration rate dysfunction.  After discussing his findings and recommendations with the patient and obtaining consent, the urologist schedule the patient for a right ureteroscopy, possible stone basketing or laser lithotripsy of the stone, and insertion of a right double-J ureteral stent for the evening of 11/14/2012.

The patient entered the operating room at 5:40 p.m. on 11/14/2012.  The operative procedure with the patient under general anesthesia commenced at 6:20 p.m. and concluded at 8:50 p.m.  The urologist commenced the cystoscopy and ureteroscopy and had difficulty inserting the Glidewire to place surgical implements due to fluid retention and edema in the kidney.  The placement of the initial Glidewire took 45 minutes.  Once the catheter and other implements were in place, an anesthesiologist reported to the urologist that the patient had developed a fever of 38.6 C (101.48 F) and that a large amount of darker urine was issuing from the right ureteral orifice.  The urologist elected to continue and complete the stone removal and stent placement.  Approximately 6 liters of IV fluid resuscitation were administered intraoperatively.  The patient’s temperature fell to near normal, but hypotension and tachycardia continued.  The urologist completed the ureteroscopy, stone retrieval, and placement of a right ureteral stent despite the development of signs of sepsis in the patient.  Postoperatively, the patient’s infection was diagnosed as sepsis, presumably urosepsis.  It required IV fluid boluses, IV antibiotics, pressors, and ICU admission for treatment of septic shock.

Ureteral stones can cause sepsis if there is an infection trapped behind a ureteral stone.  Many times, the urine culture is clear, despite having an infection building behind an impacted stone.  Any sign of infection, including an elevated white blood cell count, fever, blood pressure abnormality, tachycardia, or purulence behind the stone, should warn the urologist of impending infection and sepsis.  A patient with an impacted ureteral stone and infection should be treated with either percutaneous nephrostomy tube or ureteral stent placement, and the stone should be treated only after the infection has resolved.

The Medical Board of California judged that the urologist committed negligent acts in his care and treatment of the patient given that he completed the operative procedure, instead of aborting it or placing a stent only and treating the infection first, despite the presence of signs and symptoms of serious infection.

For this case and others, the Medical Board of California issued a public reprimand and ordered that the urologist complete a clinical training or educational program equivalent to the Physician Assessment and Clinical Education Program (PACE) offered at the University of California, San Diego School of Medicine (Program) within 60 calendar days.

State: California

Date: October 2015

Specialty: Urology, Nephrology

Symptom: Abdominal Pain, Bleeding, Fever, Nausea Or Vomiting

Diagnosis: Sepsis, Post-operative/Operative Complication, Urological Disease

Medical Error: Improper treatment, Procedural error

Significant Outcome: N/A

Case Rating: 3

Link to Original Case File: Download PDF

In 5/22/2012, a family practitioner saw a wheelchair-dependent female.  The family practitioner took an in-depth history with regards to the patient’s care with over 15 doctors, a hospitalization for severe pain, and a complete medical workup.  The patient told the family medicine physician that she had been bitten by a tick while working outside, after which she suffered from a target rash and joint pain typical of Lyme Disease.  The family practitioner had the patient sign a consent for treatment and another consent for treatment for IV antibiotics on 5/22/2012.  The records showed that the patient was advised that the use of the IV antibiotics had specific risks, such as sepsis related to a catheter infection, and that is why the family practitioner enforced monthly blood draws and monthly appointments while patients remained on intravenous therapy.  No physical examination was noted on the initial chart provided by the family practitioner regarding the patient’s functional capacity while confined to a wheelchair.  There was also no documentation of a supportive individual present with the patient, and she had stated that she had once been her boyfriend’s caretaker prior to falling ill herself.

The patient followed up with the family practitioner after the initial labs had been drawn on 6/29/2012.  The family practitioner charted in her notes that the patient was Lyme disease positive and prescribed IV antibiotics for the patient.  There were no vital signs charted on the preliminary notes provided or a physical exam charted.  The family practitioner informed the patient in the consent forms that Lyme Disease is a controversial disease and is largely a clinical diagnosis when the primary test, Western Blot, was negative.  The patient signed her consent understanding the risks were more severe with IV therapy than oral antibiotic therapy, and there was a greater need for accountability and follow up.

The patient’s records reflected notes for an 8/14/2012 “follow up.”  However, this appeared to be a “telephone appointment” during which the family practitioner notified the patient that her laboratory results came back positive for Lyme Disease.  The family practitioner asked her staff to email the test results and labs to the patient.  It appeared that prior to the telephone appointment, the patient had received three weeks of antibiotic therapy and had reported some improvement.  The patient was told to return in a month for her standard monthly laboratory tests and blood tests to be drawn prior to her appointment.

The patient returned on 8/18/2012 for her follow up appointment without any labs.  There were no vital signs or a physical exam of the wound site noted in the chart.  The patient told the family practitioner that she could not afford ertapenem, and she had several other concerns about how she could not get certain labs drawn or referrals due to cost.  As a result, the family medicine physician switched antibiotics, but first ordered an abdominal ultrasound to assess if the patient had a healthy gallbladder.

The family practitioner’s staff appeared to have asked the patient if she was working with a registered nurse to help her with weekly wound care and home assessments.  A registered home health nurse must provide chart notes to the attending physician who is supervising the patient’s care.  Thus, such an inquiry would be unnecessary if proper protocols were being followed.  The family practitioner’s records, or the lack thereof, indicated that she and/or her staff failed to communicate on a regular basis with nursing staff providing home health care monitoring to the patient, but the family practitioner’s re-written chart notes included new charted notes warning the patient of the consequences for non-compliance.  The specific entries were not present in the original provided notes produced and called into question when they were actually written.

In October 2012, the patient did not appear for her appointment.  She also went an additional month being non-compliant with labs, did not follow up with a neurologist, and did not enroll in physical therapy.  The family practitioner’s staff made several attempts to reach the patient to reschedule, but the family practitioner did not discontinue the IV antibiotics by calling the infusion center.  The patient was responsible for mixing and administering her own home IV antibiotics with no skilled nursing assistance.

In November 2012, the family practitioner’s staff reached out to the patient trying to reach her to come and make an appointment, but this call appeared to have occurred only because the infusion center notified the family practitioner’s clinic that they would no longer provide IV antibiotics to the patient due to non-payment.  The records for this month indicated that the family practitioner requested a referral for removal of the Hickman catheter and a request for the patient to come into the clinic to pick up that removal referral.  At no time did the family practitioner take responsibility and attempt to telephone the patient herself to warn her of the risk of sepsis if the Hickman catheter was not removed.  Although the patient listed her daughter as the emergency contact person, at no time did the family medicine physician’s office document that they tried to contact the daughter.

The family practitioner took a detailed history on the patient’s new patient intake but failed to assure that at least two other people would serve as contact points to ascertain that the patient was safe and capable of self-care.  In fact, the family medicine physician failed to determine the name or phone number of the patient’s boyfriend stated that she lived with as an emergency contact.

In December 2012, the patient’s sister, a registered nurse, found the patient at her home soiled in urine with adult diapers around the room.  When discovered, the patient was unable to even support herself to get in and out of her bed.  Also, the patient had fallen at some point in time and had fractured her hip and not sought medical care.  The patient’s sister eventually took the patient to the hospital, where the line sepsis was discovered and the Hickman catheter was removed.  The patient was hospitalized for three weeks on IV antibiotics as a result.

The Medical Board of California judged that the family practitioner committed gross negligence in her care and treatment of the patient given that she failed to take an appropriate intake history when she chose to allow the patient to do home IV therapy, failed to establish a point of contact and safety for the patient, allowed the patient to mix and administer her own IV antibiotics, and gave the patient a new ceftriaxone medication on 9/18/2012 even though the patient failed to obtain an abdominal ultrasound as ordered, which was necessary for the family practitioner to know if it was safe to administer ceftriaxone.  The family practitioner also failed to appropriately monitor and survey the safety of the patient’s home IV, cancel the home IV antibiotics in September 2012 when the patient failed to have her laboratory tests and blood draws done prior to her appointment or at all, and discontinue home IV antibiotics following the patient’s repeated failures to comply with the signed patient plan as well as failing to communicate on a regular basis with nursing staff providing home health care monitoring to the patient and/or the patient herself as to her status.

The Medical Board of California issued a public reprimand and ordered that the family practitioner complete a prescribing practices course, medical record-keeping course, and education course for at least 20 hours equivalent to the courses offered at the University of California San Diego School of Medicine (Program).

State: California

Date: September 2015

Specialty: Family Medicine, Infectious Disease, Internal Medicine

Symptom: Weakness/Fatigue

Diagnosis: Sepsis, Fracture(s)

Medical Error: Failure to examine or evaluate patient properly, Failure of communication with other providers, Failure of communication with patient or patient relations, Failure to follow up, Improper medication management, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 3

Link to Original Case File: Download PDF

On 10/2/2009, a 55-year-old female underwent an open incisional hernia repair performed by a vascular surgeon.  The hernia was repaired primarily, and the patient left the operating room in a hemodynamically stable state. There were no significant intraoperative complications noted by the vascular surgeon in the operative report.  The vascular surgeon was responsible for the patient’s care during the entire duration of the hospitalization.

On 10/3/2008, the patient began developing intermittent episodes of tachycardia as well as respiratory distress.  The patient underwent a CT scan of the chest, which showed no evidence of pulmonary embolism and was treated with intravenous pain medications as well as beta blockers.

On 10/4/2009, the patient’s condition continued to deteriorate clinically, and she was intubated.  After this event and while still in the ICU, the patient underwent multiple imaging studies, including a CT scan of the abdomen area, which showed pneumoperitoneum and free fluid.  Both findings were thought to be related to the recent surgery.

From 10/5/2009 through 10/11/2009, the patient continued to deteriorate and developed renal failure, worsening oxygen requirements ultimately requiring tracheostomy, candidemia, as evidenced by a blood culture obtained several days after the patient’s surgery, and hemodynamic instability requiring vasopressors.  The patient had many laboratory abnormalities, including a rising white count, which peaked at 43,000, high CPK levels, and uremia. An echocardiogram was performed, which showed normal left ventricular function with an ejection fraction of 65%, some mild left ventricular diastolic dysfunction and left atrial enlargement, and mild pulmonary artery systolic hypertension.

On 10/12/2009, the patient developed a gastrointestinal bleed, but did not undergo endoscopy due to her unstable hemodynamic status.  On 10/15/2009, the patient continued to deteriorate and expire.

On 10/16/2009, an autopsy was performed that showed more than 2500 mL of fecal fluid, multiple intra-abdominal abscesses, and an area of recent acute hemorrhage along the right lateral abdomen.  There were also dense fibrous adhesions that completely obliterated the normal anatomy of the abdomen, and rupture sites in the small bowel and colon with spillage of fecal and small bowel contents into the abdominal cavity.  The autopsy report also stated that the rupture sites were most likely due to the extensive adhesions rather than the pre-existing diverticula. The patient also had evidence of systemic inflammatory response with injury and congestion of the lungs, kidney, and heart.  Examination of the heart showed significant coronary artery atherosclerosis and evidence of congestive heart failure.

The Medical Board of California judged that the vascular surgeon’s conduct departed from the standard of care because he failed to provide timely care to the patient when she developed symptoms of infection and decompensation soon after a complex abdominal procedure and failed to take the patient to the operating room for an exploratory laparotomy.

The Medical Board of California ordered the vascular surgeon to surrender his license.

State: California

Date: September 2015

Specialty: Vascular Surgery, General Surgery

Symptom: Shortness of Breath

Diagnosis: Post-operative/Operative Complication, Heart Failure, Hemorrhage, Procedural Site Infection, Acute Abdomen, Sepsis

Medical Error: Diagnostic error

Significant Outcome: Death

Case Rating: 4

Link to Original Case File: Download PDF

On 3/25/2005, a patient presented to an orthopedic surgeon for elective right total knee arthroplasty (TKA).  Although at the time of admission, the patient had multiple comorbidities, the surgical procedure went without complication.  The patient was discharged on 11/11/2005 and was thereafter followed by the orthopedic surgeon. Her blood was drawn 15 times between 11/21/2005 and 1/27/2006.  During this time, the patient’s ESR and WBC remained elevated while her hemoglobin level was dangerously low. The orthopedic surgeon saw the patient at least 12 times during this 8-week period.  Her chart indicated wound dehiscence, separation of the layers of a surgical wound, on 11/30/2005, and again on 12/2/2005. By 12/10/2005, the wound and bone became necrotic. In addition, there was cellulitis and drainage.  An additional surgical procedure was consequently performed on 1/7/2006, and the patient was placed on oral antibiotics. Throughout January 2007, the wound continued to drain, and the tendon, bone, and prosthesis became visible and/or exposed through the skin.

On 1/28/2006, the patient was readmitted to the hospital.  The orthopedic surgeon provided a consultation with a final impression of “Open wounds at the right knee with cellulitis, rule out sepsis.”  During the first week of admission, however, the patient’s treatment was based on her multiple comorbidities rather than the infection. She subsequently was taken back into surgery on 2/14/2006 for “severe right knee joint sepsis with 2 open wounds,” which included removal of the infected TKA.

The standard of care requires that situations be managed appropriately and timely in order to try to minimize additional complication and sequela.  It requires the physician to weigh the risks and benefits of all treatment options, and use his knowledge, training, and experience to make the most appropriate treatment recommendations.

The orthopedic surgeon did not inform the patient of the risks associated with all treatment options or provide a clear description of the potential outcome of delayed treatment between 11/21/2005 and 1/27/2006.  The orthopedic surgeon did not document his discussion with the patient or her family regarding the specific risks of delayed treatment once he recognized the infection and continued drainage. The orthopedic surgeon neither discussed nor documented the need for aggressive treatment and urgent hospitalization during this time.  He also did not document the risks of the patient not being admitted to the hospital.

The patient’s laboratory tests were ordered frequently during 11/21/2005 and 1/27/2006.  The results remained abnormal. The severity of the patient’s consistently elevated ERS and WBC levels, in addition to her dangerously low hemoglobin levels, required immediate action.  The orthopedic surgeon did not treat the abnormal values during this time.

The Medical Board of California judged that the orthopedic surgeon’s conduct departed from the standard of care because he failed to treat her post-operative deep infection, did not adequately discuss with the family the risks of delaying aggressive treatment and documenting the discussion in the record, failed to interpret and investigate abnormal laboratory test values, and relied solely on the primary physician for hospital admission.

The Medical Board of California placed the orthopedic surgeon on probation for 3 years and ordered the orthopedic surgeon to complete a medical record keeping course, a clinician-patient communication course, and a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.  The orthopedic surgeon was also assigned a practice and billing monitor and was prohibited from supervising physician assistants.

State: California

Date: September 2015

Specialty: Orthopedic Surgery

Symptom: Wound Drainage

Diagnosis: Sepsis, Procedural Site Infection

Medical Error: Delay in proper treatment, Failure of communication with patient or patient relations, Failure to follow up, Lack of proper documentation

Significant Outcome: Hospital Bounce Back

Case Rating: 2

Link to Original Case File: Download PDF

On 7/6/2011, a 55-year-old man presented to clinic with reports of buttock and leg pain after working in the garden.  He had a fever of 101 for the last 2 days.  Physician A documented that he had lumbosacral spine tenderness with reduced range of motion and tenderness with movement.  There was pain upon palpation of the sciatic notch and paralumbar muscle spasm on the right.

On 7/11/2011, the patient presented to Physician B at another location with symptoms of nausea, abdominal pain, fever, and low back pain.  Physician B documented paraspinal tenderness and tachycardia.  Urinalysis, CBC, and an ECG were ordered.  He was sent home with recommendation to follow up if symptoms worsened and depending on lab results.

On 7/13/2011, presented to Physician A again and reported abdominal discomfort, weakness, and inability to keep food down.  Physician A documented that the patient was clammy and perspiring.  There was no documentation of any fever.  Physician A reviewed labs from 7/11/2011 and noted mild elevation of the liver function tests, mild elevation of the bilirubin levels, and an elevation in creatinine (doubling of his normal).  Physician A suspected a viral illness with mild hepatitis and ordered labs for hepatitis along with CT scan of the abdomen.  He considered IV fluids but elected to wait for the results of the lab work.  The patient was then sent home.

On the same day, the patient was taken to the emergency department with decreased energy, mottling of the skin, hallucinations, fever, and back pain.  Staff diagnosed the patient with hypovolemic shock, rhabdomyolysis, alcohol withdrawal with hallucinations, back pain, and fever.  He was then sent home.  On 7/14/2011, the patient was taken to the hospital via med flight.  He was diagnosed with lactic acidosis, renal failure, possible rhabdomyolysis, alcohol withdrawal, fever, possible sepsis, and respiratory distress.  He died that day.  Autopsy listed the cause of death as community-acquired Staphylococcus aureus septicemia, disseminated intravascular coagulation, and widespread septic thromboembolism.

The Board determined that Physician A fell below the minimal standard of care by failing to recognize sepsis.  Physician A completed CME pending resolution of the issue: LAMMICO – Sepsis – Early Recognition and Treatment of Severe Sepsis and Septic Shock: A New Paradigm and Blackwell Futura Media Services – Early Identification and Management of Severe Sepsis.

State: Wisconsin

Date: August 2015

Specialty: Family Medicine, Internal Medicine

Symptom: Fever, Nausea Or Vomiting, Abdominal Pain, Back Pain, Extremity Pain, Pelvic/Groin Pain, Weakness/Fatigue

Diagnosis: Sepsis

Medical Error: Diagnostic error

Significant Outcome: Death

Case Rating: 3

Link to Original Case File: Download PDF

On 7/22/2010, a 74-year-old male was seen by a vascular surgeon for a recently diagnosed gastric adenocarcinoma (cancer of the digestive tract).  A follow-up CAT scan revealed a “3.5 cm polypoid mid gastric cancer” and gallstones. There was no obvious metastatic disease. The plan was for the patient to undergo a partial gastrectomy (removal of the lower portion of the stomach) to address the gastric adenocarcinoma with cholecystectomy (surgical removal of the gallbladder) to address the patient’s gallstones.

On 8/5/2010, the patient was admitted for his scheduled surgery that was performed on the same date by the vascular surgeon.  The surgery was uneventful with findings of a more extensive tumor than expected, but with accomplishment of the subtotal gastrectomy with a B1 (gastroduodenostomy) anastomosis and the cholecystectomy to address the gallstones.

On 8/7/2010, the patient’s post-operative course became unstable with hypotension (low blood pressure) and respiratory difficulties associated with oxygen desaturation and worsening acute renal insufficiency.  A CT scan of the abdomen and pelvis without contrast was ordered by the vascular surgeon at approximately 5:19 p.m. with the physician’s order listing “sepsis” as the reason for ordering the CT scan.

On 8/8/2010, the results of the CT scan were electronically signed by a radiologist with findings of “gas collected in the operative bed” with “[a] large amount of free intraperitoneal air is also present.”  The CT impression section noted, among other things, that there was “[g]as collected at the operative site. This has somewhat unusual appearance and an infected collection cannot be absolutely excluded.”

On 8/10/2010, the patient underwent a Gastrografin UGI (upper gastrointestinal) study (radiological study of the gastrointestinal tract) that was ordered by the vascular surgeon, which revealed a leak above the gastroesophageal (GE) junction.  At this point, the patient was stable with improved overall renal and pulmonary parameters using conservative therapy, which included NGT suction, TPN, and antibiotics.

On 8/14/2010, a repeat Gastrografin UGI study was completed, which showed a larger leak and collection of fluid, which was drained.  Thereafter, the patient’s condition steadily declined. On 8/15/2010, the patient was seen by another surgeon, who was covering for the vascular surgeon, with the covering surgeon documenting a possible return to the operating room for exploratory surgery and lavage with a notation that the patient and family were “hesitant regarding re-exploration and washout.”

On 8/16/2010 at 4 a.m., the patient’s clinical condition was noted to “have gotten progressively worse by the hour” with the patient having “agonal breathing.”  The attending physician confirmed the patient’s DNR and DNI status with the patient’s son, who was at bedside. The patient was placed on morphine for comfort and expired at 4:30 a.m.  The discharge summary prepared by the vascular surgeon listed the patient’s complications as leak from gastric anastomosis, acute renal insufficiency, bronchopneumonia, and severe sepsis.

The Medical Board of California judged that the vascular surgeon’s conduct departed from the standard of care because he failed to respond in a timely and appropriate manner to the patient’s anastomotic leak, which delayed the expeditions and effective treatment of the anastomotic leak.

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

State: California

Date: July 2015

Specialty: Vascular Surgery, General Surgery

Symptom: Shortness of Breath

Diagnosis: Post-operative/Operative Complication, Cancer, Acute Abdomen, Sepsis

Medical Error: Delay in proper treatment

Significant Outcome: Death

Case Rating: 3

Link to Original Case File: Download PDF

On 8/28/2009 at 7:00 a.m., a 31-year-old female presented to the emergency department.  She was diagnosed with a right-side kidney stone and was discharged the same day with pain medications and instructions to follow up with a urologist.  Later that afternoon, the patient returned to the emergency department with her husband complaining of persistent flank pain. After a 2.5 hour wait without being seen, the patient left with her husband.

On 8/29/2009 at 3:40 a.m., the patient returned to the emergency department with increasingly severe flank pain.  She had experienced vomiting while at home. Her initial triage signs were documented as having a temperature of 99.6 F, a pulse of 145, a blood pressure of 128/84, a respiratory rate of 22, and a pulse oximetry of 99%.  An IV was established. An ED physician evaluated the patient at approximately 4:30 a.m.

The ED physician dictated his initial note at 4:50 a.m.  He ordered blood work, including a CBC with manual differential, a urinalysis, and a CT scan.  Per his initial orders, the patient was given pain for nausea and pain. The CT scan was performed at 5:04 a.m.  The results read by the ED physician showed a 1-2 mm stone at the right ureterovesical junction with moderate hydroureter (dilation of the ureter) and hydronephrosis (dilation of the pelvis and calices of the kidney).  The report was available at 5:48 a.m. It was called to the emergency department at 6:12 a.m. Chemistry results were called to the emergency department at 6:12 a.m. The CBC results showed a significant bandemia (excess of mature white blood cells) of 48%.  The urinalysis showed pyuria (pus in the urine) with 5-20 white blood cells and epithelial cells.

The ED physician dictated an addendum at 6:18 a.m. that included discharge impressions of acute renal colic, hypokalemia, and a UTI.  At 6:20 a.m., the patient was given Levaquin for the UTI and KCL per the ED physician’s orders. Repeat vital signs at 6:23 a.m. showed a temperature of 100.1 F, a pulse of 116, a blood pressure of 123/56, and a respiratory rate of 20.  Her IV was discontinued at 6:37 a.m. At discharge, the patient remained tachycardic (with a pulse of 108 and a low-grade fever of 99.5 F).

Later that day, the patient returned to the emergency department.  At that time, she was critically ill, necessitating air transfer to another medical facility, where she ultimately expired.  An autopsy the following day included a 2 mm stone and “ascending urinary tract infection due to renal lithiasis [kidney stones] leading to right acute pyogenic uteritis [inflammation of the uterus with pus] and acute pyogenic pyelonephritis [infection of the kidneys], sepsis, multisystem organ failure, and death.”

The standard of care in emergency medicine is to identify patients with criteria for Systemic Inflammatory Response Syndrome (SIRS) and/or sepsis and treat them appropriately per established guidelines.  SIRS is defined as having two or more of the following variables: (1) fever of more than 100.4 F; (2) heart rate of more than 90 beats per minute; (3) respiratory rate of more than 20 breaths per minute or arterial carbon dioxide tension of less than 32 mm Hg; and (4) abnormal white blood cell count.  Sepsis is defined as SIRS with a confirmed or suspected infection. SIRS and sepsis are associated with increased morbidity and mortality.

The patient’s initial vital signs showed that she had a heart rate of 145 and a respiratory rate of 22.  Per the above definition, she met the criteria for SIRS upon her arrival. Her low-grade fevers should have raised suspicion for infection, and the presence of pyuria confirmed a source.  This would mean that she met the criteria for sepsis during her stay in the emergency department. The ED physician was notified that the patient met one or more of the criteria for SIRS. He stated, “I admit that she had the early signs of sepsis when I saw her.”  Nevertheless, he did not recognize the significance of the patient’s vital sign abnormalities and did not make the diagnosis of either SIRS or sepsis. With a diagnosis of sepsis, she carried an increased risk of mortality and should have been admitted to that the hospital for hydration, broad spectrum antibiotics, monitoring, and further interventions.

The standard of care in treating hypokalemia is to replete potassium and to assess the efficacy of such an intervention.  The patient’s potassium was 2.7 when she was evaluated by the ED physician, and he ordered oral potassium, but did not recheck a level to determine the efficacy of his treatment.  The standard of care in interpreting serum chemistry results is to identify abnormalities, account for these abnormalities, and take steps to treat any emergent condition they represent.  The patient’s chemistries revealed a sodium of 139, potassium of 2.7, chloride of 106, a bicarbonate level of 19, and a reported anion gap of 17. This gap suggested a metabolic acidosis. The presence of this acidosis was not identified by the ED physician and therefore not investigated.  The ED physician’s dictation mentioned a serum potassium of 2.6, but did not show that he took notice of other significant abnormalities, such as the low bicarbonate, elevated anion gap, or elevated creatinine. These values suggested more significant underlying systemic disease beyond simple kidney stone and UTI.  The ED physician should have identified their significance and taken appropriate actions to initiate further testing, treatment, and stabilization.

The Medical Board of California judged that the ED physician’s conduct departed from the standard of care because he failed to recognize and treat the patient’s SIRS/sepsis, order a repeat potassium level after repletion, and appreciate the significance of the patient’s low bicarbonate, elevated anion gap, and elevated creatine.

The Medical Board of California issued a public reprimand and ordered the ED physician to complete an education course.

State: California

Date: July 2015

Specialty: Emergency Medicine, General Surgery

Symptom: Back Pain, Fever, Nausea Or Vomiting

Diagnosis: Sepsis

Medical Error: Diagnostic error, Failure to follow up, Failure to properly monitor patient

Significant Outcome: Death, Hospital Bounce Back

Case Rating: 5

Link to Original Case File: Download PDF

On 2/6/2012, a general surgeon closed the ileostomy on a 51-year-old diabetic male with a history of ulcerative colitis.  The patient had a restorative proctocolectomy with diverting loop ileostomy in 2011. After the patient’s surgery, there was no bowel output for a week, and he developed signs of sepsis (he had a WBC of 2.2 four days post-surgery and a WBC of 3.3 with a left shift 6 days post-surgery).  On 2/13/2012, the patient showed increased signs of infection including shaking, chills, and a blood culture that was positive for E. coli. The patient’s abdomen was very distended, tympanitic, and somewhat diffusely tender. The general surgeon returned the patient to surgery on 2/15/2012 for a loop ileostomy to stop the ileus leakage.

In the operative report for the patient for the 2/6/2012 procedure, the general surgeon failed to state where the stoma was located, what size GIA stapler was used to make the anastomosis, and whether the skin and facial closures were transverse or vertical.  In the second operative report of the patient dated 2/15/2012, the general surgeon failed to state that the new loop “ileostomy” was an exteriorization and missed stating where the incision was located, how long the extended incision was, what technique was used to make the anastomosis, and how far the new loop ileostomy was from the new anastomosis.  In the third operative report of the patient dated 2/25/2012, where the general surgeon sought to de-exteriorize the loop and then matured it as a loop ileostomy, the general surgeon failed to state whether the patient’s abdomen was open, what the technique of ileostomy maturation was, and where the incision was on the patient.

The Medical Board of California judged that the general surgeon’s conduct departed from the standard of care because he delayed in recognizing signs of sepsis in the patient from 2/10/2012 to 2/15/2012, and he failed to maintain accurate records.

The Medical Board of California issued a public reprimand and ordered the general surgeon 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: June 2015

Specialty: General Surgery

Symptom: GI Symptoms (GERD, Abdominal Distention, Dysphagia)

Diagnosis: Post-operative/Operative Complication, Sepsis

Medical Error: Delay in diagnosis, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF