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California – Interventional Radiology – Pain And Cold Foot After Arteriogram, Angioplasty, And Atherectomy
On 6/26/2015, a patient presented to an interventional radiologist’s outpatient clinic for a left lower extremity arteriogram and intervention for a thrombosed left lower extremity bypass graft, originally placed in 2007. The patient had an extensive medical history including a renal transplant, diabetes, right leg amputation, and multiple revascularization procedures, including prior thrombectomies of the left lower extremity graft.
The patient reportedly had pain both at rest and with activity, and had a cold left leg prior to and immediately before the procedure. In order to improve blood flow in the patient’s left leg, the interventional radiologist performed an arteriogram, angioplasty, tPA administration, atherectomy, and stent placement within the left lower extremity, including an attempt to revascularize the native superficial femoral artery.
Images show an initially thrombosed femoral artery to popliteal bypass graft and deep femoral artery. Further images show balloons inflated in various parts of the graft and native arteries. Final images show flow through a patent common femoral artery (CFA), bypass graft, and peroneal and anterior tibial arteries. The deep femoral artery appeared occluded shortly beyond its origin.
After the procedure, a nurse noted the patient’s foot was cold. The interventional radiologist also assessed the patient post-procedure and found the foot to be cold, both two (2) and four (4) hours post-procedure. The interventional radiologist recommended to the patient that she travel to the emergency department of a university hospital.
The patient was then driven by her companion two hours to the emergency department, where she was assessed by an ED physician and a vascular surgeon. She was taken to the operating room where she underwent surgery, which included a left leg above-the-knee amputation and a deep femoral artery thrombectomy.
The Board stated that the standard of care for an interventional radiologist when performing an intervention is to recognize complications and to take appropriate steps to manage them. Although the patient’s foot was reportedly cold and painful immediately post-procedure, it can take some time for the foot to warm, and pain could be caused by reperfusion. However, it is clear that two to four hours after the procedure, the interventional radiologist recognized that the patient’s leg had not improved and was worsening and that further care was needed. Thus, when it became clear to the interventional radiologist that the foot was not improving, he recommended that the patient seek more treatment.
The records of the interventional radiologist’s care of the patient were inadequate in that they do not state whether the patient’s clinical status post-procedure was worse than before the procedure. A post-procedure pulse examination was lacking which would have helped in determining the patient’s clinical status.
The patient reported to the ED physician that the pain began after the procedure and steadily worsened, which indicates that the patient rethrombosed her bypass graft and deep femoral artery (source of collateral flow) immediately. This event should have been recognized by the interventional radiologist.
However, the interventional radiologist’s documentation for this patient was inadequate and sparse. The medical records lacked documentation of the change in the patient’s status post-procedure, the discussion with the patient leading up to the discharge from his center, and the patient’s disposition. The interventional radiologist discharged the patient to her own care directly from his clinic instead of calling Emergency Medical Services (EMS), which indicates that the interventional radiologist failed to recognize the gravity of what was occurring.
His conduct did not ensure that the patient would be attended continuously until definitive treatment was given. The patient arrived at the emergency department at approximately 8:00 p.m., two hours after the patient was discharged from the interventional radiologist’s clinic.
Had the process of discharge and transfer occurred earlier, it is possible that the outcome could have been different. The interventional radiologist failed to communicate with the ED physician ahead of the patient’s arrival. The interventional radiologist gave the patient a CD of the procedure, a copy of the medical records, and his phone number, as an attempt of communicating with the emergency department personnel regarding the events that occurred at the interventional radiologist’s clinic.
However, the interventional radiologist failed to telephone the ED physicians at the emergency department to give a verbal report on the patient and to provide a more informative transition and preparation for continued care. In expecting the practitioners at the emergency department to call the interventional radiologist to gain more information, the interventional radiologist improperly sought to shift his responsibility to provide needed information about the patient to the staff at the emergency department.
The interventional radiologist failed to maintain documentation regarding the change in the patient’s status post-procedure, the discussion leading up to the discharge from his center, and the patient’s disposition. He stated that he was not sure if he documented these events, and if he did, he sent them with the patient. Documentation sent with the patient has since been lost. Documentation of a change in the patient’s clinical status was lacking. The medical records lacked documentation of what was discussed regarding the patient’s disposition and where she was told to go for further care.
The Board judged the interventional radiologist’s conduct to have fallen below the standard of care for the following reasons:
1) The interventional radiologist failed to offer to transport the patient by ambulance or EMS services to ensure that she would be attended continuously until definitive treatment was given. His failure to do so indicates that he failed to understand the gravity of the situation which was occurring.
2) The interventional radiologist failed to adequately communicate with the emergency department, to call ahead of time to inform them that the patient was in transit, and to inform them of the circumstances.
3) The interventional radiologist failed to maintain adequate and accurate records.
The Board issued a public reprimand.
State: California
Date: December 2017
Specialty: Interventional Radiology, Vascular Surgery
Symptom: Extremity Pain
Diagnosis: Acute Ischemic Limb, Post-operative/Operative Complication
Medical Error: Diagnostic error, Delay in proper treatment, Underestimation of likelihood or severity, Failure of communication with other providers, Lack of proper documentation
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Emergency Medicine – Patient With Chest Pain Radiating To The Neck, Throat, And Back Discharged With Instructions To Follow up In 3-5 Days
On 11/15/2013, a patient complained of chest pain radiating to his neck, throat, and across his back. The patient stated the onset of the pain was noted to be one hour prior to his arrival at the hospital while he was screwing something into the wall, and that the pain was exacerbated by movement.
An ED physician performed an initial EKG, labs, and a chest x-ray on the patient.
The ED physician initially treated the patient with nitroglycerin and a GI cocktail, and subsequently with diazepam, morphine, Toradol, and Dilaudid.
The ED physician’s final assessment of the patient noted that the patient was still complaining of left side neck pain and “trap pain.”
The ED physician discharged the patient with a diagnosis of “musculoskeletal chest pain” and prescribed naproxen, Norco, and diazepam, along with instructions to follow up with him in three to five days.
The patient returned to the hospital the following day in cardiac arrest and expired on 11/16/2013.
The Medical Board of Florida judged the ED physician’s conduct to be below the minimal standard of competence given that he failed to perform a CT of the patient’s chest to evaluate for aortic dissection. He also failed to adequately document bilateral pulses and/or blood pressures in the patient. He failed to pursue other etiologies of the patient’s reported pain. The ED physician failed to admit the patient for further observation.
It was requested that the Medical Board of Florida order one or more of the following penalties for the ED physician: 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: December 2017
Specialty: Emergency Medicine
Symptom: Chest Pain, Back Pain, Chest Pain, Head/Neck Pain
Diagnosis: Aneurysm
Medical Error: Failure to order appropriate diagnostic test, Delay in proper treatment, Failure to examine or evaluate patient properly, Lack of proper documentation
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF
Florida – Gynecology – CBC Tests Show Neutropenia And Leukopenia At An Annual Gynecological Exam
On 8/15/2013, a 34-year-old female presented to a gynecologist for an annual gynecological exam. At the exam, the patient expressed concerns about infertility. The gynecologist and the patient discussed various tests that may be used to address infertility and the gynecologist began ordering tests.
On 2/23/2015, the patient gave blood for a complete blood count (“CBC”) test that was ordered by the gynecologist.
On 3/5/2015, the gynecologist received and signed for the results of the CBC test. The CBC test indicated the patient had an abnormal white blood cell count, marked leukopenia, and severe neutropenia.
The gynecologist failed to notify the patient of the abnormal results of the CBC test.
The gynecologist failed to ensure that the patient had otherwise established a plan of care to address the abnormal results of the CBC test.
On 5/28/2015, the patient presented to the gynecologist for an annual gynecological exam. At the exam, it was determined that the patient was pregnant, and the gynecologist ordered blood tests for the patient. The gynecologist failed to order a repeat CBC test.
On 7/17/2015, the gynecologist received and signed for the results of the repeat CBC test. The repeat CBC test indicated that the patient’s white blood cell count had decreased further, the neutropenia had worsened, and she now had pancytopenia with a drop in the red blood cell and platelet count.
On 7/30/2015, the gynecologist notified the patient of the results of her repeat CBC test and referred her to a hematologist.
On 8/8/2015, the patient experienced a massive intracranial hemorrhage with herniation, as well as severe pancytopenia.
On 8/12/2015, the patient expired in the hospital. The fetus was also lost at that point.
The Medical Board of Florida judged the gynecologists conduct to be below the minimal standard of competence given that she failed to ensure that the patient had been notified of the abnormal results of the CBC test. The gynecologist failed to ensure that the patient had otherwise established, a plan of care to address the abnormal results of the CBC test. The gynecologist failed to order a repeat CBC test at the patient’s May exam.
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 $8,500 against her license and pay reimbursement costs for the case at a minimum of $3,126.31 and not to exceed $5,126.31. The Medical Board of Florida ordered that the gynecologist complete five hours of continuing medical education in “risk management.”
State: Florida
Date: December 2017
Specialty: Gynecology, Obstetrics
Symptom: N/A
Diagnosis: Hematological Disease, Intracranial Hemorrhage
Medical Error: Failure to follow up, Delay in proper treatment, Failure of communication with patient or patient relations
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF
Vermont – Emergency Medicine – Suspected Ventricular Tachycardia Not Addressed In A Patient With Respiratory Distress, Fever, And An Elevated Heart Rate
On 2/6/2013 a patient’s father contacted EMS (emergency medical services) because his son had respiratory distress, fever, and an elevated heart rate.
EMS documented a heart rate of 278 and performed a pre-hospital EKG because ventricular tachycardia (VTach) was a concern. EMS contacted the hospital to report vital signs and their impression of VTach.
The patient presented to the emergency department at 11:29 p.m. The patient was triaged at 11:42 p.m. and a pulse of 245, blood pressure of 53/39, and a temperature of 101.02 were recorded. An EKG was performed at 11:43 p.m. The results were shown to the ED physician at 11:47 p.m.
The ED physician’s notes state that at 12:13 a.m. the patient was examined. It was documented that the ED physician suspected the patient was in VTach, but no therapy was administered.
The ED physician then contacted the on-call cardiologist, who advised the ED physician to treat the patient for probable sepsis with fluids and Tylenol. The ED physician then ordered IV antibiotics and spoke to a critical care physician about transfer of the patient.
At 12:29 a.m. the patient had a ventricular fibrillation cardiac arrest. He was treated with various medications but no shock was given. At 12:45 a.m. the patient was pronounced dead.
The Board concluded that the ED physician be reprimanded, complete 15 hours of continuing education on Advanced Cardiac Life Support, and pay a fine of $1000.
State: Vermont
Date: September 2017
Specialty: Emergency Medicine, Cardiology
Symptom: Shortness of Breath, Fever, Palpitations
Diagnosis: Cardiac Arrhythmia
Medical Error: Improper treatment, Delay in proper treatment
Significant Outcome: Death
Case Rating: 3
Link to Original Case File: Download PDF
North Carolina – Vascular Surgery – Abdominal Aortic Aneurysm 8.3 cm In Size With Large Type I Endoleak
On 3/31/12, a 76-year-old male with a history of heart disease, chronic obstructive pulmonary disease (COPD), prior endovascular repair of a large abdominal aortic aneurysm (AAA) in 2010 at an outside hospital (OSH) presented to the VA Medical Center emergency department with complaints of back, flank, and hip pain.
On 4/1/12 in the early morning, the patient had a CT scan with contrast which revealed an 8.3 cm AAA with large Type I endoleak. There was retroperitoneal stranding consistent with an aneurysm rupture. At 7:45 a.m., these findings were communicated to the emergency department physician.
At 8:00 a.m., the patient was evaluated by a vascular surgeon. Based on the vascular surgeon’s interpretation of the CT films and the patient’s clinical presentation, the vascular surgeon recommended admission for observation with a follow-up consultation with orthopedic surgery and interventional radiology.
The patient was admitted to the medical ward for the next three days during which he continued to have severe ongoing pain that was managed with pain medications.
On 4/4/12, the patient had a precipitous decline in his clinical status with severe hemodynamic compromise. A repeat CT scan demonstrated a ruptured AAA with aortocaval fistula. The patient was taken to the operation room where the vascular surgeon performed an open repair of the aortocaval fistula and ruptured AAA. However, the patient suffered extensive operative blood loss, perioperative myocardial infarction, and neurological injury.
The patient survived the procedure but remained critically ill. Over the next several days, the patient improved to a certain degree, but it was felt that the patient had suffered brain injury with little chance for meaningful recovery.
On 4/9/12, supportive measures were withdrawn, and the patient died.
In January 2017, the Board received information regarding a medical malpractice lawsuit settlement payment related to the care provided by the vascular surgeon to the patient.
The Board obtained the patient’s records and sent them to a qualified independent medical expert for review. The independent medical expert judged the vascular surgeon’s conduct to be below the minimum standard of competence given failure to adequately diagnose and aggressively treat the patient’s symptomatic, ruptured AAA despite evidence of the patient’s life-threatening condition.
The vascular surgeon was reprimanded.
The Board reported the Consent Order to the Federation of State Medical Boards.and the National Practitioner Data Bank.
State: North Carolina
Date: July 2017
Specialty: Vascular Surgery, Emergency Medicine
Symptom: Back Pain, Pelvic/Groin Pain
Diagnosis: Aneurysm, Post-operative/Operative Complication
Medical Error: Delay in proper treatment
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF
North Carolina – Internal Medicine – Three Emergency Department Visits With Persistent Severe Headache And A Negative CT Head Scan
The Board was notified of a professional liability payment paid on 3/8/16.
A 48-year-old female presented to the emergency department three times over the course of two days with complaints of severe headache.
During the 7/28/12 visit, she had a non-contrast CT head, which was reported as normal. The patient’s headache was treated as an acute migraine attack. She was discharged with anti-migraine, anti-nausea, and anti-anxiety medications.
On 7/29/12, the patient returned with persistent symptoms, was treated symptomatically, and discharged. Later that day, the patient again returned to the emergency department with continuing headache and persistent nausea and vomiting.
The patient was admitted to the hospital under the care of an internist. The patient was started on maintenance IV fluids to treat dehydration and was treated for the underlying migraine with analgesics and antiemetic.
During the internist’s care of the patient, the internist did not order a spinal tap or additional CT scan, instead relying on the 7/28/12 emergency department CT scan.
On hospitalization day three, the patient was discharged with anti-migraine and anti-nausea medications, and was advised to follow up with her primary care physician or neurologist within a week.
On 8/2/12, the day after discharge, the patient returned to the emergency department with a continuing headache and a CT scan of her head showed intracranial hemorrhage in the right temporal lobe.
The patient was then airlifted to a tertiary care center and had clipping of a brain aneurysm/hematoma removal and ventriculoperitoneal shunt placement.
The Board obtained the patient’s records and sent them to a qualified independent medical expert for review.
The independent medical expert judged the internist’s conduct to be below the minimum standard of competence given failure to provide adequate care for severe persistent headache with normal neurological exam. The medical expert found that the internist failed to perform a lumbar puncture and repeat imaging or seek neurology input.
The Board issued a public letter of concern, which was reported to the Federation of State Medical Boards. It was not reported to the National Practitioner Data Bank.
State: North Carolina
Date: July 2017
Specialty: Internal Medicine, Hospitalist
Symptom: Headache, Nausea Or Vomiting
Diagnosis: Intracranial Hemorrhage
Medical Error: False negative, Delay in proper treatment, Failure to order appropriate diagnostic test, Underestimation of likelihood or severity
Significant Outcome: Permanent Loss Of Functional Status Or Organ, Hospital Bounce Back
Case Rating: 4
Link to Original Case File: Download PDF
Florida – Cardiology – Patient With Serious Hemodynamic Compromise After Receiving A Cardiac Stent For Myocardial Infarction
On 4/5/2012, a patient arrived at a hospital after suffering a heart attack. He received a stent to the left anterior descending artery and was transferred to the intensive care unit.
At 9:00 p.m., the patient began to experience chest pains and lowered blood oxygen. A cardiologist did not report to the hospital to examine the patient at the time.
At 12:00 a.m., the patient began to have serious hemodynamic compromise. The cardiologist did not report to the hospital to examine the patient at the time.
At 3:00 a.m., over three hours after the onset of the patient’s serious hemodynamic compromise, the cardiologist reported to the hospital to examine the patient.
Prior to reporting to the hospital, the cardiologist had been made aware of each of the patient’s clinical status changes. The cardiologist planned to transfer the patient to another hospital where the patient was to undergo a pericardial window, performed by a cardiothoracic surgeon.
Prior to undergoing a pericardial window, the patient expired.
The Board judged the cardiologist’s conduct to be below the minimal standard of competence given that he failed to report to the hospital to attend to the patient’s clinical status changes, to properly recognize the need for an immediate pericardiocentesis, and to perform an immediate pericardiocentesis. Upon arriving at the hospital, the cardiologist failed to recognize that the patient’s clinical deterioration was such that an immediate pericardiocentesis needed to be performed to improve the patient’s blood flow.
The Board issued a letter of concern against the cardiologist’s license. The Board ordered the cardiologist pay a fine of $7,500 against his license and pay reimbursement costs for the case at a minimum of $5,239.98 and not to exceed $7,239.98. The Board also ordered that the cardiologist complete five hours of continuing education in “risk management” and complete five hours of continuing medical education in cardiology.
State: Florida
Date: July 2017
Specialty: Cardiology, Hospitalist, Internal Medicine
Symptom: Chest Pain
Diagnosis: Acute Myocardial Infarction, Acute Myocardial Infarction
Medical Error: Improper treatment, Delay in proper treatment
Significant Outcome: Death
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Emergency Medicine – Delayed Response In Spine Immobilization And Ordering X-Rays And CT Scan In Patient With Lumbar Spine Fractures
On 6/22/2012 at 12:30 a.m., a patient was an unrestrained back seat passenger of a taxicab when it was involved in a motor vehicle accident. The patient was intoxicated at the time of the accident.
EMT-Paramedics were dispatched to the scene of the accident and documented that the patient was moving all extremities and had a pulse, motor, and sensation in all four extremities. The EMT-Paramedics transported the patient to the emergency department without back-board or spinal immobilization precautions.
At 12:58 a.m., the patient arrived at the hospital.
At 1:32 a.m., an ED physician performed an exam of the patient’s back and documented equivocal lumbar back tenderness. The ED physician performed an exam of the patient’s pelvis and documented equivocal pelvic tenderness. He also performed a neurologic exam and documented no movement of the patient’s toes or leg muscles. The ED physician performed a rectal exam and documented that the patient exhibited an absence of anal sphincter tone.
AT 1:48 a.m., the ED physician ordered x-rays of the patient’s lumbosacral spine and pelvis. The lumbosacral spine x-ray results showed a comminuted fracture dislocation at T12-L1.
At 2:58 a.m., the ED physician ordered a computed tomography scan of the patient’s lumbar spine. The CT scan of the patient’s lumbar spine also showed a comminuted fracture dislocation at T12-L1.
At 3:17 a.m., the ED physician ordered that the patient be placed on a backboard.
At 4:20 a.m., the patient was transferred by ambulance to a level 1 Trauma Center.
The patient was ultimately diagnosed with paraplegia. A medical malpractice lawsuit was filed against the physician.
The Board judged the ED physician’s conduct to be below the minimal standard of competence given that he failed to immediately perform a full trauma evaluation, immediately immobilize the patient’s spine, immediately order an x-ray of the patient’s chest, immediately order a CT scan of the patient’s abdomen, and immediately order a CT scan of the patient’s pelvis.
The Board issued a letter of concern against the ED physician’s license. The Board ordered that the ED physician pay a fine of $5,000 against his license and pay reimbursement costs for the case at a minimum of $6,452.58 and not to exceed $8,452.58. The Board also ordered that the ED physician complete five hours of continuing medical education of emergency medicine and five hours of continuing medical education in “risk management.”
State: Florida
Date: June 2017
Specialty: Emergency Medicine, Trauma Surgery
Symptom: N/A
Diagnosis: Fracture(s), Spinal Injury Or Disorder
Medical Error: Failure to examine or evaluate patient properly, Delay in proper treatment
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 4
Link to Original Case File: Download PDF
Florida – Internal Medicine – Patient With Suicidal Ideations Referred To A Psychiatrist For The Following Day
On 12/1/2014, a 68-year-old female presented to an internist for a three-month follow-up appointment for hyperlipidemia, anxiety with panic attack, and hypertension. The patient reported a twenty-year history of untreated depression that was worsening.
The patient reported suicidal ideations, including that the patient had been sitting with a gun to her head.
The internist’s progress note for the patient included a statement that the patient needed to see a psychiatrist that day. The internist referred the patient to a psychiatrist and scheduled an appointment with the patient with the psychiatrist the following day.
The Board judged the internist’s conduct to be below the minimal standard of competence given that he failed to arrange for the patient to be escorted to a psychiatrist or an emergency department that day.
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 her license and pay reimbursement costs for the case at a minimum of $1,983.04 and not to exceed $3,983.04. The Board also ordered that the internist complete five hours of continuing medical education in depression, which shall include the diagnosis and treatment of patients with depression, and complete five hours of continuing medical education in “risk management.”
State: Florida
Date: June 2017
Specialty: Internal Medicine, Psychiatry
Symptom: Psychiatric Symptoms
Diagnosis: Psychiatric Disorder
Medical Error: Delay in proper treatment
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
California – Otolaryngology – Public Letter Of Reprimand For Delayed Care And Failure To Inform Patient Of Potential Complication Of Epistaxis Treatment
An otolaryngologist failed to inform a patient of the potential for a septal perforation during treatment for epistaxis.
In another patient, there was a delay in care. The otolaryngologist made an initial diagnosis of a nasopharyngeal mass. However, there was a prolonged period of time between that initial diagnosis and when the biopsy was actually performed.
These actions were deemed to have constituted gross negligence and repeated negligent acts.
A Public Letter of Reprimand was issued against him.
State: California
Date: June 2017
Specialty: Otolaryngology
Symptom: Bleeding, Mass (Breast Mass, Lump, etc.)
Diagnosis: Hemorrhage, Post-operative/Operative Complication
Medical Error: Failure of communication with patient or patient relations, Delay in proper treatment
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF