Found 743 Results Sorted by Case Date
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Florida – Emergency Medicine – Sharp Chest Pain After Intercourse



On 4/4/2015, a 47-year-old male presented to the emergency department with sharp chest pain after intercourse.

The RN on duty noted taking the patient’s vitals and performing an EKG, chest radiograph, and labs.

In his physician note, the ED physician documented the following: the patient did not take his medication for hypertension or dyslipidemia despite having a history of hypertension and homelessness;  the patient reported a history of coronary artery disease and possible coronary artery stent placement; and the patient reported chest discomfort and dyspnea for the week prior to presentation as well as a history of tobacco use.

The ED physician recorded a differential diagnosis including acute myocardial infarction, non-ST segment elevation myocardial infarction (“NSTEMI”), angina, and acute coronary syndrome.

The ED physician did not diagnose the patient with possible cardiac etiology of chest discomfort.  He also did not contact the on-call cardiologist.  The ED physician did not perform provocative testing or cardiac catheterization.  He also did not admit the patient for hospitalization and cardiology consultation.  The ED physician discharged the patient without requiring any further evaluation/treatment or serial EKG/troponin.  He did not arrange for close outpatient follow-up prior to discharge.

The Board issued a letter of concern against the ED physician’s license and ordered that he pay a fine, reimburse costs for the proceedings, and complete 5 hours of continuing education in risk management.

State: Florida


Date: November 2017


Specialty: Emergency Medicine


Symptom: Chest Pain


Diagnosis: Cardiovascular Disease


Medical Error: Failure to order appropriate diagnostic test, Referral failure to hospital or specialist, Failure to follow up


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Family Medicine – Three Patients Seen At Once Without Proper Examination and Documentation



On 9/21/2012, Patient A, Patient B, and Patient C presented to a geriatric practitioner at the same time in his office.  The geriatric practitioner saw the patients for less than nine minutes total.  At no time were the patients separated for individual assessments.  The patients were an undercover detective and two informants, using pseudonyms.  The appointment was audiotaped and videotaped.

The geriatric practitioner failed to perform a physical examination on any of the three patients.  The geriatric practitioner failed to create a treatment plan for any of the three patients.  He also sent the three patients for x-rays without a physical examination.  Per the geriatric practitioner’s instructions, all three patients presented for x-rays;  however, only Patient A and Patient C actually had x-rays performed.  The geriatric practitioner failed to create or maintain documentation of referring the three patients for x-rays.

On 10/30/2012, the three patients presented to the geriatric practitioner for a follow-up visit.  At that time, the geriatric practitioner failed to review readily available medical records from the patients’ first visit, failed to inquire about x-ray results, failed to review physical therapy results, failed to perform physical examinations and/or failed to create treatment plans for all three patients.

The Board judged the geriatric practitioner’s actions to be below the minimum standard of competence given his failure to perform a physical examination, perform a complete individual physical examination for each patient prior to referral for x-rays, other diagnostic testing, or further treatment.  Also, the geriatric practitioner failed to review any medical records or results at a follow-up visit, including x-rays, from prior visits, and/or procedures and review and analyze the physical therapy progress of the patients, and create treatments plans for each patient.

The Board ordered that the geriatric practitioner pay a fine of $12,000 against his license and pay reimbursement costs for the case for a minimum of $37,421.80 and not to exceed $39,421.80.  The Board also ordered that the geriatric practitioner complete a medical records course and complete five hours of continuing medical education on “Risk Management.”  The Board put the geriatric practitioner’s license on probation and required that he have indirect supervision to practice by a Board-approved physician.

State: Florida


Date: November 2017


Specialty: Family Medicine


Symptom: N/A


Diagnosis: N/A


Medical Error: Failure to examine or evaluate patient properly, Ethics violation, Failure to follow up, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Internal Medicine – Retained Guide Wire Found After Replacement Of Dialysis Catheter



On 3/19/2015, a patient presented to a hospital with complaints of chest pain, history of acute stent thrombosis, and renal failure.

On 3/21/2015, a physician referred the patient to an internist for replacement of temporary dialysis catheter to address her acute kidney failure.  The internist placed a double-lumen dialysis catheter in the patient’s left subclavian vein.

Due to the catheter not functioning properly, another physician performed a catheter exchange procedure on the patient on 3/23/2015.  After the procedure, the inspection of the catheter revealed that the guide wire remained in one of the lumens of the catheter.

Neither the internist nor his staff removed the guide wire from the catheter prior to the insertion of the catheter into the patient’s left subclavian vein.

The Board judged the internist’s conduct to be below the minimum standard of competence given that he left a foreign body in a patient.

The Board ordered that the internist pay a fine of $3,500 against his license and pay reimbursement costs for the case for a minimum of $3,419.35 and not to exceed $5,419.35.  The Board also ordered that the internist complete five hours of continuing education in “Risk Management” and complete a lecture/seminar on retained foreign body objects to medical staff.

State: Florida


Date: November 2017


Specialty: Internal Medicine, Nephrology


Symptom: Chest Pain


Diagnosis: Renal Disease


Medical Error: Retained foreign body after surgery


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Neurosurgery – Cervical Microdiscectomy At Levels C5/7 And C6/7 Instead Of Levels C4/5 And C5/6



On 11/17/2014, a patient presented to a neurosurgeon for an anterior cervical microdiscectomy for decompression with allograft fusion at cervical levels C4/5 and C5/6.  During the procedure, it was discovered that the initial localization x-ray was misinterpreted and that the neurosurgeon performed the fusion at cervical levels C5/7 and C6/7 instead of cervical levels C4/5 and C5/6.  After the neurosurgeon discovered the error, he proceeded to perform the fusion at the correct cervical levels, C4/5 and C5/6.

The Board judged the neurosurgeons conduct to be below the minimum standard of competence given that he performed the procedure on the wrong site.

The Board ordered that the neurosurgeon pay a fine of $5,000 against his license and pay reimbursement costs of a minimum of $1,859.22 but not to exceed $3,859.22.  The Board also ordered that the neurosurgeon complete five hours of continuing medical education in “Risk Management” and complete a one hour lecture/seminar on wrong site surgeries.

State: Florida


Date: November 2017


Specialty: Neurosurgery


Symptom: N/A


Diagnosis: Spinal Injury Or Disorder


Medical Error: Wrong site procedure


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Anesthesiology – Proceeding With A Colonoscopy With A Non-Functioning End Tidal CO2 Monitor



A 59-year-old female presented to an anesthesiologist during her colonoscopy.  The anesthesiologist conducted a pre-operative anesthesia assessment of the patient.  She was then transported to the procedure room where a certified registered nurse anesthetist (“CRNA”) was to provide total intravenous anesthesia to the patient.

The end-tidal CO2 monitor (“ETCO2 monitor”) located in the scheduled procedure room was non-functional on the day before the surgery and a functioning ETCO2 monitor had not been received on the day of the surgery.

The anesthesiologist instructed the CRNA to proceed with the anesthesia without the ETCO2 monitor.  The anesthesiologist did not delay the procedure or postpone it for another date to allow time to obtain a functioning ETCO2 monitor.  The anesthesiologist did not transfer the patient to another procedure room that had a functioning ETCO2 monitor.  The anesthesiologist did not implement additional precautionary measures by closely monitoring the patient with his presence since he elected to proceed without an ETCO2 monitor as recommended by the ASA (American Society of Anesthesiologists).  The anesthesiologist was not present in the procedure room during the procedure.

The CRNA experienced difficulties with the patient’s airway soon after the induction of anesthesia.  The oral airway was inserted to assist the patient’s breathing, and the amount of oxygen flow was increased to help with the falling oxygen saturation.  Despite the increase in the amount of oxygen flow, the CRNS reported transient desaturations and reported repositioning the pulse oximeter numerous times throughout the procedure.

The patient developed bradycardia, which culminated to intubation and cardiac arrest, and the anesthesiologist’s presence was requested in the procedure room.  The anesthesiologist started chest compressions and resuscitated the patient.

The Board judged the anesthesiologist’s conduct to be below the minimum standard of competence given that he should have delayed the procedure, or postponed it for another date to allow time to obtain a functioning ETCO2 monitor.  He should also have transferred the patient to another procedure room that had a functioning ETCO2 monitor and implemented additional precautionary measures by closely monitoring the patient with since he elected to proceed without an ETCO2 monitor.

The Board ordered that the anesthesiologist pay a fine of $5,000 against his license and pay reimbursement costs for the case for a minimum of $6,841.07 and not to exceed $8,841.07.  The Board also ordered that the anesthesiologist complete five hours of continuing medical education in general anesthesia and complete five hours of continuing medical education in “Risk Management.”

State: Florida


Date: November 2017


Specialty: Anesthesiology


Symptom: N/A


Diagnosis: Post-operative/Operative Complication


Medical Error: Failure to properly monitor patient


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Washington – Internal Medicine – Proper Monitoring Of Thyroid Dysfunction And High Blood Pressure



Beginning in June 2014, a physician began treating Patients A and B for thyroid dysfunction and Patient C for high blood pressure. The physician communicated with Patient A and B through phone consultation and met Patient C in social situations and during at least two office visits. The physician reviewed previous lab work on thyroid functions for Patients A and B. The physician based Patient C’s treatment upon his physical observation of her conditions, two Zytoscans (device that measures electrical currents in the skin), and taking her blood pressure. Patient A and B’s lab work indicated both patients having lower than normal thyroid function. The physician started both Patients A and B on a thyroid hormone supplement. He prescribed medication commonly used for treating high blood pressure for Patient C based upon his observations, oral reports of Patient C, and the Zytoscans. The physician failed to do lab work, took minimal chart notes, and did not schedule follow-up examinations for Patients A, B, or C.

For several months, the physician continued prescribing for Patients A, B, and C without ever seeing the patients in person for further work up. The physician’s interactions with Patients A and B were solely over the phone, while the physician notes state that he had two office visits with Patient C. The physician did not order thyroid stimulating hormone (TSH) testing to further verify if continuing the thyroid hormone supplement would be appropriate in managing Patient A and B’s conditions.

In June 2015, Patient A presented to another provider with concerns of heart palpitations. Patient A told the provider he noticed the palpitations reduced when he reduced his thyroid hormone supplement dosage. During this consultation, Patient A disclosed his treatment with the physician which alerted the provider to have Patient A’s TSH levels checked. Patient A’s lower than normal TSH result prompted the provider to immediately begin weaning Patient A off of his thyroid hormone supplement.

Patient B also presented to the same provider in June 2015. At her visit, Patient B presented with a rash on her chest which she had for over a month. The new provider assessed the rash being unrelated to her treatment with the physician; however, due to her receiving similar treatment as Patient A, the provider had Patient B’s TSH level tested. Patient B’s results indicated her TSH level was below the normal range.

On 8/26/2015, the physician saw Patient C for what he thought was a urinary tract infection. The physician first prescribed Keflex but changed it to ciprofloxacin based upon the results of a Zytoscan. Caution is required when giving ciprofloxacin to patients with hypokalemia.

On or about 9/9/2015, Patient C presented to the hospital emergency department where she was diagnosed with significant hypokalemia (lowered levels of potassium in the blood) and hyponatremia (lowered levels of sodium in the blood) which caused Patient C to suffer fatigue and heart palpitations. Patient C went immediately from the emergency department to a new care provider. After an oral interview with Patient C, the new care provider learned that Patient C was taking a number of medications prescribed by the physician. The new care provider attempted to contact the physician a number of times to obtain the physician’s chart notes, lab studies, and other medical records for Patient C but was unsuccessful. Patient C told her new care provider that the physician had been giving her medications for a number of years. She stated, “I tell him what I need.” In the physician’s response to the Commission, he stated that “if [Patient C] called me to have a prescription filled, I would do that for her.”

The Commission stipulated the physician reimburse costs to the Commission and write and submit a paper of at least 2000 words, with references and annotated bibliography, regarding Washington State rules for physicians forming and maintaining patient/physician relationships, the differential diagnosis of hyperthyroidism and hypothyroidism, the proper monitoring of electrolyte levels for patients with high blood pressure, and the importance of complying with Commission sanctions.

State: Washington


Date: November 2017


Specialty: Internal Medicine, Family Medicine


Symptom: Palpitations, Rash


Diagnosis: Endocrine Disease


Medical Error: Failure to follow up, Failure to properly monitor patient, Improper medication management


Significant Outcome: N/A


Case Rating: 1


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



Virginia – Psychiatry – Adjusting Lithium Dosage Based Only On Patient Symptoms



A psychiatrist increased and decrease a patient’s lithium dosage based on the patient’s symptoms.  She did not test the patient’s lithium blood serum level.

On 8/28/2015, the patient was admitted to a hospital for lithium toxicity.  The psychiatrist stated that lithium blood serum levels for long-term lithium patients should be tested at least annually, but also at any time a patient complains of adverse side effects.  The psychiatrist admitted her failure to test the patient’s lithium levels and stated that it “was an inadvertent oversight for which [she] is remorseful.”  The psychiatrist reported that following the patient’s hospitalization for lithium toxicity, she reviewed the charts for her other patients on lithium and determined if they needed testing for lithium blood serum levels.

She provided evidence that she completed 99 hours of CME in psychiatry in 2015 and 58 credit hours of CME in psychiatry in 2017.  She provided a spreadsheet that she created for use in monitoring her patients on lithium.  She was reprimanded by the Virginia Board of Medicine.

State: Virginia


Date: October 2017


Specialty: Psychiatry


Symptom: N/A


Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Psychiatric Disorder


Medical Error: Improper medication management, Failure to properly monitor patient


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Interventional Radiology – Assigning A Diagnosis To The Wrong Patient Leads To Cardiac Catheterization Performed On The Wrong Patient



On 1/28/2015, Patient A, a 47-year-old male, presented to the hospital with chest pain and was admitted for treatment.  A radiological technician was ordered to complete a CT angiogram of the heart for Patient A.

On 1/29/2015, a radiologist received Patient A’s angiogram images to review, as well as heart images for another Patient B.  The radiologist assigned a diagnosis of sixty to seventy percent stenosis to Patient A.

The diagnosis of sixty to seventy percent stenosis was intended for Patient B, not Patient A, who did not have any noticeable blockage or stenosis.

On 1/29/2015, subsequent to the radiologist assigning the diagnosis of sixty to seventy percent stenosis to Patient A, Patient A underwent an unnecessary cardiac catheterization without further incident.

On 1/30/2015, the radiologist conducted a corrected review and diagnosis of Patient A’s angiogram.

On 2/3/2015, the radiologist informed Patient A of the error.

The Board judged the radiologist’s conduct to be below the minimal standard of competence given that he assigned a diagnosis to the wrong patient, which resulted in the patient undergoing a medically unnecessary procedure, a cardiac catheterization.

It was requested that the Board order one or more of the following penalties for the radiologist: 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: October 2017


Specialty: Interventional Radiology


Symptom: Chest Pain


Diagnosis: Cardiovascular Disease


Medical Error: Accidental error, False positive, Unnecessary or excessive treatment or surgery


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Obstetrics – Excessive And Unindicated Antepartum Testing Performed Over the Course Of A Pregnancy



Between May 2011 and December 2011, an obstetrician provided obstetric services to a 16-year-old female and followed the course of her pregnancy.

The patient had an estimated delivery date of 12/1/2011 and ultimately delivered her baby on 12/1/2011.

On 5/5/2011 and 5/19/2011, the obstetrician performed first-trimester ultrasounds on the patient to monitor the patient’s fetus.

On 6/17/2011, the obstetrician performed a second-trimester ultrasound on the patient to monitor the patient’s fetus.

On 10/11/2011, the obstetrician performed a third-trimester ultrasound on the patient to monitor the patient’s fetus.  The patient’s fetus was in the 29th percentile for growth, which was normal.

On 10/20/2011, the obstetrician performed a third-trimester ultrasound on the patient to monitor the patient’s fetus.  The patient’s fetus was in the 44th percentile for growth, which was normal.

There was no indication for the third-trimester ultrasound that the obstetrician performed on the patient on 10/20/2011.

On 10/28/2011, the obstetrician performed a biophysical profile with ultrasound on the patient and her fetus in order to monitor the patient’s fetus.

The indications documented for the biophysical profile with ultrasound that the obstetrician performed for the patient and her fetus on 10/28/2011 were intrauterine growth restriction and “size less than dates.”  Both intrauterine growth restriction and “size less than dates” were ruled out by the ultrasound conducted on 10/11/2011 and 10/20/2011.

There was no indication for the biophysical profile with ultrasound that the obstetrician performed on the patient and her fetus on 10/28/2011.

On 11/4/2011, the obstetrician performed a biophysical profile with ultrasound on the patient and her fetus in order to monitor the patient’s fetus.  The indications documented for the biophysical profile with ultrasound that the obstetrician performed on the patient and her fetus on were intrauterine growth restriction and “size less than dates.”

Both intrauterine growth restriction and “size less than dates” were ruled out by the ultrasound conducted on 10/11/2011 and 10/20/2011, and the biophysical profile performed on 10/28/2011.

There was no indication for the biophysical profile with ultrasound that the obstetrician performed on the patient and her fetus on 11/4/2011.

On 11/11/2011, the obstetrician performed a third-trimester ultrasound on the patient to monitor the patient’s fetus.  The patient’s fetus was in the 34th percentile for growth, which was normal.  There was no indication for the third-trimester ultrasound the obstetrician performed on the patient on 11/11/2011.

On 11/18/2011, the obstetrician performed a third-trimester ultrasound on the patient to monitor the patient’s fetus.  The patient’s fetus was in the 68th percentile for growth, which was normal.  There was no indication for the third-trimester ultrasound that the obstetrician performed.

The standard of care required that the obstetrician adequately manage the patient’s pregnancy through the use of only indicated antepartum testing and to refrain from performing excessive and unindicated antepartum testing.

It was requested that the Board order one or more of the following penalties for the internist: 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: October 2017


Specialty: Obstetrics


Symptom: N/A


Diagnosis: N/A


Medical Error: Unnecessary or excessive diagnostic tests


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



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