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California – Interventional Radiology – Pain And Cold Foot After Arteriogram, Angioplasty, And Atherectomy
On 6/26/2015, a patient presented to an interventional radiologist’s outpatient clinic for a left lower extremity arteriogram and intervention for a thrombosed left lower extremity bypass graft, originally placed in 2007. The patient had an extensive medical history including a renal transplant, diabetes, right leg amputation, and multiple revascularization procedures, including prior thrombectomies of the left lower extremity graft.
The patient reportedly had pain both at rest and with activity, and had a cold left leg prior to and immediately before the procedure. In order to improve blood flow in the patient’s left leg, the interventional radiologist performed an arteriogram, angioplasty, tPA administration, atherectomy, and stent placement within the left lower extremity, including an attempt to revascularize the native superficial femoral artery.
Images show an initially thrombosed femoral artery to popliteal bypass graft and deep femoral artery. Further images show balloons inflated in various parts of the graft and native arteries. Final images show flow through a patent common femoral artery (CFA), bypass graft, and peroneal and anterior tibial arteries. The deep femoral artery appeared occluded shortly beyond its origin.
After the procedure, a nurse noted the patient’s foot was cold. The interventional radiologist also assessed the patient post-procedure and found the foot to be cold, both two (2) and four (4) hours post-procedure. The interventional radiologist recommended to the patient that she travel to the emergency department of a university hospital.
The patient was then driven by her companion two hours to the emergency department, where she was assessed by an ED physician and a vascular surgeon. She was taken to the operating room where she underwent surgery, which included a left leg above-the-knee amputation and a deep femoral artery thrombectomy.
The Board stated that the standard of care for an interventional radiologist when performing an intervention is to recognize complications and to take appropriate steps to manage them. Although the patient’s foot was reportedly cold and painful immediately post-procedure, it can take some time for the foot to warm, and pain could be caused by reperfusion. However, it is clear that two to four hours after the procedure, the interventional radiologist recognized that the patient’s leg had not improved and was worsening and that further care was needed. Thus, when it became clear to the interventional radiologist that the foot was not improving, he recommended that the patient seek more treatment.
The records of the interventional radiologist’s care of the patient were inadequate in that they do not state whether the patient’s clinical status post-procedure was worse than before the procedure. A post-procedure pulse examination was lacking which would have helped in determining the patient’s clinical status.
The patient reported to the ED physician that the pain began after the procedure and steadily worsened, which indicates that the patient rethrombosed her bypass graft and deep femoral artery (source of collateral flow) immediately. This event should have been recognized by the interventional radiologist.
However, the interventional radiologist’s documentation for this patient was inadequate and sparse. The medical records lacked documentation of the change in the patient’s status post-procedure, the discussion with the patient leading up to the discharge from his center, and the patient’s disposition. The interventional radiologist discharged the patient to her own care directly from his clinic instead of calling Emergency Medical Services (EMS), which indicates that the interventional radiologist failed to recognize the gravity of what was occurring.
His conduct did not ensure that the patient would be attended continuously until definitive treatment was given. The patient arrived at the emergency department at approximately 8:00 p.m., two hours after the patient was discharged from the interventional radiologist’s clinic.
Had the process of discharge and transfer occurred earlier, it is possible that the outcome could have been different. The interventional radiologist failed to communicate with the ED physician ahead of the patient’s arrival. The interventional radiologist gave the patient a CD of the procedure, a copy of the medical records, and his phone number, as an attempt of communicating with the emergency department personnel regarding the events that occurred at the interventional radiologist’s clinic.
However, the interventional radiologist failed to telephone the ED physicians at the emergency department to give a verbal report on the patient and to provide a more informative transition and preparation for continued care. In expecting the practitioners at the emergency department to call the interventional radiologist to gain more information, the interventional radiologist improperly sought to shift his responsibility to provide needed information about the patient to the staff at the emergency department.
The interventional radiologist failed to maintain documentation regarding the change in the patient’s status post-procedure, the discussion leading up to the discharge from his center, and the patient’s disposition. He stated that he was not sure if he documented these events, and if he did, he sent them with the patient. Documentation sent with the patient has since been lost. Documentation of a change in the patient’s clinical status was lacking. The medical records lacked documentation of what was discussed regarding the patient’s disposition and where she was told to go for further care.
The Board judged the interventional radiologist’s conduct to have fallen below the standard of care for the following reasons:
1) The interventional radiologist failed to offer to transport the patient by ambulance or EMS services to ensure that she would be attended continuously until definitive treatment was given. His failure to do so indicates that he failed to understand the gravity of the situation which was occurring.
2) The interventional radiologist failed to adequately communicate with the emergency department, to call ahead of time to inform them that the patient was in transit, and to inform them of the circumstances.
3) The interventional radiologist failed to maintain adequate and accurate records.
The Board issued a public reprimand.
State: California
Date: December 2017
Specialty: Interventional Radiology, Vascular Surgery
Symptom: Extremity Pain
Diagnosis: Acute Ischemic Limb, Post-operative/Operative Complication
Medical Error: Diagnostic error, Delay in proper treatment, Underestimation of likelihood or severity, Failure of communication with other providers, Lack of proper documentation
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Family Medicine – Diagnosis Of Deep Cellular Fibrous Histiocytoma With A Differential Diagnosis Of Myofibroblastic Sarcoma
On 3/28/2014, a patient presented to a family practitioner with complaints of a right forearm mass.
On 4/4/2014, the family practitioner excised a 3-4 cm mass from the patient’s right forearm. The family practitioner sent the specimen out for review by a pathologist.
On 4/15/2014, the pathologist via a pathology report listed a diagnosis of deep cellular fibrous histiocytoma with a differential diagnosis of low grade myofibroblastic sarcoma. The pathology report further stated that re-excision was ‘“strongly recommended.”
On 4/16/2014, at a follow-up appointment, the family practitioner informed the patient that the mass was benign. He informed the patient that a wait-and-see approach would be appropriate, and, if the mass returned, further excision would be recommended. The family practitioner did not inform the patient of the differential diagnosis listed on the pathology report. He also did not advise the patient that a re-excision was strongly recommended by the pathologist.
On 1/30/2015, the mass on the patient’s forearm returned and was larger.
On 3/5/2015, a general surgeon performed a second excision on the patient.
On 3/11/2015, the pathology report of the second excision stated a diagnosis of high grade myxofibrosarcoma.
The Board judged the family practitioners conduct to be below the minimum standard of competence given that he failed to fully inform the patient of the pathology report findings and advise the patient that re-excision wass strongly recommended.
It was requested that the Board order one or more of the following penalties for the family practitioner: permanent revocation or suspension of his license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Board deemed appropriate.
State: Florida
Date: November 2017
Specialty: Family Medicine
Symptom: Mass (Breast Mass, Lump, etc.)
Diagnosis: Cancer
Medical Error: Underestimation of likelihood or severity, Failure of communication with patient or patient relations
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Plastic Surgery – Excessive Use Of Lidocaine During SmartLipo Results In Severe Complications
On 11/2/2012, a 39-year-old female presented to an internist for skin tightening intervention in the lower abdomen under local anesthesia with mild oral and intramuscular sedation, a procedure commonly known as “smart lipo.”
The patient was given 700 to 800 ml of an IV of various medicines, including lidocaine, and then three injections of 1% lidocaine.
Shortly after administration of the IV of various medicines and the lidocaine shots, the patient began to have a grand mal seizure. The internist treated the patient with IV fluids and Narcan.
The patient reportedly had normal vital signs at the time, but then had another seizure fifteen minutes later.
According to the internist, ten minutes later, on the third seizure, the internist requested an ambulance.
The internist indicated that the patient, upon the third seizure, lost all pulse and respiration.
According to the EMS staff, the internist did not recognize that the patient was in cardiac arrest upon EMS arrival and was not assisting the patient.
The patient was taken to the emergency room in full cardiac arrest, where she died.
The medical examiner listed the patient’s cause of death as acute lidocaine toxicity due to use of lidocaine in a medical procedure.
The internist failed to adequately prepare or maintain medical records in this case in a way that allowed any medical professionals to adequately know the amount of lidocaine administered to the patient.
The Medical Board of Florida judged the internist’s conduct to be below the minimal standard of competence given that he failed to recognize a lack of blood pressure and administer cardiac support (CPR) upon recognition of a lack of blood pressure. The internist also administered excess lidocaine that caused the patient’s death due to lidocaine toxicity.
The Medical Board of Florida issued a reprimand against the internist’s license. The Medical Board of Florida ordered that the internist pay of $5,000 for his license and pay reimbursement costs for the case at a minimum of $10,683.65 and not to exceed $12,683.65. The Medical Board of Florida ordered that the internist complete a records course, complete ten hours of continuing medical education in liposuction procedures and complete five hours of continuing medical education in “risk management.”
State: Florida
Date: August 2017
Specialty: Plastic Surgery, Internal Medicine
Symptom: N/A
Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Post-operative/Operative Complication
Medical Error: Improper medication management, Underestimation of likelihood or severity, Lack of proper documentation
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF
North Carolina – Internal Medicine – Three Emergency Department Visits With Persistent Severe Headache And A Negative CT Head Scan
The Board was notified of a professional liability payment paid on 3/8/16.
A 48-year-old female presented to the emergency department three times over the course of two days with complaints of severe headache.
During the 7/28/12 visit, she had a non-contrast CT head, which was reported as normal. The patient’s headache was treated as an acute migraine attack. She was discharged with anti-migraine, anti-nausea, and anti-anxiety medications.
On 7/29/12, the patient returned with persistent symptoms, was treated symptomatically, and discharged. Later that day, the patient again returned to the emergency department with continuing headache and persistent nausea and vomiting.
The patient was admitted to the hospital under the care of an internist. The patient was started on maintenance IV fluids to treat dehydration and was treated for the underlying migraine with analgesics and antiemetic.
During the internist’s care of the patient, the internist did not order a spinal tap or additional CT scan, instead relying on the 7/28/12 emergency department CT scan.
On hospitalization day three, the patient was discharged with anti-migraine and anti-nausea medications, and was advised to follow up with her primary care physician or neurologist within a week.
On 8/2/12, the day after discharge, the patient returned to the emergency department with a continuing headache and a CT scan of her head showed intracranial hemorrhage in the right temporal lobe.
The patient was then airlifted to a tertiary care center and had clipping of a brain aneurysm/hematoma removal and ventriculoperitoneal shunt placement.
The Board obtained the patient’s records and sent them to a qualified independent medical expert for review.
The independent medical expert judged the internist’s conduct to be below the minimum standard of competence given failure to provide adequate care for severe persistent headache with normal neurological exam. The medical expert found that the internist failed to perform a lumbar puncture and repeat imaging or seek neurology input.
The Board issued a public letter of concern, which was reported to the Federation of State Medical Boards. It was not reported to the National Practitioner Data Bank.
State: North Carolina
Date: July 2017
Specialty: Internal Medicine, Hospitalist
Symptom: Headache, Nausea Or Vomiting
Diagnosis: Intracranial Hemorrhage
Medical Error: False negative, Delay in proper treatment, Failure to order appropriate diagnostic test, Underestimation of likelihood or severity
Significant Outcome: Permanent Loss Of Functional Status Or Organ, Hospital Bounce Back
Case Rating: 4
Link to Original Case File: Download PDF
Florida – Gynecology – MRI Reveals Two Adjacent Large Intraperitoneal Complex Cystic Masses With Plan For Removal
On 11/19/2013, a 44-year-old female presented to a gynecologist for abdominal/pelvic discomfort.
The gynecologist performed an ultrasound and reported a “large ovarian cyst 14 cm in greatest extent… simple in nature.” The gynecologist ordered additional imaging of the patient’s abdomen and pelvis to further evaluate the cyst.
The patient was scheduled for surgical removal of the cyst to be performed by the gynecologist on 11/27/2013.
On 11/22/2013, an MRI of the patient’s pelvis was performed, which indicated the presence of “two adjacent large intraperitoneal complex cystic masses.”
On 11/27/2013, preoperatively, the gynecologist indicated that he read the history and physical and examined the patient and that there were “no changes.”
After receiving and reviewing the MRI report, the gynecologist failed to further evaluate, or alternatively, did not create, keep, or maintain adequate legible documentation of evaluating, whether a malignancy was present.
Prior to the surgery on 11/27/2013, the gynecologist failed to discuss, or alternatively, did not create, keep, or maintain adequate legible documentation of discussing, with the patient her desired plan-of-care in the event that the cysts contained malignant cells.
The gynecologist attempted to remove the cysts laparoscopically, by intentionally puncturing and aspirating the cysts. Prior to intentionally puncturing the cysts, the gynecologist did not place the cysts into a specimen bag to prevent contamination in the event that the cysts contained malignant cells. During the procedure, the contents of the cysts spilled into the patient’s abdominal cavity.
Intraoperatively, the procedure was converted to a laparotomy and the gynecologist removed the patient’s left ovary in its entirety and sent it to pathology. The pathology report indicated that the specimen was “of at least low malignant potential” indicating possible higher grade abnormality.
Accordingly, the gynecologist performed a total abdominal hysterectomy and removal of the right ovary.
The Board judged the gynecologist’s conduct to be below the minimal standard of competence given that he failed to further evaluate, preoperatively, to determine whether a malignancy was present, proceed with the correct surgical approach on 11/27/2013, by performing a laparotomy and removing the cysts intact, or by placing a specimen bag around the cysts prior to intentionally puncturing and aspirating the cysts, and discussing with the patient, preoperatively, to determine the patient’s desired plan-of-care for the possibility of malignancy.
It was requested that the Board order one or more of the following penalties for the gynecologist: permanent revocation or suspension of his license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Board deemed appropriate.
State: Florida
Date: July 2017
Specialty: Gynecology
Symptom: Abdominal Pain, Mass (Breast Mass, Lump, etc.)
Diagnosis: Gynecological (Endometrial, Ovarian, Cervical) Cancer
Medical Error: Underestimation of likelihood or severity, Failure of communication with patient or patient relations, Procedural error
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Family Medicine – Patient With Hypotension And Tachycardia Treated With 2 Liters Of Intravenous Normal Saline
On 11/12/2013, a patient presented with complaints of nausea, vomiting, and abdominal pain. The patient also had a history of deep vein thrombosis (DVT) and renal cell carcinoma.
The patient’s pertinent physical findings included a hypotensive blood pressure of 84/56 and a pulse of 158 beats per minute. The patient received two liters of intravenous normal saline without improvement in his blood pressure.
On 11/13/2013, at 2:00 a.m., a family practitioner admitted the patient to the hospital and implemented a plan of care to include a routine lab work, normal saline, chest x-ray, and medications.
The family practitioner failed to address the patient’s history of DVT and anticoagulation therapy.
At 3:50 a.m., the patient suffered a fall, became unresponsive, and could not be resuscitated.
The prevailing standard of care in an urgent care setting is to identify the patients who can be treated with basic intervention and be safely discharged to the ambulatory setting, or alternatively to identify the patients who are at risk of losing life or limb and must be transferred to a higher level of care where resources are available to address, diagnose, and treat the life-threatening condition in a timely manner.
The Medical Board of Florida judged the family practitioner’s conduct to be below the minimal standard of competence given that he failed to recognize and address the patient’s grossly abnormal vital signs, which included a heart rate of 158 beats per minute and a systolic blood pressure under 100 mmHg, which did not stabilize after an intravenous fluid bolus. The family practitioner also failed to treat the patient with more aggressive intravenous fluid resuscitation. He failed to order STAT lab work, instead of routine lab work. He failed to acknowledge, document, or treat the patient’s anticoagulated blood by reversing the anticoagulation with intravenous vitamin K and transfusing fresh frozen plasma.
The Medical Board of Florida issued a letter of concern against the family practitioner’s license. The Medical Board of Florida ordered that the family practitioner pay a fine of $7,500.00 against his license and pay reimbursement costs for the case at a minimum of $2,023.11 and not to exceed $4,023.11. The Medical Board of Florida also ordered that the family practitioner complete five hours of continuing medical education in emergency medicine and five hours of continuing medical education in “risk management.”
State: Florida
Date: April 2017
Specialty: Family Medicine, Emergency Medicine, Internal Medicine
Symptom: Abdominal Pain, Nausea Or Vomiting
Diagnosis: Cardiovascular Disease
Medical Error: Underestimation of likelihood or severity, Failure to order appropriate diagnostic test, Referral failure to hospital or specialist, Improper medication management
Significant Outcome: Death
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Obstetrics – Postpartum Bleeding Following Early Labor In A Patient With A History Of Anemia
On 9/7/2012 at 8:00 p.m., a 27-year-old female presented to a medical center with a complaint of early labor. The patient had a history of anemia.
At 8:50 p.m., a biophysical profile was ordered for the patient due to heart tracing concerns for the fetus.
By the time the patient arrived back from her biophysical profile, she was found to have made cervical changes from 1-½ cm to 4 cm, and she then very rapidly went from 4 cm to 9 cm.
At 11:15 p.m., the patient’s membranes were artificially ruptured and meconium stained fluid was obtained. At this time, the cervix was now completely dilated.
At 11:55 p.m., an obstetrician applied a fetal scalp lead to better evaluate the monitor tracing.
At 12:15 a.m., the obstetrician then called in additional medical personnel and proceeded to apply a Kiwi vacuum extractor.
At 12:17 a.m., a second vacuum was applied and at 12:27 a.m. a third vacuum was applied.
At 12:27 a.m., the fetus was delivered with the baby weight 9 pounds and 8 ounces
The patient then experienced a severe postpartum hemorrhage, and the obstetrician inspected the cervix and found there to be no lacerations. The obstetrician used appropriate medications to cause the uterus to clamp down.
At 12:45 a.m., the obstetrician repaired episiotomy and third-degree perineal laceration, and the uterus was still boggy in spite of the medications. The bleeding continued.
At 1:00 a.m., the uterus was described as firm, the bleeding had decreased and the patient was sleepy but responsive.
At 1:15 a.m., the patient had a steady trickle of lochia resulting in the obstetrician being called back into the room.
At 1:20 a.m., the obstetrician performed a repair of laceration.
At 1:25 a.m., the patient was administered a Foley catheter per the obstetrician’s instructions.
At 1:35 a.m., following repair of the laceration, the patient was bleeding dark blood vaginally. Additionally, the patient was hypotensive and lethargic.
Sometime after 1:35 a.m. but before 2:10 a.m., the obstetrician left the hospital.
At 2:00 a.m., the patient continued to bleed vaginally, small to moderately.
At 2:10 a.m., the patient’s family called medical staff to the room due to the patient “acting funny” as the patient was lying on her stomach and moving her legs and moaning that she was hurting but would not say where.
At 2:10 a.m., the patient was noted to have bloody fluid in the Foley catheter.
The obstetrician was not present in the hospital at the time. The obstetrician was informed of the patient’s behavior and the continuation of her steady trickle of blood.
At 2:25 a.m., a registered nurse stayed in the room with the patient as the patient became more combative and a large amount of blood poured from the patient’s vagina.
At 2:25 a.m., the obstetrician was called to return to the hospital.
At an unidentified time, the obstetrician was called again to ensure she was on her way back to the hospital.
At 2:55 a.m., the obstetrician arrived back in the hospital room with the patient.
At 3:14 a.m., the patient became unresponsive and a code blue was called. The patient experienced cardiac arrest and cardiopulmonary resuscitation was started.
At 6:03 a.m., the patient was pronounced dead.
The Medical Board of Florida judged the obstetricians conduct to be below the minimal standard of competence given that she failed to determine the source of the bleeding for the patient who had been bleeding heavily after a vaginal delivery. The obstetrician failed to transfer the patient to the operating room for evaluation. She also failed to remain at the physical location of the hospital to monitor the patient who had been bleeding continuously.
It was requested that the Medical Board of Florida order one or more of the following penalties for the obstetrician: 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: February 2017
Specialty: Obstetrics
Symptom: Abnormal Vaginal Bleeding
Diagnosis: Obstetrical Hemorrhage
Medical Error: Underestimation of likelihood or severity, Failure to examine or evaluate patient properly, Failure to properly monitor patient
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF
Florida – Family Medicine – Weakness Of The Left Hand And Slurred Speech For Three Weeks
On 8/14/2014, a 54-year-old male presented to an urgent care clinic with complaints of weakness in his hands and slurred speech for three weeks.
The patient was initially seen by a triage nurse who noted weakness in the left hand, affected speech, and feeling “stroke-like symptoms.”
The patient’s checklist listed “stroke symptoms” as a concern to be addressed by the family practitioner.
The family practitioner reportedly did a complete neurological exam of the patient with the family practitioner noting weakness as the only finding.
There was a later note by the family practitioner that the neurological exam was normal.
The family practitioner diagnosed the patient with a transient ischemic attack (“TIA”).
The family practitioner also diagnosed the patient with an allergic reaction and increased blood pressure.
The family practitioner treated the patient for the allergic reaction and increased blood pressure but never treated the patient for the TIA.
The next morning, the patient went to an emergency room due to inability to walk.
The patient was diagnosed with a massive cerebral infarction.
The patient became severely incapacitated and had to reside at an assisted living facility.
The Medical Board of Florida judged the family practitioner’s conduct to be below the minimal standard of competence given that he failed to treat the TIA and/or make an urgent referral to a facility for further evaluation including neuroimaging, cervical cephalic vasculature imaging, cardiac evaluation, statin medication, and blood pressure management.
It was requested that the Medical Board of Florida order one or more of the following penalties for the family practitioner: permanent revocation or suspension of his license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Medical Board of Florida deemed appropriate.
State: Florida
Date: February 2017
Specialty: Family Medicine, Internal Medicine
Symptom: Weakness/Fatigue
Diagnosis: Ischemic Stroke
Medical Error: Underestimation of likelihood or severity, Referral failure to hospital or specialist
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Oncology – Oncologist Unable To Load Up Images From Imaging Disc
In the months and/or years leading up to January 2013, an oncologist’s care for a patient included monitoring her for recurrence of lung cancer.
Sometime in 2012, the oncologist ordered diagnostic imaging services for the patient that were to be performed around January 2013.
On 1/8/2013, the patient received diagnostic imaging services. The ensuing diagnostic imaging report noted abnormal densities/masses in the patient’s lungs that were indicative of malignant neoplasm.
On 1/21/2013, the patient presented to the oncologist for an appointment. During the appointment, the oncologist failed to mention any of the January 2013 diagnostic imaging report findings to the patient.
On 1/22/2013, the oncologist electronically signed, and/or otherwise approved, a medical progress note for the patient that acknowledged the diagnostic imaging performed on 1/8/2013. The progress note referenced in the preceding paragraph stated that the patient exhibited no evidence of recurrent disease.
In May 2013, the patient telephoned the oncologist’s office and advised that one of her other physicians was concerned about areas of growth in her lung(s) shown on the patient’s January 2013 diagnostic images.
Personnel affiliated with the oncologist’s office indicated that the oncologist would be advised of the patient’s call.
In the time between the oncologist’s May 2013 telephone call and 1/10/2014, the oncologist did not order or perform any additional diagnostic services for the patient. He did not indicate/communicate concern that the patient’s cancer was returning.
On 1/10/2014, the patient returned to the imaging center for diagnostic imaging services. The ensuing diagnostic imaging report noted an enlarging mass in the patient’s lungs that was concerning for recurrent cancer.
On 1/14/2014, the patient presented to the oncologist for an appointment. During the appointment, the oncologist was unable to load an imaging disc provided by the imaging center. The oncologist instructed the patient that she could follow up with a local oncologist.
Between 1/10/2014 and May 2014, the oncologist did not obtain and/or review the January 2014 diagnostic imaging report for the patient.
Between 1/10/2014 and May 2014, the oncologist did not order or perform any additional diagnostic services for the patient, nor did he indicate/communicate concern that the patient’s cancer was returning.
In May 2014, the patient presented to and was diagnosed with lung cancer by a different physician.
The Medical Board of Florida judged the oncologists conduct to be below the minimal standard of competence given that he failed to accurately interpret or characterize all known and available diagnostic imaging reports of the patient’s lungs. He failed to timely obtain, review, and communicate with the patient regarding any ordered but unreviewed diagnostic imaging reports of the patient’s lungs.
The Medical Board of Florida ordered that the oncologist pay an administrative fine of $7,000 to the Board. He also was ordered to complete five hours of continuing medical education in “risk management” and complete five hours of continuing medical education in the area of diagnosis and treatment of lung cancer. The Medical Board of Florida also placed the oncologist’s license on probation for a period of one year.
State: Florida
Date: February 2017
Specialty: Oncology, Internal Medicine
Symptom: N/A
Diagnosis: Lung Cancer
Medical Error: Failure to follow up, Underestimation of likelihood or severity, Failure of communication with patient or patient relations
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
North Carolina – Nephrology – Deciding To Initiate Vancomycin For Patient With Prior History Of Tachycardia And Dyspnea After Receiving Vancomycin
The Board was notified of a professional liability payment made on 6/5/15.
A 31-year-old male with end-stage renal disease presented to the emergency department with cough, fever, and acute pain. The initial diagnosis was sepsis. He was given cefazolin and gentamicin. The patient’s allergy history was noted to include penicillin and vancomycin.
The patient subsequently underwent two transfers of care. During these transfers, it was indicated by various physicians that the patient would require intravenous vancomycin to treat sepsis. Given the patient’s ambiguous allergy history, the evening hospitalist made the decision to defer to a nephrologist the decision regarding the treatment of the patient with vancomycin as the nephrologist had treated the patient in the past. As the patient’s nephrologist, he was aware that the patient had received vancomycin in the past both intravenously and intraperitoneally. The patient had previously developed tachycardia and dyspnea after receiving vancomycin. The nephrologist had concluded that the patient’s reaction to the most recent exposure to vancomycin was not a true allergic reaction, but rather “red man syndrome” and that the patient now required vancomycin to successfully treat the sepsis. Within minutes of the start of the vancomycin infusion, the patient developed tachycardia, dyspnea, and ultimately cardiac arrest from which he could not be revived.
The Board expressed concern that the nephrologist’s care of the patient fell below the standard of care.
The Board issued a public letter of concern, which was reported to the Federation of State Medical Boards. It was not reported to the National Practitioner Data Bank.
State: North Carolina
Date: February 2017
Specialty: Nephrology
Diagnosis: Sepsis
Medical Error: Improper medication management, Underestimation of likelihood or severity
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF