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A 14-year-old girl was referred by her pediatrician to a child neurologist for seizures.  The child neurologist first saw the patient on 8/10/2009. The patient’s first seizure occurred at age 10, early morning on 2/21/2006, and a second episode occurred in the early morning sometimes around December 2008.  At the time the patient saw the child neurologist, her medication included Klonopin 0.5 mg p.m., Depakote at 750 b.i.d., and Vistaril 10 mg p.m. The patient’s MRI on October 2008 was normal. The patient’s EEG performed on October 2007 noted 3-13 seizures.  The child neurologist’s assessment was “juvenile myoclonic epilepsy; rule out adverse effect of med correctly given; insomnia unspecified; depressive disorder; and cafe au lait spots x 2.” The child neurologist ordered a video EEG “to rule out any epileptogenic foci.”

On 8/12/2009, the video EEG was performed.  The technician reported sharp and slow waves left F3-C3.  The child neurologist read it as normal. A BAER was performed on the same day even though it was not ordered by the child neurologist.  The BAER was not indicated, and the referring diagnosis for the BAER was not in the record and was used only for billing.

The child neurologist next saw the patient on 8/21/2009 for a follow-up visit.  The child neurologist noted that the patient was tolerating Depakote well. The Depakote level was 101.  The child neurologist diagnosed breakthrough seizures despite the fact that no seizures were reported. The child neurologist added Topamax Sprinkles 25 mg to increase to 50 mg b.i.d.  She stopped the Klonopin and Vistaril.

On 11/2/2009, the child neurologist saw the patient for a follow-up visit.  She noted that patient was gaining weight with Topamax and wanted to stop Depakote, though it was well tolerated.  The patient had no seizures and no myoclonic jerks. The child neurologist ordered another video EEG without medical indication.  The result of the second video EEG was normal. The child neurologist’s reading of the video EEG followed a template and was the same with all of her video EG reports except for the first paragraph regarding time of sleep, wake, and meals.

The child neurologist next saw the patient on 5/3/2010.  The patient reported no auras or seizures. The child neurologist noted under past medical history that the patient had suicidal thoughts.  The child neurologist did not address this issue during this visit. The child neurologist continued Topamax 50 mg b.i.d., even though there was a note of memory problems.  The child neurologist reduced Depakote to 500 b.i.d. She ordered labs and a 4-day ambulatory EEG without any medical indication. The 2 previous video EEGs were normal, and the patient did not have any seizures.  The patient underwent a third video EEG on this visit, which was not ordered nor medically indicated.

On 6/8/2010, the child neurologist saw the patient for a follow-up visit.  The patient was taken off Topamax. Her memory improved, but her headaches recurred.  The child neurologist diagnosed migraines without asking sufficient questions to make that diagnosis.  She added amitriptyline 10 mg, Imitrex 100 mg, and continued Depakote 500 b.i.d.

The 4-day ambulatory EEG ordered on 5/3/2010 was performed on 7/6/2010.  It was completed despite the fact that the patient just underwent a third video EEG on 5/3/2010.  There was no medical indication for the 3 previous EEGs and the 4-day ambulatory EEG. The 4-day ambulatory EEG was read as normal.

On 8/23/2010, the child neurologist saw the patient for 2 back-to-back seizures that occurred on 8/11/2010.  The patient was taken to the emergency room with a history of early morning twitching since the seizures. The child neurologist’s assessment was breakthrough seizures.  The child neurologist added Lamictal 100 mg b.i.d. and raised Depakote from 500 mg b.i.d. to 1000 mg b.i.d. The child neurologist failed to recognize that on 7/29/2010, the patient was having myoclonic jerks, which were described as twitches.  The patient had been on 750 mg b.i.d. with a level of 100 and had been seizure free for 2 years. The child neurologist failed to recognize the important interaction between Lamictal and Depakote. The child neurologist failed to consider that it was very likely that the patient had toxic levels of both Depakote and Lamictal.  The child neurologist did not check the patient’s blood levels. The child neurologist ordered another video EEG and another ambulatory EEG. The video EEG was performed on September 2010 and was normal. The child neurologist used the same template on her report.

The child neurologist next saw the patient on 11/4/2010.  The patient was unable to sleep, had difficulties with coordination and balance, was forgetful; all symptoms consistent with medication toxicity.  The child neurologist failed to recognize it as such. The patient was on Depakote 500 mg b.i.d. and Lamictal 100 mg b.i.d. Suicidal ideation was noted in the child neurologist’s previous notes, but the child neurologist failed to address this issue.  The child neurologist added Prozac 20 mg, which had a black box warning for suicidal ideation.

The Medical Board of California judged that the child neurologist’s conduct departed from the standard of care because she ordered 4-5 video EEGs and an ambulatory EEG without medical indication, ordered a BAER with no medical indication, lacked knowledge and/or did not consider the important interaction between Depakote and Lamictal.  The child neurologist diagnosed migraines without establishing diagnostic criteria, diagnosed circadian sleep disorder without asking any questions regarding symptoms and adding the polysomnogram report in the chart, and prescribed Prozac to patient with a history of suicidal thoughts despite the black box warning.

For this case and others, the Medical Board of California placed the child neurologist on probation and ordered the child neurologist to complete a medical record keeping course, a professionalism program (ethics course), an education course (at least 40 hours per year for each year of probation), and a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.  The child neurologist was assigned a practice monitor and was prohibited from supervising physician assistants and advanced practice nurses.

State: California

Date: January 2018

Specialty: Neurology, Pediatrics

Symptom: Headache

Diagnosis: Neurological Disease, Drug Overdose, Side Effects, or Withdrawal, Psychiatric Disorder

Medical Error: Improper medication management, Diagnostic error, Failure to examine or evaluate patient properly, Unnecessary or excessive diagnostic tests

Significant Outcome: N/A

Case Rating: 3

Link to Original Case File: Download PDF

A 56-year-old female was referred by her primary care physician to a neurologist.  The patient’s primary care physician noted neck pain and numbness of the upper extremities, left greater than right, present for 1 year.  Her medications were lisinopril 5 mg daily, Lyrica 50 mg 3 times daily, Flexeril 10 mg 3 times daily, Mobic 15 mg daily, and Nexium 40 mg daily.  Her primary care physician noted that she had lumbar laminectomy for disk herniation in the past for low back pain and tingling of the left leg. He also noted that the MRI of her cervical spine was abnormal and requested a neurological evaluation.  It revealed an abnormal signal intensity C2-3 affecting posterior columns with the radiologist’s comment of “could account for arm numbness and tingling.” The x-ray of her cervical spine performed on 11/5/2012 ordered by her primary care physician showed moderate degenerative changes.  The x-ray of her lumbar spine performed on 2/23/2012 showed similar findings.

The neurologist first saw the patient on 12/10/2012 for the abnormal cervical spine MRI.  The patient’s complaints were “neck pain; left neck and arm numb; right arm and right knee; losing urine; and generalized weakness on the left.”  The patient also complained that she “also feels ‘dead’ hips down, [d]izzy spells several times, no energy, difficult to concentrate.” The neurologist noted the “neuro exam essentially normal.”  The neurologist’s diagnoses were demyelinating disease; paresthesias of face and her extremities, vertigo, and memory loss. The neurologist ordered the following tests: EMG/NCV lower extremities, though later she also did upper extremities; MRI of the brain; neuromuscular junction tests with EMG; BAER with vestibular testing; VEP; EEG, overnight; and EEG awake and sleep with digital analysis 95957.

The upper extremity EMG/NCV study was performed on 1/3/2013.  She tested 4 motor nerves, 5 sensory nerves, and F waves. The neurologist tested every muscle, which was present in the upper extremities.  The results of the study were normal.

The electrodiagnostic study of the lower extremities were performed on 1/10/2013.  The neurologist tested 4 motor nerves, 6 sensory nerves, 2 H reflexes, bilateral F waves of the motor nerves.  She did a needle EMG of all muscles in the lower extremities and paraspinal muscles. The results of the study were normal.

There was a report of a video-monitored EEG utilizing a 32-channel digital EEG system manufactured by Cadwell.  This test was performed on 12/26/2012. The report stated that the technician performed hyperventilation, but the patient reported she did not, and that the patient was videotaped, though the patient reported she was not.  It was read as normal.

The ambulatory EEG was performed on 2/5/2013 to 2/6/2013.  In the report, it was termed a 2-day ambulatory EEG despite lasting only 1 day.  The neurologist prepared the report. The report contained a printout of 1 page. It was timed 6:21 a.m., and it contained widespread artifacts lasting 10 seconds.  This was the exact time that the patient reported she stood in front of her microwaves. The neurologist read this as “Isolated sharp waves were noted in the frontal left hemispheric area. The isolated sharp waves may be epileptogenic in nature.”  The visual and brainstem auditory evoked potentials were normal.

On 2/26/2013, the neurologist saw the patient for a follow-up visit.  The test results were available to the neurologist at the visit. The neurologist noted that the EEG for the patient was normal for both awake and drowsy.  The neurologist also noted that the 2-day EEG, which lasted only 1 day and the MRI of the brain showed a corpus callosum lesion. Her assessment and plan contained the same diagnoses as the first visit of 12/10/2012, and she failed to consider new information that should have changed her initial diagnoses.

The neurologist did not diagnose seizures in the assessment and plan, but she prescribed Depakote.  The neurologist discussed with the patient that she met criteria for relapsing and remitting Multiple Sclerosis with an acute exacerbation.  The neurologist also noted that the patient had pain with neck movement, which was sharp and went to the toes. She believed that the symptom was consistent with the finding of the ambulatory EEG and thus started the patient on Depakote 500 mg b.i.d.  The neurologist failed to recognize Lhermitte’s sign, consistent with the myelopathy. The neurologist ordered laboratory studies for Lyme disease, lupus, and lumbar puncture. She ordered monitoring labs for Depakote, CBC, and liver function tests to be done before the next visit.

The MRI of the brain the neurologist referred to in the 2/26/2013 follow-up visit was performed at the neurologist’s request on 12/28/2012.  The report indicated 20 FLAIR hyperintensities and a possible tiny corpus callosum lesion. The neurologist concluded it was consistent with multiple sclerosis.  The 12/28/2012 report contained a comparison to a previous MRI of the brain performed on 7/1/2007. The radiologist thought the new MRI showed abnormalities “probably very slightly more numerous” than the 2007 MRI.  He further considered the appearance to be nonspecific, and the tiny lesion in the corpus callosum was considered possible.

The 2007 MRI was requested by another physician.  It was read as showing “a few nonspecific scattered punctate of unlikely clinical significance.”  Multiple sclerosis was not raised as a possible cause. Referring diagnosis was “recent vertigo and left-sided dizziness.”  The neurologist failed to question the patient on symptoms that occurred in 2007.

On 3/12/2013, the patient was seen in the emergency room for nausea and vomiting.  She was diagnosed with Depakote toxicity with a level of 108. She was told to stop the medication.  She was scheduled for the lumbar puncture the following day and was told to keep that appointment. The day following the lumbar puncture, she developed symptoms consistent with a postspinal headache.  She was seen by the neurologist in her office on the same day and diagnosed with Depakote toxicity. At this point, the neurologist erroneously believed that the patient had “definite” multiple sclerosis.  She also erroneously believed that “the patient wrongfully assumed” Depakote caused her symptoms and believed that they were from the lumbar puncture.

The neurologist next saw the patient on 3/26/2013 for an office visit.  The neurologist noted that the patient had a postspinal headache. She noted that the spinal fluid was negative for oligoclonal bands, but incorrectly thought the IgG synthesis was abnormal.  She incorrectly diagnosed “primary stabbing headache” despite her earlier entry of postspinal headache.

In a subsequent interview with a Medical Board investigator, the neurologist was questioned as to why she did not take a history of previous symptoms, such as optic neuritis, that help to establish a diagnosis of multiple sclerosis.  She was questioned if the examination was normal and why she did not check the “saddle” area for sensory loss, and she reported, “Why should I check the saddle area?” There were no “incontinence of stools.” When asked if she would have documented Lhermitte’s symptom or sign if present, she answered yes.  She obtained a history of symptoms consistent with Lhermitte’s, but did not recognize it as such. Memory loss was given as a diagnosis, but when asked how it was based, she could not recall. When asked to explain the reasons that each test was ordered, she responded that the EMG was based on symptoms, the neuromuscular test was based on the possibility of myasthenia gravis causing general weakness, the BAER and VEP as part of the multiple sclerosis work-up, and the EEG to rule out seizures as the cause of numbness and weakness.  She stated video monitoring on EEG was standard practice. Hearing loss was her reason for performing the BAER, but no hearing loss or visual disturbance was documented. She stated that the 2007 MRI showed infratentorial and supratentorial lesions whereas there was no mention of an infratentorial lesion in the radiology report. She ordered the EMG of the upper extremities to “rule out any other diseases” and stated “EMG is part of differential diagnosis,” and the indication she believed was numbness and tingling in the hands. When asked why she did 24 upper extremity and 6 cervical paraspinal muscles on EMG, she stated she wanted to make sure there was “no polyradiculopathy,” but she admitted there were no findings to suggest that diagnosis.  Further, she believed that numbness and tingling and incontinence would indicate polyradiculopathy. When questioned regarding indications for EMG of the lower extremities, she stated back problems, numbness right arm and right knee, and feeling the hips on down were “dead.” In the lower extremities, she tested 12 different muscles and 6 paraspinal muscles. She was then questioned about what were the indications for the EEG, and she believed they were generalized weakness, dizzy spells, no energy to work, and difficulty focusing. She was questioned as to why the first EEG was not sufficient. She stated that on 2/26/2013 visit, she had findings of generalized seizure disorder, but this was not the wording in the EEG report nor was it in her letter to the Board.  She was not aware that a microwave can cause artifacts. Regarding indication for Depakote, her answer was because of the EEG and numbness and tingling. She thought it would be trial and error to see if it would help. She thought that the patient’s symptom of “neck killing her” would be consistent with a multiple sclerosis plaque. When asked why she ordered Lyme disease and lupus blood tests, she stated that they were “on my mind.”

The Medical Board of California judged that the neurologist’s conduct departed from the standard of care because she failed to recognize symptoms and findings on the MRI of a partial transverse cervical myelopathy, ordered an EMG for the upper and lower extremities, video EEG, and ambulatory EEG without medical indication, conducted an excessive number of nerve tests for any diagnosis, misdiagnosed epilepsy, lacked knowledge in reading EEGs, and had no knowledge and/or did not consider the important interaction between Depakote and the patient’s other medications.  The neurologist also lacked knowledge in several fundamental areas.  She failed to recognize symptoms of a partial transverse cervical myelopathy and Lhermitte’s symptoms even though it was described to her by the patient.  She did not recognize or, if she did, did not reflect in her records that almost all of the patient’s symptoms were caused by the cervical myelopathy. The neurologist erroneously believed that a multiple sclerosis plaque could cause severe neck pain and that IgG synthesis could indicate active or inactive multiple sclerosis.  She diagnosed multiple sclerosis on the basis of the McDonald criteria, and she included the original report, but she gave no information in her records how those criteria fit the patient. She failed to question the patient for previous symptoms, which might establish an initial exacerbation of multiple sclerosis. The neurologist was aware that the patient had an MRI in 2007 and did not question the patient regarding her symptoms at that time.  She ordered laboratory studies for possible Lyme disease or “lupus” and a monophasic cervical myelopathy despite the fact that it was exceedingly unlikely to be caused by any of those disorders. She failed to consider alternative causes for the patient’s presentation, specifically B12 deficiency or adrenomyeloneuropathy.

For this case and others, the Medical Board of California placed the neurologist on probation and ordered the neurologist to complete a medical record keeping course, a professionalism program (ethics course), an education course (at least 40 hours per year for each year of probation), and a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.  The neurologist was assigned a practice monitor and was prohibited from supervising physician assistants and advanced practice nurses.

State: California

Date: January 2018

Specialty: Neurology

Symptom: Head/Neck Pain, Dizziness, Headache, Nausea Or Vomiting, Numbness, Urinary Problems, Weakness/Fatigue

Diagnosis: Spinal Injury Or Disorder, Drug Overdose, Side Effects, or Withdrawal

Medical Error: Diagnostic error, Failure to examine or evaluate patient properly, Unnecessary or excessive diagnostic tests, Improper medication management

Significant Outcome: N/A

Case Rating: 4

Link to Original Case File: Download PDF

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

From 2009 until 2014, an internist served as the patient’s primary care physician.

In 2009, the internist referred the patient to Cardiologist A for a cardiology evaluation.  The results of the 2009 cardiology evaluation revealed that the patient’s electrocardiogram and stress test were both abnormal.

At this time, Cardiologist A recommended that the internist increase the patient’s medication as needed in order to get the patient’s cholesterol to below seventy.

The patient was evaluated by Cardiologist A again in June 2010.

The June 2010 cardiac evaluation revealed that the patient had shortness of breath on exertion at times, possibly related to hypertension and subclinical congestive heart failure.

On 7/17/2013, the patient underwent lab work, the results which showed that his glomerular filtration rate (GFR) was thirty-four.  The internist staged the patient’s chronic kidney disease (CKD) at a stage III/IV.

The patient’s next set of lab work was conducted on 11/18/2013, the results of which showed that his GFR was twenty-two.  The internist wrote in a progress note that the patient’s CKD was a stage III/IV.

On 1/13/2014, the patient had lab work done again, the results which showed that his GFR was twenty-six.  In his progress note he wrote that the patient’s CKD was now a stage IV.

Despite a dramatic decline in the patient’s GFR levels indicative of worsening CKD, the internist did not refer the patient to a nephrologist.

On 1/13/2014, the patient presented to the internist complaining of left arm pain, numbness radiating to both hands, and shortness of breath.  The internist ordered an EKG, chest x-ray, and lab work.  His assessment of the patient at this time was dyspnea on exertion, questionable coronary artery disease, questionable pulmonary disease, and questionable anxiety.

On 1/14/2014, the patient returned to the office for an echocardiogram.  After the echocardiogram, the internist referred the patient to Cardiologist B for a consult.  The patient could not obtain an appointment with Cardiologist B until 2/3/2014.

The internist ordered that a stress test be conducted prior to the patient’s visit with Cardiologist B, and advised that the patient bring the results of the stress test to his appointment with Cardiologist B.

On 1/23/2014, the stress test was performed and the results were abnormal.

The Medical Board of Florida judged that the internist failed to adequately evaluate the patient’s symptoms and recognize the patient’s worsening coronary artery disease, development of congestive heart failure, and worsening chronic kidney disease.  He failed to refer the patient to a nephrologist for further evaluation upon seeing a dramatic decline in the patient’s GFR levels.  He also failed to send the patient to the emergency department for treatment when the patient presented to him with exhibiting cardiac symptoms and had a known history of heart disease.

The Medical Board of Florida issued a letter of concern against the internist’s license.  The Medical Board of Florida ordered that the internist pay a fine of $2,500 against his license and pay reimbursement costs for the case at a minimum of $5,756.36 and not to exceed $7,756.36.  The Medical Board of Florida also ordered that the internist complete five hours of continuing medical education in the treatment of patients with chronic kidney disease and chronic heart disease.

State: Florida

Date: December 2017

Specialty: Internal Medicine

Symptom: Extremity Pain, Numbness, Shortness of Breath

Diagnosis: Heart Failure, Cardiovascular Disease, Renal Disease

Medical Error: Failure to examine or evaluate patient properly, Referral failure to hospital or specialist

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

On 12/4/2013, a 78-year-old female presented to an ophthalmologist for phacoemulsification with posterior chamber implant (“cataract surgery”) on her right eye.

During the cataract surgery, the patient experienced a posterior capsule tear, a known complication and an accepted risk associated with cataract surgeries.

On 2/3/2014, the patient presented to the ophthalmologist for an examination, and the ophthalmologist noted inflammation in the patient’s operative eye.

On 3/27/2014, the patient presented to the ophthalmologist for an examination, and the ophthalmologist noted inflammation in the patient’s operative eye.

On 4/8/2014, the patient presented to the ophthalmologist for an examination, and the ophthalmologist noted that the patient experienced post-operative chronic iritis in her operative eye.

On 5/6/2014, the patient presented to the ophthalmologist for a follow-up examination of her operative eye.

On 8/14/2014, the patient presented to the ophthalmologist for a follow-up examination of her operative eye.

On 9/18/2014, the patient presented to the ophthalmologist and reported throbbing pain in her operative eye.

Despite knowing that the patient experienced a complicated cataract surgery, followed by persistent inflammation in her operative eye, the ophthalmologist did not perform a dilated examination until 9/18/2014.

Despite knowing the patient experienced a complicated cataract surgery, followed by persistent inflammation in her operative eye, the ophthalmologist did not refer her to a retina specialist.

The Board judged the ophthalmologist’s conduct to be below the minimum standard of competence given his failure to perform a dilated examination on the patient’s operative eye to investigate the causes of persistent post-operative inflammation within a reasonable time after the cataract surgery.  The ophthalmologist also failed to refer the patient to a retina specialist to investigate the causes of persistent post-operative inflammation within a reasonable time after cataract surgery.

The Board ordered that the ophthalmologist pay a fine of $2,500 against his license and that the ophthalmologist pay reimbursement costs for the case for a minimum of $4,634.56 but not to exceed $6.634.56.  The Board also ordered that the ophthalmologist complete five hours of continuing medical education in post-operative care and complete one hour of continuing medical education in “Risk Management.”

State: Florida

Date: November 2017

Specialty: Ophthalmology

Symptom: Head/Neck Pain, Swelling

Diagnosis: Post-operative/Operative Complication, Ocular Disease

Medical Error: Failure to examine or evaluate patient properly, Referral failure to hospital or specialist

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

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

On 8/27/2012 a 47-year-old female presented with complaints of hypertension, possible hyperlipidemia, and pain in her foot.  A family practitioner assessed the patient and diagnosed her with poor control of her hypertension and reinforced medical advice for the patient to increase her lisinopril.  Additionally, the family practitioner waited for the results of the previous laboratory work and recommended conservative management and stretching for the foot and ankle.

On 4/1/2013, the patient again presented to the family practitioner to address difficulties with concurrent chest pain.  The patient stated the chest pains were very severe and “stopped her in her tracks at times.”  The patient stated that she felt she was having a heart attack, although she reportedly realized that that was not the case.  The family practitioner deemed the chest pain was likely an esophageal spasm, for which he prescribed the patient Librax (chlordiazepoxide/clidinium) and recommended that she see a gastroenterologist for an endoscopy if the medication failed to provide relief.  The family practitioner also assessed the patient for hypertension and instructed the patient to stop taking hydrochlorothiazide.  The family practitioner provided the patient with a trial of Dyrenium (triamterene).

On 4/12/2013, the patient complained of chest pain and suffered a cardiac arrest.  Upon EMS arrival, the patient was unstable and unresponsive.  The patient was transported to a hospital where she was later pronounced deceased.

The Board judged the family practitioners conduct to be below the minimal standard of competence given that he failed to conduct an adequate history, which included a risk factor assessment for a patient complaining of chest pain, to order or perform an EKG on a patient complaining of chest pain, and send a patient complaining of chest pain to an emergency room or an expedited outpatient facility for a chest pain evaluation.

The Board ordered that the family practitioner pay a fine of $5,000 against his license and pay reimbursement costs for a minimum of $2,122.00 and not to exceed $4,122.00.  The Board also ordered that the family practitioner complete ten hours of continuing medical education in diagnosis in cardiology and five hours of continuing medical education in “Risk Management.”

State: Florida

Date: November 2017

Specialty: Family Medicine

Symptom: Chest Pain, Extremity Pain

Diagnosis: Cardiovascular Disease

Medical Error: Diagnostic error, Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Referral failure to hospital or specialist

Significant Outcome: Death

Case Rating: 3

Link to Original Case File: Download PDF

A 24-year-old female was transferred from a physician to an obstetrician.  The patient first saw the obstetrician on 6/24/2009, and she was due with her first child in July 2009.  Her patient chart listed her at 120 lbs and 4’0” tall, but when she came to see the obstetrician, she weighed 170 lbs.

The patient was seen by the obstetrician twice in June and every week in July until 7/27/2009.  The patient was scheduled to be induced 7/29/2009. There was nothing in the records about her bony pelvic exam or pelvic adequacy for vaginal delivery.  The obstetrician did not do an ultrasound. The patient was admitted to the hospital on 7/29/2009. There was no risk assessment, no estimate fetal size, no ultrasound ordered, and a Bishop score of 4.

The patient was started on Pitocin at 9:30 a.m. and had made no progress by 6:00 p.m. that evening.  The patient was allowed to rest, and the next morning, on 7/30/2009 at 7:30 a.m., Pitocin was started again.  During this time, it was noted that she had “reactive” fetal heart tracings. The nurses did not place an order for an internal fetal monitor.  When the fetal heart tones were low, the Pitocin should be turned off. If the mother keeps having contractions, the baby gets no rest, which is what likely occurred in this case.

At 8:18 p.m., she was only dilated 4-5 cm.  The patient had spontaneous rupture of the membranes with thick meconium noticed.  At 8:50 p.m., the patient was dilated to 8 cm, 0 station. There was no mention of a possible Cesarean section in the notes.  On 7/31/2009, a female infant weighing 9 lbs 5 oz was delivered using a vacuum because a shoulder dystocia was encountered. Unfortunately, the baby was deceased.

The Medical Board of California judged that the obstetrician’s conduct departed from the standard of care because he failed to estimate the fetal size, fetal lie, and pelvic adequacy.  The obstetrician also did not mention the application of a fetal electrode. This is important because the obstetrician did not know if the heart rate was coming from the mother or the baby; thus, an internal electrode would have been an accurate way to measure the baby’s heart rate.  Review of the fetal monitor strips showed back to back contractions and inadequate recordings. During labor and delivery, Pitocin should have been stopped in the contractions showed a low fetal heart rate and tachysystole (no rest between contractions). This patient was also a poor candidate for induction because she had a Bishop score of 4.  When the membranes were ruptured with 3+ meconium, this should have alerted the obstetrician that the baby was somehow compromised and action by the obstetrician was required. Also, the patient was a transfer patient, but the obstetrician did not order lab studies or an ultrasound. There were many errors which lead to the untimely demise of this baby.  Had there been an estimate of fetal weight, or an ultrasound performed within 6 weeks of induction of labor, the obstetrician would have known the patient was having a big baby, and the obstetrician might have performed a Cesarean section.

The Medical Board of California issued a public reprimand and ordered the obstetrician to complete a clinical competence assessment program.

State: California

Date: November 2017

Specialty: Obstetrics

Symptom: N/A

Diagnosis: Obstetrical Complication

Medical Error: Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Failure to properly monitor patient, Improper treatment, Improper medication management

Significant Outcome: Death

Case Rating: 4

Link to Original Case File: Download PDF

From 8/12/2015 to 4/1/2016, (“treatment period”) a 69-year-old male presented to an ophthalmologist with complaints of blurred vision in his eyes.

During the treatment period, the ophthalmologist diagnosed the patient with a mature cataract in his right eye, and complicated cataract, proliferative diabetic retinopathy, and epiretinal membrane (“ERM”) in his left eye.

During the treatment period, the ophthalmologist did not perform or document performing the appropriate objective preoperative diagnostic testing, such as an Optical Coherence Tomography (“OCT”), of the retina to adequately assess the ERM in the patient’s left eye.

During the treatment period, the ophthalmologist did not thoroughly examine or document a thorough examination of the patient’s eyes by performing objective preoperative testing and imaging, such as fundus photos documenting the ERM, an Amsier grid showing distortion of the patient’s vision, an Amsier grid on either eye, or showing the patient’s retina and irregularities in the retina to support the epiretinal membrane peel in the patient’s left eye.

During the treatment period, the medical records maintained by the ophthalmologist did not clearly document any indication of the ERM on the patient’s left eye preoperatively.

During the treatment period, the ophthalmologist did not perform or document performing, objective preoperative testing and imaging studies, such as an OCT of the retina, an Amsier grid showing distortion or metamorphopsia, taking fundus photos, or a fluorescein angiogram to justify his course of treatment in the patient’s left eye.

During the treatment period, the ophthalmologist did not thoroughly discuss with the patient or document thoroughly discussing with the patient the option of cataract surgery alone versus cataract surgery with the ERM.

On 8/27/2015, the ophthalmologist performed a cataract removal and intraocular lens implantation on the patient’s right eye.

On 10/8/2015, the ophthalmologist performed a cataract removal and epiretinal membrane peel on the patient’s left eye.

During the treatment period, the ophthalmologist did not maintain medical records that justified an appropriate plan or treatment for the patient’s condition.

The Board judged the ophthalmologist’s conduct to be below the minimal standard of competence given that he failed to perform and document appropriate diagnostic and preoperative testing.  The ophthalmologist also failed to discuss with the patient the option of cataract surgery alone versus cataract surgery with the ERM.

It was requested that the Board order one or more of the following penalties for the ophthalmologist: 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: October 2017

Specialty: Ophthalmology

Symptom: Vision Problems

Diagnosis: Ocular Disease

Medical Error: Failure to order appropriate diagnostic test, Failure to examine or evaluate patient properly, Failure of communication with patient or patient relations, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

On 6/15/2012, a 47-year-old female presented to a family practitioner with multiple lesions on her back, chest, and arms.

The family practitioner informed the patient that the lesions on her left humerus, right upper abdomen, mid upper back, left anterior mid chest, lower back, right lower back, and/or right upper anterior chest were malignant and/or potentially malignant.

On 7/6/2012, the family practitioner documented that the patient had a history of keloid formation after surgical excision.

On 6/15/2012, the family practitioner excised a lesion on the patient’s left humerus.  The lesion excised from the patient’s left humerus measured approximately 3 mm by 3 mm.  The family practitioner made an excision 4 cm by 4 cm or sixteen square centimeters to excise the lesion on the patient’s left humerus.

On 6/19/2012, a dermatopathology report determined that the excision taken from the patient’s left humerus was not malignant or premalignant.

On 6/27/2012, the family practitioner excised a lesion on the patient’s right upper abdomen.  The lesion on the patient’s right upper abdomen measured 3 mm.   The family practitioner made an excision 7 cm by 6 cm, or forty-two square centimeters to excise the lesion on the patient’s right upper abdomen.

On 6/29/2012, a dermatopathology report determined that the excision taken from the patient’s right upper abdomen was not malignant or premalignant.

On 7/6/2012, the family practitioner excised a lesion the patient’s mid upper back.  The lesion on the patient’s back measured approximately 3 mm.   The family practitioner made an excision 5 cm by 7 cm, or thirty-five square centimeters to excise the lesion on the patient’s mid upper back.

On 7/13/2012, the family practitioner excised a lesion on the patient’s left anterior mid chest.  The lesion on the patient’s left anterior mid chest measured approximately 4 mm by 4 mm.
The family practitioner made an excision 8 cm by 6 cm or forty-eight square centimeters to excise the lesion on the patient’s left anterior mid chest. He referred the patient for radiation treatment to prevent keloid formation.

On 7/20/2012, a dermatopathology report determined that the excision taken from the patient’s left anterior mid chest was not malignant or premalignant.

On 8/3/2012, the family practitioner excised a lesion the patient’s left lower back.  The lesion on the patient’s left lower back measured 5 mm by 4 mm.  The family practitioner made an excision 9 cm by 7 cm or sixty-three square centimeters to excise the lesion on the patient’s left lower back.

On 8/7/2012, a dermatopathology report determined that the excision taken from the patient’s left lower back was not malignant or premalignant.

On 8/10/2012, the family practitioner excised a lesion on the patient’s right lower back.  The lesion on the patient’s right lower back measured 4 mm by 4 mm.  The family practitioner made an excision 9 cm by 8 cm or seventy-two square centimeters to excise the lesion on the patient’s right lower back.

On 8/14/2012, a dermatopathology report determined that the excision taken from the patient’s right lower back was not malignant or premalignant.

On 8/27/2012, the family practitioner excised a lesion on the patient’s right upper anterior chest.  The lesion on the patient’s right upper anterior chest measured 2 mm by 2 mm.   He made an excision 10 cm by 7 cm, or seventy square centimeters to excise the lesion on the patient’s right upper anterior chest.

On 8/29/2012 a dermatopathology report determined that the excision taken from the patient’s right upper anterior chest was not malignant or premalignant.

The Board judged that the family medicine practitioners conduct to be below the minimal standard of competence given that he failed to perform a complete and comprehensive physical examination of the patient’s lesions; adequately consider the characteristics of the lesions, including the size, color, regularity, and degree of pigmentation; refer the patient for consultation with a dermatologist; refrain from diagnosing the patient with malignant and/or potentially malignant lesions without having adequate justification; accurately and appropriately diagnose the patient’s condition; confirm that each of the lesions on the patient was malignant or premalignant prior to excising the lesion; perform a shave biopsy, punch biopsy, or limited excisional biopsy with 1 mm margins on each of the lesions on the patient to determine whether the lesion was malignant or premalignant; make an excision with margins no greater than 5 mm to excise each of the lesion on the patient; refrain from making an excision on the patient without having adequate justification; avoid potential keloid formation on the patient, by making the fewest and/or smallest excisions appropriate and/or justifiable.

The family practitioner agreed to voluntarily cease practicing medicine and agreed to never reapply for licensure as a medical doctor in the state of Florida.

State: Florida

Date: August 2017

Specialty: Family Medicine, Dermatology

Symptom: Dermatological Abnormality

Diagnosis: Dermatological Issues

Medical Error: Unnecessary or excessive treatment or surgery, Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Referral failure to hospital or specialist, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 1

Link to Original Case File: Download PDF