Found 21 Results Sorted by Case Date
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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



Florida – Pain Management – Wrong Concentration Of Hydromorphone Programmed Into Intrathecal Pain Pump



In December 2007, a 55-year-old male had an intrathecal pain pump inserted for pain control at the recommendation of his pain management specialist.  He had been prescribing the patient hydromorphone with a concentration of 10 mg/ml.

From 1/31/2012 to 2/15/2012, upon referral by his physician, the patient presented to a new pain management specialist for pain management.

At the initial visit, on 1/31/2012, the pain management specialist ordered a prescription of hydromorphone injectable solution with a concentration of 30 mg/ml to refill the patient’s intrathecal pain pump.

On 2/15/2012, the patient presented to a pain management center to have his intrathecal pain pump refilled with the hydromorphone prescription and reprogrammed.

A physician assistant refilled the patient’s intrathecal pain pump with hydromorphone with a concentration of 30 mg/ml; however, the concentration of the hydromorphone that was programmed into the intrathecal pain pump remained at 10 mg/ml.

The Medical Board of Florida judged the pain management specialists conduct to be below the minimal standard of competence given that he failed to verify that the correct concentration of hydromorphone was administered into the intrathecal pain pump after it was refilled on 2/15/2012 and he failed to verify the correct concentration of the hydromorphone was programmed into the intrathecal pain pump.

The patient expired at his home on 2/15/2012.

It was requested that the Medical Board of Florida order one or more of the following penalties for the pain management specialist: 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 Medical Board of Florida deemed appropriate.

State: Florida


Date: April 2017


Specialty: Pain Management, Anesthesiology


Symptom: Pain


Diagnosis: Drug Overdose, Side Effects, or Withdrawal


Medical Error: Accidental Medication Error, Improper supervision


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Kansas – Physician Assistant – High Dosing Regimen Of Amitriptyline For A Pediatric Patient With Headache, Vomiting, And Incontinence



On 11/19/2015, a patient presented to a physician assistant at a family care clinic with chief complaints of headache, vomiting, and incontinence since 11/17/2015.  The patient’s father reported, in addition to the severe headache, the patient was experiencing involuntary arm jerking.  Furthermore, the night prior, the patient experienced hearing voices.

The patient had a history of respiratory problems, was noted to have “poor” functional status, and was noted to be in preschool.

The physician assistant did not complete a neurological examination; however, he diagnosed the patient with pediatric migraine and ordered thirty 10 mg tablets of amitriptyline with instructions for the patient to take one tablet three times daily and the patient was to have one refill.  The physician assistant did not perform a thorough workup to include additional studies or tests prior to prescribing amitriptyline.

On 2/3/2016, the Board received a response from the physician assistant wherein he indicated, “I recall little about the episode, except possibly after reviewing his chart and the nurses [sic] report, in investigating his headache and cyclic vomiting and physical exam in UpToDate that the treatment I initiated would have been per the UpToDate recommendations.”

UpToDate is an online website claiming to be an evidence-based, physician-authored clinical decision support resource.

The physician assistant inappropriately prescribed amitriptyline due to the excessive dose and age of the patient.

The Board judged the physician assistant’s conduct to be below the minimum standard of competence given his inappropriate prescribing of amitriptyline.

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, Family Medicine, Pediatrics


Symptom: Headache, Nausea Or Vomiting, Psychiatric Symptoms, Urinary Problems


Diagnosis: Neurological Disease


Medical Error: Improper medication management, Accidental Medication Error, Failure to examine or evaluate patient properly


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Gynecology – Administration Of Glacial Acetic Acid During A Gynecological Procedure



On 11/30/2011, a patient was prepared for a scheduled diagnostic laparoscopy, fulguration of endometriosis, loop electrosurgical excision procedure (“LEEP”), and r-ov cystectomy (remotely operated vehicle laparoscopic ovarian cyst removal) to be performed by a gynecologist.

On 11/30/2011 at 8:35 a.m., the patient was placed under anesthesia.  The gynecologist requested Lugol’s solution (a combination of iodine and potassium iodide in water) from the operating room nurse for use in the patient’s LEEP.  However, Lugo’s solution was not available.  Therefore, the gynecologist directed the OR nurse to go to obtain a 5% acetic acid from the pharmacy.

When the OR nurse returned to the operating room, she entered through a door approximately fifteen to twenty feet from the operating table where the gynecologist was setting up the patient.  The gynecologist asked the OR nurse to read the label to her.  The OR nurse read aloud “acetic acid,” but did not read the concentration of the acid.  The gynecologist did not ask about the concentration of the solution.  The OR nurse poured the solution into a specimen cup.  However, instead of bringing 5% acetic acid, the OR nurse brought the gynecologist Glacial acetic acid (a stronger form of acetic acid), obtained from a laboratory.

During the patient’s procedure, the gynecologist applied 5 or 10 cubic centimeters of the Glacial acetic acid solution from the specimen cup directly into the patient’s vagina and cervix, swabbed out the excess, and completed the procedure.  The patient was discharged that same day.

On 12/5/2011, the patient was seen for a post-operative visit and was readmitted to the hospital for an examination under anesthesia and wound debridement for second degree burns to her vagina and buttocks.  The patient’s records documented a complication of surgery due to thermal or chemical injury.  The patient was discharged on 12/6/2011 but was later readmitted on 12/8/2011.  There were no further hospitalizations.  By 1/10/2012, the patient was noted to have returned to work.

The Board expressed concern that the gynecologist practiced below the standard of care given failure to confirm the concentration of the solution of acetic acid she requested with both visual and verbal validation.  She did not use a read-back process with the OR nurse to verify critical information.  On 11/30/2011, the gynecologist poured the solution of acetic acid directly into the patient’s vagina and cervix rather than applying the solution to the patient’s body with a cotton swab or a similar application item.

The Board issued a public reprimand and an order that the gynecologist complete no less than 40 hours of continuing medical education on gynecological surgical procedures.

State: California


Date: April 2017


Specialty: Gynecology


Symptom: N/A


Diagnosis: Post-operative/Operative Complication, Gynecological Disease


Medical Error: Accidental Medication Error, Procedural error


Significant Outcome: Hospital Bounce Back


Case Rating: 4


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



Florida – Gynecology – Trichloroacetic Acid Administered Instead Of Acetic Acid During Routine Vaginal Procedure



On 9/29/2014, a patient presented to the health department to a gynecologist for a routine vaginal procedure.

The gynecologist asked the nurse assisting him to hand him acetic acid to prepare for the procedure.  However, the nurse gave the gynecologist trichloroacetic acid by mistake.

The gynecologist used a cotton swab to apply the trichloroacetic acid to the patient’s vaginal area.

The patient began to experience extreme burning, and the gynecologist immediately washed the patient’s vaginal area.  The patient sustained burns and sloughing of skin to the surface and inside her vagina.  The gynecologist applied lidocaine gel to the area.

On 9/30/2014, the patient returned to the health department with complaints of pain and bleeding as a result of the burns.  She was examined and given lidocaine for the pain.

The Medical Board of Florida judged the gynecologist’s conduct to be below the minimal standard of competence given that he applied the wrong medication, trichloroacetic acid, to her vagina and cervix instead of acetic acid.

The Medical Board of Florida issued a letter of concern against the gynecologist’s license.  The Medical Board of Florida ordered that the gynecologist pay a fine of $2,500 for his license and pay reimbursement costs for the case at a minimum of $2,757.86 and not to exceed $4,757.86.  The Medical Board of Florida also ordered that gynecologist complete five hours of continuing medical education in gynecology and complete five hours of continuing medical education in “risk management.”

State: Florida


Date: November 2016


Specialty: Gynecology


Symptom: Pain, Bleeding


Diagnosis: N/A


Medical Error: Accidental Medication Error


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Virginia – Physician Assistant – Administration Of Orthovisc Instead Of Cortisone



On 3/14/2014, without verifying the medication/dosage or consulting the patient’s record, a physician assistant confirmed that the patient was to receive an injection of Orthovisc when asked for guidance by a registered nurse.

In actuality, the patient’s treatment plan provided that he was to receive cortisone injections, not Orthovisc.  The physician assistant administered the Orthovisc medication laid out for her without confirming what medication was needed or what medication she was injecting.  Upon realizing her error, she noted in the patient’s record that she “assumed” the patient was to receive Orthovisc due to the note that “bilateral knee injections” were due.

Further, the physician assistant claimed in a written statement to the Board’s investigator that, before injecting a patient, she did “not make a habit of questioning [the] nurses because they have all been extremely competent.”

The physician assistant told the Committee that she never tried to cover up her error.  She informed the patient about the error, documented it in the patient’s record, and discussed the issue with the clinic supervisor.  In an effort to avoid this type of error from recurring, the physician assistant told the Committee that she now draws up the medications herself, checks the chart, and counts back the appropriate number of months to ensure that the administration of a particular medication is timed correctly.

When she was contacted by a Board investigator, she panicked and feared that she was about to lose her job.  As a consequence of her anxiety, she took a family member’s alprazolam.  On 2/27/2015, she submitted to a urine drug screen as part of the Board’s investigation, which turned up positive for the benzodiazepine.

The Board investigated two other medication errors that had occurred as well as a posting of the physician’s assistant on Facebook that contained sensitive medical information.

She stated that these incidents occurred during a time when she had an extremely busy schedule and after another physician assistant left the clinic requiring her to increase her workload.  She also was planning her wedding around this time.

She reported being employed by a new practice for almost a year.  Her new position did not include nights or weekends, as did her last employment.  She also has her own medical assistant compared to her prior practice when she had to share her medical assistant with another provider.

She submitted a letter written by her current supervising physician who reported that she “has performed well as a provider and an employee.”  She told the Committee that she had learned from her mistakes and had made changes in her practice and personal life to ensure she would be diligent in her work and that she would avoid any repeat problems.  In her current practice, she wrote all of her own prescriptions and her medical assistant double-checked each one behind her.

She was administered a reprimand.  Within 45 days of the order, she was to submit a written statement certifying that she had read the laws and regulations governing the practice of Physician Assistants.  She was to submit documentation that she completed courses in ethics and pain management.

State: Virginia


Date: April 2016


Specialty: Physician Assistant, Family Medicine, Internal Medicine


Symptom: Joint Pain


Diagnosis: Musculoskeletal Disease


Medical Error: Accidental Medication Error, Ethics violation


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



Virginia – Physician Assistant – Dosing Regimen Error When Prescribing Coumadin



On 6/26/14, a physician assistant erroneously prescribed Coumadin 10 mg every evening for a patient.  The patient was hearing impaired, and the physician assistant did not use an interpreter when communicating with her or did not use any other assistive devices to communicate with the patient.  The patient took 10 mg of Coumadin every night for six nights prior to her scheduled surgery instead of one 10 mg tablet of Coumadin the evening prior to surgery.

On 7/2/2014, the patient was admitted with a pre-operative INR level of 3.8, and her surgery was rescheduled.

The physician assistant stated that the electronic medical record defaulted to 30 tablets in a prescription, and she forgot to change the pill number from 30 to 1.  Unintentionally, the patient was sent home with the “default number” of 30 tablets instead of the one tablet.

On 12/13/2014, the physician assistant prescribed Coumadin 2.5 mg for a different patient with instructions to “take 30 tabs by mouth every evening.”  The correct instructions would have been for the patient to take one tablet every evening.

She stated that these incidents occurred during a time when she had an extremely busy schedule and after another physician assistant left the clinic requiring her to increase her workload.  She also was planning her wedding around this time.

She reported being employed by a new practice for almost a year.  Her new position did not include nights or weekends, as did her last employment.  She also has her own medical assistant compared to her prior practice when she had to share her medical assistant with another provider.

She submitted a letter written by her current supervising physician who reported that she “has performed well as a provider and an employee.”  She told the Committee that she had learned from her mistakes and had made changes in her practice and personal life to ensure she would be diligent in her work and that she would avoid any repeat problems.  In her current practice, she wrote all of her own prescriptions and her medical assistant double-checked each one behind her.

She was administered a reprimand.  Within 45 days of the order, she was to submit a written statement certifying that she had read the laws and regulations governing the practice of Physician Assistants.  She was to submit documentation that she completed courses in ethics and pain management.

State: Virginia


Date: April 2016


Specialty: Physician Assistant, Family Medicine, Internal Medicine


Symptom: N/A


Diagnosis: N/A


Medical Error: Accidental Medication Error, Failure of communication with patient or patient relations


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Washington – Allergy And Immunology – Injections Administered To The Wrong Patients



On 1/9/2014, Patient A, a 34 year old male who suffers from allergies to pollen and pet dander and is asthmatic, presented to a physician’s allergy and asthma center for an allergy shot.

The allergist administered an allergy shot to Patient A.  Shortly after administering the shot, the allergist realized she had injected Patient A with another patient’s dose.  The other patient had a similar name to Patient A, and the allergist had confused the two patients.  The allergist observed Patient A, and after thirty minutes noted he had developed hives on his abdomen and hands but experienced no difficulty with breathing, wheezing, or throat constriction.  The allergist administered 0.4 mg epinephrine (EpiPen) to Patient A.  The allergist further monitored Patient A, ensuring the treatment was adequate, and released Patient A home with an additional EpiPen.

Later that day, Patient A phoned the allergist stating he felt generally unwell and dizzy.  Patient A told the allergist he had used the EpiPen at home and felt severe cramping in his arm from it.  The allergist visited Patient A at his home, examined his lungs, and provided him with additional EpiPens.  The allergist stayed with Patient A to ensure he was doing well.

On 6/27/2014, eight year old Patient B presented to the allergist’s clinic along with his father. Patient B’s father had been receiving allergy shots by the allergist for about one year when Patient B began treatment.  The allergist gave Patient B an allergy shot, however, the dose she administered was his father’s dose which was over a thousand times more than the dose Patient B should have been given.  About five minutes later, Patient B experienced shortness of breath.  The allergist administered 0.3 ml EpiPen, noted progressed symptoms, and administered another 0.4 ml EpiPen.  Patient B had a sensation of his throat tightening and experienced some wheezing.  Ten minutes following the injections, the allergist called 911 and Patient B was transported to the emergency department (ED). The ED diagnosed Patient B with anaphylaxis due to inappropriate immunotherapy.  Patient B’s condition stabilized and he was discharged a few hours later.

The allergist has since sold her clinic and now works as a hospitalist in a nearby hospital.

The Commission stipulated the allergist reimburse costs to the Commission, submit semi-annual reports to the Commission from her supervising physician on the quality of her clinical practice and any documented medicine errors, write and submit a paper of at least 2000 words, with references, concerning medication errors and how they can be prevented and how to ensure patients get the correct medication at the correct dose at the correct time, and present this paper to a group of her peers at a hospital which she has privileges.

State: Washington


Date: February 2016


Specialty: Allergy and Immunology


Symptom: Allergic Reaction Symptoms


Diagnosis: Drug Overdose, Side Effects, or Withdrawal


Medical Error: Accidental Medication Error


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



Washington – Family Practice – Warfarin Dose Texted To Nurse Who Enters Incorrect Dosing Schedule



A family practitioner saw an 81-year-old patient, who lived in an assisted living facility, to help manage his multiple chronic medical conditions which required several medications.  One of the medications was warfarin.  The family practitioner would have the patient’s blood level tested monthly using the prothrombin time (PT) test and the international normalized ratio (INR) method.  In March 2014, the patient’s INR level was measured at 2.3 and the family practitioner continued the patient’s dosage of warfarin to remain at 1 mg four days a week, alternating 2 mg for the other three days.

On 4/24/2014, the family practitioner received a text message from a nurse at the assisted living facility stating that the patient’s INR had increased to 3.2.  This level was slightly higher than the 2.0-3.0 target range.  The family practitioner replied via text message ordering the patient’s warfarin to be decreased to 1 mg five a days a week with 2 mg administered on the other two days.  The nurse incorrectly transcribed the new order as “5 mg by mouth 5 days per week and 2 mg for 2 days per week” which increased the patient’s dosage exponentially.  The plan was for a lab recheck in one month.

The family practitioner made her routine visits over the next couple of weeks and signed off on the incorrectly transcribed 4/24/2014 order while also signing off on other orders and lab results she would review from a binder the facility collected for her.

On 5/4/2014, the family practitioner received a text message saying the patient had some bleeding from his gums while brushing his teeth.  The family practitioner ordered a new PT and INR to be done later that week.

On 5/8/2014, the patient had his blood work done.  On 5/9/2014, the family practitioner was advised the patient’s INR was at 15.2.  She inquired as to the amount of warfarin the patient had been receiving.  The nurse responded that he had been receiving 5 mg for five days and 2 mg for two days per week.  The family practitioner knew this was not the correct dosage she ordered on 4/24/2014.  She ordered the warfarin to be discontinued and to immediately administer 10 mg vitamin K as an antidote.

On 5/10/2014, the patient was found in his bed with “coffee ground emesis, and not responding.”  The facility called 911 and the patient was transported to a nearby hospital.  Later that day, the patient passed away from an internal brain hemorrhage.

The Commission stipulated the family practitioner reimburse costs to the Commission, allow a representative to conduct an annual audit of her records, and write and submit a paper of at least 1000 words, with references, on the proper management of anticoagulation therapy and critical INR patients and how she has changed her anticoagulation-related patient care.  She will also present this paper and discuss the events that occurred in this case and the policy and procedural changes that have since been implemented at the facility where the patient resided.

State: Washington


Date: January 2016


Specialty: Family Medicine, Internal Medicine


Symptom: Bleeding


Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Intracranial Hemorrhage


Medical Error: Accidental Medication Error


Significant Outcome: Death


Case Rating: 5


Link to Original Case File: Download PDF



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