Page 1 of 13
Florida – Radiology – Gastrografin GI Series Performed to Ascertain GI Leak But No Leak Reported By Radiologist
On 6/23/2014, a 66-year-old male presented to the Physicians Regional Medical Center for gastric bypass surgery.
Following the gastric bypass procedure, on 6/24/2014, a radiologist performed a Gastrografin upper GI series on the patient to ascertain whether there was a leak or obstruction in the patient’s digestive tract. A leak of contrast material was visible on radiographic images obtained by the radiologist during the procedure; however, the radiologist failed to detect the leak in the patient’s digestive tract and reported a negative GI series. The patient was subsequently discharged from the hospital.
Approximately thirty hours after his discharge, the patient returned to the hospital suffering from abdominal pain and sepsis. It was discovered that the patient had a perforation in his digestive tract. During surgery to repair this perforation, the patient suffered cardiac arrest and anoxic brain injury. The patient ultimately expired as a result of these complications on 7/10/2014
The Board judged the radiologist’s conduct to be below the minimum standard of competence given his failure to detect a leak in the patient’s digestive tract during the performance of a Gastrografin upper GI series.
State: Florida
Date: December 2017
Specialty: Radiology
Symptom: N/A
Diagnosis: Acute Abdomen
Medical Error: False negative
Significant Outcome: Death, Hospital Bounce Back
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Emergency Medicine – Patient With Intussusception Involving Loop Of Small Bowel Discharged Home With Magnesium Citrate
At 1:45 a.m. on 7/26/2014, a 46-year-old female presented to the emergency department with complaints of severe abdominal pain. Upon arrival at the emergency department, the patient was evaluated by the ED physician.
The patient complained of severe abdominal pain and stated the pain was “10 out of 10.” The patient then underwent laboratory studies and a CT scan of the abdomen/pelvis with intravenous and oral contrast.
A radiologist reviewed the CT scan at some time before 4:16 a.m., when he read and signed the preliminary report. Upon review of the CT scan results the radiologist recorded in the preliminary report “intussusception involving loop of small bowel in the left lower quadrant with involved loops appearing edematous.” The radiologist relayed the results of the CT scan to the ED physician via teleradiology.
The ED physician recorded the results of the CT scan in the patient’s emergency provider report and noted “thickened loop of small bowel in the left lower quadrant, [m]ay be intussuception [sic].”
At 4:32 a.m. the ED physician discharged the patient to her home with a magnesium citrate prescription and no additional discharge instructions.
At 8:28 a.m. a physician signed the final radiology report and noted “[i]ntussesception involving loop of small bowel in the left lower quadrant” and “preliminary report related to referring physician teleradiology at the time of the exam by the radiologist.”
Later that day, the patient developed worsening pain, and presented to another emergency department, and underwent an emergency surgery for resection of necrotic bowel.
The Board judged the ED physician’s conduct to be below the minimum standard of competence given his failure obtain emergent surgical consultation for further evaluation and treatment and continue hospitalization for operative intervention or ongoing evaluation of abdominal pain.
The Board ordered the ED physician to pay an administrative fine in the amount of $8,000. Also, the Board ordered the ED physician to complete five hours of continuing medical education in the area of emergency medicine.
State: Florida
Date: December 2017
Specialty: Emergency Medicine
Symptom: Abdominal Pain
Diagnosis: Acute Abdomen
Medical Error: Improper treatment, Referral failure to hospital or specialist
Significant Outcome: Hospital Bounce Back
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Interventional Radiology – Guidewire Found In Patient’s Abdomen Following CT-Guided Percutaneous Drainage
On 8/24/2015, a 63-year-old male presented to a medical center for a CT-guided percutaneous aspiration with possible drainage of an abdominal abscess.
During the course of the procedure, an interventional radiologist placed a guidewire into the operative field. Once the procedure was completed the patient had stable vital signs and no immediate complications were known.
On 9/12/2015, the patient was re-admitted to the medical center with complaints of abdominal pain. A subsequent CT scan revealed a foreign body on the left side of the patient’s abdomen.
On 9/15/2015, a general surgeon performed laparoscopic retrieval of the foreign body, at which time a portion of the guidewire, measuring 11.0 centimeters in length, was found and removed intact.
The Board ordered that the interventional radiologist pay a fine of $5,000 against his license and that the radiologist pay reimbursement costs for the case at a minimum of $4,737.16 and not to exceed $6,737.16. The Board also ordered that the interventional radiologist complete five hours of continuing medical education in “Risk Management” and that the interventional radiologist complete a one hour lecture/seminar on retained foreign body objects.
State: Florida
Date: November 2017
Specialty: Interventional Radiology
Symptom: Abdominal Pain
Diagnosis: Post-operative/Operative Complication, Acute Abdomen
Medical Error: Retained foreign body after surgery
Significant Outcome: Hospital Bounce Back
Case Rating: 2
Link to Original Case File: Download PDF
Florida – Urology – Stent Placed For Kidney Stone Placed In Wrong Ureter
On 7/16/2016, a 50-year-old male presented to the medical center emergency department with abdominal pain.
The patient was diagnosed with renal kidney stones and admitted to the hospital.
The patient was taken to the operating room for a planned cystoscopy, right ureteroscopy, and placement of right ureteral stent.
Informed consent was obtained from the patient for the placement of the right ureteral stent.
On 7/20/2016, a urologist placed a stent in the patient’s left ureter (wrong site), rather than the right ureter (correct site). The patient was then discharged home.
On 7/25/2016, the patient returned to the hospital with complaints of abdominal pain.
A CT scan of the patient’s abdomen and pelvis revealed right distal ureteral stones with moderate right hydronephrosis. The CT scan also revealed a left ureteral without left hydronephrosis.
On 7/26/2016, the patient was informed by the Chief Medical Officer of the hospital that the surgery was performed on the wrong side.
On 7/26/2016, the patient underwent a second procedure to remove the foreign body (left stent) and right ureteroscopy with laser lithotripsy and placement of right ureteral stent.
The second surgery was performed without incident and the patient was discharged home on 7/27/2016.
It was requested that the Board order one or more of the following penalties for the urologist: 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: August 2017
Specialty: Urology
Symptom: Abdominal Pain
Diagnosis: Renal Disease
Medical Error: Wrong site procedure
Significant Outcome: Hospital Bounce Back
Case Rating: 3
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 – Interventional Radiology – Kyphoplasty Performed On T11 Instead Of T12 Site For T12 Fracture After A Fall
On 10/13/2015, a 70-year-old male was transported to the emergency department after a fall from a hammock when the rope broke.
A CT scan of the lumbar spine was done and a 20% anterior wedge compression fracture on the T12 section was found. An MRI of the lumbar spine, on the same day, showed an acute T12 compression fracture. An MRI of the thoracic spine was done, on the same day, and showed an acute T12 compression fracture with bone marrow edema.
The patient was admitted to the hospital and recommended for T12 kyphoplasty.
On 10/14/2015, an interventional radiologist performed a kyphoplasty on the patient’s T11 vertebrae (wrong site), instead of the T12 vertebrae.
The patient was discharged on 10/19/2015 and began having progressively more pain.
On 10/22/2015, the patient was readmitted to the hospital by ambulance with progressively worsening pain.
On 10/23/2015, a two-view x-ray of the lumbar spine revealed that a T12 compression fracture had remained unchanged despite the 10/12/2015 surgery, and that the T11 vertebrae had been unnecessarily operated upon.
The patient was discharged to a rehabilitation center for two weeks to recover.
The Board issued a letter of concern against the interventional radiologist’s license. The Board ordered that the interventional radiologist pay a fine of $4,000 against his license and pay reimbursement costs for the case at a minimum of $2,009.04 and not to exceed $4,009.04. The Board also ordered that the interventional radiologist complete five hours of continuing medical education in “risk management” and complete a one-hour lecture/seminar on wrong site surgeries.
State: Florida
Date: June 2017
Specialty: Interventional Radiology
Symptom: Pain
Diagnosis: Fracture(s), Spinal Injury Or Disorder
Medical Error: Wrong site procedure
Significant Outcome: Hospital Bounce Back
Case Rating: 2
Link to Original Case File: Download PDF
Florida – Radiology – Failure To Diagnose Subdural Hematoma From Radiology Report
On 10/27/2015, a patient presented to the emergency department after suffering a fall.
An emergency department physician ordered a computerized tomography (CT) scan of the patient’s head.
Radiologist A reviewed the CT scan. Radiologist A failed to recognize or failed to report the presence of a significant subdural hematoma. Radiologist A erroneously reported that the CT scan showed no acute intracranial abnormalities.
The patient’s wounds from the fall were treated, and the patient was discharged home. That night, the patient became unresponsive at home and was transported back to the hospital.
A second CT scan was performed and was reviewed by Radiologist B. Radiologist B compared the second CT scan to the first CT scan performed earlier that day.
Radiologist B noted that the first CT scan showed a 6 mm hematoma. He reported that the second CT scan showed that the hematoma had markedly increased in size to 28 mm since the first scan taken approximately six hours before.
The patient expired the morning of 10/28/2015, due to complications from an acute subdural hematoma.
The Board judged Radiologist A’s conduct to be below the minimal standard of competence given that she failed to recognize and report any significant abnormalities present on a patient’s CT scan.
It was requested that the Board order one or more of the following penalties for Radiologist A: 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 Board deemed appropriate.
State: Florida
Date: June 2017
Specialty: Radiology
Symptom: N/A
Diagnosis: Intracranial Hemorrhage, Trauma Injury
Medical Error: False negative
Significant Outcome: Death, Hospital Bounce Back
Case Rating: 3
Link to Original Case File: Download PDF
California – Emergency Medicine – Spontaneous Movement And Loss Of Sensation Of The Left Arm
On 6/1/2015, a 65-year-old male with a history of hypertension, atrial fibrillation, hyperlipidemia, depression, and anxiety, visited his primary care physician (PCP) complaining of spontaneous movement and loss of sensation in his left arm. On physical examination of this patient, his PCP identified a loss of coordination and sensation in the upper left extremities. Three years prior, this patient had undergone a surgical C4 partial corpectomy and fusion of cervical level C4 and C5 for cervical cord compression with impaired gait. On 6/1/2015, his PCP diagnosed intermittent left limb ataxia and transferred the patient to the emergency department of the Veterans Administration Medical Center.
In the emergency department, ED physician A diagnosed upper extremity neuropraxia after obtaining a CT scan of the cervical spine. ED physician A also ordered an MRI for 6/4/2015 before discharging the patient.
On 6/2/2015, the patient returned to the emergency department. The patient described to a triage nurse and a direct care nurse symptoms of worsening left arm numbness, light flashes, a change in depth perception, imbalance and overall feeling “a lot worse.” Thereafter, ED physician B, who was the on-duty emergency physician, saw the patient. ED physician B documented that the patient had recurrent loss of left upper extremity control and paresthesias and that the patient expressed fear that he was having a stroke and might die. ED physician B’s medical note further stated that the patient had no vision changes and that his sense and strength were grossly intact. ED physician B informed the patient that he would have to wait for his cervical MRI until 6/4/2015, and ED Physician B did not appear to complete a brain MRI for the patient. ED physician B found the patient’s primary diagnosis to be anxiety.
After the patient’s discharge from the emergency department, he continued to have persistence of his symptoms. The patient was ultimately referred to a neurologist who ordered a brain MRI on 7/27/2015, which showed right cerebral sub-acute watershed infarcts and an occluded right internal carotid artery. The patient was transferred to a specialty stroke center for additional evaluation and treatment.
According to the Board, when ED Physician B undertook the care and treatment of the patient, a worried patient with substantial risk factors who returned to the emergency department less than 24 hours for progressing complex neurological symptoms, and failed to obtain an accurate history and review of systems.
In addition, the Board judged ED Physician B’s conduct of the patient to be below the minimal standard of care given his failure to perform an effective neurological examination of the patient, failure to perform indicated imaging studies, and failure to obtain a neurology consult. The Board deemed ED physician B’s failures to collectively constitute an extreme departure from the standard of care.
The Board issued a public reprimand with stipulations to complete a continuing medical education course on the topic of patient communication and a course on medical record keeping.
State: California
Date: May 2017
Specialty: Emergency Medicine
Symptom: Numbness, Vision Problems, Weakness/Fatigue
Diagnosis: Ischemic Stroke
Medical Error: Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Lack of proper documentation
Significant Outcome: Hospital Bounce Back
Case Rating: 3
Link to Original Case File: Download PDF
California – Gastroenterology – Fevers And Chills After Endoscopic Retrograde Cholangiopancreatography (ERCP)
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
California – Gastroenterology – Endoscopy In High Risk Patient With Esophageal Scleroderma Results In Complications
A 69-year-old male with diffuse systemic sclerosis, interstitial lung disease, end stage renal disease on hemodialysis, anemia, hypertension, hypoalbuminemia, secondary hypothyroidism, and gastric antral vascular ectasia (“GAVE”) had been referred to a gastroenterology clinic for evaluation of recurrent problems with weight loss and dysphagia. It was assumed that the patient’s disease had progressed to esophageal scleroderma and that a percutaneous endoscopic gastrostomy (“PEG”) would be necessary to bypass his esophagus and would allow him to take in adequate nutrition without swallowing. The patient was referred to the gastroenterology clinic for evaluation and a PEG.
On 6/25/2012, the gastroenterologist ordered a PEG, and she scheduled an esophagogastroduodenoscopy (“EGD” or upper endoscopy) and esophageal manometry for the afternoon of 6/25/2012, both elective, non-emergent diagnostic procedures, scheduled to be done on an outpatient basis. On 6/23/2012 or 6/24/2012, the patient had been discharged from the hospital on antibiotics with home oxygen administration after treatment for aspiration pneumonia.
The gastroenterologist performed a pre-endoscopy history and physical examination in the early afternoon of 6/25/2012 and noted that the patient had active diffuse scleroderma complicated by renal crisis, diffuse systemic sclerosis, interstitial lung disease, GAVE with multiple cauterizations, and end stage kidney disease. In past medical history, she listed “scleroderma renal crisis, “Started dialysis December 30, 2011,” and “Pneumonia. Admitted to er 6/24/12.” She noted that the patient had had multiple upper endoscopies for gastrointestinal bleeding prior to this EGD. Her physical examination listed “Lungs: Clear Auscultation. Clear percussion and Normal Symmetry and Expansion.” She noted that she, not an anesthesiologist, was ordering sedation.
Sedation was to be administered by a registered nurse. The gastroenterologist listed Airway as Class 2 and ASA Level (American Society of Anesthesiologists physical status classification system) as 3 (severe systemic disease).
On 6/25/2012 at 2:48 p.m. and ending at approximately 3:15 p.m., the gastroenterologist performed an upper endoscopy on the patient and took biopsies. Nursing records indicate that sedation consisted of midazolam, 7 mg, administered over the 22 minutes; fentanyl, 175 mcg administered over the 22 minutes, and Cetacaine spray applied to the throat prior to the procedure.
The patient was transferred from the endoscopy procedure room to the recovery area under the care of a registered nurse. The nurse noted that the patient was unresponsive to verbal and painful stimuli, with blood pressure 108/70, heart rate 86, and O2 saturation 89% on 2 liters delivered by nasal cannula. A face mask was applied at 10 liters O2 and oxygen saturation went up to 97%. When the gastroenterologist was notified, she ordered reversal medications: flumazenil 0.25 mg IVP over 15 seconds and Narcan 0.4 mg IVP at 3:40 p.m., and the patient was still unresponsive. A second dose of flumazenil 0.25 mg IVP was given at 3:43 p.m., and the patient became responsive at 3:44 p.m. Once the patient was responsive, the gastroenterologist performed the esophageal manometry procedure. No time is entered in the medical record for this procedure although the gastroenterologist acknowledges that it was done and the results are recorded.
The gastroenterologist was later notified by nursing staff of concerns with the patient’s breath sounds, and the gastroenterologist noted stridor at 4:26 p.m. She was notified at 5:19 p.m. that the patient’s oxygen saturation was 89% on 5 liters oxygen delivered by nasal cannula. At 5:20 p.m., the gastroenterologist ordered a chest x-ray due to the inability to wean the patient off oxygen after the endoscopy. A face mask was applied at 10 liters oxygen at 5:21 p.m., and oxygen saturation went up to 93%. The chest x-ray indicated “a dense retrocardiac opacity and a left pleural effusion” and a “volume loss in the left lung with mild shift of the mediastinum towards the left.”
After the manometry procedure in the recovery room, the patient’s oxygen saturation was monitored, and when the oxygen saturation remained above 90% for 30 minutes on room air, the patient met endoscopy discharge criteria. The patient was discharged home with instructions concerning any complications that might arise.
The gastroenterologist states that she arranged to admit the patient to the hospital, but the patient left against medical advice (AMA). Neither notation of this nor a signed AMA release was found in the record. Pathology results revealed gastritis and the manometry procedure revealed a condition consistent with esophageal scleroderma.
On 6/27/2012, the patient presented to the emergency department with shortness of breath and cough. Chest x-ray showed new right lung patchy opacities, and the patient was cachectic. He was admitted to the intensive care unit for treatment of pneumonia. The admission diagnosis was “most likely persistent pneumonia, likely aspiration due to esophageal dysmotility.” The patient failed to improve despite intensive hospital care. Although the gastroenterologist had scheduled a PEG for 7/2/2012, it was decided that the patient would not go through with the procedure. Instead, it was decided that the medical team would provide palliative care for the patient.
On 7/4/2012, the patient died with the cause of death listed as aspiration pneumonia due to esophageal dysmotility and end-stage scleroderma with severe malnutrition as a contributing factor.
The Board deemed the gastroenterologist’s conduct as falling below the standard of care for the following reasons:
1) The gastroenterologist failed to provide an accurate analysis of the patient’s suitability for the endoscopic and manometry procedures.
2) She classified the patient as an ASA Level 3, which denotes an individual with stable multiple system disease that limits daily activity without immediate danger of death.
3) At the time of the EGD and manometry done by the gastroenterologist, the patient had just been released from another hospital, where he had been treated for aspiration pneumonia and discharged on antibiotics and home oxygen.
4) By reason of the patient’s recent aspiration pneumonia and the necessity for home oxygen administration, his ongoing scleroderma renal crisis which necessitated hemodialysis, his persistent interstitial lung disease, and his frequent bleeding and cauterizations for GAVE, his condition was not stable, and elective procedures at this time were contraindicated. The patient’s classification was clearly ASA level 4, which denotes an individual with severe, incapacitating disease, poorly controlled or end-stage, at risk for death due to organ failure.
5) The gastroenterologist failed to provide for an anesthesiology consultation, given the patient’s unstable and life-threatening condition, and instead elected to provide conscious sedation directed by the gastroenterologist and administered by a registered nurse. The level of sedation administered to the patient during the upper endoscopy procedure was relatively large for an individual with so many co-morbid conditions, and an anesthesiologist or nurse anesthetist should have been in attendance.
6) Since both procedures were elective, the gastroenterologist failed to reschedule the procedures for a time when the patient was stable and able to tolerate conscious sedation directed by the gastroenterologist and administered by a nurse.
7) The patient had a very unstable post-procedure course in the recovery room. He was unresponsive to verbal and painful stimuli and oxygen saturation was below 90%. Reversal medications had to be administered before the patient became responsive. When the patient became responsive, the gastroenterologist performed the esophageal manometry in the recovery room. This procedure was unnecessary to determine the need for a PEG and further endangered the health of the patient.
8) The respondent approved sending the patient home with instructions after his oxygen saturation was above 93% for 30 minutes. The patient was a very high-risk patient for elective procedures and had had a very unstable post-procedure course in the recovery room, including the development or exacerbation of pneumonia. Under these circumstances, in conjunction with his numerous co-morbidities, it was unsafe to send the patient home. There was no record found of the patient leaving the clinic AMA.
The Board issued a public reprimand against the gastroenterologist. Stipulations included continuing medical education in the topics of pre-operative patient evaluation, informed consent, sedation, and medical record keeping.
State: California
Date: May 2017
Specialty: Gastroenterology, Hospitalist, Internal Medicine
Symptom: GI Symptoms (GERD, Abdominal Distention, Dysphagia), Cough, Shortness of Breath, Weight Loss
Diagnosis: Gastrointestinal Disease, Pneumonia, Pulmonary Disease
Medical Error: Unnecessary or excessive treatment or surgery, Failure of communication with other providers, Lack of proper documentation
Significant Outcome: Death, Hospital Bounce Back
Case Rating: 5
Link to Original Case File: Download PDF