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Florida – Family Medicine – Three Patients Seen At Once Without Proper Examination and Documentation
On 9/21/2012, Patient A, Patient B, and Patient C presented to a geriatric practitioner at the same time in his office. The geriatric practitioner saw the patients for less than nine minutes total. At no time were the patients separated for individual assessments. The patients were an undercover detective and two informants, using pseudonyms. The appointment was audiotaped and videotaped.
The geriatric practitioner failed to perform a physical examination on any of the three patients. The geriatric practitioner failed to create a treatment plan for any of the three patients. He also sent the three patients for x-rays without a physical examination. Per the geriatric practitioner’s instructions, all three patients presented for x-rays; however, only Patient A and Patient C actually had x-rays performed. The geriatric practitioner failed to create or maintain documentation of referring the three patients for x-rays.
On 10/30/2012, the three patients presented to the geriatric practitioner for a follow-up visit. At that time, the geriatric practitioner failed to review readily available medical records from the patients’ first visit, failed to inquire about x-ray results, failed to review physical therapy results, failed to perform physical examinations and/or failed to create treatment plans for all three patients.
The Board judged the geriatric practitioner’s actions to be below the minimum standard of competence given his failure to perform a physical examination, perform a complete individual physical examination for each patient prior to referral for x-rays, other diagnostic testing, or further treatment. Also, the geriatric practitioner failed to review any medical records or results at a follow-up visit, including x-rays, from prior visits, and/or procedures and review and analyze the physical therapy progress of the patients, and create treatments plans for each patient.
The Board ordered that the geriatric practitioner pay a fine of $12,000 against his license and pay reimbursement costs for the case for a minimum of $37,421.80 and not to exceed $39,421.80. The Board also ordered that the geriatric practitioner complete a medical records course and complete five hours of continuing medical education on “Risk Management.” The Board put the geriatric practitioner’s license on probation and required that he have indirect supervision to practice by a Board-approved physician.
State: Florida
Date: November 2017
Specialty: Family Medicine
Symptom: N/A
Diagnosis: N/A
Medical Error: Failure to examine or evaluate patient properly, Ethics violation, Failure to follow up, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
Florida – Anesthesiology – Multiple Procedural Errors While Performing Cervical Epidural Steroid Injections
On 4/6/2016, a 69-year-old female with a prior history significant for pulmonary tuberculosis, essential hypertension, paroxysmal supraventricular tachycardia, osteoporosis, menopause, hypothyroidism, arthritis, chronic asthmatic bronchitis, and a former smoker, presented to a medical clinic.
An anesthesiologist initially diagnosed the patient with cervicalgia and cervical radiculopathy due to degenerative chronic cervical spondylosis. The patient was also hearing and speech impaired and used an interpreter and tablet for communication during all preoperative meetings.
The patient presented to the anesthesiologist in the surgery room for a signed consent of cervical transforaminal epidural steroid injection at right C4 and C5. The anesthesiologist instead performed a cervical epidural steroid injection (“CESI”) above C6-C7 without obtaining consent from the patient.
The anesthesiologist failed to have an interpreter in the surgery room during the patient’s evaluation and treatment so that he could effectively communicate with her.
The patient was positioned in the prone position on the table and the anesthesiologist administered Versed 2 mg IV and Fentanyl 100 mcg for IV conscious sedation.
The anesthesiologist failed to administer local anesthesia to numb the patient’s skin, while she was awake and alert, prior to injecting the first epidural steroid injection at C5-C6. The patient, unaware that she was receiving an injection and unable to clearly communicate her discomfort, responded to the initial puncture to her skin by a sudden jumping movement.
The anesthesiologist withdrew the needle and targeted lower interspace, C7-T1, using fluoroscopy. He used a seventeen gauge Tuohy needle under intermittent fluoroscopic guidance for entry into the epidural space at C7-T1 for the second attempt to perform the CESI. The anesthesiologist then injected the medication between C4 and C5 neural foramen.
The anesthesiologist documented one or more times prior to the 4/6/2016 procedure that he was performing a TFESI on the right at C4 and C5; however, he instead performed a cervical interlaminar epidural steroid injection (“ILESI”) at C5-C6, and additionally at C7-T1, without obtaining consent from the patient. He inappropriately elected to perform a CESI above C6-C7. The anesthesiologist did not create or maintain fluoroscopic images of his initial attempt to inject at C5-C6.
After the procedure, the patient was taken to the recovery room, where an interpreter and tablet was present for communication. The patient was no longer able to move her arm to communicate using the tablet and she experienced right upper extremity weakness and some right sided facial numbness.
The patient was transferred out of the medical center as a “Stroke alert” to a hospital, where she received a CAT or MRI scan, and again transferred to another hospital which did not have a neurosurgeon on staff.
After the CESI, the patient was diagnosed with iatrogenic cervical nerve root injury.
It was requested that the Board order one or more of the following penalties for the anesthesiologist: permanent revocation or suspension of his license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Board deemed appropriate.
State: Florida
Date: August 2017
Specialty: Anesthesiology
Symptom: Weakness/Fatigue, Numbness
Diagnosis: Spinal Injury Or Disorder, Post-operative/Operative Complication
Medical Error: Wrong site procedure, Ethics violation, Failure of communication with patient or patient relations, Procedural error
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 3
Link to Original Case File: Download PDF
Arizona – Pediatrics – Pediatrician Suddenly Resigns And Leaves Without Prior Arrangements Or Warning
A pediatrician held the position of Chief Medical Officer.
On 10/22/2014, the pediatrician was scheduled to see patients, but informed his Chief Operating Officer that morning that he was resigning effective immediately. The pediatrician was asked to stay 48 hours to allow the employer to seek a locum tenens to replace him, but he declined, and provided a letter of resignation for himself and another physician employed by his Employer.
Consequently, the Employer’s clinic did not have any physicians to see the patients scheduled that day. The Employer was ultimately unable to secure a locum tenens for 10 days following the resignations and appointments for pediatric patients had to be cancelled, rescheduled, or the patients were referred elsewhere during that time period. The pediatrician did provide prescription refills for established patients for a period of time following his resignation.
The standard of care requires a physician to give a reasonable amount of time before resigning from a practice to assure seamless care of the patients in that practice setting.
The Board judged the pediatrician’s conduct to be below the minimum standard of competence given failure to allow for a seamless transition of patient care, which ultimately increased the risk of patient harm.
The Board ordered the pediatrician be reprimanded.
State: Arizona
Date: April 2017
Specialty: Pediatrics
Symptom: N/A
Diagnosis: N/A
Medical Error: Ethics violation
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
Kansas – Physician Assistant – Inappropriate Altering Of Medical Records In A Patient With Diverticulitis
On October 2015, a patient had been hospitalized for eight days with acute sigmoid diverticulitis.
On 11/9/2015, the patient was seen by an internist at a clinic for a hospital follow-up. The internist noted that the patient still had abdominal pain in the left lower quadrant (“LLQ”), but was improved. Further, the internist noted that the patient had tenderness to palpation to the LLQ and the right lower quadrant (“RLQ”) with no guarding or rebound. The internist documented that the patient’s diverticulitis was improved and his plan was for the patient to finish taking his prescribed Levaquin.
On 11/13/2015, the patient presented to the emergency department with abdominal pain rated 10/10. A physician assistant noted that the patient “Does pause episode to speak and answer questions,” and “guards throughout exam.” The physician assistant’s impression was “Non-Acute Long Standing.” The physician assistant ordered a “GI-Cocktail” on the ED physician order sheet and then discharged the patient with a diagnosis of abdominal pain with a plan for a CT in the morning.
It is unclear why the physician assistant did not obtain the CT at that time. At some point, the physician assistant added an untimed order for Dilaudid 2 mg IV to a copy of the original ED physician order sheet.
The patient returned that morning on 11/13/2015 and had a CT scan that indicated bowel perforation and possible entero-colonic fistula.
The physician assistant took the patient to the ED, the patient was crying in pain, and the physician reported that the patient had a CT and needed to be transferred for surgery.
The physician assistant altered the patient’s medical records including the following: altered the time the patient was seen in the ED, changed the diagnosis from “Non-Acute Long Standing” to “Now-Acute/Long Standing” on the emergency physician record, crossed out the checkbox “home” and circled the checkbox “transfer” on the emergency physician record, and crossed out the ED number and wrote “From clinic.” The physician assistant did not initial the alterations, indicate when the alterations were made, nor why the alterations were made.
The Board judged that the physician assistant likely deceived, defrauded, or caused harm to the patient by inappropriately altering the patient’s medical records.
For this allegation and others, the Board ordered the physician assistant to contact The Center for Personalized Education for Physicians, (“CPEP”) for a competence assessment, follow all recommendations of the CPEP assessment, and complete a medical record keeping seminar.
State: Kansas
Date: April 2017
Specialty: Physician Assistant, Emergency Medicine, Internal Medicine
Symptom: Abdominal Pain
Diagnosis: Acute Abdomen
Medical Error: Ethics violation, Delay in proper treatment, Diagnostic error, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
California – Anesthesiology – Omniscan Used As An Alternative Contrast Agent During A MILD Procedure
On 9/21/2012, an anesthesiologist performed a minimally invasive lumbar decompression (MILD) procedure on a 77-year-old patient at a hospital.
The anesthesiologist had been treating the patient for a history of “failed back surgery syndrome” and central canal stenosis two years prior to 9/21/2012. She had been stable up until six months prior to the procedure. Epidural injections provided temporary relief. Additional surgery had been recommended by a neurosurgeon, but the patient was reluctant to go undergo major surgery given concern over recovery and her preference to avoid general anesthesia. The anesthesiologist had performed the MILD procedure 18 to 20 times previously.
The anesthesiologist’s medical records indicate that the patient had no known drug allergies. However, immediately prior to the MILD procedure, a pre-operative nurse informed the anesthesiologist that the patient was allergic to iodine, which was the contrast agent the anesthesiologist planned to use. The patient’s allergy to iodine was anaphylaxis.
The anesthesiologist asked the nurse to contact the hospital pharmacy for an alternative contrast agent, and Omniscan (gadolinium) was provided. The anesthesiologist did not speak to the pharmacist, and he acknowledged that he would not have used Omniscan had he known it was gadolinium, a neurotoxin, because of the risks if used intrathecally.
In the operative report, under “Name of Procedures, “ the anesthesiologist documented that the MILD procedures were performed at levels L3/4 and L4/5, when, in fact, the procedures were performed at level L2/3 and L3/4.
After the procedure, the patient developed severe post-operative pain and weakness requiring hospitalization. During the initial four to six hours post MILD procedure, the anesthesiologist could not be reached even after the nurse attempted to reach him at three different telephone numbers. The anesthesiologist also did not designate or identify a backup surgeon for coverage. The anesthesiologist testified that his cellphone died after the procedure, and he participated at a Hindu prayer meeting that afternoon. After recharging his phone and learning that the hospital had attempted to reach him, he called the hospital back.
On 10/9/2012, the Medical Executive Committee of the hospital summarily suspended the anesthesiologist’s privilege to perform MILD procedures. On 11/7/2012, the Board received a report from the hospital stating that the anesthesiologist’s privilege to perform MILD procedures at the facility had been summarily suspended.
The patient’s neurosurgeon wrote a letter dated 3/27/2013, in which he reported that the patient was back to her baseline with respect to ambulation as of early 2013. The neurosurgeon opined that the MILD procedure did not cause a permanent adverse outcome.
The Board judged the anesthesiologist’s conduct as having fallen below the standard of care given the use of Omniscan as a contrast knowing that it is the same as gadolinium, given failure to be reachable four to six hours post MILD procedure, and given failure to correctly document the level at which the procedure was performed.
The anesthesiologist was placed on five years of probation with stipulations to complete 40 hours annually for each year of probation in areas of deficient practice and knowledge, complete a medical record keeping course, complete an ethics course, complete a clinical competence assessment program, and undergo practice monitoring. The anesthesiologist was prohibited from engaging in the solo practice of medicine.
State: California
Date: March 2017
Specialty: Anesthesiology
Symptom: Weakness/Fatigue, Pain
Diagnosis: Post-operative/Operative Complication, Spinal Injury Or Disorder
Medical Error: Improper medication management, Ethics violation, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
California – Anesthesiology – Thoracic Radiofrequency Ablation With Administration Of Midazolam, Fentanyl, And Propofol For Sedation
An anesthesiologist had treated a male patient for back pain since June 2003. He had performed facet joint injections and epidural steroid injections. On 5/11/201, the anesthesiologist performed medial branch blocks on the patient at spinal levels T8, T9, T10, T11, and T12. The patient reported significant pain relief. Based on the patient’s response to the procedure, the anesthesiologist considered the patient to be an excellent candidate for radiofrequency ablation.
At 8:22 a.m. on 5/25/2010, the then 66-year-old patient presented to the anesthesiologist’s office to undergo a thoracic radiofrequency ablation on T8, T9, T10, T11, and T12. The procedure was performed in the anesthesiologist’s medical office, which was not an accredited outpatient setting at that time. An unlicensed medical assistant was present during the procedure. No other provider was present.
The anesthesiologist personally administered IV sedation, including 1.5 mg of IV midazolam, 50 mcg of fentanyl, and 30 mg of propofol. The anesthesiologist also personally monitored the patient’s vital signs with pulse oximetry, an end-tidal CO2 monitor, and a non-invasive blood pressure cuff. There was an EKG monitor in the room, but it was not used to monitor the patient. Oxygen through a nasal cannula was administered. Local anesthetic was injected in the left thoracic region.
As the anesthesiologist was about to start placing needles for the procedure, the patient began to complain of pain. The anesthesiologist broke sterile field and administered 1.5 mg of midazolam, 50 mcg of fentanyl, and 20 mg of propofol. The anesthesiologist put on gloves and began to place the ablation needles.
A few minutes later, just before beginning the ablation, the anesthesiologist noticed that the patient’s oxygen saturation level was dropping. The patient was in the prone position. The anesthesiologist gave the patient a jaw thrust and increased his oxygen through the nasal cannula. The patient did not respond. The anesthesiologist pulled the needles out of his back and turned the patient over. He again gave the patient a jaw thrust and checked for a pulse.
The anesthesiologist concluded that the patient had suffered a cardiorespiratory arrest. He asked for an Ambu bag, began cardiopulmonary resuscitation, and directed his office manager to call 911. At 10:19 a.m., 911 was called. At 10:23 a.m., the paramedics arrived, continued CPR, and placed the patient on an EKG monitor. The patient was in pulseless electrical activity. He was given epinephrine and atropine. The anesthesiologist injected flumazenil to reverse the effect of midazolam. The paramedics injected naloxone to reverse the effects of fentanyl. The patient’s pulse returned.
Neither the anesthesiologist nor the paramedics were successful in their attempts to intubate the patient due to a difficult airway. The paramedics placed an esophageal block tube and bag ventilated the patient, who was then transported to the hospital. In the ambulance, the patient lost his pulse. CPR was continued, and he was given epinephrine and atropine. His pulse returned, and the patient was taken to the emergency department where he was intubated, placed on hypothermia protocol, and transferred to the intensive care unit.
On 6/11/2010, the patient died. An autopsy was performed, and the cause of death was determined to be “hypoxic encephalopathy due to cardiopulmonary arrest due to sedation/anesthesia for neural radioablation.”
The anesthesiologist’s medical records include an “In-Office Procedure Record,” documenting the administration of midazolam, fentanyl, and propofol. However, there is no documentation of a focused history of examination conducted prior to administering sedation. The record also contains numerous handwritten cross-outs of times and dosages of the drugs administered, which are overwritten by different times and dosages, making the record difficult to decipher.
During his physician interview, the anesthesiologist acknowledged altering the “In-Office Procedure Record.” The anesthesiologist stated that the medical assistant documented only the total amount of midazolam, fentanyl, and propofol administered and did not document the times the drugs were administered. The anesthesiologist stated that when he returned to the office several hours after the patient’s cardiac arrest, he wrote down the times the drugs were administered based on his recollection. He then realized that his recollection was incorrect, and he crossed out the times he had initially written and overwrote them with different times, making the record very difficult to read. The anesthesiologist then dictated a procedure note. In addition, the anesthesiologist added information to indicate that the dosages of midazolam, fentanyl, and propofol were given in incremental dosages.
During testimony, the anesthesiologist testified at the hearing that he did not know if the patient took any hydrocodone/acetaminophen the morning of the surgery. He testified that he was aware the patient took 10 to 12 hydrocodone/acetaminophen tablets each day. It was noted that the anesthesiologist performed radiofrequency ablation procedures both at his office and at surgery centers and that he made more money when performing the procedures at his office.
On 12/31/2012, the Board received a report of a settlement in a medical malpractice action against the anesthesiologist.
The Board judged the anesthesiologist guilty of unprofessional conduct and gross negligence given the performance of radiofrequency ablation where IV sedation was administered without having a separate qualified provider administer the sedation and monitor the patient, failure to conduct a focused history and examination prior to administering IV sedation, failure to record vital signs and sedation drug administration in real-time, failureto use EKG monitoring during the procedure, and alteration of his documentation by writing over the original numbers and notes.
It was further noted that the anesthesiologist’s medical assistant was not trained in moderate sedation. During testimony, the anesthesiologist conceded that the standard of care required a nurse or physician to be present during a procedure involving moderate sedation to monitor the patient. It was noted that the anesthesiologist did not communicate to the patient regarding the increased risk of not having another qualified professional monitor the patient during the procedure, although the anesthesiologist stated that he did notify the patient that he would be doing the procedure and acting as the anesthesiologist. However, it was noted that it would be very difficult to perform the procedure, which requires close attention to inserting the needle in the correct area, and paying attention to the cardiorespiratory status of the patient at the same time.
The Board notes that the anesthesiologist was convicted for driving with a blood alcohol content over 0.15 percent. He failed to report this conviction to the Board.
The anesthesiologist was placed on five years of probation with stipulations to complete 40 hours annually for each year of probation in areas of deficient practice and knowledge, complete a medical record keeping course, complete an ethics course, complete a clinical competence assessment program, and undergo practice monitoring. The anesthesiologist was prohibited from engaging in the solo practice of medicine.
State: California
Date: March 2017
Specialty: Anesthesiology
Symptom: Back Pain
Diagnosis: Post-operative/Operative Complication, Drug Overdose, Side Effects, or Withdrawal, Spinal Injury Or Disorder
Medical Error: Improper medication management, Failure to examine or evaluate patient properly, Ethics violation, Failure to properly monitor patient, Lack of proper documentation, Procedural error
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF
California – Interventional Radiology – Radiologist Uses Profanity And Hits Patient’s Hand In Anger During Procedure
On 5/4/2015, between 6:00 p.m. and 6:45 p.m., an interventional radiologist entered the hospital’s Room 9 to perform a cerebral angiogram. The interventional radiologist intended to perform a procedure on the patient, a 99-year-old patient who had just suffered a stroke. The cerebral angiogram procedure involves the practitioner gaining access to the patient’s femoral artery, near the patient’s groin, by inserting and threading a catheter from the patient’s femoral artery to the brain. The catheter absorbs and/or extracts any blood clots and can control bleeding in the patient’s brain.
Previously, between 5:30 p.m. and 5:50 p.m., three female ancillary staff, namely Registered Nurse (RN) A, Technician A, and Registered Nurse B, prepared both Room 9 and the equipment in Room 9 for the medical procedure. In addition, ancillary staff prepared the patient by restraining the patient’s head and hands to the surgical table, as well as covering portions of her body with drapes. When the interventional radiologist entered the room, he was immediately upset that the ultrasound machine was not fully ready and had not been placed by the patient’s head. The interventional radiologist yelled, using profanity, at Technician A, regarding the fact that the ultrasound machine was not ready.
As the procedure began, the interventional radiologist started to gain access to the femoral artery to insert a guide wire into the femoral artery, near the patient’s groin, while the patient was lying on a table with her head taped to the table and her right arm was restrained to a board. At that time, the patient managed to move or wriggle her hand toward her groin, a sterile field where the interventional radiologist was trying to insert the guide wire. The interventional radiologist immediately grabbed the patient’s right arm with his hands and yelled at the patient, “God Damn It! Don’t F—— Move! I Said Don’t Move.” The interventional radiologist was standing to the side of the patient when he then took the patient’s right hand and hit it with his closed fist hard. The patient was not yet sedated and she cried out in pain. The interventional radiologist then yelled at Technician A, “Look at what you made me do! This is all your fault.”
After the hitting incident occurred, but during the procedure, a charge nurse came into the room to make her observations. As the charge nurse was Technician A’s supervisor, Technician A wrote on a piece of paper, “He hit the patient” and gave the note to the charge nurse. The charge nurse then left the room. This note exchange occurred approximately between 6:45 p.m. and 6:55 p.m.
Once the procedure was completed, the interventional radiologist requested to look at the patient’s right hand. Staff removed the drape over the hand and observed that the hand was bleeding and bruised. The interventional radiologist ordered that the hand be x-rayed. Later, the interventional radiologist returned to the room and told staff that he had informed the son how his mother had received the injury. However, the interventional radiologist’s version as told to the son was that he had grabbed the patient’s hand and not that he hit her hand with a fist. The interventional radiologist never documented in the patient’s chart that the bruising and bleeding of the hand occurred at all nor how it occurred.
The interventional radiologist’s conduct of swearing at the patient when she moved her hand constituted an extreme departure from the standard of care. The interventional radiologist’s act of hitting the patient’s right hand with his closed fist also constituted an extreme departure from the standard of care.
The Board issued a public reprimand against the interventional radiologist. Stipulations included enrolling in a course on anger management and a course on professionalism.
State: California
Date: February 2017
Specialty: Interventional Radiology
Symptom: N/A
Diagnosis: Ischemic Stroke
Medical Error: Ethics violation, Failure of communication with patient or patient relations
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
California – Plastic Surgery – Liposuction And Mini Tummy Tuck With Complications
On 8/22/2014, Physician A first saw a patient when she responded to a Vietnamese magazine advertisement placed by Physician A. The records reflect that at the initial visit, the patient paid a two-hundred dollar consultation fee and a two-hundred eighty dollar fee for botox injections.
At the initial visit, the patient completed the medical history forms and a consent for botox injections. Physician A’s physical examination notes indicated that the patient was normal, except for a right lower abdominal appendectomy scar and loose skin. The notes reflected that Physician A marked the patient’s abdomen where he would remove fat, described his laser liposuction technique, and the mode of anesthesia employed. Physician A’s documented surgical plan was tumescent liposuction with fat transfer to the hands and the removal of excess lower abdominal skin. He injected botox at that visit.
Physician A provided a price quote of three thousand dollars for “lipo full abdomen and love handles” and a mini tummy tuck for an additional three thousand five hundred dollars. The documentation indicates that Physician A told the patient there would be a scar the size of which was dependent upon the amount of skin removed.
Physician A had not received any formal training in cosmetic plastic surgery. There has been no documentation that Physician A had competed any residency program in any specialty successfully.
Physician A’s records indicated that the patient returned on 9/9/2014, bringing a friend to see the plastic surgeon. At that visit, the patient complained to Physician A about the prior botox injections, and Physician A performed a free “touch-up” botox injection on the patient. Physician A also mentioned performing a “mini tummy tuck” and fat grafting to the patient’s hands, in addition to the liposuction he described at her first visit.
Physician A next saw the patient on 10/9/2014, and she was again advised of the surgery and risks of scars and infection.
Physician A next saw the patient on 10/13/2014 to undergo the procedures outlined above and was assured by Physician A that the mini tummy tuck scars would be small. The patient signed a consent for full abdominal/love handles tumescent liposuction/laser lypolysis and mini tuck. She also signed the treatment record on the possible surgical scar line. There is no consent for fat grafting to the hands.
Physician A’s records indicated that the surgery was performed on 10/13/2014. At 12:30 p.m., prior to surgery, the patient was given lorazepam 2 mg, 2 tabs of diphenhydramine 25 mg, 2 tabs of cephalexin 500 mg, and hydromorphone 4 mg. Clonidine 0.1 mg was given at 12:48 p.m. and again at 1:05 p.m. The procedure started at 1:00 p.m. and ended at 4:30 p.m. The records indicated that vital signs were taken every 15 to 30 minutes and were stable, except for an increased blood pressure at the beginning and end of the procedure.
Physician A’s records indicated that for the liposuction of the abdomen and love handles, 3.8 liters of normal saline was infiltrated and 2.5 liters was aspirated. Total fat removed was 1.5 liters and total lidocaine used was 1500 mg. The operative report in the medical records was a printed standard paragraph followed by “liposuction performed under local without complications.” The records also indicated that a small flap was removed and closed with 3-0 PDS suture deep layer and “subQ.”
Following the procedure, the patient was instructed to return to Physician A’s clinic “in 1-2 weeks for suture removal.” There was no description in the records of the fat grafting procedure to the hands, how the fat was processed for the transfer, or details of the mini tummy tuck. The patient woke up in a different room and stated that she recalled no blood pressure, heart rate, weight or other monitoring devices placed on her during the procedure.
The patient was discharged into the care of her husband with a stool softener, pain medication, and an antibiotic. The patient reported that she felt dizzy and weak for two or three days following the procedure. When the patient removed the surgical dressing, she reported that she was shocked to see a 10 inch long scar along her lower abdomen. A photo labeled “post op day 7” showed a fresh transverse Pfannenstiel type of scar whose lateral ends are about the level of the mid-femoral triangle. The patient called Physician A’s office to complain about the scar and was told to wait 2 weeks before coming in, at which time the sutures would be removed. The patient called almost daily to be seen but was told to wait the full 2 weeks.
The patient returned to Physician A’s office on 10/20/2014, at which time the swelling had decreased, the bruising had resolved, and there were no indentations. The patient was advised to continue wearing the pressure garment. According to the patient, after Physician A removed the sutures, Physician A denied ever having said that the scar would be smaller than it actually was. The patient reported that she left his office after that conversation and never returned.
The patient stated she was out of work for two months due to pain that finally resolved.
Physician A’s records did not reflect the patient’s complaints. Physician A said he did not chart any complaints in his notes because the patient did not voice any complaints.
Undated photos from the file showed an undulating transverse infraumbilical pink slightly hypertrophic scar, infraumbilical stretch marks, loss of the supraumbilical fat as compared to preoperative photographs (also in the file), and persistent supraumbilical skin excess that completely covered the umbilicus with multiple fine horizontal rhytides just above the umbilicus. The horizontal fold at the level of the umbilicus was no longer present because the fat had been removed.
Physician A’s notes did not indicate that he ever informed the patient of the potential negative outcome from the suggested procedures, evidencing a lack of knowledge on the part of Physician A of the indications of a mini tummy tuck as opposed to an abdominoplasty.
Physician A first saw the patient on 8/22/2014 when he performed a physical examination and history. The documentation reflected that on 10/13/2014, the day of surgery, no physical examination was performed prior to that surgery. Thus, more than 30 days had elapsed since the patient’s physical examination took place.
Physician A’s notes indicated that the patient was a 53-year-old female who was operated upon without a medical clearance or a recent CBC blood test.
Physician A’s notes indicated that 1.5 liters of material was aspirated from the patient. Intravenous access and monitoring (pulse oximeter, blood pressure measurement, fluid loss/replacement monitoring/recording, and electrocardiogram) are required for aspiration of 2000 cubic centimeters or more.
Physician A did not have admitting privileges at a local general acute care hospital and did not have a written transfer agreement with such a hospital or a licensed physician with admitting privileges at such a hospital.
Physician A’s notes indicated that no medical record documentation of fluids infused, aspirate quantity, procedure duration, and the nature of the procedure performed were properly maintained.
Physician A’s notes indicated that regulatory discharge criteria were not met and that no ACLS certified staff person was present until the patient was discharged.
Physician A’s notes indicated that medication logs were not kept in that there are no such logs in the medical records produced. Unlicensed medical assistants appeared to have had unsupervised and unfettered access to controlled substances and other medications.
Physician A’s facility was not an accredited facility and lacked the necessary equipment for accreditation.
The Board judged Physician A’s conduct as having fallen below the standard of care given failure to take an appropriate medical history and perform a physical examination within 30 days prior to a procedure, given the performance of a 2.5 liter liposuction and mini tummy tuck in a non-accredited facility without IV access and without admitting privileges at a local general acute care hospital, and given the performance of a mini tummy tuck when the indication was questionable.
Physician A was placed on probation for five years with stipulations to complete 40 hours annually of continuing medical education in areas of deficient practice or knowledge, a prescribing practices course, a medical record keeping course, a professionalism program, and a clinical training program equivalent to the Physician Assessment and Clinical Education Program. He was ordered to undergo clinical monitoring. He was prohibited from performing any procedures requiring sedation, performing body liposuction, and performing a mini tummy tuck.
State: California
Date: February 2017
Specialty: Plastic Surgery
Symptom: N/A
Diagnosis: N/A
Medical Error: Procedural error, Ethics violation, Unnecessary or excessive treatment or surgery, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
Washington – Orthopedic Surgery – Bilateral Shoulder Pain After A Motor Vehicle Accident And Repair Attempt Of Os Acromiale
On 1/4/2011, a patient was involved with a head on motor vehicle collision. The patient sought care the following day at a hospital.
On 1/20/2011, the patient followed up with his primary care provider (PCP). A magnetic resonance imaging (MRI) of the patient’s right shoulder was performed. The MRI showed an abnormal rotator cuff, areas of a partial tear, and an injury to the tendon.
On 2/3/2011, the patient presented to an orthopedic surgeon’s clinic with complaints of right shoulder pain. The orthopedic surgeon reviewed the previous MRI and performed a physical examination. The orthopedic surgeon diagnosed the patient with rotator cuff tendinosis with possible tear, degenerative arthritis of the acromioclavicular joint, and inflammation of the tendon around the biceps muscle.
For the following four months, the orthopedic surgeon continued to see the patient. Though the orthopedic surgeon encouraged the patient to engage in conservative treatment, including physical therapy, the patient’s pain did not completely resolve.
On 6/1/2011, the patient complained of pain in both of his shoulders. The orthopedic surgeon discussed surgical options with the patient. The patient consented to have surgery.
On 6/9/2011, the orthopedic surgeon performed right shoulder surgery. During the surgery, the orthopedic surgeon discovered the patient had an unfused os acromiale (a developmental aberration in which the acromion fails to fuse). Without the patient’s consent, the orthopedic surgeon decided to attempt to repair the os acromiale. The orthopedic surgeon claims he placed two pins within the acromion and a screw down the center. K wires (stainless steel sharpened pins) were cut and placed.
On 7/6/2011, the patient had x-rays taken of his right shoulder. The orthopedic surgeon believed the x-rays showed the hardware was placed appropriately in the patient’s shoulder. Later, the patient saw a different physician, who took a new set of x-rays and believed the hardware was angled inappropriately and the wires were loose. He also believed based on the new x-rays that the screw thread appeared to be just barely in the bone.
Following the patient’s surgery, the patient continued to experience varying degrees of shoulder pain and soreness. On 9/9/2011, the orthopedic surgeon took x-ray images of the patient’s left shoulder, which revealed the patient had bilateral os acromiale.
On 11/21/2011, x-rays were taken of the patient’s right shoulder and showed the screw had pulled out, the bone had not fused, and the wire was broken. The orthopedic surgeon had allegedly failed to appropriately place the original fixation and should have been aware of this when reviewing earlier x-ray images.
The Commission stipulated the orthopedic surgeon reimburse costs to the Commission and write and submit a paper of at least 1000 words with annotated bibliography on the diagnosis and proper treatment of os acromiale.
State: Washington
Date: February 2017
Specialty: Orthopedic Surgery
Symptom: Extremity Pain
Diagnosis: Musculoskeletal Disease
Medical Error: Procedural error, Diagnostic error, Ethics violation
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
Washington – Orthopedic Surgery – iO-Flex Use For Spinal Decompression
On 7/24/2012, a patient saw an orthopedic surgeon for a preoperative appointment concerning the decision for unilateral decompression surgery at L4-5 secondary to chronic lower back pain radiating to the right lower extremity with numbness and tingling. The orthopedic surgeon failed to document in his preoperative report his intention to use the iO-flex (minimally invasive micro-blade shaver), a newly-marketed surgical device, during the patient’s upcoming surgery. The orthopedic surgeon did not disclose to the patient that he had never used this device before. Specifically, the orthopedic surgeon did not obtain the patient’s informed consent to use the iO-flex.
On 8/9/2012, the patient returned to the orthopedic surgeon’s clinic presenting with a sudden onset of back pain radiating to the left lower extremity. Magnetic resonance imaging (MRI) revealed a new large disc herniation at L4-5. This newly discovered injury caused the original surgical plan to change, which the orthopedic surgeon failed to document in his preoperative report and failed to tell the patient.
On 8/15/2015, the orthopedic surgeon began the patient’s decompression with the iO-flex and the progress was being observed by a remote neuromonitoring physician and an on-site neuromonitoring technician. The neuromonitoring technician informed the orthopedic surgeon that there was a decrease in some of the patient’s sensory nerve signals. In response, the orthopedic surgeon removed all of the iO-Flex tools and waited for improvement.
While waiting for improvement, there was a lack of clear communication between the orthopedic surgeon, the neuromonitoring physician, and the neuromonitoring technician about a drop in neuromonitoring function. The orthopedic surgeon had a duty to make sure the information received from the neuromonitoring physician and the neuromonitoring technician was correct. The changes in function should have been noted in the orthopedic surgeon’s operative report, but were not included. Due to this omission, the orthopedic surgeon’s report incorrectly implied there were no complications. When the orthopedic surgeon inserted the iO-flex micro-blade shaver into the patient’s spine and performed about sixty reciprocations for decompression, the orthopedic surgeon unknowingly damaged the patient’s cauda equina (bundle of spinal nerves and spinal nerve roots).
On 8/16/2012, the orthopedic surgeon examined the patient in the recovery room. The patient had weakness and numbness in both feet. On 8/17/2012, based on the patient’s presentation of weakness in both feet and a newly experienced loss of bladder control, an MRI was ordered and the orthopedic surgeon recommended exploratory surgery.
On 8/18/2012, the orthopedic surgeon performed the exploratory surgery. The exploratory surgery revealed cauda equina damage and a tear in the patient’s dura (a watertight sac of tissue that covers the spinal cord and spinal nerves). Given the seriousness of the neurological complications (weakness, numbness, bladder dysfunction), the exploratory operation should have been completed when those symptoms were first noted, not two days later.
The orthopedic surgeon treated the patient’s dural tear with a sealant. The orthopedic surgeon failed to document fluid leaking in the patient’s spine in his post-operative report and there was no documentation of an appearance of fluid collection in the patient’s exploratory MRI report. The orthopedic surgeon should have documented these complications.
The Commission stipulated the orthopedic surgeon reimburse costs to the Commission, complete a continuing education course on ethics, complete a continuing education course on medical record keeping, and write and submit a paper of at least 1000 words on what he learned from the courses and how information he learned applies to this case.
State: Washington
Date: January 2017
Specialty: Orthopedic Surgery, Neurosurgery
Symptom: Back Pain, Numbness, Extremity Pain
Diagnosis: Post-operative/Operative Complication, Spinal Injury Or Disorder
Medical Error: Procedural error, Delay in proper treatment, Ethics violation, Failure of communication with other providers, Failure of communication with patient or patient relations, Lack of proper documentation
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 1
Link to Original Case File: Download PDF