Search Cases

On 6/22/2010, Gastroenterologist A provided a consultation for a patient after an abdominal ultrasound showed that the patient had cholelithiasis and choledocholithiasis.  The patient’s elevated liver enzymes and dilated bile duct indicated a moderate to high probability of the possibility of stones and warranted a preoperative ERCP and sphincterotomy.  The purpose of the consultation was to remove a suspected common bile duct stone prior to a cholecystectomy.

On 6/28/2010, Gastroenterologist A performed an ERCP with sphincterotomy and balloon sweeping of the common bile duct.  He was unable to determine if he had successfully removed the suspected common bile duct stone from the patient’s dilated bile duct and placed an 8.5-French 5 cm stent into the common bile duct.

In the patient’s chart, Gastroenterologist A noted: “will pull the stent out in 2 months.”

On 11/24/2010, Gastroenterologist A next saw the patient in his office.  A second ERCP was scheduled for 2/10/2011 to remove the stent.  The patient’s medical chart contains no record of instructions given to the patient or his family members regarding the removal of the stent.  The patient’s medical chart contains no explanation for the passage of time between the placement of the stent on 6/28/2010 and the removal of the stent on 2/10/2011.  The Board noted that stents can be expected to occlude after six months and form a nidus for the formation of other stones, mud, and debris.

At 8:30 a.m. on 2/10/2011, Gastroenterologist A performed a second ERCP on the patient and removed the stent.  During the second ERCP, Gastroenterologist A performed a balloon sweep.  The patient’s medical chart contains no clear documentation that all ducts were swept.  No antibiotics were prescribed or administered to the patient immediately before, during, or after the second ERCP.  After the second ERCP, the patient was discharged from the endoscopy facility.  Several hours later, the patient’s wife called Gastroenterologist A’s office to report that the patient was experiencing chills and pain in his back and stomach.  Gastroenterologist A and/or his staff advised that the patient should be brought to Gastroenterologist A’s office right away.

At 6:00 p.m., after efforts to convince the patient’s wife to bring the patient to his office had been unsuccessful, Gastroenterologist A noted in the patient’s chart that he advised the patient’s wife to bring the patient to the office the following morning if the pain were to continue.

Thereafter, Gastroenterologist A prescribed amoxicillin 500 mg to be taken three times a day for the patient.

The following morning, the patient’s condition had not improved.  Further conversations took place between Gastroenterologist A and/or his office staff and the patient’s wife.

At noon on 2/11/2011, the patient arrived at the hospital.

On 10/7/2014, Gastroenterologist A testified that there had been several telephone calls between his office and the patient’s wife on 2/10/2011 and 2/11/2011.  Further, he stated that he and/or his staff had impressed upon the patient’s wife the severity of the patient’s condition and that it was matter of life and death that the patient receive urgent medical attention, but that patient’s wife apparently failed to understand and/or take Gastroenterologist A’s comments seriously.

However, Gastroenterologist A did not document in the cart for the patient.  He did not document the frequency of the conversations, the information given to the patient’s wife, or his wife’s failure or refusal to understand the information.

At 1:30 p.m. on 2/11/2011, the patient was admitted to a hospital and was found to be critically ill with severe sepsis.

Gastroenterologist A consulted Gastroenterologist B, who performed an ERCP on the patient on 2/12/2011.  Gastroenterologist B found “clear evidence of a biliary obstruction as evidenced by darkly pigmented bile and extensive amounts of bloody liquid and sand-like material concerning for hemobilia.”  Gastroenterologist B diagnosed “biliary obstruction resulting in ascending cholangitis and sepsis” and placed a stent in the common bile duct.

On 2/12/2011, the patient passed away.

On 2/16/2011, Gastroenterologist A completed a two-page note in the patient’s medical chart entitled “Death Summary” and marked “Final Report, ” in which he made the following comments.

“Endoscopic retrograde cholangiopancreatography was performed 2 or 3 months ago … for common bile stone retrieval with stenting of the common bile duct … His condition continued to deteriorate.  During the night, his oxygen saturation began to deteriorate, suggesting acute respiratory distress syndrome.  He was intubated and put on the machine.  The blood pressure was kept on Dopamine and Neo-Synephrine.  But, in spite of this, on 2/12/2011 after all the resources have [sic] been pulled out, I have a hunch that he would not make it because of multiorgan [sic] failure.  Therefore, I called the family and explained the grave situation as best that I could.  The patient finally expired on 2/12/2011.”

Gastroenterologist A listed the final diagnosis as “septic shock, death.”

Gastroenterologist’s “Death Summary” for the patient contained no mention of the third ERCP, performed on 2/12/2011, or Gastroenterologist’s B diagnosis of biliary obstruction.

After a hearing, the State Medical Board concluded that Gastroenterologist A committed repeated negligent acts given failure to ensure timely removal of the temporary stent, failure to ensure that the patient had a clear understanding of the importance of timely removal of the temporary stent, failure to ensure that the patient had an understanding of the risks associated with performing the second ERCP and the possible warning signs to monitor after the procedure, and failure to maintain appropriate documentation of his care and treatment of the patient.

The State Medical Board placed Gastroenterologist A on probation with stipulations to complete a professionalism program, complete a medical record keeping course, complete 40 hours annually of continuing medical education for each year of probation, and undergo clinical practice monitoring with an emphasis on medical record keeping.  During probation, Gastroenterologist A was prohibited from performing ERCP procedures.

State: California

Date: May 2017

Specialty: Gastroenterology, Internal Medicine

Symptom: Fever

Diagnosis: Sepsis

Medical Error: Physician concern overridden, Delay in proper treatment, Failure of communication with patient or patient relations, Lack of proper documentation

Significant Outcome: Death, Hospital Bounce Back

Case Rating: 4

Link to Original Case File: Download PDF

In May 2011, a 61-year-old female was seen by an internist to provide body contouring to her outer thighs, hips, flanks, and waist/abdomen area.  The patient had previously undergone a complete abdominoplasty in January 2011 by another physician, but she wanted additional body sculpting.

On 6/3/2011, the internist performed Smart-Lipo on the patient on her inner/outer thighs, hips, and waist.  On the day of the surgery, the patient told the internist that, years before, she had undergone liposuction and breast augmentation.  Prior to surgery, the internist reviewed blood work and an EKG study. The only abnormal finding was a slightly elevated blood glucose level.

On 7/8/2011, the internist performed Smart-Lipo on the patient’s upper and lower abdominal region.  The internist also contoured the patient’s pubic area, which was not discussed beforehand, nor was the patient charged for this.

At several post-operative visits, including on 7/11/2011, the patient expressed dissatisfaction with the results.  At a follow-up appointment on 12/2/2011, the internist prescribed phentermine for weight loss, but the patient suffered side effects and was taken off of the medication the following week.

On 5/4/2012, the internist performed revision surgery on the patient’s hips and outer thighs.  The internist did not order new EKG studies or labwork before the surgery, almost one year after the previous studies were done.  The internist also did not review or contact the patient’s primary care provider to ensure there were not any changes to the patient’s health in the previous year.  At follow-up appointments, the patient continued to complain of the results, including asymmetry with the inner and outer thighs and her pubic region. The patient requested that the internist do another Smart-Lipo procedure.  The internist initially refused to do the procedure, but eventually agreed even though she wrote in the patient’s medical record that the patient would not benefit from a further revision surgery.

The internist admitted during her interview with an investigator of the health Quality Investigations Unit for the Medical Board on 4/24/2014 that she agreed to do the additional surgery despite not providing any benefit to the patient because the patient claimed to be a physician, and this was “elective cosmetic surgery.”

On 12/5/2012, the internist performed Smart-Lipo on the patient’s upper abdomen, inner thighs, and right hip.  The internist did not order new EKG studies or lab work before the surgery. The internist encountered fibrosis during the procedure.  The patient continued to complain about the results and requested more procedures. The internist finally refused the patient’s request for more surgery and offered to do free laser hair removal instead.  The patient never returned to the internist’s clinic.

The Medical Board of California judged that the internist’s conduct departed from the standard of care because she failed to order repeat blood work and EKG studies and contact the patient’s primary care provider to determine if there were any changes in the patient’s health before the 5/4/2012 Smart-Lipo procedure and 12/5/2012 Smart-Lipo procedure.  The internist also performed a surgical procedure on the patient because the patient wanted additional surgery despite acknowledging it was not in the patient’s best interest, and she lacked sufficient skills and knowledge to perform Smart-Lipo safely, including knowledge about alternative body contouring procedures that might be more beneficial to her patients.

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), medical record keeping course, education course (at least 25 hours per year for eat year of probation), and 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, Plastic Surgery

Symptom: N/A

Diagnosis: N/A

Medical Error: Failure to order appropriate diagnostic test, Failure of communication with patient or patient relations, Physician concern overridden, Unnecessary or excessive treatment or surgery

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

On 1/11/2014, a patient presented to the urgent care clinic reporting that she had injured her ankle the night before.  The physician assistant that saw her ordered x-rays of the injured ankle.  The physician assistant correctly interpreted the x-ray results as showing a closed nondisplaced bimalleolar fracture of the ankle (a closed fracture of both leg bones where they join the ankle).  The physician assistant offered an immediate treatment plan of a fiberglass splint, a walking boot, and a prescription for pain medication.  She recommended evaluation by an orthopedist, crutches, avoidance of weight bearing, and pursual of emergency care for any change in condition.  The patient left the urgent care clinic with a prescription for pain medication but declined the splint and walking boot.

The patient presented to an emergency department two days later with increased pain, swelling, some loss of sensation, and a blister on the ankle.  An exam showed the fracture had been displaced and the medial tibia bone was tenting the skin and causing the blister.  The patient required surgery for the re-alignment of her broken bones and the placement of pins in the damaged areas to repair the breaks.

The Commission judged the physician assistant’s conduct below the minimum standard of competence given failure to communicate to the patient the seriousness of her injuries.  The patient went two extra days without proper medical treatment and her fracture displaced.  The patient suffered moderate harm due to increased and sustained pain from her injury and increased tissue aggravation due to the broken ends of the bones pushing against her flesh.

The Commission stipulated the physician assistant reimburse costs to the Commission, complete 6 continuing medical education credits on identification, diagnosis, and treatment of ankle trauma and unstable ankle injuries, and write and submit a paper of at least 1000 words, with annotated bibliography, on the diagnosis of unstable ankle injuries, how to properly treat them, and the potential consequences for failing to properly treat them.

State: Washington

Date: August 2016

Specialty: Physician Assistant, Emergency Medicine, Orthopedic Surgery

Symptom: Extremity Pain, Numbness, Swelling

Diagnosis: Fracture(s)

Medical Error: Failure of communication with patient or patient relations, Physician concern overridden

Significant Outcome: Hospital Bounce Back

Case Rating: 4

Link to Original Case File: Download PDF

In 2006, an internist diagnosed a fourth-year medical student with attention deficit hyperactivity disorder and prescribed her Adderall.  She reported that she was having problems focusing and paying attention in medical school.   The Board expressed concern there was a lack of testing and a lack of an independent, adequate work up to establish the diagnosis.

From July 2010 to September 2010, the internist treated the patient.  On 7/2/2010, the internist resumed treatment with the patient, now a physician in a fellowship program, when she returned to the Charlottesville area after a four-year absence from his practice.

During this office visit, based solely upon the patient’s representations that she had been treated for ADHD with up to 160 mg per day of Adderall by her psychiatrist in Norfolk, the internist prescribed Adderall (90 dosage units, 30 mg tid) and Adderall XR (40 dosage units, 20 mg po bid) to the patient.  Per the Board, the dosage that was prescribed is more than three times the maximum recommended dose to treat adult ADHD.

Prior to prescribing Adderall, the internist did not obtain records of testing and/or documentation from any other treatment provider and did not perform any independent work up to establish the ADHD diagnosis and/or the need for Adderall.  Throughout the course of treatment, the internist allowed the patient to self-titrate her dosages and failed to properly monitor and manage the patient’s use of Adderall when he repeatedly escalated his prescribing to coincide with the patient’s medication decisions and self-determined doses, which resulted in the prescription of 1074 dosage units of Adderall in 71 days.

Specifically, on 7/14/2010, just 12 days after receiving a 30-day prescription, the patient informed the nurse practitioner under the internist’s supervision that she had stopped taking Adderall XR because it kept her awake and that already she had taken all 90 pills of her short-acting Adderall.  Despite noting concerns in the patient’s treatment record that the patient was “taking too much Adderall,” the nurse practitioner prescribed an additional 54 dosage units of Adderall (20 mg tid) to last until the patient could see the internist.

When the internist saw the patient on 7/19/2010, he increased her dosage of Adderall from 30 mg tid to 30 mg qid.

On 7/30/2010, without documenting any reason for another change in dosage, the internist increased the patient’s Adderall dosage to 30 mg q4h (max 5 tabs in 24 hrs) while also noting that the patient’s symptoms of distractibility were “fairly stable.”

The internist prescribed another 150 dosage units of Adderall (30 mg q4h with a max of 5 tablets in 24 hours) for the patient.

On 9/9/2010, after the patient telephoned him requesting an early prescription because she had “upped” the Adderall to 1.5 tablets every four hours, the internist prescribed 210 dosage units of Adderall (30 mg q4h with a max of 5 tablets in 24 hours.

Despite the foregoing evidence that the patient was misusing or abusing her medications, the internist failed to address these concerns or refer her for substance abuse evaluation and treatment.

In a letter to the Board dated 9/14/2015, the internist stated that he recognized that the patient was taking an unusually high dose of Adderall in 2010, but he believed the treatment was effective for her.  He stated that he was concerned about drug-seeking behavior and discussed the issue with the patient, but she assured him that she sought additional medication only because she lost her medications and because it had gotten wet on at least one occasion.  (This discussion with the patient is not documented in the internist’s records.)

The internist stated “looking back,” he wished he had obtained the records of her prior treating psychiatrist and that it had been his “consistent practice to…obtain treatment records from any previous treaters who prescribed Adderall” for his patients.  He explained that he did not attempt to obtain prior treatment records for the patient because he “knew her from the time [he] treated her as a patient in 2006.”  He stated that only a few of his patients are treated with Adderall.

The internist was issued a reprimand.  He was to complete 15 hours of continuing medical education in the subject of the proper prescribing of controlled substances and recognizing the signs of abuse/misuse of prescription medication.

State: Virginia

Date: May 2016

Specialty: Internal Medicine, Family Medicine

Symptom: Psychiatric Symptoms

Diagnosis: Psychiatric Disorder

Medical Error: Improper medication management, Failure of communication with other providers, Physician concern overridden, Failure to properly monitor patient

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

On 1/25/2015, a patient, previously a retired nurse, presented to the emergency department (ED) with cough, headache, fever, muscle pain, nausea, and neck pain after three days of increasing symptoms.  The patient disclosed a medical history including surgery for an acoustic neuroma about two years prior and stated that her neck pain may be related to recent heavy lifting.  The patient was examined by a physician who noted no meningismus and diagnosed an influenza-like illness.  The patient was discharged with medications for nausea and migraine headache, and was directed to return to the ED if there were new or worsening symptoms.

On 1/26/2015, the patient was treated by an ED physician when she returned to the ED with complaints of uncontrolled neck pain and nausea.  The patient’s headache and back pain were improved by IV pain medication while treated in the ED, but not her neck pain.  The ED physician ordered an MRI study of the patient’s cervical spine based on the patient’s highly elevated white blood cell count and concerns of a possible bacterial infection.  The radiology report noted an abnormality that could have been produced by meningitis or prior lumbar puncture, and recommended that a lumbar puncture be performed.

Later that morning, the ED physician discussed the imaging findings with the patient.  The patient disclosed that she had a previous lumbar puncture and the ED physician sensed that the patient did not want to undergo another lumbar puncture procedure, unless necessary.  The ED physician and patient discussed various medical factors, including the patient’s improved condition and lack of other symptoms indicating meningitis.  The ED physician decided not to order an LP and discharged the patient with medication for nausea and pain with instructions to return if her condition worsened.  The patient returned to the ED later that evening and presented with increased confusion.

The patient had a seizure, became comatose, and lost brainstem reflexes.  The patient was examined by a neurologist who confirmed brain death.  The patient was taken off life support and expired.  An autopsy was performed and concluded that the cause of death was acute bacterial meningitis.

The Commission stipulated that the ED physician reimburse costs to the Commission, make a presentation regarding the diagnosis and management of meningitis (with specific reference to this case) to other physicians and physician assistants at her group practice, complete 4 hours of continuing education on the diagnosis and management of meningitis, and write and submit a paper of at least 1000 words, plus bibliography, addressing the diagnosis and management of meningitis.

State: Washington

Date: February 2016

Specialty: Emergency Medicine

Symptom: Fever, Confusion, Cough, Headache, Head/Neck Pain

Diagnosis: Meningitis/Encephalitis

Medical Error: Diagnostic error, Physician concern overridden

Significant Outcome: Death, Hospital Bounce Back

Case Rating: 5

Link to Original Case File: Download PDF

On 11/17/2006, a plastic surgeon performed ear surgery as part of a larger operation on a patient.  The plastic surgeon failed to describe the actual procedure performed on the patient in her medical records.  On 1/9/2007, the plastic surgeon injected the patient’s scars with Kenalog, a corticosteroid, for treatment of scar thickness.  The plastic surgeon failed to identify the location of the scars or the relative success of the injection in the patient’s medical records.  On 1/22/2007, 2/26/2008, and 4/5/2009, the plastic surgeon transferred fat from an unknown location on the patient to her submental area.  The plastic surgeon failed to document why these procedures were performed or the results in the patient’s medical records.

On 9/13/2007, 10/4/2007, and 10/25/2007, the plastic surgeon performed mesotherapy for which there were multiple solutions and solution concentrations available for mesotherapy.  The plastic surgeon failed to document what solution or solution concentrations he used on the patient in her medical records.  The plastic surgeon also failed to document the results of these procedures.  On 10/30/2007, the plastic surgeon used a needle to try to release scars around the patient’s chin.  The plastic surgeon failed to document the results in the patient’s medical records.  On 12/11/2007, the plastic surgeon performed a minor post-auricular scar revision on the patient but failed to describe the actual procedure performed on the patient in her medical records.

On 5/27/2008, the plastic surgeon documented that the patient was planning on having a chin implant and had requested eyelid skin removal.  The plastic surgeon failed to document why the chin implant was going to be placed or the goals of the implant.  On 6/4/2008, the patient consented to a chin implant, fat injection, and eye lift.  That same day, the plastic surgeon only performed a chin implant, but there was no documentation in the patient’s medical records indicating that the fat injection and eye lift were either performed or canceled.  There was also no documentation indicating that the plastic surgeon and the patient decided to only perform a chin implant or the reasons why only a chin implant was performed.  Also, the sticker from the chin implant that contains identification data for the prosthesis was placed in the chart next to a note dated 6/16/2008.  The sticker should have been placed in the chart next to the date on which the implant was used.

On 6/10/2008, the plastic surgeon prescribed a “refill” of Augmentin, an antibiotic, to the patient.  However, the initial antibiotic that the plastic surgeon ordered on 6/4/2008 was Penicillin, not Augmentin.  The plastic surgeon failed to indicate the reason why he prescribed additional and different antibiotics only six days after the chin implant that he performed on the patient.  The plastic surgeon also failed to document any assessment of the surgical incision or chin implant status in the patient’s medical records.  On 6/16/2008, the plastic surgeon removed the chin implant due to the patient’s insistence.  The chart entries indicated that the plastic surgeon could not convince the patient to wait until the swelling was resolved.  The plastic surgeon failed to document why the patient wanted the implant removed, what the physical examination showed, what his assessment of the surgical results was, or whether pre-operative goals were reached.

The Medical Board of California judged that the plastic surgeon failed to cease performing new procedures on a non-compliant patient.  The patient continued to smoke cigarettes despite the plastic surgeon’s instructions to stop, showed up to his medical office smelling of alcohol, and asked him for Vicodin to sell on the black market.  The patient had a poorly healing wound, which the plastic surgeon attributed to ongoing smoking.  There were also contentious interactions between them, such as telephone calls by the patient to the plastic surgeon’s home at odd hours in the middle of the night, sometimes while drunk.  In spite of the foregoing, the plastic surgeon continued to schedule and perform new elective procedures on the patient, including placement and later removal of the chin implant.

The Medical Board of California ordered that the plastic surgeon be placed on probation for 2 years and complete a medical record-keeping course and an education course (at least 25 hours per year for four years) equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California

Date: September 2015

Specialty: Plastic Surgery

Symptom: N/A

Diagnosis: N/A

Medical Error: Physician concern overridden, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 1

Link to Original Case File: Download PDF

On 5/6/2009, a 35-year-old male was treated by a nurse practitioner for gout and received an order for further laboratory testing.  On 5/10/2008, the patient had laboratory testing done, which confirmed his chief complaint of gout.

On 6/27/2008, the patient was evaluated by a family practitioner.  The family practitioner evaluated the patient in the presence of the patient’s wife and their four boys.  The patient’s complaints included “fever, arm problem (swollen under right arm), vomiting, diarrhea,  dizziness, perspiration problem, and test results (labs).”  The family practitioner noted that the patient reported a fever the previous night of 103 F, had cold sweats and right arm pain.  The family practitioner noted that the patient had taken ibuprofen for his fever.  On examination, the patient appeared “malaised with profuse [sic] sweating.”  The patient’s pulse was 139, his blood pressure was 98/60, and he had a temperature of 99.68 F.  The patient kept his right arm raised throughout the exam because of pain and complained of shortness of breath.  The patient appeared seriously ill and presented with both hypotension and tachycardia.

The family practitioner informed the patient that he needed to seek medical treatment at the emergency department because he may have a serious bacterial infection.  The exam became confrontational with the patient’s wife demanded that the family practitioner provide treatment to the patient after the patient refused to go to the emergency department.  The exam was further truncated because the clinic was in the process of closing for the weekend, and the family practitioner needed to pick up her children from childcare.  The family practitioner refused to provide treatment, either parenteral antibiotics or oral antibiotics, at the clinic because she didn’t believe she could provide any treatments that would treat the patient’s illness.  The family practitioner failed to perform an examination of the patient’s right upper extremity for a portal of entry of infection or for active infection.  The family practitioner also didn’t accurately record information in the patient’s electronic medical record.

The Medical Board of California judged that the family practitioner’s treatment of the patient departed from the standard of care because she failed to immediately begin life-stabilization and treatment of the patient upon realizing that he was seriously ill, allowed outside logistical considerations to limit her ability to provide treatment to the patient, allowed the electronic medical record-keeping software to interfere with her treatment of the patient, allowed her relationship to become confrontational with the patient, did not administer a dose of parenteral antibiotics to the patient, did not prescribe oral antibiotics despite the patient asserting that he was not going to the emergency department, and didnot examine the patient’s right upper extremity for evidence of a portal of entry for infection or for active infection.  The family practitioner also failed to properly manage a noncompliant patient, never activated the Emergency Medical System when she realized that the patient was seriously ill, never had the patient sign a written formal acknowledgment form that the patient understood that the family practitioner believed he would die unless he received immediate emergency department treatment, never attempted to provide a dose of parenteral antibiotics or oral antibiotics to the patient after he asserted that he was refusing to go to the emergency department, lacked familiarity with how to discharge a patient Against Medical Advice, and failed to note that the patient was discharged Against Medical Advice.

The Medical Board of California also judged that the family practitioner’s record keeping departed from the standard of care because she didn’t record respiratory rate, did not carefully document the axillary examination, failed to document the examination of the upper right extremity, failed to document an accurate diagnosis in the medical record, failed to discuss the management options for the patient’s condition in the medical record, failed to document the patient’s refusal to comply with the family practitioner’s request that he go to the emergency department.  The family practitioner also failed to document the physical findings and care of the patient, document the patient’s respiratory rate, document that the patient may have been suffering from Systemic Inflammatory Response Syndrome or early stages of septic shock, document that the patient was holding his right arm away from his body at a 90 degree level of abduction, and document whether she performed a detailed examination of the patient’s right upper extremity.  The family practitioner documented that the patient’s resting heart rate was a “normal rate” despite having a pulse of 139, documented her discharge instructions only for mild to moderate acute gastroenteritis, and failed to document her actual clinical diagnosis: serious bacterial infection with impending septic shock.  The family practitioner did not document that she planned on sending the patient to the emergency department and had requested that he go to the emergency department, did not document that the patient refused to go to the emergency department, did not document that the patient left her office AMA, did not document provide the patient with an informed refusal of treatment, did not document that she considered activating EMS, did not document that she considered and rejected administering parenteral antibiotics in the clinic or prescribe oral antibiotics, and did not document that she had a discussion with the patient regarding his treatment options.

The Medical Board of California issued a public reprimand and ordered the family practitioner to complete a medical record-keeping course and education course.

State: California

Date: September 2015

Specialty: Family Medicine, Internal Medicine

Symptom: Fever, Diarrhea, Dizziness, Nausea Or Vomiting, Extremity Pain, Shortness of Breath, Swelling

Diagnosis: Infectious Disease, Gout

Medical Error: Physician concern overridden, Failure to examine or evaluate patient properly, Improper treatment, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 4

Link to Original Case File: Download PDF

A plastic surgeon provided medical care and treatment to a 49-year-old patient between August and September 2011.

On 8/18/2011, the patient presented to the plastic surgeon for a consultation regarding vaginal rejuvenation.  On physical examination, the patient had a senescent batwing deformity of the labia minora and melanosis. She was also noted to have a rectocele and a cystocele.  The plan was for a laser vaginal tightening with labiaplasty and liposuction of the lower abdomen with fat transfer to the labia major.

A pre-operative visit was conducted on 8/22/2011.  At this visit, the patient’s blood pressure was taken and was elevated at 138/105.  Her surgery was scheduled for 8/25/2011, consents were signed, and she was given prescriptions, which included Keflex 500 mg to be taken twice per day, starting the day prior to surgery.

On 8/25/2011, the patient presented to the plastic surgeon’s surgical center for surgery.  Her blood pressure was noted to be elevated at 163/105. The plastic surgeon performed a GyneShape incisionless vaginal rejuvenation procedure on the patient.  Following application of the laser, the plastic surgeon found that the introitus was gaping wider than 4 cm. He therefore performed a hiatoplasty, where he excised a portion of the introitus and sutured the mucosa closed.  A labiaplasty was performed with scissor excision of the labia minora, bilaterally. Anesthesia was provided by the plastic surgeon’s wife, a pediatrician. Although anesthesia was listed as conscious sedation, the medications administered, propofol, fentanyl, ketamine, and Versed, induced deep sedation.

The patient returned the next day, 8/26/2011, for a post-operative examination.  She complained that her vaginal area was swollen, more on the left than the right side.  The plastic surgeon explained that post-operative swelling was normal and would reduce. There were no signs of infection noted.

The patient returned on 9/2/2011 still complaining of vaginal swelling, the left greater than the right.  The plastic surgeon noted that the patient insisted on liposuction to the left side despite his advisements that the swelling would reduce over time.  A re-touch procedure was planned for 9/6/2011.

There was no note for the 9/6/2011 re-touch procedure; however, an anesthesia record indicated that the patient was given Versed for a “vaginal re-touch.”

There was no indication that the patient returned to the plastic surgeon after 9/6/2011.  She complained of a constant pain to her vaginal area. She cannot wear pants, use a tampon, or engage in sexual intercourse due to the pain from the plastic surgeon’s procedures.

The standard of care when performing a vaginal rejuvenation and labiaplasty calls for using techniques to alter the normal anatomy so that it appears improved.  Techniques to improve the vaginal area should result in a more youthful appearance and less flaccidity of the tissues. This is accomplished by judicious excision of redundancies, filling of flaccid areas with fat transfer, and tightening of tissues using surgery or laser.  While results may vary, there should be full function and a normal appearance of the vaginal area.

Based on the patient’s complaints and the appearance of her vaginal area, the plastic surgeon performed an over-aggressive resection of the labia minora and tightening of the vaginal introitus to the point that the patient’s vagina was non-functional.

When a patient presents for a pre-operative physical, as the patient did on 8/22/2011, the physician has a duty to note the patient’s vital signs.  If the patient has high blood pressure, the physician should refer the patient for a consultation to an internist prior to surgery. A hypertensive patient is not a candidate for elective cosmetic surgery under deep sedation.  At each pre-operative visit to the plastic surgeon, when her blood pressure was checked, the patient’s blood pressure was abnormally elevated. The plastic surgeon failed to refer the patient for a consultation for her hypertension and failed to address that he was even aware of her elevated blood pressure condition.

The standard of care calls for the administration of antibiotics within one hour of the surgical incision.  Further antibiotic treatment is unnecessary unless there is evidence of increased risk for infection. Further, when prescribing Keflex, the customary dose is 500 mg every 6 hours.  There was no indication for pre or post-operative antibiotics in this patient. The plastic surgeon prescribed Keflex for the patient to be taken 500 mg, twice daily. This inappropriate use of Keflex put the patient at risk for development of a drug resistant super-infection.

The plastic surgeon’s care and treatment of the patient as set forth included the following acts and omissions which constituted extreme departures from the standard of practice: his over-aggressive resection of the labia minora and tightening of the vaginal introitus; his failure to refer the patient to an internist for consultation for her hypertensive condition; and his inappropriate prescription of Keflex.

For the allegations in this case and others, the Medical Board Of California ordered that the plastic surgeon lose all his rights and privileges as a physician and surgeon in California. His license was revoked.

State: California

Date: October 2013

Specialty: Plastic Surgery

Symptom: Swelling, Pelvic/Groin Pain

Diagnosis: Post-operative/Operative Complication

Medical Error: Unnecessary or excessive treatment or surgery, Referral failure to hospital or specialist, Physician concern overridden, Improper medication management, Lack of proper documentation, Procedural error

Significant Outcome: Permanent Loss Of Functional Status Or Organ

Case Rating: 4

Link to Original Case File: Download PDF

On 7/24/2006, a 59-year-old female patient came under a family practitioner’s care.  At her initial examination, the patient complained of wheezing in her chest and stated that the symptoms had been going on for the past month.  She reported that her nose and sinuses had been congested for a similar period of time and her ears were congested. The family practitioner did not review prior medical records.  Family history was stated to be negative for asthma or chronic lung disease. The patient was stated to have no allergies. Vital signs were within normal range, and findings on physical examination were reported to be normal.  Tympanic membranes were retracted. Her nasal mucosa was pale and edematous. Her lungs were described as clear, without wheezing or rales. The family practitioner’s assessment was allergic rhinitis. He prescribed a cortisone nasal spray to be used for 5 days with a 12-hour nasal decongestant and thereafter, to be used alone for 30 days.

The patient returned on 9/5/2006, complaining of a cough in addition to the wheezing she had reported at her July visit.  Using a software template for medical charts, the family practitioner replicated his prior note, including the same previous syntactic and typographical errors.  An additional history of tobacco use was obtained on this visit. Vital signs were normal and physical examination was reported to be unchanged. No additional diagnostic tests were performed or ordered, nor was there any documentation that possible tests or x-rays were considered by the family practitioner or discussed with the patient.  Extrinsic asthma with exacerbation was added to the family practitioner’s diagnoses for the patient, albeit the family practitioner did not follow the formal diagnostic protocol for asthma. The family practitioner did not stratify the patient’s asthma by spirometry and type and time of symptoms. She was given prescriptions for an albuterol inhaler, and a 5 day supply of prednisone and Zithromax were added to orders for a repeat course of Flonase and Afrin.

In a note written on 9/14/2006, the patient reported that she felt much improvement after the second course of treatment, however, on 10/6/2006, the patient telephoned to report that her symptoms had returned.  The family practitioner ordered a second course of prednisone, a 10-day course of Biaxin, 500 mg BID, and a repeat course of Zithromax. The rationale for the repeat courses of antibiotic treatment with Biaxin and Zithromax was not documented.  On 10/25/2006, the patient telephoned again to report that she was still wheezing and coughing. The patient stated that she was using her albuterol inhaler on a daily basis. The note stated that the patient desired additional antibiotics before she would come in and, according to the family practitioner’s chart, he agreed to prescribe another course of Zithromax.  He either did not inform the patient of the risks associated with another course of antibiotics, including ineffectiveness of the treatment or possible development of bacterial resistance, or he did not document the discussion. Although the family practitioner later stated that he would have considered a chest x-ray by this point in the patient’s course of treatment, there was no documentation of that, and moreover, there was no documentation of the patient’s informed refusal of an x-ray.

On 11/6/2006, the patient returned.  According to the family practitioner’s chart, she reported that illness had now lasted 4 months, that she had a cough productive of green sputum, and that the five courses of antibiotics she had been prescribed were not helpful.  As a result of an error in record keeping, the family practitioner’s chart notes for this examination was incomplete and did not document what occurred in this visit. No additional tests or x-ray examinations were ordered on this occasion.

On 12/18/2006, the patient returned to the family practitioner.  She stated that she had a cough that was productive of yellow sputum, which was worse at night, and that she had to sit up to catch her breath.  As on other visits, medical information from previous visits was copied into the chart note for this visit. Diffuse wheezing was noted. Inspiratory to expiratory ratio was noted to be prolonged.  The family practitioner gave the patient a prescription for another course of prednisone and a prescription for antibiotics, which was to be used only if she failed to improve after several days of prednisone.  She was prescribed another albuterol inhaler and instructed on the value of the Flunisolide nasal spray. The family practitioner continued his prior diagnosis of allergic rhinitis and asthma.

On 12/27/2006, the family practitioner re-examined the patient.  Although the patient had been noted to have gained weight on the two previous examinations, she now had lost 11 pounds in 9 days; however, the family practitioner’s records did not comment on the possible significance of that change.  The patient continued to complain of a cough, which was productive of green sputum. Spirometry was performed for the first time on that examination and the results were reported as “mild obstructive pattern without significant reversibility.”  The family practitioner continued his prior diagnoses and advised the patient to continue her use of nasal spray and the inhaler. The patient was told to return to the clinic in 3 months.

The patient continued to suffer from a persistent cough.  She reported to an acquaintance that she had coughed up blood on several occasions.  The acquaintance urged her to get a chest x-ray, which she did on 3/6/2007. The report of that examination including a detailed history of a cough for years, with gradual progression.  On physical examination, a diffuse wheezing was noted. A chest x-ray showed a possible mass in the right infrahilar region. A CT scan was recommended.

On 4/11/2007, the patient returned to the family practitioner’s office at which time he noted the results of the chest x-rays as a “right infrahilar density typical of mass lesion.”  The family practitioner made the diagnosis of possible lung cancer. He referred the patient to a pulmonary consultant for a CT scan.

On 4/16/2007, a chest CT was performed, and a 6 cm mass was discovered in the right hilum.  Hepatic lesions were also noted. The diagnosis was probable metastatic bronchogenic carcinoma.  The patient’s metastatic lung cancer, which the family practitioner failed to test for or consider during his care and treatment of the patient over 5 months in 2006, ultimately resulted in her death.

The family practitioner was grossly negligent in his care of the patient in the following: failure to maintain adequate and accurate medical records for the patient; failure to recognize that a cough and dyspnea can be signs of serious illness and failed to appropriately evaluate the patient’s condition or to maintain an appropriate differential diagnosis; failure to follow formal diagnostic protocol for diagnosing and stratifying new onset asthma in an adult patient, including obtaining a chest x-ray, a complete blood count, spirometry, and pulmonary function testing; inappropriately prescribing multiple courses of antibiotics without documenting the presence of a bacterial infection and without obtaining the patient’s informed consent to repeated courses of antibiotics; failure to recommend a chest x-ray for the patient and failure to document informed refusal of a chest x-ray; and lack of medical knowledge.

For this allegation, the Medical Board of California issued the surrender of the family practitioner’s license.

State: California

Date: October 2013

Specialty: Family Medicine, Internal Medicine

Symptom: Shortness of Breath, Bleeding, Cough, Weight Loss

Diagnosis: Lung Cancer

Medical Error: Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Failure of communication with patient or patient relations, Physician concern overridden, Improper medication management, Lack of proper documentation

Significant Outcome: Death

Case Rating: 5

Link to Original Case File: Download PDF

On 9/15/2011, a 26-year-old woman presented for her first prenatal visit.  Her weight was 194 pounds and her blood pressure was 140/88.  On 3/30/2011, her pre-pregnancy blood pressure was 138/86.  The physician, a family practitioner, prescribed prenatal vitamins and ordered labs.  He did not order a 24 hour urine protein.  On 9/19/2011, an ultrasound confirmed a 25 week pregnancy.

On 9/22/2011, the patient presented with headache, a weight of 200 pounds and had a blood pressure of 158/120.  The physician documented the possibility of pre-eclampsia.  Labetalol 200 mg twice a day was prescribed.  Urinalysis revealed urine protein of 100.  On 9/23/2011, she was called by the physician to discuss the lab results and to advise her to go to the hospital.  She refused.  The physician obtained the support of the patient’s mother, but the patient still refused.  The physician called a specialist, who agreed to see the patient.  The patient was supposed to call the specialist, but she never did.  The physician documented that he advised the patient on the risk of seizures, but not stroke, maternal death, or fetal death.

On 9/29/2011, the patient complained of nasal congestion and yellow drainage.  Her blood pressure was 150/120.  Again, she was told that she needed to go to the hospital given the risk of seizures and hypertension,  The patient again refused.  Labetalol was increased to 300 mg three times a day.  Amoxicillin 500 mg twice a day was prescribed.  A 24 hour urine study revealed urine protein at 10930 (normal was less than 149).  The physician increased labetalol.

The patient presented on October 3rd (Monday), where her blood pressure was 160/130.  She was again advised to go to the hospital.  The patient declined and said she would see the specialist, but over the next several days, the patient had not seen the specialist.  The physician then called the specialist to set up an appointment for Thursday.  On October 5th, the patient was hospitalized for eclampsia.  She had a code blue with resuscitation, renal failure requiring diuresis, anemia requiring multiple transfusions, and pneumonia requiring intubation.  A Cesarean section was done at 27 weeks of pregnancy.  The baby required managing in the NICU.

The Board concluded that the physician’s care of the patient was below the minimal standard of care.  There was no documentation that he notified the patient of the risk of maternal or fetal death.  He did not order a 24 hour urine protein study at the first visit.  He did not insist that the patient see an obstetrician or a specialist in maternal fetal medicine that day on October 3rd, where the patient was at high risk for complications.  He increased labetalol for management of preeclampsia, when such treatment would be considered insufficient.  The Board reprimanded the physician and ordered completion of 6 hours of continuing medical education in recognizing and managing preeclampsia and obstetrical emergencies.  A pre-approved course was noted to be “Family Centered Maternity Care Self-Study Package” offered by the American Academy of Family Physicians.

State: Wisconsin

Date: December 2012

Specialty: Obstetrics, Family Medicine

Symptom: Headache

Diagnosis: Preeclampsia

Medical Error: Improper treatment, Failure of communication with patient or patient relations, Physician concern overridden, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 5

Link to Original Case File: Download PDF