Found 128 Results Sorted by Case Date
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Washington – Internal Medicine – Dizziness And Right-Sided Weakness Diagnosed As Vertigo



An internist failed to provide appropriate care for a patient when she presented at an urgent care facility complaining of dizziness and right-sided weakness.  Dizziness and right-sided weakness were included in the triage notes available to the internist when he saw the patient.  The internist evaluated the patient’s right arm and found no weakness.  The internist diagnosed vertigo and discharged the patient home.

The internist did not obtain computed tomography (CT) imaging, electrocardiogram (EKG) testing, appropriate laboratory tests, or carotid duplex testing.  The internist did not consider obtaining magnetic resonance imaging (MRI) or referral to an emergency department for appropriate evaluation and care.

The patient suffered a stroke at home approximately 12 hours after discharge.  She was taken to the hospital where she was diagnosed with an acute cerebrovascular accident (CVA) on the left side of the brain.  CT head showed a hyperacute ischemic CVA with an apparent large clot in the middle cerebral artery.

The Commission stipulated the internist reimburse costs to the Commission, have his license be placed on probation for a period of 2 years, complete a continuing education course in stroke and TIA evaluation, and write and submit a paper of at least 1500 words on the subject of medical error in the evaluation of stroke and TIA symptoms.  The paper will specifically address the material the internist has learned in the course and will discuss how to avoid the issues that lead to the complaint in this case.  The internist will also arrange for a presentation to other providers in his workplace on this material.

State: Washington


Date: June 2013


Specialty: Internal Medicine


Symptom: Dizziness, Weakness/Fatigue


Diagnosis: Ischemic Stroke


Medical Error: Failure to order appropriate diagnostic test


Significant Outcome: Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



California – Family Medicine – Failure Of Diagnosis In Patient With Altered Mental Status, Shortness Of Breath, And Chest Pain



A long-term patient saw a family practitioner at a prison on an emergency basis on 2/10/2006.  The patient was 59-years-old with a history of a splenectomy, serologic evidence of hepatitis B and C, and oxygen-dependent chronic obstructive pulmonary disease.  On the afternoon of 2/9/2006, the patient complained of “compressing chest pain” and was taken to the emergency room. The patient was attended to by the on-call physician that day.  The physician noted that the patient had a history of substernal chest pain and shortness of breath and had been out of inhalers for the previous month. The patient’s oxygen saturation was 91%.  The patient was given “breathing treatments” with bronchodilators. The physician determined the patient should be seen at a fully equipped emergency room and had the patient transported by ambulance to the emergency room.

The patient was evaluated at the hospital and told the doctor there that he had no chest pain and “felt better.”  His oxygen saturation was 97%. The doctor wanted to admit him to the hospital but the patient refused all medical treatment and left against medical advice. He arrived back at the prison in the early evening on the same day and stated he had no pain.  He was given Levaquin tablets, 500 mg for 10 days and had blood drawn for lab work. He was told to return to the “MD line” for further evaluation.

The family practitioner was the on-call doctor on 2/10/2006.  The patient came into the emergency room at 8:05 p.m. The notation on the “flow sheet” showed a chief complaint of “hard to arouse.”  The medical technician noted that the patient was “unresponsive to verbal stimuli, responds to sternal rub and answers questions appropriately.”  The Glasgow Coma Scale rating showed the patient was oriented. His pupils were norms, and showed “brisk” response. His blood pressure was 117/60 and his oxygen saturation was 88% on room air.

The family practitioner examined the patient at 9:38 p.m.  He noted the patient was “sleepy.” The patient’s blood pressure was 117/60.  The patient’s lungs were clear and his oxygen saturation had risen to 94% after having been given oxygen by nasal cannula.  The family practitioner charted that the patient’s lungs were “clear to auscultation” and there were no heart murmurs. The family practitioner found the patient’s blood sugar level to be normal.  The family practitioner noted the patient had “skin dehydration” and “throat secretions in mouth.” He assessed the patient as having dehydration and his plan was to give him 1 liter of saline solution intravenously at the rate of 100 ml per hour.  The family practitioner next saw the patient at 11:24 p.m. He noted that the oxygen saturation had risen to 96% and blood pressure was 121/78. He increased the saline drip rate to 200 ml per hour and made the following chart entry, “RTC when infusion of saline completed and VS O2 WNL.”  An issue that arose was the meaning of “RTC” in this context. The Board’s reviewer and expert both read this as meaning “return to custody.” In a summary that the family practitioner prepared 2 weeks before the hearing, the family practitioner agreed RTC meant that the patient was to return to his “housing.”  However, at trial, the family practitioner testified RTC meant “return to clinic.”

The emergency care flow sheet showed that at 1:30 a.m., the patient was still in the emergency room and received albuterol on a metered-dose inhaler.  At 3:00 a.m., the “interdisciplinary progress notes” showed the patient’s vital signs had deteriorated. His oxygen saturation dropped to 80% and his blood pressure dropped to 80/50.  These vital signs could not have been taken in the prisoner’s housing, and the progress notes were the type that are recorded in a medical facility; the inference was that the patient was in the treatment and triage area at this time.  The patient was noted to have an unsteady gait and said he felt “cold” but “okay.”

The family practitioner saw the patient for the last time at 4:30 a.m.  He noted that the patient had been “sent back to ER.” There was no clear indication as to where the patient was between 3:00 a.m. and 4:30 a.m.  It was unlikely that a patient known to be in distress would have been sent back to his housing unit. Since 3:00 a.m. the patient’s vital signs were not within normal limits, and the family practitioner had ordered that the patient not be returned to custody until his vital signs were normal, the reasonable inference to be drawn was that the patient remained in the treatment and triage area until he was seen by the family practitioner for the last time.  When he saw the patient at 4:30 a.m. he noted the low vital signs and ordered oxygen and an intravenous saline line to be kept open. He then ordered that the patient be transferred to the emergency room. The patient was transported and admitted for treatment. He died on 3/8/2006. The cause of death was cardiopulmonary arrest, due to multi-organ failure, due to disseminated coccidioidomycosis commonly known as “valley fever,” a fungal-based lung infection.

The family practitioner was grossly negligent in his care and treatment of the patient for his failure to properly evaluate and treat a patient with “altered mental status” by not conducting a neurological or cardiovascular examination, not performing an adequate pulmonary examination, and not ordering screening laboratory tests.

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

State: California


Date: April 2013


Specialty: Family Medicine, Internal Medicine


Symptom: Chest Pain, Psychiatric Symptoms, Shortness of Breath


Diagnosis: Infectious Disease, Pulmonary Disease


Medical Error: Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test


Significant Outcome: Death, Hospital Bounce Back


Case Rating: 5


Link to Original Case File: Download PDF



Washington – General Surgery – Intra-Abdominal Fluid Discovered Post-Cholecystectomy



On 11/15/2007, a general surgeon performed a laparoscopic cholecystectomy on a 63-year-old male patient.  The procedure was without complications and the patient was discharged the same day.

The patient returned to the medical center on 11/17/2007 with abdominal distention and discomfort, difficulty breathing, and not having had a bowel movement since surgery.  An ileus was initially suspected.  The patient was provided with fluid resuscitation, and a bowel program was started.  Laboratory studies revealed prerenal azotemia and hyperbilirubinemia, and an ultrasound study revealed the presence of intra-abdominal fluid.  The patient was initially seen by an emergency department physician, and the general surgeon was consulted.  A CT scan at this point would have been helpful but was not ordered until three days after readmission.

The patient subsequently developed several additional or worsening medical conditions.  On 11/18/2007, the patient developed atrial fibrillation.  A hospitalist took over as the patient’s attending physician on the morning of 11/19/2007, and several specialists were consulted throughout the patient’s hospital stay, including the general surgeon.  The general surgeon continued to see the patient in rounds.  Chest x-rays during this period of time showed progressive atelectasis and possible small bilateral pulmonary infiltrates.  It was noted the patient still had prerenal azotemia and fluid in the intra-abdominal cavity of unknown etiology.

On 11/20/2007, a CT scan without contrast showed a free-flowing collection of fluid.  A HIDA scan was then performed and did not reveal conclusive evidence of a bile leak.  The general surgeon indicated that the risks of general anesthesia and surgery were significant at this point due to the patient’s multiple medical conditions.  The patient’s attending physician, therefore, approached the radiologist who had interpreted the images taken of the patient regarding placement on a percutaneous drain to remove the fluid in the patient’s abdomen.  The radiologist declined to perform this procedure and plans were made to transfer the patient the following day to another facility for placement of a percutaneous drain.

On 11/21/2007, lab tests on fluid removed from the patient’s abdomen through paracentesis revealed peritonitis.  The patient was transferred to another facility for placement of a percutaneous drain, but became asystolic en route to the hospital. After being resuscitated, the patient died two days later.  The patient’s autopsy revealed extensive peritonitis but the actual cause of death was not clear in this report.

It is the Commission’s position that while the patient did not have rebound tenderness (a classic sign of a surgical abdomen), the prerenal azotemia, hyperbilirubinemia, abdominal distention, and evidence of fluid in the peritoneal cavity demonstrated on an early ultrasound were indications that intraperitoneal sepsis was the cause of the patient’s return to the hospital.  The percutaneous drain placement recommended by the general surgeon and hospitalist on 11/20/2007 may have been an effective treatment, but the need for this treatment should have been recognized much earlier in the patient’s stay.  The patient’s medical condition did decline in the days following admission, making surgical intervention more of a risk. However, earlier intervention and treatment by the general surgeon may have changed the outcome for this patient.

The Commission stipulated the general surgeon reimburse costs to the Commission, have his license placed on probation for a period of 60 days, provide reports to the Commission regarding serious post-surgical complications involving patient death or major disability, and write and submit a paper of at least 1000 words, with bibliography, on the early evaluation and treatment of post-operative complications.

State: Washington


Date: April 2013


Specialty: General Surgery, Emergency Medicine


Symptom: Abdominal Pain, Shortness of Breath


Diagnosis: Post-operative/Operative Complication, Gastrointestinal Disease, Sepsis


Medical Error: Diagnostic error, Delay in proper treatment


Significant Outcome: Death, Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



Washington – Emergency Medicine – Abdominal Pain, Nausea, Vomiting, Diarrhea, Elevated Bilirubin, And Low Platelets



On 10/23/2009, a 23-year-old male was referred to the hospital emergency department by a provider at an urgent care clinic.  The patient presented to the emergency department at 5:45 p.m., reporting abdominal pain, nausea, vomiting, and diarrhea.

The patient was seen in the emergency department by a physician assistant, one or more nurses, and an ED physician.  A lab report obtained from the urgent care clinic revealed an elevated bilirubin and low platelet count.  The lab values also indicated mild anemia and liver function abnormalities.  The emergency department providers acknowledged these abnormalities in the medical record but did not explain or address their cause.

The patient was examined, given IV fluids, and an ultrasound was performed, which showed borderline hepatosplenomegaly and hepatic steatosis.  At approximately 7:30 p.m., the patient was discharged with instructions to follow up with an internist on 10/26/2009, to increase fluids, and to continue promethazine prescribed by the urgent care clinic.  Records from the patient’s 10/23/2009 emergency room visit indicated that the patient told a nurse he was taking Percocet 5/325 on an “as need” basis.

On 10/24/2009, the patient again presented to the emergency room in the morning.  The patient complained of persistent abdominal pain, nausea, a bout of vomiting within the last 12 hours, no diarrhea and, and loss of appetite.  The patient reported that he was unable “to keep anything down.”  The patient was mildly tachycardic, as he was the night before, and appeared “uncomfortable” with abdominal tenderness.  The patient complained that the promethazine given to him the day before made him tired.  A urine sample provided by the patient was “cola-colored.”

The patient was again seen by the ED physician in the emergency department.  The patient was given Reglan, by mouth, which was effective in relieving his nausea.  The ED physician’s impression was that the patient had intrahepatic cholestasis (mechanical or chemical interference within the liver obstructing the flow of bile) and discharged him about one and a half hours after arrival with instructions to take the Reglan instead of promethazine, to increase fluid intake, and to follow up as previously planned with the internist in 3 days.  The ED physician did not repeat laboratory analysis and did not order intravenous fluid resuscitation and appropriate inpatient monitoring.

On 10/25/2009, the patient was again admitted to the emergency department in the evening.  The patient complained of shortness of breath, continuing abdominal pain, nausea, vomiting, diarrhea, and loss of appetite.  The patient was cared for by another emergency department physician on this visit.  Emergency department staff obtained imaging, laboratory testing, and performed various interventions, but the patient suffered cardiac arrest approximately two hours after admission and emergency staff were unable to resuscitate him.

An autopsy report described the patient’s cause of death as disseminated intravascular coagulopathy due to liver and renal failure that was caused by combining Percocet and alcohol abuse. Even though the patient was taking Percocet, the patient had denied taking any aacetaminophen-containing substances, so no acetaminophen level was determined and no treatment was directed toward possible acetaminophen toxicity.

The Commission stipulated that the ED physician reimburse costs to the Commission, complete 12 hours of continuing education on toxicology, hepatorenal failure, hepatic failure, and disseminated intravascular coagulopathy, and the Commission to conduct a review of the ED physician’s practice for a period of 3 years.

State: Washington


Date: April 2013


Specialty: Emergency Medicine, Internal Medicine


Symptom: Abdominal Pain, Diarrhea, Nausea Or Vomiting, Shortness of Breath


Diagnosis: Drug Overdose, Side Effects, or Withdrawal


Medical Error: Diagnostic error


Significant Outcome: Death, Hospital Bounce Back


Case Rating: 4


Link to Original Case File: Download PDF



Wisconsin – Emergency Medicine – Left Shoulder Pain, Fever, And Hypoxia



A 75-year-old man with a history of congestive heart failure and chronic obstructive pulmonary disease presented to the emergency department complaining of pain in his left shoulder.  He had a fever and his oxygen saturation was 82%.  Blood gases showed he had metabolic acidosis and was hypoxic.  His blood cell count had 41% bands and blood cultures were drawn.

Six hours after his arrival he was transferred into the care of the ED physician.  The blood cultures returned positive for streptococcus. As a result, he ordered IV levofloxacin.

The next morning the ED physician examined the patient, including a lung examination, and noted the patient was afebrile.  He discharged the patient on oral levofloxacin.  Prior to discharge, the physician did not check the patient’s oxygen saturation and the patient was discharged without oxygen.  No notes address the acidosis and the patient’s blood gases were not checked nor was a complete blood count ordered to reassess bandemia.

Hours after being discharged the patient returned to the emergency department with decreased responsiveness and an oxygen saturation of 77%.  Blood work revealed renal failure, bandemia, and electrolyte and enzyme abnormalities.  The patient was also acidotic and became hypotensive and required intubation.  It was later revealed patient had group A streptococcal sepsis.

The Board found the ED physician failed to appropriately diagnose and treat sepsis, resulting in multi-organ failure and other complications.  The emergency physician was ordered to pay a fine and participate in 25 hours of continuing medical education in the area of infectious diseases or critical care medicine.

State: Wisconsin


Date: March 2013


Specialty: Emergency Medicine, Family Medicine, Internal Medicine


Symptom: Extremity Pain, Fever


Diagnosis: Sepsis


Medical Error: Improper treatment, Failure to follow up


Significant Outcome: Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



Wisconsin – Family Medicine – Sinus Pain And Tachycardia With Patient Seeing Her 6th Health Care Provider



On 01/31/2010, a 38-year-old woman presented to a family practitioner with persistent sinusitis after a 2 week course of Augmentin.  She had no improvement.  Vitals revealed a blood pressure of 180/100, heart rate 135, and temperature of 98.9.  There was no documentation of a respiratory rate.  The family practitioner was the 6th health care provider the patient had seen in the prior 7 days.  The family practitioner documented “Extraocular motions were intact without pain.  Conjunctiva are clear.  Tympanic membranes are clear.  She has some erythema and swelling below the right eye and maybe some mild tenderness in that area.  There is no crepitation or fluctuance.  Nasal mucosa appears normal.  Oropharynx appears normal.  Neck: supple.  There is no adenopathy.  Lungs: clear.”  Moxifloxacin, prednisone, and hydrocodone 5 mg/acetaminophen 500 mg were prescribed.  There was no comment documented regarding the abnormal vital signs.

While under investigation, the family practitioner testified that he offered hospitalization, ENT consult, and CT scan.  He reported that the patient had declined these options and preferred outpatient management.  There is no documentation of this discussion.

Less than 50 minutes after the visit, the patient presented to the emergency department of a nearby community hospital.  Vitals revealed a blood pressure of 150/105, heart rate of 76, temperature of 97.5, and a respirator rate of 26-28.

The nurse practitioner documented: “oropharyngeal inspection revealing what appears to be findings consistent with ANUG [acute necrotizing ulcerative gingivitis].  She has necrotic-appearing tissue as well as some punched out lesions along the buccal gingiva and the papillae are necrotic in appearance…respirations are deep and certainly suggesting the possibility of a Kussmaul’s type respiration pattern.”  Bicarbonate was 6.  Glucose was 592.  She was diagnosed with diabetic ketoacidosis and acute necrotizing ulcerative gingivostomatitis.  She was flown to a tertiary care hospital and treated in the intensive care unit where she recovered.

The Board reprimanded the family practitioner for conduct considered below the minimum standard of care.

State: Wisconsin


Date: February 2013


Specialty: Family Medicine, Emergency Medicine, Endocrinology, Internal Medicine


Symptom: Pain


Diagnosis: Diabetes


Medical Error: Failure to examine or evaluate patient properly, Lack of proper documentation


Significant Outcome: Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



California – Internal Medicine – HIV Patient Presents With Hematuria And Proteinuria



An internist began treating a patient in 1993.  The internist was his primary care physician and treated him for HIV among other things.  Over the years, the patient was hospitalized numerous times for repeated episodes of pancreatitis and paroxysmal atrial fibrillation.

The patient had a history of urinalyses reflecting protein and red blood cells in his urine.  As far back as 2001, the internist received fax from a nurse at a medical center alerting him to an abnormal urinalysis showing 3+ protein and red blood cells too numerous to count.

On 9/22/2005, the patient had a urinalysis done, which reflected 3+ protein and 3+ blood and a red blood cell count of 186.  The internist received the laboratory report and a copy of the laboratory report, but did not document the abnormal levels of protein and blood in the patient’s chart and did not contact the patient to perform a follow-up urinalysis or to investigate the possible causes.

The internist saw the patient at his office on 1/3/2006 and on 8/12/2006.  The chart notes did not include vital signs and did not reflect that a physical examination was done.  The abnormal results from the urinalysis done on 9/22/2005 were not mentioned in the chart notes. The internist did not order a repeat urinalysis or document any investigation into the potential causes of the recurring protein and blood in the patient’s urine.

On 11/30/2006, the patient was admitted to the hospital with pneumonia and gastroenteritis.  The internist wrote the admission note and the history and physical. In the note, he wrote that the patient had, among other things, mild renal insufficiency.  The patient had a urinalysis done on the day of admission, which reflected 2+ protein and 3+ blood and a red blood cell count of 25. The internist made a note in the patient’s office chart that his creatinine was 1.9, and he had 2+ protein in his urine.

The patient was discharged on 12/2/2006.  In the internist’s discharge summary, he documented the abnormal level of protein in the patient’s urine but not the abnormal levels of blood.  He noted that since the patient’s electrolytes and creatinine had returned to normal with hydration, his renal function appeared to have shown “elevation” only because of dehydration.  The internist had initially discontinued the medication Viread because of its potential to cause renal insufficiency, but after the patient’s creatinine improved, he reinstated Viread. His discharge diagnoses included “Transient increase in creatinine.”  Without a follow-up urinalysis, he concluded that there were no current signs of renal insufficiency. He did not investigate the potential cause or causes of the protein and blood in the patient’s urine.

The internist saw the patient in his office on 12/20/2006.  The chart noted did not include vital signs and, other than noting that the patient’s lungs were clear, did not reflect that a physical examination was done.  The abnormal urinalysis results from 11/30/2006 were not mentioned in the chart notes. The internist noted that the patient’s creatinine was 1.6 up from 0.9 and that he was replacing Viread with Episicom because of “increased renal.”  He did not order a repeat urinalysis or any studies that might reveal the cause or causes of recurrent protein and blood in the patient’s urine.

The patient was hospitalized again on 5/11/2007.  The internist ordered blood tests but did not order a urinalysis.  The patient was released the following day.

The internist next saw the patient on 6/5/2007.  The chart notes did not include vital signs and did not reflect that a physical examination was done.  Once again there was no mention of the patient’s history of abnormal urinalyses.

The internist saw the patient at his office on 5/14/2008.  The patient presented with stomach pain after a trip to Mexico.  The chart notes did not include vital signs. Medication was prescribed and laboratory tests ordered.  There was no mention of any of the earlier abnormal urinalyses, and the internist did not order a urinalysis or any studies that might reveal the causes of recurrent protein and blood in the patient’s urine.

On 6/11/2008, the patient was admitted to the hospital under the internist’s care for recurrent pancreatitis.  The internist wrote the admission note and history and physical. In it, he noted that a urinalysis done that day showed, among other things, 2+ protein and 3+ blood.  The laboratory report also reflected a urine red blood cell count of 275. The internist’s notes written by hand on the hospital records read, in part, “Correct management of acute increased creat, increased BUN during acute pancreatitis….Renal insuf?  Cause…. BUN-27=at least partly dehydration with acute pancreatitis.”

The patient remained in the hospital overnight.  The internist did not order a repeat urinalysis or any studies that might reveal the cause of recurrent protein and blood in the patient’s urine.  The patient was discharged on 6/12/2008.

On 7/7/2008, the patient had blood tests that had been ordered by the internist.  The internist did not order a urinalysis. The blood test showed an elevated creatinine of 1.5.

On 12/8/2008, the internist wrote a note to the patient advising him to discontinue some of his medications, to discontinue all of his medications if he felt sick on them, and to have stool studies done if he experienced any diarrhea.

On 12/9/2008, the patient was admitted to the hospital, where he was cared for by the internist.  The blood tests showed an elevated creatinine of 2.1 and an elevated uric acid level of 17. The internist did not order a urinalysis.  The patient was discharged on 12/10/2008. On 12/30/2008, the internist wrote a note to the patient setting out a new HIV regimen and advising him to hydrate with “8 glasses/day” and discontinue “6 lb of anchovies.”  The internist next saw the patient at his office on 1/8/2009. The chart notes did not include vital signs and did not reflect that a physical examination was done. The patient’s antiretroviral medications were changed, and his previous letter to the patient was referenced.  On 4/22/2009, the patient was admitted to the hospital where he was cared for by the internist. Blood tests showed an elevated creatinine of 1.9 and an elevated uric acid level of 10.9. No urinalysis was ordered. The patient was discharged on 4/23/2009.

The internist next saw the patient at his office on 5/4/2009. The charts did not include vital signs and did not reflect that a physical examination was done.  The patient reported feeling better on the new treatment regimen, but complained of having had a nosebleed. The internist started the patient on allopurinol for gout and noted that alcohol abuse remained an issue.  There was no mention of any of the earlier abnormal urinalyses, and the internist did not order one. This was the last office visit with the internist. The internist stated that the patient told him that at that visit he planned to see another physician.  The internist did not document the patient discontinuing their physician-patient relationship in his chart notes or in any other way. The patient’s insurer continued to list the internist as the patient’s primary care physician, and the internist continued to receive copies of hospital records and laboratory tests for the patient.  At no time during this course of the internist’s treatment of the patient did he refer him for a urologic workup.

The Medical Board of California ordered that the internist be placed on probation for three years and attend an education course, a medical record keeping course, and was prohibited from supervising physician assistants.

State: California


Date: February 2013


Specialty: Internal Medicine


Symptom: Urinary Problems, Abdominal Pain


Diagnosis: Infectious Disease, Acute Abdomen, Pneumonia


Medical Error: Failure to follow up, Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Referral failure to hospital or specialist, Lack of proper documentation


Significant Outcome: Hospital Bounce Back


Case Rating: 1


Link to Original Case File: Download PDF



Wisconsin – General Surgery – Post-Operative Abdominal Pain After Laparoscopic Cholecystectomy For Acute Acalculous Cholecystitis



On 10/07/2010, the patient was referred to general surgery to consider elective cholecystectomy.  Ultimately, the patient wanted to have the procedure done.  She spoke Hmong, and communications with the general surgeon were translated by the patient’s daughter.

On 10/21/2010, the patient presented to the hospital to undergo laparoscopic cholecystectomy for acute acalculous cholecystitis.  In recovery, the nurse documented that the patient was still having “really bad pain” at 8:50 a.m.  She received 2 doses of dilaudid 0.3 mg iv x1.  At 9 a.m., the patient stated that her pain was tolerable.  The patient was discharged at 3 p.m. and was prescribed hydrocodone/acetaminophen 5/325 mg 1-2 tablets every 4 hours as needed for pain.

On 10/22/2010, the patient presented to the emergency department with severe abdominal pain and difficulty breathing.  Admission records documented: “…[the patient] stated she has been having abdominal pain and pain in her shoulders.  The patient was not controlled with the Vicodin, however, I am not sure that she was taking it.  Therefore, she came to the Emergency Department.  Upon arriving to the Emergency Department, the patient stated that she had pain on a scale of 10, 10/10.  She did go over to x-ray and actually had one episode of emesis as well…”

The general surgeon started IV fluids, oral and IV narcotics as needed, a regimen of acetaminophen and ibuprofen, and rechecked labs in the morning.  The general surgeon noted: “I am not terribly concerned about this, however, I think that this is mostly likely represents a postoperative reaction.  However, I will follow this up to make sure there is nothing else going on.”  IV fluids, morphine, oxycodone, ondansetron, acetaminophen, and ibuprofen were ordered.

On 10/23/2010, the associate physician considered discharging the patient, who was reluctant to be discharged given persistent abdominal pain.  The associate physician kept the patient overnight.  On 10/24/2010, the associate physician documented a pain level of 5/10 and gave icy hot patch for the left shoulder.

On 10/25/2010, the patient appeared to be improving, although the nurses’ notes documented persistent pain.  At 3:58 pm, the nurse documented “…Patient reports comfort level at time of discharge as < with PO analgesia…Instructed on the following new medications: Tylenol, docusate, norco 5/325, ibuprofen, magnesium hydroxide, omeprazole.  Instructed to contact physician about concerns regarding pain management or treatment plan…”  Clinical impression was “postoperative pain.”  The discharge summary noted: “The patient wishes to go home.”  According to the patient’s daughter, the abdominal pain was worsening and the patient did not want to go home.

On 11/04/2010, the patient visited the general surgeon with complaints of left lower abdominal pain, difficulty breathing, and weakness.  The associate physician ordered a CT abdomen and pelvis which revealed a large amount of fluid.  He documented: “Given the history of surgery two weeks ago, the presence of such a large amount of fluid within the peritoneal cavity raises the possibility of a bile leak as the etiology of these findings.  Hepatobiliary imaging to rule out a bile leak may be useful for further evaluation.  There is no evidence of an abscess.  There is no evidence of bowel perforation, and no other evidence for acute abdominal or pelvic process seen.” The patient was “still having pain in her shoulders, left greater than right, and on her sides when she lies down.  She is eating, but not a great amount, bowels are working.”  A HIDA scan was ordered.

On 11/05/2010, the associate physician documented: “Findings are concerning for a partial bile leak, with abnormal uptake seen around the dome the (sic) liver…”  On 11/06/2010, she was transferred to a hospital for ERCP, but the patient’s throat was too swollen to perform the procedure.

On 11/07/2010, the patient underwent a second surgery for biliary leak repair by laparoscopy.  Postoperative diagnoses were noted: “1. Bile leak status post cholecystectomy.  2. Incomplete cholecystectomy with remnant infundibulum and gallbladder neck and widely patent nonclipped cystic duct.  3.  Bile peritonitis.”

The Board judged that the general surgeon’s conduct fell below the minimal standards of competence given his failure to identify the cystic duct, failing to identify the cause of the postoperative pain, and failure to perform further diagnostic studies in a timely manner.  The Board ordered the general surgeon pay a fine, be reprimanded, and complete 4 hours of education on laparoscopic gallbladder surgery.

State: Wisconsin


Date: December 2012


Specialty: General Surgery


Symptom: Abdominal Pain


Diagnosis: Post-operative/Operative Complication, Gastrointestinal Disease


Medical Error: Underestimation of likelihood or severity


Significant Outcome: Hospital Bounce Back


Case Rating: 4


Link to Original Case File: Download PDF



Wisconsin – Physician Assistant – Right Knee, Chest Pain, Vomiting, And Neck Pain After Motor Vehicle Accident



On 02/18/2008, a 22-year-old male presented to the ER after a motor vehicle accident with right knee and chest pain.  CT chest was performed and was negative.  An emergency physician diagnosed right knee contusion and chest wall abrasion.  He was sent home with ibuprofen and hydrocodone/acetaminophen with instructions to follow up with his primary care physician.

On 02/25/2008, the patient presented to Physician Assistant A with soreness of his chest, knees, and shoulder, along with numbness of his left hand.  Physical exam revealed no neurological abnormalities.  Discharge instructions included rest, ice, ibuprofen, acetaminophen, and follow up in 2 weeks.  He was advised to return with any change in his condition.

On 03/10/2008, he had another follow up visit.  He reported gradual improvement.  He had neck pain that he was treating with ice packs and ibuprofen.  He denied headaches.  Neurological examination was documented as normal.  Discharge instructions included physical therapy in addition to what was instructed at the prior visit.

On 03/11/2008, the patient presented to a physical therapist complaining of neck, shoulder, and knee pain.  The physical therapist was unable to complete her exam of the cervical spine given severe pain.  The patient reported that 2 days prior he started having headaches, neck pain, and sharp shooting pain on the right side of his neck.  He said that he could not sleep the prior night given the headache and he had vomited four to five times.  The headache was associated with blurred vision.  Standing was difficult.  The physical therapist noted that on exam, the patient had guarded neck movements, he became pale when standing, and he had body shaking along with pain when moving.  The physical therapist talked to Physician Assistant A about the pain and headaches.  It is unclear if other symptoms were related to Physician Assistant A.  Physician Assistant A ordered an x-ray of the cervical spine, which was negative for fracture.  He believed the headaches to be related to neck pain.

On 03/12/2008, the patient presented to the physical therapist again.  The physical therapist documented that the patient was still having difficulty sleeping and vomiting and then called Physician Assistant A’s office to set up an appointment.  No one was available for that day, so the follow up was made for the next morning.  The patient’s father cancelled all future physical therapy appointments.  Physician Assistant A was not made aware of the physical therapist’s concerns.

On 03/13/2008, the patient presented to Physician Assistant A with pain in his neck that radiated to the right side of his head.  The patient reported blurred vision, dizziness, photophobia, phonophobia, nausea, and vomiting.  Physician Assistant A documented a normal neurological exam and concluded that the patient’s symptoms were likely due to a whiplash-type injury.  He discussed ordering a head CT with the patient and his father, but ultimately recommended against it, given concern for radiation risk.  The patient was given an IV dose of morphine and prescribed oxycodone-acetaminophen and metoclopramide with instructions to follow up in a week.

Although not documented, Physician Assistant A claimed that the differential diagnosis on that date included whiplash with migrainous symptoms, intracranial abnormality, and meningitis.  He reported performing a full neurological exam, which was normal.

On 03/21/2008, the patient presented to Physician Assistant A.  His pain was better, but he still had neck pain radiating to the top of his head.  The patient said that he attempted to decrease the amount of oxycodone intake, but then had an increase in pain.  Physician Assistant A documented the diagnosis of “whiplash injury suffered in a motor vehicle accident.”  Intracranial abnormality was not considered given that the patient appeared to be improving.  He recommended follow up in 3 days.  From 03/10/2008 to 03/21/2008, he did not discuss the patient’s condition with his supervising physician.

On 03/02/2008, the patient had drainage of a subdural hematoma.  Physician Assistant A was judged to have fallen below the minimum standard of care on 03/11/2008 and 03/13/2008 for failing to discuss his findings with his supervising physician and failing to pursue further imaging studies.  He was reprimanded by the Board and ordered to complete 10 hours of CME in the diagnosis and management of head trauma.

State: Wisconsin


Date: July 2012


Specialty: Family Medicine, Emergency Medicine, Internal Medicine


Symptom: Head/Neck Pain, Chest Pain, Extremity Pain


Diagnosis: Intracranial Hemorrhage


Medical Error: Underestimation of likelihood or severity, Failure to order appropriate diagnostic test


Significant Outcome: Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



Wisconsin – Orthopedic Surgery – Severe Left Ankle Pain After An Injury Associated With Paresthesias And Left Foot Weakness



A pediatric patient presented to the emergency department with left ankle pain secondary to an injury that occurred earlier in the day.  The ED physician noted that the severe pain was disproportionate to the injury and documented the possibility of compartment syndrome.  The ED physician prescribed Percocet for severe pain and discharged the patient home with instructions to return to the hospital for worsening symptoms.  Seven hours later, the patient returned to the emergency department with increased left ankle pain.  The ED physician noted that symptoms were consistent with compartment syndrome and paged the orthopedic surgeon on call.  Three hours later, the orthopedic surgeon evaluated the patient and diagnosed contusion of the fibula and lateral leg muscles, but documented “no compartment syndrome.”  The patient was discharged home with cam boot and crutches.  Seven hours later, the orthopedic surgeon was contacted by a member of the patient’s family by phone and reported that the patient was experiencing continued “uncontrollable pain” with a “new motor neurological deficit.”  The orthopedic surgeon reiterated that the patient did not have compartment syndrome.  The patient returned to the emergency department with complaints of severe left lower leg pain, paresthesias of the left lower leg, and left foot weakness.  The ED physician’s clinical impression was “worsening compartment syndrome” and coordinated with another physician to obtain further diagnostic studies.  The ED physician again notified the orthopedic surgeon and documented that he “arranged to come in and do this.”  The orthopedic surgeon performed a fasciotomy on the patient’s left leg.  After surgery, he ordered post-operative fluids at 50 ml an hour, although the patient’s creatine kinase was elevated with concern for rhabdomyolysis.  The hospitalist increased IV fluids to administer a total of 2 L for treatment of rhabdomyolysis.  The orthopedic surgeon was reprimanded with order to complete a course in the diagnosis and treatment of acute compartment syndrome.

State: Wisconsin


Date: July 2012


Specialty: Orthopedic Surgery


Symptom: Extremity Pain


Diagnosis: Compartment Syndrome


Medical Error: Diagnostic error, Physician concern overridden


Significant Outcome: Hospital Bounce Back


Case Rating: 4


Link to Original Case File: Download PDF



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