Found 29 Results Sorted by Case Date
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Florida – Pain Management – Wrong Concentration Of Hydromorphone Programmed Into Intrathecal Pain Pump



In December 2007, a 55-year-old male had an intrathecal pain pump inserted for pain control at the recommendation of his pain management specialist.  He had been prescribing the patient hydromorphone with a concentration of 10 mg/ml.

From 1/31/2012 to 2/15/2012, upon referral by his physician, the patient presented to a new pain management specialist for pain management.

At the initial visit, on 1/31/2012, the pain management specialist ordered a prescription of hydromorphone injectable solution with a concentration of 30 mg/ml to refill the patient’s intrathecal pain pump.

On 2/15/2012, the patient presented to a pain management center to have his intrathecal pain pump refilled with the hydromorphone prescription and reprogrammed.

A physician assistant refilled the patient’s intrathecal pain pump with hydromorphone with a concentration of 30 mg/ml; however, the concentration of the hydromorphone that was programmed into the intrathecal pain pump remained at 10 mg/ml.

The Medical Board of Florida judged the pain management specialists conduct to be below the minimal standard of competence given that he failed to verify that the correct concentration of hydromorphone was administered into the intrathecal pain pump after it was refilled on 2/15/2012 and he failed to verify the correct concentration of the hydromorphone was programmed into the intrathecal pain pump.

The patient expired at his home on 2/15/2012.

It was requested that the Medical Board of Florida order one or more of the following penalties for the pain management specialist: 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: Pain Management, Anesthesiology


Symptom: Pain


Diagnosis: Drug Overdose, Side Effects, or Withdrawal


Medical Error: Accidental Medication Error, Improper supervision


Significant Outcome: Death


Case Rating: 4


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



California – Internal Medicine – RN Conducts Fractional Laser Treatments For Age Spots



On 5/18/2012, a 39-year-old female went to an internist’s clinic for SmartSkin Fractional CO2 laser treatments to remove black spots (age spots) on her hands and face.  The patient paid $2,100 for two laser treatments and associated products. The patient received the second laser treatment on 6/24/2012. The fractional laser treatments were conducted by an RN employed by the internist.

On 7/30/2012, the patient was seen by an RN for her one-month post-laser treatment follow-up.  The RN noted that the patient should continue using hydroquinone (a skin bleaching topical ointment) for hyperpigmentation.  The internist was not called in to look at the hyperpigmentation to the patient’s skin. Hyperpigmentation is a known complication of laser treatments.

The internist only personally saw the patient on 2 occasions, 9/23/2012 and 12/2/2013 for post-Smart-Lipo follow-up appointments.  During her interview with the Board, the internist specifically disavowed any knowledge about the laser treatments provided by her staff to the patient or the work done by the RN.

On 12/6/2012, an RN saw the patient and noted that the patient was pleased with her results except for her hands, where there was little-to-no change in the black spots.  The internist’s staff sold the patient “total skin lightening serum” and recommended additional chemical peels.

The Medical Board of California judged that the internist’s conduct departed from the standard of care because she failed to provide adequate supervision of the RN performing laser skin treatments, particularly when there was a known complication (hyperpigmentation) following the use of the laser.

For this case and others, the Medical Board of California placed the internist on probation for 4 years and ordered the internist to complete a professionalism program (ethics course), a  medical record keeping course, an education course (at least 25 hours per year for eat 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 internist was assigned a monitor for practice and billing, and she was prohibited from practicing or attempting to perform liposuction or laser skin treatments. The internist was also prohibited from supervising physician assistants.

State: California


Date: April 2017


Specialty: Internal Medicine


Symptom: Dermatological Abnormality


Diagnosis: N/A


Medical Error: Improper supervision


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Wisconsin – Physician Assistant – 25-Year-Old Man With Cough, Fever, Chills, And Night Sweats



On 12/15/2003, a 25-year-old non-smoking man presented to a clinic with 10 days of cough, fever, chills, and night sweats.  He was noted to have a heart rate of 142 and a respiratory rate of 24.  He was on amoxicillin, doxycycline, and prescription cough medication.

Physician Assistant A switched him to a different cough medication.  He reported that he had re-checked the heart rate, but there was no documentation of the re-check.  He recommended that the patient continue with amoxicillin and doxycycline.  A TB skin test was ordered.  Physician A was supervising Physician Assistant A.  She reviewed and signed the note sometime after 2/13/2004.

On 12/18/2003, the patient returned to the clinic to have his TB test read.  At that time, he was doing worse.  He saw Physician Assistant B, who was also being supervised by Physician A.  Physician Assistant B reviewed Physician Assistant A’s notes and documented that “his cough seems to be worse” and that the antibiotics “do not seem to be helping.”  His temperature was noted to be 101.3, respiratory rate 32, and on physical exam, it was noted that he was coughing, the coughing intensified when he was reclined, he had a headache with coughing, he had bilateral lower pleuritic pain, and he had “decreased breath sounds to the right base.”   The TB test was negative.  He was diagnosed with “probable pneumonia.”

She recommended a chest x-ray and a CBC, but the patient declined due to cost.  Antibiotics were changed to gatifloxacin 400 mg daily.  It was recommended that he increase fluid intake.  On 12/19/2003, Physician Assistant B dictated the note for the patient visit from the prior day.  The note contained her signature, but not the date.  The medical records reflected that Physician A reviewed and signed the note, but did not reflect when she reviewed or signed it.  On review of the chart, oxygen saturation was not documented.  Physician A did not contact the patient or direct Physician Assistant B to contact the patient, in order to obtain an updated oxygen saturation.

On 12/23/2003, the patient was admitted to the ICU.  Oxygen saturation was at 71%.  On 12/26/2003, he was placed on a mechanical ventilator.  On 1/1/2004, the patient suffered cardiac arrest and could not be resuscitated.

The cause of death was noted to be acute respiratory distress syndrome secondary to pneumonia due to blastomycosis.  On 10/2/2009, a jury concluded that Physician A was negligent in her supervision of Physician Assistant A and B.  The jury attributed 35% of the total causal negligence to Physician A.

The Board addressed the issue of whether Physician A should have sought to obtain an oxygen saturation level.  The Board ultimately decided that Physician A was within the standard of care.

Physician Assistant B’s conduct in her treatment of the patient was below the minimum standards for the profession in the following respects: she failed to document in the patient’s chart that the chest x-ray and CBC were not done “against medical advice”; failed to recommend admission for the patient; failed to consult with her supervising physician; and failed to request a pulmonary consult.

The Board ordered Physician Assistant B be reprimanded, complete 4 hours of continuing medical education in the areas of evaluation and treatment of pneumonia and respiratory distress, and pay the costs of the proceeding.

State: Wisconsin


Date: January 2017


Specialty: Physician Assistant, Internal Medicine


Symptom: Cough, Fever, Headache, Chest Pain, Shortness of Breath


Diagnosis: Pneumonia


Medical Error: Improper treatment, Failure to order appropriate diagnostic test, Failure of communication with other providers, Referral failure to hospital or specialist, Improper supervision, Lack of proper documentation


Significant Outcome: Death, Hospital Bounce Back


Case Rating: 5


Link to Original Case File: Download PDF



Arizona – Emergency Medicine – Recent Cardiac Catheterization With Subsequent Presentation Of Right Groin Pain



The Board received notification of a malpractice settlement.

On 07/20/2011, a 66-year-old male presented to the emergency department.  He reported bleeding of his right groin status post cardiac catheterization performed 2 days prior.  The patient was evaluated by ED physician A, who noted that the bleeding had improved and that the right groin swelling had not gotten worse.  The patient reported taking enoxaparin and warfarin for his mechanical aortic valve.  The remainder of the examination was unremarkable with the exception of some noted bruising to the right groin.  The patient was discharged home after prolonged observation in the ED.

On 07/23/2011, the patient returned to the same ED and was evaluated by a resident.  The patient complained of right groin pain that radiated into the right lower back and was associated with numbness and tingling of his anterior right thigh.  ED physician B was supervising the resident.  The resident noted that the patient had developed a “knot” over the insertion site the night before, which was followed by increased pain into the right back.  At the time of the second ED visit, the patient reported that the pain was more persistent, and he was having difficulty walking.

The resident noted that the patient was taking blood thinners and that he “bruises/bleeds easily” secondary to the blood thinning medications.  Tenderness to palpation of the right groin was noted as well as a 3 x 6 cm oval area of ecchymosis with a small palpable round mass underneath and a 3 cm long longitudinal mass that was extremely tender.

There was no documentation of a back examination.  The neurologic portion of the examination was limited to the patient’s mental status.  A blood analysis and a CT scan were ordered.  The CT scan revealed a small to moderate retroperitoneal bleed on the right side consistent with right psoas hematoma as well as enhancement of the right common femoral artery and vein concerning for an aneurysm.

The reading radiologist recommended an ultrasound and the findings were discussed with the resident.  No ultrasound was available at that time.  The patient was subsequently discharged home with instructions to return with any worsening pain, fevers, chest pain, or shortness of breath, and to follow up with his cardiologist.  The ED physician submitted an addendum to the medical record noting that he examined the patient with the resident and agreed with the care plan.

Later that same day, the patient was taken to a different ED by ambulance complaining of shortness of breath.  The patient was noted to be in significant respiratory distress and was subsequently intubated for pending respiratory failure.  A blood analysis showed a hemoglobin of 4.2, creatinine of 3.4, potassium of 6.6, and an INR of 2.2.  The patient was severely anemic with hyperkalemia from acute renal failure.  When treatment was initiated to correct hyperkalemia, the patient went into cardiac arrest.

At 5:45 a.m. on 07/24/2011 and despite aggressive treatment efforts, the patient was pronounced dead.

An autopsy performed revealed the immediate cause of death was a massive right-sided retroperitoneal hematoma likely resulting from an intimal tear in the right femoral artery with dissection and adventitial hemorrhage.

The Board judged the ED physician’s conduct to be below the minimum standard of competence given failure to obtain an ultrasound to determine if an aneurysm was present.  He also failed to appreciate the risks of sending a patient home who has a bleed and who is on blood thinners.

The ED physician testified that the recommendation to obtain further ultrasound imaging was not communicated to him.  The ED physician expressed deep remorse for the error in judgment and stated that it would never be repeated.

The Board ordered the ED physician be reprimanded.

State: Arizona


Date: June 2016


Specialty: Emergency Medicine, Cardiology, Internal Medicine


Symptom: Bleeding, Numbness, Back Pain, Pelvic/Groin Pain, Swelling


Diagnosis: Hemorrhage


Medical Error: Failure to order appropriate diagnostic test, Underestimation of likelihood or severity, Failure of communication with other providers, Failure to follow up, Improper supervision


Significant Outcome: Death, Hospital Bounce Back


Case Rating: 5


Link to Original Case File: Download PDF



California – Anesthesiology – Lack Of Proper Indication And Physician Assistant Supervision For Transforaminal Cervical Epidural Administration



A patient was seen by a physician assistant on 6/15/2010, and the note was “cosigned” by an anesthesiologist.  The patient complained of neck pain and low back pain. There were no nerve conduction studies performed, and there were no neurologic findings of the objective type noted in the objective section of the exam.  No vital signs appeared on the “pain consult.” No loss of reflexes in any of the cervical reflex distributions (C5 or C7) were noted or described, no muscle atrophy was noted in any associated myotome, and no provocative maneuvers described.  It was unclear whether the anesthesiologist actually evaluated the patient on 6/15/2010. However, the patient was given a prescription for controlled substances under the anesthesiologist’s signature. The patient signed an opioid agreement, but left vital sections of the agreement blank, specifically the pharmacy where prescriptions were to be filled.  There was no risk evaluation and mitigation strategies described, which would include a CURES report, obtaining a urine sample for baseline consistency, or another questionnaire that might indicate an increased risk of addiction to opioids. The patient was ordered to undergo a CT scan of the cervical spine.

A CT scan of the cervical spine was performed on 6/29/2010, which revealed minimal pathologic findings.  Specifically, there was mention of mild bilateral facet disease, and the discs of the intervertebral space appeared to be relatively normal with the exception of a 2 mm protrusion at C6-7 in the left direction.  However, the radiologist report clearly stated that no nerve root appeared to be impacted. Furthermore, all the neural foramen were clear. The radiologist suggested correlation with a physical exam and an MRI.

The patient returned to the anesthesiologist’s office on 7/15/2010 and was again seen by the physician assistant.  Again, no vital signs were recorded. No urine collection was performed to check for compliance with controlled substance protocols.  It was again unclear whether the anesthesiologist actually saw the patient on 7/15/2010, because the co-signature on the report was undated.  The physician assistant decided, apparently on his own, to do a left transforaminal epidural steroid injection. However, the level-selection for the injection was confusing and appeared to have been overwritten in the notes provided.  The initial level was listed as C6-7, but there appeared to be a scribble over those numbers showing C5-6. Again, the physical exam did not demonstrate any objective findings of radiculopathy. No MRI was ordered, as suggested by the radiologist interpreting the CT scan.  No electromyographic studies were ordered to help clarify which level may be the target of a precise injection. No reference was made for potential surgical referral for the patient based on the expected diagnostic results of a precise injection. Finally, there was absolutely no discussion noted in the record with the patient regarding the extreme risks associated with the proposed procedure.

On 7/26/2010, the patient presented to the surgery center for the left transforaminal C5-6 injection.  The patient received deep sedation by the anesthesiologist’s physician partner in the operating room. The pre-procedure description stated that the patient had received up to 50-60% relief from the previously performed procedures; however, this appeared to be incorrect because this was the patient’s first procedure with the anesthesiologist.  The anesthesiologist dictated that in order to perform the procedure safely, deep sedation involving an anesthesiologist was required. The procedure was performed at the C5-6 level, and the anesthesiologist billed for an epidurogram. However, in keeping with the American Medical Association Current Procedural Terminology code description, no corresponding interpretation report for such a procedure was included.  Further, there was no mention of use of digital subtraction with the fluoroscopy unit, and no such images were presented with the supplemental records, which meant they did not exist.

Finally, the procedure was performed with a particulate steroid associated with infarction, paralysis, and death.  It should be noted that the patient, on presentation prior to the procedure, did not indicate any arm pain of any kind, but the anesthesiologist did not question either the level to be injected or whether it was appropriate to continue with the procedure based on her lack of symptoms.

A document in the file dated 8/18/2010, appeared to be a procedural visit at the surgical center.  However, there was no record of an interval evaluation of the patient, and there was no record of a pain diary being presented for review after the selective nerve root block.  The records reflected that the patient indicated that she still had neck pain but without arm pain and stated in her own writing that the previous injection made her pain worse.  However, the indication for the procedure as dictated by the anesthesiologist stated that the patient received 50-60% pain relief from a prior injection; this appeared to be boilerplate language, did not reflect what the patient actually related, and was seriously misleading. Furthermore, the patient was scheduled with the anesthesiologist’s partner for deep sedation utilizing propofol again.  The stated rationale was that the deep sedation was for the patient’s safety.

The patient was then scheduled for a bilateral intra-articular facet block from C3-C7.  The operative notes by the anesthesiologist indicated that the procedure took exactly 2 minutes.  However, not only was this a highly unusual injection series, but the time claim of 2 minutes was either physically impossible or highly dangerous.  The medical records indicated that the patient was not given a pain diary for diagnostic purposes to interpret the benefit of such an unusual injection series.

The patient follow-up on 9/27/2010 with a physician assistant then scheduled, inexplicably, yet again, for a left C5-C6 transforaminal injection.  The patient had indicated on 8/18/2010 that the similar injection performed in July 2010 made her pain worse. There was no further discussion for diagnostic purposes on whether to obtain the radiologist-recommended MRI, or to send the patient for an EMG to help clarify the expressed concern.  There was no documented neurologic change suggesting radiculopathy. The patient then followed up at the surgery center on 9/29/2010 for the scheduled left C5-6 transforaminal injection. The anesthesiologist dictated again that the previous surgery was 50-60% effective; however, previously the patient stated that her pain was worse after prior treatment.  The patient received anesthesia with propofol for this injection, with the addition of fentanyl and Versed. No indication that a pain diary was given to the patient was reflected in the records.

The patient again visited the anesthesiologist’s office on 10/21/2010 and was seen by the physician assistant, who noted in the medical records that there had been no relief from any of the cervical procedures and that the patient wished to focus on her low back.  She was referred for a CT scan of the lumbar spine without contrast, and the prescriptions for controlled substances were refilled. No objective findings, as noted on the physical examination, suggested radiculopathy or a progressive neurologic deficit.

The patient returned on 11/4/2010 and was again seen by the physician assistant and not the anesthesiologist.  The patient was diagnosed by the physician assistant with lumbar facet syndrome and was scheduled for a lumbar facet block.  The notes of 11/24/2010 suggested that the patient underwent a procedure with deep sedation in the operating room by the partner of the anesthesiologist.  Boilerplate language appeared in the records with respect to the need for this type of sedation, as well as the response to previous procedures.

In the original records provided, it appeared that the anesthesiologist himself saw the patient several times at the surgery center only, but that the physician assistant was the primary medical professional who saw the patient in the office.  No copy of the Delegation of Services agreement for this physician assistant was in the records. It was unclear if the physician assistant had the necessary training in prescriptions of controlled substances. Neither was there a formulary presented by the anesthesiologist or advanced notification and authorization for refilling of controlled substances.  In the original records, there was no date and time stamp indicating when or even if the anesthesiologist co-signed the notes for the patient. Little documentation was provided and most of the handwriting was completely illegible. There did appear to be a small scrawl by the anesthesiologist’s name, which could have been liberally interpreted as a cosignatory of the provided notes, but again, there was no date or timestamp as to when that actually occurred.  Additionally, the notes of 11/17/2011 did not appear to have any co-signature by the anesthesiologist.

The anesthesiologist’s overall treatment of the patient was grossly negligent in that he failed to obtain proper opioid treatment agreements, failed to determine if misuse was occurring, failed to monitor the physician assistant prescribing opioids, failed to perform proper examinations, and failed to determine if the opioid treatment modality was effective.  The anesthesiologist’s transforaminal cervical epidural steroid injections were unnecessary and dangerous. The decision to perform the procedure was not supported by medical evidence. The anesthesiologist’s delegation of the decision-making process for the patient to a physician assistant for facet blocks was grossly negligent. There was no evidence contained in the records that the physician assistant had the skills, training, or the competency to perform such an important function.  The anesthesiologist’s failure to properly supervise the physician assistant in the treatment and care of the patient was grossly negligent.

For this allegation and others, the Medical Board of California issued the anesthesiologist a public reprimand.

State: California


Date: January 2016


Specialty: Anesthesiology, Physician Assistant


Symptom: Head/Neck Pain, Back Pain


Diagnosis: N/A


Medical Error: Improper supervision, Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Failure to properly monitor patient, Improper medication management, Unnecessary or excessive treatment or surgery, Lack of proper documentation, Procedural error


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Arizona – Internal Medicine – Propofol Initiated To Sedate An Agitated Patient Receiving A Lumbar Puncture



On 03/09/2014, a 60-year-old man was admitted to the VA Medical Center with lethargy and worsened chest pain for a month.  The patient had reportedly left the hospital earlier that day against medical advice.  The patient’s urine drug screen was positive for opiates and methamphetamines.  Over the following 24 hours, the patient became agitated and was noted to have a Clinical Institute Withdrawal Assessment score (CIWA) of 19.  The patient was being followed by the non-teaching hospitalist on the ward, given medication to help calm him, and a sitter was placed at his bedside.

On 03/11/2014, the patient became increasingly agitated and was documented to have a CIWA score of 26.  He was evaluated by cardiology and psychiatry.  The agitation progressed, and he was transferred to the intensive care unit for airway protection monitoring and nursing care.  Multiple “Code Greens” were called overnight and into the following morning for the patient’s combative and threatening behavior.

On 03/12/2014, the patient’s care was assumed by the internal medicine teaching service, and he remained somnolent and intermittently combative in four point restraints.  IV access was problematic as the patient was pulling out his IV lines and foley catheter, and he required IV medications to help sedate and calm him.

ON 03/13/2014, the patient’s CIWA score was 19 with worsened agitation.  The following day, the patient remained in the intensive care unit and began to improve.  IV access continued to be troublesome with three attempts to place an IV overnight.

On 03/15/2014, additional attempts were made at placing an IV in the morning.  The patient was unable to safely take medication orally, but was less combative.  Per the resident physician’s progress note, the plan was to hold off on line placement and to continue monitoring the patient.  The attending Internist A was unable to supervise the resident for the necessary procedures.  Internist B agreed to supervise after being asked.  The resident physician obtained verbal consent for central line access and lumbar puncture from the patient’s medical power of attorney.  Internist B witnessed the consent.  The consent stated that moderate sedation would be used for both procedures.

After consent was obtained, Internist B attempted central line placement with the resident physician.  A nurse was present.  Internist B used lidocaine locally and placed the central line.  Once the line was placed, 5 mg of IV diazepam and 25 mg of IV diphenhydramine were administered.  Aripiprazole was also administered around time of the procedure.  The patient continued to move during the procedure.  Venous blood gas was obtained at the time of the line placement, and a pharmacy consult was obtained for initiation of dexmedetomidine.  Due to the patient’s heart failure, it was felt that this medication was contraindicated, and it was eventually discontinued.  The resident physician elected to use propofol for sedation.  Internist B admitted that he knew that propofol was being used.  However, he was not immediately available to monitor the effects of the sedation.

Two hours later, a chest x-ray confirmed that the line was placed too distally, and the line was pulled back by 2 cm.  Nursing staff documented the initiation of propofol at 5 mcg/kg/min in anticipation of the lumbar puncture procedure.  Twenty minutes later, propofol was increased to 10 mcg/kg/min.  After an additional twenty minutes, propofol was increased to 20 mcg/kg/min.  The lumbar puncture attempt was abandoned.  The patient’s oxygen saturation became difficult to obtain via pulse oximetry, and the propofol was discontinued.

The oncoming nurse performed a head-to-toe assessment of the patient, who was noted to have agonal breathing with respirations of 6.  An internal medicine intern notified Internist B that the patient’s bedside that the patient’s heart rate was in the 20’s without a blood pressure and no measurable pulse oximetry.  Internist B subsequently contacted the attending to pronounce expiration of the patient.

The patient was noted to be DNR/DNI.

The Board judged Internist B’s conduct to be below the minimum standard of competence given failure to adequately monitor the use of propofol and failure to supervise the resident’s use of propofol.

The Board ordered Internist B to be reprimanded.

State: Arizona


Date: October 2015


Specialty: Internal Medicine


Symptom: Chest Pain, Confusion


Diagnosis: Drug Overdose, Side Effects, or Withdrawal


Medical Error: Improper medication management, Improper supervision


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



California – Pain Management – Stolen Leads Used For Temporary Spinal Cord Stimulator



On 2/17/2011, a pain management specialist percutaneously implanted temporary spinal cord stimulator leads in a patient’s epidural space.  The temporary leads were implanted for a trial period to assess whether stimulation would relieve the patient’s intractable back, hip, and lower extremity pain.

The leads themselves were supplied by a terminated employee of Boston Scientific, who had stolen them from that company.  The pain management specialist knew that the employee had been terminated and that the leads came from Boston Scientific. The pain management specialist nonetheless purchased the leads (as well as numerous other items) directly from the employee, and not through Boston Scientific, for a sum which was a small fraction of their usual cost.

The pain management specialist never confirmed with Boston Scientific whether the leads were legitimately in the possession of the employee, and in fact, told a Boston Scientific representative that he was using another company’s products in the patient’s implantation procedure.  The pain management specialist then allowed the employee, who had no medical license, to assist him in the patient’s procedure, but misrepresented his identity in his operative notes, calling him “John Simpson.” The pain management specialist also used leads that had expired two years before, and allowed a licensed massage therapist, who had no other medical certification or license, to position the C-Arm Fluoroscope during the procedure.  He also allowed a licensed Physician Assistant to administer the anesthetic (which was propofol, a potent narcotic) to the patient. The pain management specialist did not sign the anesthesia record indicating that he was the supervising physician.

The following day, the Boston Scientific representative called officers from the police department to go to the pain management specialist’s office to recover medical equipment and supplies worth approximately $143,980.  The Boston Scientific Representative had been informed that these were in the pain management specialist’s possession by one of his employees. The pain management specialist initially refused to allow the officers access his premises, but relented when the officers indicated that they would obtain a search warrant if the pain management specialist did not voluntarily allow them to proceed.  The items were removed and returned to Boston Scientific.

Allowing the employee with no medical license to assist in the implantation, and implanting expired leads in the patient were an extreme departure from the applicable standard of care and placed the patient’s health and safety at risk.

For this allegation and others, the State Board of California ordered that the pain management specialist be placed on probation for five years and attend a professionalism program (ethics course), as well as a prescribing practices course, be assigned a practice monitor, and maintenance of records of controlled substances.  During this time, the pain management specialist was prohibited from supervising physician assistants.

State: California


Date: May 2015


Specialty: Pain Management


Symptom: Back Pain, Extremity Pain, Joint Pain


Diagnosis: N/A


Medical Error: Ethics violation, Improper supervision


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Family Medicine – Treating Lyme Disease And Babesia With Improperly Managed Medications And Unaddressed Psychiatric Symptoms Leads To Complications



On 2/28/2011, a 58-year-old male visited a family practitioner.  The patient had traveled from his home to consult with the family practitioner in order to “confirm a diagnosis of Lyme disease.”  The patient completed a Questionnaire and a Symptoms Checklist during the visit. On the Questionnaire, the patient checked the “Yes” boxes for the following questions regarding his psychological status: “sudden, abrupt mood swings” (daily), “unusual depression” (weekly), “feeling as if you are losing your mind” (daily), “paranoia” and “obsessive/compulsive” (weekly), “decreased frustration tolerance” (constant), and “generalized anxiety” (weekly).  The patient also checked the “Yes” boxes for “sleeping too much,” “difficulty falling or staying asleep,” “decreased social functioning,” and “decreased job performance.”

For the visit, the patient took with him the results of a blood test, which were reported on 1/27/2011.  The blood test included testing for Lyme disease antibodies. The result of the Lyme disease test showed IgG/IgM values at <0.91 (Reference Range: Negative<0.91; Equivocal 0.91 – 1.09; Positive>1.90).  The laboratory report contains the following: “Note: The CDC currently advises that Western Blot testing be performed following all equivocal or positive EIA results. Final diagnosis should include appropriate clinical findings and positive EIA which is positive by Western Blot.”  The patient was attended to by the family practitioner’s nurse practitioner. The nurse practitioner attended to the patient on all five of his visits between February 2011 and September 2011. The family practitioner reviewed and approved of all the care and treatment the nurse practitioner provided with the patient.

The nurse practitioner obtained a medical history and performed a physical examination of the patient.  She noted that the patient had a history of “tick exposure” and a rash, which she noted to be erythema migraines.  However, the nurse practitioner failed to note where (geographical location) the tick exposure occurred, the character of the rash, and whether the rash was related to the tick bite.  Despite the mental health symptoms the patient noted in the Questionnaire, the nurse practitioner failed to perform and/or note she performed a psychological assessment of the patient on this visit.  The nurse practitioner ordered laboratory tests to be performed by IgeneX Inc. Her assessment included Lyme disease and “GI yeast.” There was no medical justification for the Lyme disease assessment.  The nurse practitioner prescribed amoxicillin and Flagyl for the Lyme disease and nystatin for the “GI yeast.”

The patient made a follow-up visit on 4/13/2011.  He was again seen by the nurse practitioner, who noted that the IgeneX lab tests results reported on 3/24/2011 were “positive” for Lyme disease.  This notation was incorrect because the IgeneX results were actually negative for Lyme disease according to CDC criteria. Also, the nurse practitioner failed to note that the lab results the patient brought with him to the 1/21/2011 visit were also negative for Lyme disease.  The nurse practitioner’s plan included ordering lab tests for Babesia and Bartonella. The nurse practitioner added rifampin and artemisinin to the amoxicillin and Flagyl medications. The nurse practitioner failed to note the medical justification and/or rationale for the addition of rifampin and artemisinin medications.

On 5/27/2011, the patient had a telephone consultation with the nurse practitioner.  The nurse practitioner noted the patient reported he felt better, but she failed to inquire or note she inquired about the patient’s psychological issues or whether he was in the care of a psychiatrist.  On this date, the nurse practitioner noted a diagnosis that included Babesia. There was no medical justification for this diagnosis. Indeed, the Babesia serology results from IgeneX reported on 5/10/2011 were “negative” for Babesia.  Also, the nurse practitioner arrived at the diagnosis without performing any standard testing, such as obtaining and examining blood smears, for Babesia. The nurse practitioner’s plan included prescribing Malarone to treat Babesia.

The patient made a visit to the family practitioner’s office on 6/14/2011.  He was again attended by the nurse practitioner, who noted the patient reported feeling better, but she failed to inquire into or note she inquired into the patient’s psychological issues or whether the patient was in the care of a psychiatrist.  The nurse practitioner’s assessment included Babesia and Candida. The nurse practitioner prescribed Malarone for the Babesia and added Mycelex for the yeast infection. There was no medical justification for the Babesia assessment and no medical justification for the Malarone prescription.  On 6/20/2011, the nurse practitioner issued a telephone prescription for fluconazole, another antifungal agent, for the patient. There was no notation of the medical justification for prescribing a third antifungal agent for this patient. Also, the nurse practitioner failed to discontinue the nystatin and Mycelex medications before prescribing the fluconazole.

On 6/27/2011, the patient telephoned the family practitioner’s clinic to inquire whether he should be taking rifampin and Malarone medications simultaneously.  The patient indicated that the label on the Malarone medication container indicated the two medications should not be taken together. On 6/29/2011, the nurse practitioner informed the patient it was “ok” to take Rifampin and Malarone simultaneously so long as they are taken two hours apart.

On 8/7/2011, the patient made a follow-up visit and was attended to by the nurse practitioner.  Among other things, she noted that the patient reported he was having “waves of nausea daily.” The nurse practitioner again failed to inquire into or note she inquired into the patient’s psychological symptoms or whether the patient was in the care of a psychiatrist.  She performed a physical examination of the patient, but she failed to perform a psychological evaluation of the patient during this examination. The nurse practitioner’s plan included increasing the rifampin and Malarone medications to treat the Lyme disease and adding doxycycline and Lariam medications to treat the Babesia.

On 10/27/2011, the police received a report stating the patient had become mentally ill, had been referring to himself as the “Angel of Death,” and had threatened to assault his girlfriend.  The girlfriend reported that the patient’s behavior “changed” after use of the Lariam medication. The patient was arrested and hospitalized.

The Medical Board of California judged that the family practitioner’s conduct departed from the standard of care because he failed to obtain appropriate history for the patient’s psychological issues, arrive at an appropriate diagnosis for the psychological issues, adequately follow up on the patient’s psychological issues, and properly refer patient to a psychiatrist for evaluation for his psychological issues.  The family practitioner also inappropriate treated the patient for Lyme disease and Babesia with artemisinin, Malarone, and Lariam as well as diagnosing the patient with Lyme disease without obtaining an appropriate history and inappropriately diagnosed the patient with Lyme disease despite the fact that the IgeneX lab results were “negative” for Lyme disease according to the CDC criteria.  The family practitioner also inappropriately prescribed rifampin and Flagyl over a long period of time for the treatment of Lyme disease and failed to consider and/or document she considered the effect of the “drug interaction” from the multiple drugs she prescribed to the patient for treatment of Lyme disease, Babesia, and yeast infection.

The Medical Board of California ordered the family practitioner to complete a prescribing practices course, a clinical training program, and a chronic disease 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: March 2015


Specialty: Family Medicine, Internal Medicine, Psychiatry


Symptom: Nausea Or Vomiting, Rash, Psychiatric Symptoms


Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Infectious Disease


Medical Error: Failure to examine or evaluate patient properly, Accidental error, Failure to order appropriate diagnostic test, Referral failure to hospital or specialist, Failure to follow up, Improper supervision, Improper medication management


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



California – Internal Medicine – Internist Fails to Adequately Advocate for Detainee to Ensure Adequate Care and Treatment for Penile Lesion



On 3/27/2006, a patient was housed at a detention facility.  Medical treatment for detainees was provided by the DIHS (Division of Immigration Health Service) at the detention facility.  The patient requested a medical visit for a lesion on his penis that was painful, growing, and was accompanied by a discharge.  On 3/28/2006, the patient was seen by a physician assistant and was diagnosed with a larger genital lesion and severe phimosis. He recommended a urology consult and biopsy as soon as possible.

On 3/28/2006, the physician assistant submitted a Treatment Authorization Request (TAR) in order to obtain authorization for a urology consult and biopsy.  The TAR was denied. On the same day, an internist authored a chart note. On 4/11/2006, the physician assistant resubmitted another TAR for a urology consult and biopsy.  On 5/31/2006, DIHS granted the TAR for the patient, authorizing a urology consultation, biopsy, and surgical follow-up. On 6/7/2006, the patient consulted with an oncologist who opined that the lesion on the patient’s penis was either a cancer or a viral infection.  The oncologist advised the internist and the physician assistant of the urgent need to treat the patient and offered to admit the patient for an urgent urologic assessment with biopsy and definitive treatment. The internist informed the oncologist that DIHS considered the assessment and biopsy to be outpatient procedures; therefore, the recommended urologic assessment and biopsy would not be authorized.

On 6/23/2006, the physician assistant saw the patient who complained that the symptoms in his penis were getting worse.  The patient presented with increased swelling, a malodorous discharge, difficulty urinating, and bleeding from the foreskin.  On 7/13/2006, the physician assistant sent the patient to the emergency room for evaluation and treatment. A History and Physical Examination performed by the ED physician noted a 1.5 x 2-cm fungating lesion on the patient’s penis.

On 8/22/2006, a urologist saw the patient and noted a 1.5 cm verrucous lesion on the internal surface of the prepuce. The urologist’s diagnosis was probable condyloma accuminata, diffuse vitiligo, and possible distal urethral condylomata.  The urologist recommended a circumcision in order to allow for a biopsy and care for the ongoing side effects of the lesion. The urologist indicated that the procedure could be done on an outpatient basis under general anesthesia. The internist instead elected to monitor the patient.

Between September 2006 and December 2006, the patient made multiple complaints of continued symptoms, including increased size of his penile lesion, bleeding, discharge, pain, and difficulty urinating.  The patient was seen by various nurses and physician assistants, but had nothing definitively done for his complaints.

In December 2006, the patient was transferred to a processing center, was subsequently discharged from DIHS, was diagnosed with penile cancer, and ultimately died from his disease.

The internist committed gross negligence in her care and treatment of the patient, which included: failure to adequately supervise the physician assistant; failure to adequately evaluate the patient’s penile lesion to determine if a biopsy was indicated; failure to arrange for a timely biopsy of the patient’s lesion after a biopsy was recommended by a urologist and an oncologist; allowing the patient to suffer unnecessarily; and failure to adequately advocate for the patient to ensure the patient received adequate care and treatment for his penile lesion.

The Medical Board of California ordered that the internist be placed on probation for three years and attend 65 hours of a CME course, a PACE program, a professionalism program (ethics course), a medical record keeping course, and a monitoring program. During this probation, the internist was prohibited from supervising physician assistants.

State: California


Date: July 2014


Specialty: Internal Medicine, Oncology, Urology


Symptom: Pelvic/Groin Pain, Bleeding, Dermatological Abnormality, Swelling, Urinary Problems


Diagnosis: Cancer


Medical Error: Failure to examine or evaluate patient properly, Delay in diagnosis, Ethics violation, Referral failure to hospital or specialist, Improper supervision


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



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