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Florida – Family Medicine – Treatment Of Elevated Blood Pressure And Headaches From Illicit Testosterone Injections
On 2/17/2014, a male patient in his early twenties presented to a family practitioner for medical assessment and/or treatment.
On 2/17/2014, the patient disclosed to the family practitioner that he was obtaining injectable testosterone from a source unknown to the family practitioner. The patient indicated that he was utilizing the testosterone for bodybuilding purposes.
On 2/17/2014, the patient reported to the family practitioner that he was suffering from headaches and elevated blood pressure.
On 2/17/2014, the family practitioner surmised that the patient’s symptoms were likely the result of excess estrogen production secondary to the patient’s high-dose testosterone use.
On 2/17/2014, the family practitioner wrote the patient a prescription for Anastrozole, an estrogen-blocking substance.
On 2/20/2014, the patient presented to the family practitioner for medical assessment and/or treatment. The family practitioner continued the patient on Anastrozole.
In February 2014, the family practitioner did not obtain or review any medical records establishing that the patient was experiencing excess estrogen production. He also did not obtain bloodwork or perform other diagnostic testing to confirm whether the patient was experiencing excess estrogen production.
On 4/6/2014, the patient presented to the family practitioner for medical assessment and/or treatment. The patient reported to the family practitioner that he was continuing to use testosterone, and that he was continuing to experience headaches. The family practitioner surmised that the patient’s ongoing headaches were caused by elevated prolactin levels. The family practitioner wrote the patient a prescription for Cabergoline, a prolactin-blocking substance.
On 4/10/2014, the patient presented to the family practitioner for medical assessment and/or treatment. The family practitioner continued the patient on Cabergoline.
In April 2014, the family practitioner did not obtain or review any medical records establishing that the patient was experiencing elevated prolactin levels. He did not obtain bloodwork or perform other diagnostic testing to confirm whether the patient was experiencing elevated prolactin levels.
On one or more occasions between 6/27/2014, and 1/9/2015, the family practitioner prescribed the following substances to the patient: clindamycin, Bactroban ointment, doxycycline, Zithromax, oral prednisone, Neurontin, and diazepam. On one or more occasions in 2015, the family practitioner also prescribed the patient Anastrozole.
The family practitioner did not keep any contemporaneous medical records regarding the medical assessment and/or treatment that he provided to the patient between 2/17/2014 and 1/9/2015.
To the extent that the family practitioner had medical records regarding the medical assessment and/or treatment that he provided to the patient between 2/17/2014 to 1/9/2015, such records were all created in October 2015.
The Medical Board of Florida issued a letter of concern against the family practitioner’s license. The Medical Board of Florida ordered that the family practitioner pay a fine of $8,000 and pay reimbursement costs for the case at a minimum of $1,457.57 and not to exceed $3,457.57. The Medical Board of Florida ordered that the family practitioner complete a drug course, a medical records course, and five hours of continuing medical education in “risk management.”
State: Florida
Date: December 2017
Specialty: Family Medicine, Endocrinology, Internal Medicine
Symptom: Headache
Diagnosis: Drug Overdose, Side Effects, or Withdrawal
Medical Error: Failure to order appropriate diagnostic test, Improper medication management, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 2
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 – Unnecessary Biopsies Performed When Lumps Are Noted on A Patient’s Breasts
Between December 2010 and August 2013, a patient presented to her gynecologist.
On 5/19/2011, the gynecologist found small, smooth, mobile lumps in the patient’s left and right breasts.
On 6/17/2011, the gynecologist performed a right breast biopsy on the patient. The gynecologist noted that the right breast lump was likely a fibroadenoma. The biopsied right breast tissue was found to be benign.
On 7/5/2011, the gynecologist performed a left breast biopsy on the patient. The gynecologist noted that the left breast lump was likely a fibroadenoma. The biopsided left breast tissue was found to be benign.
At all times, the patient was at a low risk for having breast cancer.
The Board judged the gynecologist’s conduct to be below the minimum standard of practice given that the prevailing professional standard of care required that the gynecologist medically manage the patient’s left and right breast lumps with breast exams, breast sonographies, and/or mammograms. The obstetrician’s performance of left and right breast biopsies on the patient was medically unnecessary.
The Board ordered that the gynecologist pay a fine of $16,000 against his license. Also, the Board ordered that the case fine be set at $9,486.57. The Board ordered that the gynecologist complete five hours of continuing medical education in “Risk Management.”
State: Florida
Date: December 2017
Specialty: Gynecology, Gynecology
Symptom: Mass (Breast Mass, Lump, etc.)
Diagnosis: N/A
Medical Error: Failure to order appropriate diagnostic test, Unnecessary or excessive treatment or surgery
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
Florida – Obstetrics – Lack Of Maternal Serum Alpha-Fetoprotein Testing With Pregnancy Complications
On 2/24/2014, a 36-year-old female presented to an obstetrician for fatigue, breast tenderness, and absence of menstruation. At the aforementioned visit, the obstetrician diagnosed the patient with amenorrhea and sent her to have blood work.
On 2/25/2014, the patient was notified of her positive pregnancy test.
On 3/10/2014, 3/17/2014, 3/24/2014. 4/24/2014, 8/7/2014, and 9/25/2015, the obstetrician ordered obstetrical ultrasounds and/or sonograms for the patient.
On 4/23/2014 and 8/20/2014, the patient presented to the obstetrician with thick vaginal fluid and blood discharge, morning sickness, nausea, chills, fever, and back pain.
On 5/23/2014, 6/20/2014, 7/16/2014, 8/15/2014, 9/12/2014, 10/13/2014, 10/20/2014, and 10/27/2014, the patient presented to the obstetrician for follow-up visits.
On 11/2/2014, the patient gave birth to her son, who was born with spina bifida/myelomeningocele.
The obstetrician failed to diagnose neural tube defect on imaging studies.
The obstetrician failed to order a maternal serum alpha-fetoprotein (MSAFP) test and did not maintain adequate legible documentation of ordering an MSAFP test.
The obstetrician failed to order an anatomical survey sonogram.
The Board ordered that the obstetrician pay a fine of $7000 against his license. The Board ordered that the obstetrician pay reimbursements costs of a minimum of $3,786.18 and not to exceed $5,786.18. The Board also ordered that the obstetrician complete a course on “Quality Medical Record Keeping for Health Care Professionals” and that he complete five hours of continuing medical education on “Risk Management.”
State: Florida
Date: December 2017
Specialty: Obstetrics
Symptom: Fever, Bleeding, Nausea Or Vomiting, Back Pain
Diagnosis: Obstetrical Complication, Spinal Injury Or Disorder
Medical Error: Failure to order appropriate diagnostic test, Failure to follow up, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
California – Obstetrics – Induction For A Patient With A Bishop Score Of 4 And Continued Pitocin Use Despite Fetal Heart Tracing Abnormalities
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
Florida – Radiology – Mammogram And Ultrasound Of Breast Mass Interpreted As A Cyst
On 6/30/2011, a 50-year-old female presented to a breast center for a bilateral digital diagnostic mammogram with computer-aided detection and right breast ultrasound (“mammogram and ultrasound”) for a palpable abnormality (“mass”).
On 6/30/2011, a radiologist interpreted the mammogram and ultrasound in her final report as follows: “[T]here has been no interval change in the appearance of the breasts with no evidence for malignancy. At the 7 o’clock position, 7 cm away from the nipple, correlating to the [mass] is a simple cyst….”
The radiologist recommended “[M]ammography and yearly physical examination per ACS guidelines, supplemented with monthly self-examination, If clinically indicated, the cyst could be aspirated.” At no time did the radiologist recommend a biopsy of the mass.
The radiologist rated the mammogram as a BI-RADS Category II, “[B]enign.” A correct interpretation of the mass would have indicated that it had lobular and angular margins, and increased through transmission. The mammogram should have been rated BI-RADS category V, “[H]ighly suspicious: [A]ppropriate action should be taken.” The radiologist should have recommended a biopsy of the mass.
On 1/23/2012, the patient was advised by a subsequent treating physician that she had invasive ductal carcinoma, Stage III.
The Board judged the radiologist’s conduct to be below the minimum standard of competence given her failure to correctly interpret the mammogram and ultrasound and recommend a biopsy of the mass.
The Board ordered that the radiologist pay a fine of $6,500 against her license and that the radiologist pay a reimbursement cost to the case of a minimum of $2,924.06 but not to exceed $4,924.06. The Board ordered that the radiologist complete ten hours of continuing medical education in identification and diagnosis of malignancies with a focus on interpretation of breast imaging studies.
State: Florida
Date: November 2017
Specialty: Radiology
Symptom: N/A
Diagnosis: Breast Cancer
Medical Error: False negative, Failure to order appropriate diagnostic test
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Emergency Medicine – Sharp Chest Pain After Intercourse
On 4/4/2015, a 47-year-old male presented to the emergency department with sharp chest pain after intercourse.
The RN on duty noted taking the patient’s vitals and performing an EKG, chest radiograph, and labs.
In his physician note, the ED physician documented the following: the patient did not take his medication for hypertension or dyslipidemia despite having a history of hypertension and homelessness; the patient reported a history of coronary artery disease and possible coronary artery stent placement; and the patient reported chest discomfort and dyspnea for the week prior to presentation as well as a history of tobacco use.
The ED physician recorded a differential diagnosis including acute myocardial infarction, non-ST segment elevation myocardial infarction (“NSTEMI”), angina, and acute coronary syndrome.
The ED physician did not diagnose the patient with possible cardiac etiology of chest discomfort. He also did not contact the on-call cardiologist. The ED physician did not perform provocative testing or cardiac catheterization. He also did not admit the patient for hospitalization and cardiology consultation. The ED physician discharged the patient without requiring any further evaluation/treatment or serial EKG/troponin. He did not arrange for close outpatient follow-up prior to discharge.
The Board issued a letter of concern against the ED physician’s license and ordered that he pay a fine, reimburse costs for the proceedings, and complete 5 hours of continuing education in risk management.
State: Florida
Date: November 2017
Specialty: Emergency Medicine
Symptom: Chest Pain
Diagnosis: Cardiovascular Disease
Medical Error: Failure to order appropriate diagnostic test, Referral failure to hospital or specialist, Failure to follow up
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
Florida – Family Medicine – Recurrent Chest Pain Diagnosed As Esophageal Spasm
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
Florida – Internal Medicine – Failure To Justify Suboxone Prescribing Practices
From 7/8/2011 to 8/13/2015, an internist treated a 37-year-old female with an opioid dependency for seven years with Suboxone therapy. During the treatment period, the internist prescribed the controlled substance Suboxone to the patient on one or more occasions. During the treatment period, the internist failed to substantiate, by test or positive exam, the patient’s history of opiate use to justify the use of Suboxone.
During the treatment period, the internist did not obtain a history of substance abuse, including illicit substances, or a complete medical history from the patient’s prior healthcare provider to support his diagnosis of opioid dependence and opiate withdrawal.
During the treatment period, the internist inappropriately diagnosed the patient, as his physical examination of the patient failed to indicate clinical opiate withdrawal symptoms, to help support his diagnosis of continuous opioid dependence and opiate withdrawal.
During the treatment period, the internist failed to perform tests, including screening for hepatitis B and C, complete metabolic panel, and complete blood count, to completely assess the patient’s condition.
During the treatment period, the internist failed to completely and accurately maintain medical records that justify Suboxone therapy as a proper course of treatment.
During the treatment period, the internist failed to document a clear treatment plan and time frame for detoxification, and/or thoroughly educate the patient about additional recovery.
During the treatment period, the internist failed to perform and/or maintain records of frequent urine toxicology for the patient to prevent noncompliance, dependence, addition, or diversion of controlled substances.
During the treatment period, the internist failed to document, incorporate in the medical records, or comment on all urine toxicology screens performed on the patient on one or more occasions.
During the treatment period, the internist failed to include all logs of prescriptions within his electronic medical record (“EMR”).
During the treatment period, the internist did not pursue, or document pursuing, psychological counseling, prescription drug monitoring (“PDMP”) and follow-up urine toxicology screens to guide optimal therapy.
It was requested that the Board order one or more of the following penalties for the internist: 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: Internal Medicine
Symptom: N/A
Diagnosis: Drug Overdose, Side Effects, or Withdrawal
Medical Error: Failure to properly monitor patient, Failure to order appropriate diagnostic test, Failure of communication with patient or patient relations, Improper medication management, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
Florida – Ophthalmology – Lack Of Diagnostic And Preoperative Testing To Assess An Epiretinal Membrane
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