Found 248 Results Sorted by Case Date
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Florida – Internal Medicine – Use Of Diltiazem In A Tachycardic And Hypotensive Patient



On 2/20/2012, a 31-year-old female presented to the medical emergency department with abdominal pain and shortness of breath.

On 2/20/2012 at 2:06 p.m., the patient had a blood pressure of 147/81 and a heart rate of 165 beats per minute.  At 2:52 p.m., the patient had a heart rate of 153 beats per minute.  At 3:24 p.m., the patient had a blood pressure of 94/40 and a heart rate of 132 beats per minute.  At 4:08 p.m., the patient had a heart rate of 157 beats per minute.  At 6:04 p.m., the patient had a blood pressure of 98/50 and a heart rate of 145 beats per minute.

From 2:06 p.m. until 6:04 p.m., the patient was sinus tachycardic and hypotensive.

At 6:52 p.m., an internal medicine practitioner on the unit was advised of the patient’s consistent elevated heart rate.  From 6:52 p.m., the internist was the physician treating the patient.

At 7:00 p.m., the internist ordered the administration of 10 mg of diltiazem to the patient one time, over two minutes.

At 7:10 p.m., the patient had a palpated systolic pressure of 80 and a heart rate of 125 beats per minute.  The patient’s medical records indicated that due to the patient’s low blood pressure, 5 mg of diltiazem was administered over five minutes.

Diltiazem is not indicated for the treatment of sinus tachycardia. Diltiazem is contraindicated in the setting of hypotension. Diltiazem is contraindicated in the setting of hypotension and sinus tachycardia.

The patient’s medical records include a correction that indicates that additional vital signs were obtained at 6:43 on 2/20/2012.  According to that record, the patient had a blood pressure of 186/76 and a heart rate of 82 beats per minute.

Diltiazem is not indicated for a patient with a blood pressure of 186/76 and a heart rate of 82 beats per minute.

Ultimately, the patient died after a hospitalization lasting 4 weeks.  A lawsuit was filed alleging the patient was not transferred to an ICU in a timely fashion.  There were no ICU beds available at the hospital where she had been treated.  The suit alleged the hospital should have transferred the patient to another hospital with an available ICU bed.

In the lawsuit, it was noted that the patient had developed diabetic ketoacidosis, severe metabolic acidosis, and pancreatitis.  After she was administered the doses of diltiazem mentioned above, she went into cardiac arrest before transfer to an ICU.  It was noted that the patient was held in the emergency department from the time of her arrival at 1:52 p.m. until her transfer at 12:10 a.m. the following day (for a total of over 10 hours).  On 3/18/2012, she died.

The Board judged the internists conduct to be below the minimal standard of competence given that he ordered the administration of diltiazem to a patient when diltiazem was not indicated and/or was contraindicated.

The Board issued a letter of concern against the internist’s license.  The Board ordered that the internist pay an administrative fine of $5,000 against his license and pay reimbursement costs for the case for $10,000.  The Board also ordered that the internist complete ten hours of continuing medical education in “internal medicine” and five hours of continuing medical education in “risk management.”

State: Florida


Date: June 2017


Specialty: Internal Medicine, Emergency Medicine, Endocrinology


Symptom: Palpitations, Abdominal Pain


Diagnosis: Cardiovascular Disease


Medical Error: Improper medication management


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Florida – Family Medicine – Failure Of Pain Management In A Patient With Cervical Discogenic Disease, Lumbar Discogenic Disease, And Myofascial Pain Syndrome



From 8/11/2011 to 8/12/2013, a family practitioner treated a 48-year-old female, with a prior history and diagnosis of cervical discogenic disease, lumbar discogenic disease, and myofascial pain syndrome.

During the treatment period, the family practitioner carried these diagnoses from the patient’s prior healthcare provider without obtaining, or did not document obtaining, a complete medical history and/or physical examination for the patient to support these diagnoses.

The family practitioner did not perform, or did not document performing, diagnostic testing and imaging studies, such as MRIs, x-rays, and CT scans of the cervical spine and/or lumbar spine in support of the continued diagnosis of cervical discogenic disease, lumbar discogenic disease, and myofascial pain syndrome for the patient.

The family practitioner prescribed the controlled substances Duragesic, Roxicodone, and Xanax to the patient on one or more occasions.  He did not obtain, or document obtaining a history of substance abuse including illicit substances from the patient before prescribing Duragesic, Roxicodone, and Xanax.

The family practitioner did not adequately assess the patient’s complaints and symptoms.  He did not document the nature and intensity of the patient’s pain, current and past treatments of the pain, as well as any underlying or coexisting disease or conditions that affected the pain on the physical and psychological function of the patient.  He also did not perform a complete physical examination specific to the areas of the patient’s complaints.  The family practitioner did not document the location, duration, frequency or character of the patient’s pain, including alleviating and/or aggravating symptoms.

The family practitioner did not maintain complete and accurate records of the patient’s medical history, physical examinations, diagnostic therapeutic testing, evaluations, consultations, treatment objectives and/or treatments.  He did not evaluate, or document evaluating the effectiveness of his treatment plan for the patient.

The family practitioner did not adequately monitor the patient’s medication use to prevent noncompliance, dependence, addiction, or diversion of controlled substances.

The family practitioner failed to maintain thorough and accurate records which would have helped identify the patient as a violator of the controlled substance program, and at being high risk for diversion of pain medication and controlled substances.  He also did not perform, or document performing, frequent urine drug screenings for the patient after she violated the terms of the controlled substances contract on one or more occasions.

The family practitioner did not refer, or document referring, the patient to a pain management physician for proper evaluation after she violated the terms of the controlled substance contract on one or more occasions.

On 4/12/2013, the family practitioner wrote the patient prescriptions for Duragesic, Roxicodone, and Xanax without having evaluated, and/or documented seeing or evaluating the patient.  The patient died from an overdose.  An autopsy performed on the patient revealed the case of death as “fentanyl toxicity.”

The Board judged the family practitioners conduct to be below the minimal standard of competence given that he failed to obtain a complete medical history and/or physical examination from the patient’s prior healthcare provider(s) to support his diagnoses of cervical discogenic disease, lumbar discogenic disease, and myofascial pain syndrome.  He also failed to perform additional diagnostic testing such as MRIs, x-rays, and CT scans, of the patient cervical spine and/or lumbar spine to support the history, physical examination, and the patient’s prior diagnosis of cervical discogenic disease, lumbar discogenic disease, and myofascial pain syndrome.  He failed to obtain a history of substance abuse, including illicit substances before prescribing Duragesic, Roxicodone, Xanax on one or more occasions.  The family practitioner did not assess the patient’s complaints and symptoms and perform a complete physical examination specific to the areas of the complaint.  He did not perform a physical examination to support his treatment and evaluate the effectiveness of his treatment plan for the patient.  The family practitioner should have written prescriptions for the patient only after seeing and evaluating her.  He also should have adequately monitored the patient’s medication use to prevent noncompliance, dependence, addiction, or diversion of controlled substances and perform frequent urine drug screens for the patient after she violated the terms of the controlled substances contract on one or more occasions. He should have referred the patient to a pain management physician for proper evaluation after the patient violated the terms of the controlled substance contract on one or more occasions.

It was requested that the Board order one or more of the following penalties for the family practitioner: 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: June 2017


Specialty: Family Medicine, Internal Medicine


Symptom: Pain


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


Medical Error: Improper medication management, Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Referral failure to hospital or specialist, Failure to properly monitor patient, Lack of proper documentation


Significant Outcome: Death


Case Rating: 2


Link to Original Case File: Download PDF



California – Obstetrics – Disregarding Patient’s Desire For Cesarean Section And Concerning Fetal Heart Rate Tracings



On 8/27/2010, a patient came under an obstetrician’s care and treatment for prenatal and obstetric care.  The patient, a 41-year-old Spanish-speaking primigravida in the third trimester of pregnancy, had not been receiving prenatal care prior to August 2010.

Previously, on 8/10/2010, she had been seen at the hospital for complaints of decreased fetal movement and was discharged after being reassured of fetal well-being by an ultrasound examination.  She had also returned to the hospital on 8/24/2010 and was discharged with a diagnosis of early latent labor and instructions to establish care with an obstetrician.  At her initial visit with the obstetrician, an estimated delivery date of 9/21/2010 was established by a third trimester ultrasound.  The patient was examined and given instructions on counting fetal kicks and labor precautions and was given an order for laboratory tests.

On 8/30/2010, the patient returned with complaints of pelvic pressure.  Her cervix was closed but 50% effaced and the fetal head had descended from -3 position to -1.  Although it is not documented in the obstetrician’s chart, the patient and her partner reported that they had advised the obstetrician of the patient’s desire for delivery by Cesarean section when the time came.  The patient was told to return in one week.

On 9/4/2010, the patient presented to the hospital in spontaneous labor.  She stated that contractions had started at approximately 4:00 a.m.  At 11:30 a.m., the cervix was approximately 6 cm dilated, 100% effaced, with the vertex at -2 station.  The patient was admitted by another physician, who contacted the obstetrician to take over intrapartum management.

The obstetrician arrived and assumed responsibility for the care and labor management of the patient.  In the obstetrician’s note timed 2:00 p.m., she recorded a fetal heart rate (“FHR”) of 145 beats per minute (“bpm”), with moderate variability and no decelerations.  The obstetrician noted that excellent progress in labor had been made and she anticipated a spontaneous delivery.

The obstetrician’s next note is timed at 4:30 p.m. and states that the patient had an epidural placed and was comfortable.  The FHR was reported as 145 bpm with moderate variability and accelerations and the fetal tracings were, overall, consistent with a classification of Category I, i.e., with no specific action required.  Contractions were 2-3 minutes apart.  The cervical exam was anterior lip, 100% effaced, zero station.  In her progress note timed 4:30 p.m. – albeit the obstetrician indicated that the labor was progressing well – the obstetrician documented her plan for oxytocin augmentation of labor.

The patient began pushing at approximately 5:00 p.m., with contractions coming every 1-2 minutes, at which time the obstetrician found the cervix to be complete with the head at zero to +1 station.  At this point, the tracing showed moderate variability, but recurrent variable decelerations with contractions and pushing effort.  This was consistent with Category II, i.e., requiring evaluation, continued surveillance, reevaluation and possibly ancillary tests to assure fetal well-being.  Oxytocin was increased to 6 mU/min.  During the approximate period of 5:00 p.m. to 5:40 p.m., the patient was pushing while the obstetrician coached her in Spanish.  By approximately 5:30 p.m., the fetal heart rate baseline became tachycardic and the variable decelerations more deep and prolonged.  A nurse who was present at the time noted that there were multiple late and variable decelerations and she advised the obstetrician of this.  Although it is not charted, the nurse recalled that the patient repeatedly stated that she wanted a Cesarean section, but that the obstetrician urged her to continue pushing.

At approximately 5:40 p.m., the obstetrician was called away to attend a delivery for another patient whose obstetrician was still en route to the hospital.  According to her notes, she returned at approximately 6:20 p.m.  The fetal heart tracing progressively worsened, with continued tachycardia and gradual loss of variability until, at approximately 6:40 p.m., variability is absent from the tracing.  At this point in time, the fetal heart tracing was consistent with Category III, i.e., associated with abnormal fetal acid-base status, requiring immediate evaluation, expeditious efforts to resolve the abnormal FHR pattern and, failing resolution, expedited delivery.

At 7:00 p.m., the obstetrician noted that the FHR decreased “to 60’s” for 5-6 minutes.  At that time, the obstetrician reported that she was advised there was not an available operating room, so she instructed the patient to stop pushing and had the patient change positions.  The obstetrician discontinued the oxytocin at 7:02 p.m. and terbutaline was administered at approximately 7:12 p.m.  Despite these efforts to improve the fetal status, the FHR did not improve to the point that it could be considered reassuring.

The patient was moved to the operating room at about 7:22 p.m. and arrived at 7:25 p.m.  She consented in Spanish to a vacuum-assisted delivery, with the possibility of Cesarean section.  Two attempts with the Mityvac, each approximately 20 seconds, were made at 7:34 p.m. and 7:35 p.m. without fetal descent.  The anesthesiologist arrived at about the time of the second attempt.  A Cesarean section was called by the obstetrician at 7:37 p.m.  The incision was made at 7:45 p.m. and the infant delivered at 7:47 p.m.  The obstetrician described the infant as having poor tone and pale color after delivery.  The anesthesiology note states that the infant was not crying and was not breathing.  An emergency intubation was performed, and the infant was taken to the newborn intensive care unit (“NICU”).  Apgar scores were 2, 3, and 5.

The Board judged the obstetrician’s conduct as having fallen below the standard of care for the following reasons:

1) The obstetrician failed to recognize non-reassuring fetal heart tracings consistent with abnormal fetal acid-base status.

2) The obstetrician failed to undertake appropriate steps to expedite delivery in the circumstance of Category III fetal heart tracing that had not resolved despite steps to improve fetal status.

3) The obstetrician prescribed oxytocin when the labor pattern was adequate and continued administration after the fetal heart tracing had developed to a Category III.

4) The obstetrician failed to perform a Cesarean section in response to the patient’s request and the non-reassuring fetal testing in the second stage of labor.

The Board issued a public reprimand against the obstetrician with stipulations to complete a clinical competence assessment program.

State: California


Date: June 2017


Specialty: Obstetrics


Symptom: N/A


Diagnosis: Obstetrical Complication


Medical Error: Procedural error, Diagnostic error, Improper medication management


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Anesthesiology – Anesthesia Procedural Errors During Elective Right Carotid Endarterectomy



On 5/6/2014, a patient was scheduled for an elective right carotid endarterectomy procedure with her vascular surgeon.  An anesthesiologist was assigned to the surgery and was proctored by another anesthesiologist throughout the procedure. The anesthesiologist wrote his pre-operative note at 11:10 a.m.  The note included the patient’s admitting vital signs and past history, which included a recent stroke and that she was a former smoker. His note listed her most recent labwork. The anesthesiologist did not include the patient’s pre-operative Doppler studies or her recent ECG.  The anesthesiologist noted that the patient had a prior Cesarean section, but listed her prior anesthetics as “none.” The anesthesiologist did not perform an exam of her heart or lungs, and he noted that he discussed a risk of nausea.

The anesthesiologist placed a right radial 22-gauge arterial line with local anesthetic prior to the patient being moved to the operating room.  He connected the patient to the proper monitoring machines. The anesthesiologist began anesthesia at 11:36 a.m. He provided 1 mg of midazolam, 5 mg of rocuronium, 40 mg of lidocaine, 40 mg of propofol, and incremental doses of 50 mcg x2 fentanyl.  He also administered sevoflurane and oxygen. The anesthesiologist then administered an additional dose of rocuronium and easily intubated the patient. The anesthesiologist began a phenylephrine infusion of 200 mcg/hr. At 11:45 a.m., the patient’s vital signs were recorded from the arterial line reading 130/55 and from the left cuff measuring 90/55 with pulse of 55.  During intubation, the patient’s blood pressure rose to 135/65 with a pulse of 60. The phenylephrine infusion was increased to 1000 mcg/hr and then decreased to 800 mcg/hr prior to the surgical incision at 12:17 p.m.

Systolic blood pressure prior to incision was 180 and charted at 150/110 shortly thereafter.  Pulse rose from 58 bpm to 75 bpm. Heparin, 5000 units, was administered at 12:22 p.m. prior to surgical cross camp at 12:33 p.m.  During the cross-clamp period, anesthesia was maintained. The cross clamp was removed at 1:11 p.m. The phenylephrine infusion was continued until approximately 1:15 p.m.  Blood pressure during the cross-clamp period ranged between 145/70 and 170/60. At 1:15 p.m., the patient’s blood pressure was 200/60 with a pulse of 70 bpm. The anesthesiologist administered ondansetron at 1:15 p.m.  At 1:30 p.m., he administered 10 mg of hydralazine and 30 mg of esmolol. He provided another 40 mg dose of esmolol shortly thereafter. Surgery ended at 1:37 p.m. The anesthesiologist’s post-operative note, written the following morning, showed that the patient was essentially stable, and she was released home the following day.

The Medical Board of California judged that the anesthesiologist departed from the standard of care because he failed to mention the patient’s prior ECG or Doppler studies in his pre-operative note.  The anesthesiologist did not ask her about a prior history of chest pain or exercise intolerance during his pre-operative evaluation, did not list the type of prior anesthetic that she had received in her prior surgery in his pre-operative note, did not review the degree of patency or stenosis that the non-operative side would provide cerebral blood through the Circle of Willis, did not inform the patient that there would be a small, but not uncommon, risk of stroke, heart attack, or death, and did not examine or document a heart of lung exam of the patient during his pre-operative examination.  He also failed to anticipate the patient’s hemodynamic changes related to surgical incision and cross-clamping and unclamping during surgery. When the anesthesiologist did respond to hemodynamic changes, he provided inadequate responses and prolonged response times. The anesthesiologist failed to adequately reflect the wide variations in the monitored vital signs in his clinical chart and failed to terminate the phenylephrine infusion following removal of the cross-clamp despite the patient’s hypertension. The anesthesiologist failed to promptly adjust the mechanical ventilator after intubation and failed to proactively anticipate blood pressure increases and decreases in response to carotid de-clamping.

The Medical Board of California placed the anesthesiologist on probation for 4 years and ordered him to complete a medical record-keeping course, an education course for at least 20 hours for the first 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.

State: California


Date: May 2017


Specialty: Anesthesiology


Symptom: N/A


Diagnosis: Cardiovascular Disease


Medical Error: Failure to examine or evaluate patient properly, Failure of communication with patient or patient relations, Delay in proper treatment, Improper medication management, Lack of proper documentation, Procedural error


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Pediatrics – Long Term Regimen Of Compounded Dexamethasone Cough Syrup For Pneumonia And Asthma



On 1/13/2015, a pediatrician saw a child just short of her second birthday.  She had been diagnosed with asthma and was maintained on corticosteroid and albuterol inhalers.  The patient presented with fever, coughing, and loss of appetite.  Although she had taken an antibiotic prior to this visit, it is not noted in the pediatrician’s chart notes.  The pediatrician diagnosed pneumonia, laryngotracheobronchitis (croup), and asthma and prescribed a different antibiotic for her.

The pediatrician stated that she followed up with the patient by telephone on 1/14/2015 and 1/15/2015.  Based on these follow-up calls, the pediatrician prescribed compounded cough syrup at a daily dose containing 0.55 mg dexamethasone, a corticosteroid.  She prescribed a sufficient amount of the medication to last a month and when the patient’s mother said that she was afraid that the patient would begin to cough again because her entire family had caught the cold, the pediatrician called in a partial refill for the medication.  None of this information was included in the pediatrician’s chart notes for the patient.

The pediatrician’s chart notes for the patient’s follow-up visits on 1/20/2015 and 2/20/2015 did not make reference to the compounded cough medication, instructions on how to take the medication, or to the advice she gave the patient’s mother concerning weaning the patient off the medication.  Although the pediatrician stated that she was concerned about the patient’s reduced “immunity” and recommended an over the counter immune pediatric supplement for the patient on 2/20/2015, this concern was not documented in the patient’s chart notes.

The Board judged the pediatrician’s conduct to have fallen below the standard of care given failure to appropriately prescribe dexamethasone to the patient and given failure to document the follow-up telephone calls, the fact that she had prescribed the compounded cough medication to the patient, instructions for the patient to wean off the dexamethasone, concern for the patient’s reduced “immunity,” and the fact that the patient had taken antibiotics prior to her first visit with the patient.

A public reprimand was issued against the patient with stipulations to take a medical record keeping course.

State: California


Date: May 2017


Specialty: Pediatrics


Symptom: Cough, Fever


Diagnosis: Pneumonia, Asthma


Medical Error: Improper medication management, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Anesthesiology – Improper Dosing Of Epinephrine And Atropine For Bradycardic Patient During Anesthesia For Colonoscopy



On 8/7/2015, a 51-year-old male presented to a surgical center for an outpatient esophagogastroduodenoscopy (EGD) and colonoscopy.

The patient had a history of bipolar disease, schizophrenia, obstructive sleep apnea on continuous positive airway pressure (CPAP), smoking, and morbid obesity.

The patient underwent EGD and colonoscopy via monitored anesthesia care with intravenous propofol.

During the patient’s colonoscopy, he became bradycardic, was mask ventilated, turned supine, and was given atropine, ephedrine, and epinephrine.

Specifically, the patient received two doses of 0.2 mg of epinephrine ten minutes apart.  These doses of epinephrine are not standard advanced cardiovascular life support (ACLS) resuscitation doses for a cardiac arrest.

The patient also received a 0.2 mg dose of atropine followed by a 0.4 mg dose.  The doses of atropine were inadequate for the patient’s size and considering that the patient was experiencing a bradycardic event.

The patient subsequently received cardiopulmonary resuscitation (CPR) and was transferred to a hospital for emergent care.  Shortly after arriving at the hospital, the patient passed away.

Prior to performing the procedures, the anesthesiologist failed to document a complete preoperative history and physical examination for the patient.

During the intraoperative course, the anesthesiologist failed to utilize and/or failed to document utilizing end-tidal CO2 (ETCO2) monitoring usage.

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: May 2017


Specialty: Anesthesiology


Symptom: N/A


Diagnosis: Post-operative/Operative Complication, Cardiac Arrhythmia


Medical Error: Improper medication management, Failure to examine or evaluate patient properly, Failure to properly monitor patient, Lack of proper documentation


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Plastic Surgery – Liposuction Performed On A Patient With Obesity, Diabetes, Hypertension, Asthma, And Human Immunodeficiency Virus



On 1/11/2013, a 50-year-old male presented to a plastic surgeon and underwent liposuction of his chin, upper abdomen, lower abdomen, upper back, and lower back/flanks.

The patient’s medical history included obesity, diabetes, hypertension, asthma, and human immunodeficiency virus (HIV) positive status.

Due to his medical history, the patient was at high risk of complications from the liposuction procedure.

Due to the high risk of complications, the patient was not a candidate for liposuction surgery.

During the liposuction procedure, the plastic surgeon injected tumescent wetting solution into the patient.  The tumescent liposuction technique, as opposed to “dry liposuction,” involves injection of tumescent wetting solution into a patient’s fatty deposits to reduce the amount of blood lost during the procedure.

The standard concentration of tumescent wetting solution used for liposuction is approximately one part epinephrine per 1 million units.  The tumescent wetting solution that the patient injected into the patient did not contain any epinephrine.

During the liposuction procedure, the plastic surgeon perforated the patient’s abdominal cavity and bowel.

On 1/16/2013, the patient presented to the medical center emergency department with complaints of abdominal pain, nausea, and vomiting.

Evaluation revealed that the patient was septic, in acute renal failure, and had free air in his abdomen.

The patient underwent emergent exploratory laparotomy which revealed multiple small bowel perforations, peritonitis, a mesenteric tear, pelvic abscess, and necrotizing fasciitis on the anterior abdominal wall.

The patient underwent release of a small bowel obstruction, small bowel resection, repair of the mesenteric defect, drainage of the pelvic abscess, and radical debridement of the necrotizing fasciitis.

The Medical Board of Florida judged that the plastic surgeon failed to avoid performing the liposuction procedure due to the high risk of complications posed by his medical history.  He failed to use epinephrine in the tumescent wetting solution used for the liposuction procedure.  He also failed to avoid perforating the abdominal cavity and bowel.

The Medical Board of Florida issued a letter of concern against the plastic surgeon’s license.  The Medical Board of Florida ordered that the plastic surgeon pay a fine of $5,000 against his license and pay reimbursement costs for the case at a minimum of $3,090.60 but not to exceed $5,090.60.  The Medical Board of Florida also ordered that the plastic surgeon complete five hours of continuing medical education in the area of “Tumescent Liposuction” and five hours of continuing medical education in “risk management.”

State: Florida


Date: May 2017


Specialty: Plastic Surgery


Symptom: Abdominal Pain, Nausea Or Vomiting


Diagnosis: Procedural Site Infection, Acute Abdomen, Necrotizing Fasciitis, Post-operative/Operative Complication


Medical Error: Unnecessary or excessive treatment or surgery, Improper medication management, Procedural error


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Arizona – Internal Medicine – Managing A Patient Using Alternative Medicine As Opposed To Allopathic Medicine



In November 2009, an 87-year-old man, who was Physician A’s family member, began seeing Physician A for hypotension, autonomic dysfunction syndrome, osteoarthritis, hypothyroidism, and “hormonal imbalance.”  Physician A prescribed over-the-counter herbs and supplements, prescription strength hormonal replacement therapy, and acupuncture treatments.

On 02/20/2011, the patient suffered a right frontal hemorrhagic stroke with residual left hemiplegia. Physician A took the patient to the hospital after 12 hours of initial symptoms.  Physician A said that no neurologist was available at the local hospital and the weather made it hazardous for him to drive at that time.

On 09/22/2014, an osteopathic provider Physician B saw the patient.  He advised that the patient take his blood pressure medications on a regular basis as opposed to as needed as recommended by the Physician A.  Physician B recommended albuterol for dyspnea and a follow up spirometry.  He also recommended tamsulosin in addition to saw palmetto for benign prostatic hypertrophy.

In August 2016, Physician A was removed as the patient’s primary medical provider.

The Board judged Physician A’s conduct to be below the minimum standard of competence given failure to obtain written consent regarding the treatment plan, which involved over-the counter medicines, herbs, and an absence of allopathic treatment.

Physician A did not monitor the patient’s TSH.  He prescribed magnesium when the patient had chronic kidney disease and did not monitor the patient’s magnesium levels.  He prescribed iron supplements when there was no documentation that the patient suffered from iron deficiency.  He prescribed Natto and other supplements which had blood thinning effects and could have lead to the hemorrhagic stroke along with uncontrolled hypertension.

He prescribed testosterone when the patient had an elevated PSA level and uncontrolled hypertension.

The Board issued a Decree of Censure and placed Physician A on probation for 1 year.  He was ordered to complete the Professional/Problem-Based Ethics program offered by the Center of Personalized Education for Physicians for Ethics and Boundaries.

State: Arizona


Date: May 2017


Specialty: Internal Medicine


Symptom: N/A


Diagnosis: Intracranial Hemorrhage


Medical Error: Improper medication management, Failure to properly monitor patient


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Internal Medicine – Tissue Plasminogen Activator Administered To A Patient With A History Of Intracranial Hemorrhage



On 3/12/2014, a 78-year-old male presented to the medical center.  Upon admission, a brain CT revealed a history of intracranial hemorrhage.

On 3/15/2014, a stroke alert was called due to the belief that the patient had suffered a stroke, setting in motion a hospital protocol to check for stroke.

A stat CT scan revealed subacute or chronic left suboccipital stroke, which did not correspond with the patient’s acute symptoms.

An internist ordered a neuro consult and gave a history that did not include intracranial hemorrhage.  He ordered and confirmed tissue plasminogen activator (“tPA”) to be administered to the patient, which is contraindicated for patients with a history of intracranial hemorrhage.  He did not obtain an MRI of the brain.

The Medical Board of Florida judged the internists conduct to be below the minimal standard of competence given that he did not order an MRI of the brain since symptoms and the stat CT did not correspond.  He ordered tPA for a patient with a history of intracranial hemorrhage.  He also failed to give an accurate history of intracranial hemorrhage to the neurologist.

It was requested that the Medical Board of Florida 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 Medical Board of Florida deemed appropriate.

State: Florida


Date: April 2017


Specialty: Internal Medicine, Neurology


Symptom: N/A


Diagnosis: Neurological Disease


Medical Error: Improper medication management, Failure to order appropriate diagnostic test, Failure of communication with other providers


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Emergency Medicine – Pelvic Pain And Vaginal Bleeding With Urinalysis Revealing A Glucose Level >1000



On 8/21/2014, a patient presented with complaints of pelvic pain and vaginal bleeding.  The patient was examined by a physician assistant supervised by an ED physician.

The physician assistant ordered laboratory evaluation for the patient, which included bloodwork, cervical/vaginal swabs, pelvic ultrasound, and urinalysis.

The urinalysis revealed the patient’s glucose level to be >1000, which was so high that it could not be measured.

The physician assistant gave the patient a prescription for Flagyl, an antibiotic, gave her education materials on uterine bleeding, bacterial vaginosis, dehydration, and ovarian cysts, and instructed her to follow up with her primary care physician and gynecologist.   The physician assistant discussed the patient’s case with the ED physician and the ED physician agreed with the plan of care.

The ED physician did not perform or order a finger stick glucose test or a basic metabolic panel.

The ED physician did not discuss and/or did not order the physician assistant to discuss the patient’s glucose level in relation to her possible new onset of diabetes and did not recommend or order the physician assistant to recommend further evaluation and treatment of her elevated glucose levels.

The ED physician did not administer or order the administration of intravenous fluid and insulin.

On 8/26/2014, the patient expired due to diabetic ketoacidosis.

The Medical Board of Florida judged the ED physician’s conduct to be below the minimal standard of competence give that she failed to administer or order the administration of a finger stick glucose test or basic metabolic panel, discuss or instruct the physician assistant to discuss the patient’s glucose levels in relation to her possible new onset of diabetes and recommend further evaluation and/or treatment of her elevated glucose levels, and failed to administer or order the administration of intravenous fluid and insulin.

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 her license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Medical Board of Florida deemed appropriate.

State: Florida


Date: April 2017


Specialty: Emergency Medicine, Endocrinology, Physician Assistant


Symptom: Pelvic/Groin Pain, Abnormal Vaginal Bleeding


Diagnosis: Diabetes


Medical Error: Failure to follow up, Failure to order appropriate diagnostic test, Failure of communication with other providers, Improper supervision, Improper medication management


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



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