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California – Interventional Radiology – Pain And Cold Foot After Arteriogram, Angioplasty, And Atherectomy
On 6/26/2015, a patient presented to an interventional radiologist’s outpatient clinic for a left lower extremity arteriogram and intervention for a thrombosed left lower extremity bypass graft, originally placed in 2007. The patient had an extensive medical history including a renal transplant, diabetes, right leg amputation, and multiple revascularization procedures, including prior thrombectomies of the left lower extremity graft.
The patient reportedly had pain both at rest and with activity, and had a cold left leg prior to and immediately before the procedure. In order to improve blood flow in the patient’s left leg, the interventional radiologist performed an arteriogram, angioplasty, tPA administration, atherectomy, and stent placement within the left lower extremity, including an attempt to revascularize the native superficial femoral artery.
Images show an initially thrombosed femoral artery to popliteal bypass graft and deep femoral artery. Further images show balloons inflated in various parts of the graft and native arteries. Final images show flow through a patent common femoral artery (CFA), bypass graft, and peroneal and anterior tibial arteries. The deep femoral artery appeared occluded shortly beyond its origin.
After the procedure, a nurse noted the patient’s foot was cold. The interventional radiologist also assessed the patient post-procedure and found the foot to be cold, both two (2) and four (4) hours post-procedure. The interventional radiologist recommended to the patient that she travel to the emergency department of a university hospital.
The patient was then driven by her companion two hours to the emergency department, where she was assessed by an ED physician and a vascular surgeon. She was taken to the operating room where she underwent surgery, which included a left leg above-the-knee amputation and a deep femoral artery thrombectomy.
The Board stated that the standard of care for an interventional radiologist when performing an intervention is to recognize complications and to take appropriate steps to manage them. Although the patient’s foot was reportedly cold and painful immediately post-procedure, it can take some time for the foot to warm, and pain could be caused by reperfusion. However, it is clear that two to four hours after the procedure, the interventional radiologist recognized that the patient’s leg had not improved and was worsening and that further care was needed. Thus, when it became clear to the interventional radiologist that the foot was not improving, he recommended that the patient seek more treatment.
The records of the interventional radiologist’s care of the patient were inadequate in that they do not state whether the patient’s clinical status post-procedure was worse than before the procedure. A post-procedure pulse examination was lacking which would have helped in determining the patient’s clinical status.
The patient reported to the ED physician that the pain began after the procedure and steadily worsened, which indicates that the patient rethrombosed her bypass graft and deep femoral artery (source of collateral flow) immediately. This event should have been recognized by the interventional radiologist.
However, the interventional radiologist’s documentation for this patient was inadequate and sparse. The medical records lacked documentation of the change in the patient’s status post-procedure, the discussion with the patient leading up to the discharge from his center, and the patient’s disposition. The interventional radiologist discharged the patient to her own care directly from his clinic instead of calling Emergency Medical Services (EMS), which indicates that the interventional radiologist failed to recognize the gravity of what was occurring.
His conduct did not ensure that the patient would be attended continuously until definitive treatment was given. The patient arrived at the emergency department at approximately 8:00 p.m., two hours after the patient was discharged from the interventional radiologist’s clinic.
Had the process of discharge and transfer occurred earlier, it is possible that the outcome could have been different. The interventional radiologist failed to communicate with the ED physician ahead of the patient’s arrival. The interventional radiologist gave the patient a CD of the procedure, a copy of the medical records, and his phone number, as an attempt of communicating with the emergency department personnel regarding the events that occurred at the interventional radiologist’s clinic.
However, the interventional radiologist failed to telephone the ED physicians at the emergency department to give a verbal report on the patient and to provide a more informative transition and preparation for continued care. In expecting the practitioners at the emergency department to call the interventional radiologist to gain more information, the interventional radiologist improperly sought to shift his responsibility to provide needed information about the patient to the staff at the emergency department.
The interventional radiologist failed to maintain documentation regarding the change in the patient’s status post-procedure, the discussion leading up to the discharge from his center, and the patient’s disposition. He stated that he was not sure if he documented these events, and if he did, he sent them with the patient. Documentation sent with the patient has since been lost. Documentation of a change in the patient’s clinical status was lacking. The medical records lacked documentation of what was discussed regarding the patient’s disposition and where she was told to go for further care.
The Board judged the interventional radiologist’s conduct to have fallen below the standard of care for the following reasons:
1) The interventional radiologist failed to offer to transport the patient by ambulance or EMS services to ensure that she would be attended continuously until definitive treatment was given. His failure to do so indicates that he failed to understand the gravity of the situation which was occurring.
2) The interventional radiologist failed to adequately communicate with the emergency department, to call ahead of time to inform them that the patient was in transit, and to inform them of the circumstances.
3) The interventional radiologist failed to maintain adequate and accurate records.
The Board issued a public reprimand.
State: California
Date: December 2017
Specialty: Interventional Radiology, Vascular Surgery
Symptom: Extremity Pain
Diagnosis: Acute Ischemic Limb, Post-operative/Operative Complication
Medical Error: Diagnostic error, Delay in proper treatment, Underestimation of likelihood or severity, Failure of communication with other providers, Lack of proper documentation
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Interventional Radiology – Epidural Steroid Injection On A Patient Taking Plavix
On 1/21/2014, an 85-year-old female was admitted to the hospital with complaints of lower back pain and chest pain.
The patient’s medication list, at the time of her admission, listed a prescription for 75 mg of Plavix daily.
On 1/23/2014, a radiologist performed an epidural steroid injection on the patient while she was taking Plavix. Shortly after the procedure, the patient developed an abrupt sudden onset of diffuse abdominal pain with nausea, vomiting, and a large retroperitoneal hematoma extending from the left upper abdomen into the pelvis.
The patient had a stroke, among other complications.
The Board judged the radiologists conduct to be below the minimal standard of competence given that he performed an epidural injection on a patient while the patient had been receiving antiplatelet therapy for a significant period of time.
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: Back Pain, Nausea Or Vomiting, Chest Pain
Diagnosis: Drug Overdose, Side Effects, or Withdrawal
Medical Error: Improper medication management
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 4
Link to Original Case File: Download PDF
Florida – Obstetrics – Missed Indicators Of A Neural Tube Defect
On 2/24/2014, a 36-year-old female presented to an obstetrician for fatigue, breast tenderness, and absence of menstruation. At the aforementioned visit, the obstetrician diagnosed the patient with amenorrhea and sent her to have blood work.
On 2/25/2014, the patient was notified of her positive pregnancy test.
On 3/20/2014, 3/17/2014, 3/24/2014, 4/24/2014, 8/7/2014, and 9/25/2015, the obstetrician ordered obstetrical ultrasounds and/or sonograms on the patient.
On 4/23/2014 and 8/20/2014, the patient presented to the obstetrician with thick vaginal fluid and bloody discharge and/or morning sickness, nausea, chills, fever, and back pain.
On 5/23/2014, 6/20/2014, 7/16/2014, 8/15/2014, 9/12/2014, 10/13/2014, 10/20/2014, and 10/27/2014, the patient presented to the obstetrician for follow-up visits.
On 11/2/2014, the patient gave birth to her son. The child was born with a neural tube defect called spina bifida/myelomeningocele.
The obstetrician failed to observe on imaging studies, and follow-up on, known indicators that the patient’s child may have had a neural tube defect, or alternatively, did not create, keep, or maintain adequate legible documentation of observing on imaging studies, and following up on known indicators that the patient’s child may have had a neural tube defect.
The obstetrician failed to order maternal serum alpha-fetoprotein (MSAFP) test, or alternatively, did not create, keep, or maintain adequate legible documentation of ordering a MSAFP test.
The obstetrician failed to order an anatomical survey sonogram, or alternatively, did not create, keep, or maintain adequate legible documentation of ordering an anatomical survey sonogram.
It was requested that the Board order one or more of the following penalties for the obstetrician: 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: Obstetrics
Symptom: Weakness/Fatigue, Bleeding, Abnormal Vaginal Discharge, Back Pain
Diagnosis: Neurological Disease
Medical Error: Failure to order appropriate diagnostic test, Failure to follow up, Lack of proper documentation
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 1
Link to Original Case File: Download PDF
Florida – Anesthesiology – Multiple Procedural Errors While Performing Cervical Epidural Steroid Injections
On 4/6/2016, a 69-year-old female with a prior history significant for pulmonary tuberculosis, essential hypertension, paroxysmal supraventricular tachycardia, osteoporosis, menopause, hypothyroidism, arthritis, chronic asthmatic bronchitis, and a former smoker, presented to a medical clinic.
An anesthesiologist initially diagnosed the patient with cervicalgia and cervical radiculopathy due to degenerative chronic cervical spondylosis. The patient was also hearing and speech impaired and used an interpreter and tablet for communication during all preoperative meetings.
The patient presented to the anesthesiologist in the surgery room for a signed consent of cervical transforaminal epidural steroid injection at right C4 and C5. The anesthesiologist instead performed a cervical epidural steroid injection (“CESI”) above C6-C7 without obtaining consent from the patient.
The anesthesiologist failed to have an interpreter in the surgery room during the patient’s evaluation and treatment so that he could effectively communicate with her.
The patient was positioned in the prone position on the table and the anesthesiologist administered Versed 2 mg IV and Fentanyl 100 mcg for IV conscious sedation.
The anesthesiologist failed to administer local anesthesia to numb the patient’s skin, while she was awake and alert, prior to injecting the first epidural steroid injection at C5-C6. The patient, unaware that she was receiving an injection and unable to clearly communicate her discomfort, responded to the initial puncture to her skin by a sudden jumping movement.
The anesthesiologist withdrew the needle and targeted lower interspace, C7-T1, using fluoroscopy. He used a seventeen gauge Tuohy needle under intermittent fluoroscopic guidance for entry into the epidural space at C7-T1 for the second attempt to perform the CESI. The anesthesiologist then injected the medication between C4 and C5 neural foramen.
The anesthesiologist documented one or more times prior to the 4/6/2016 procedure that he was performing a TFESI on the right at C4 and C5; however, he instead performed a cervical interlaminar epidural steroid injection (“ILESI”) at C5-C6, and additionally at C7-T1, without obtaining consent from the patient. He inappropriately elected to perform a CESI above C6-C7. The anesthesiologist did not create or maintain fluoroscopic images of his initial attempt to inject at C5-C6.
After the procedure, the patient was taken to the recovery room, where an interpreter and tablet was present for communication. The patient was no longer able to move her arm to communicate using the tablet and she experienced right upper extremity weakness and some right sided facial numbness.
The patient was transferred out of the medical center as a “Stroke alert” to a hospital, where she received a CAT or MRI scan, and again transferred to another hospital which did not have a neurosurgeon on staff.
After the CESI, the patient was diagnosed with iatrogenic cervical nerve root injury.
It was requested that the Board order one or more of the following penalties for the anesthesiologist: 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: Anesthesiology
Symptom: Weakness/Fatigue, Numbness
Diagnosis: Spinal Injury Or Disorder, Post-operative/Operative Complication
Medical Error: Wrong site procedure, Ethics violation, Failure of communication with patient or patient relations, Procedural error
Significant Outcome: Permanent Loss Of Functional Status Or Organ
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 – Urology – Unnecessary Laparoscopic Radical Prostatectomy With Bilateral Pelvic Lymph Node Dissection Performed
On 2/1/2016, a 66-year-old male presented to a urologist for a prostate biopsy. The urologist or his agents sent the specimens from the patient’s biopsy to pathology.
On 2/10/2016, a pathology report diagnosing the patient with adenocarcinoma of the prostate was issued.
On 2/16/2016 and 2/29/2016, the patient presented to the urologist to review the prostate biopsy pathology.
On 3/16/2016, the urologist performed a robotic assisted laparoscopic radical prostatectomy with bilateral pelvic lymph node dissection on the patient. The urologist or his agents sent the specimens from the patient’s surgical procedure to pathology.
On 3/25/2016, a pathology report indicating the specimens were “negative for malignancy” was issued.
On 3/25/2016, the urologist or his agents swabbed the patient to obtain a DNA sample to cross-check the DNA profile of the biopsied specimens (from the 2/1/2016 appointment) with the patient’s known DNA sample.
On 4/5/2016, a DNA report was issued, confirming that the DNA profile from the biopsied specimens (from the 2/1/2016 appointment) did not match the DNA profile of the patient.
On 3/16/2016, the urologist performed health care services that were medically unnecessary when he performed the surgical procedure on the patient.
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: July 2017
Specialty: Urology
Symptom: N/A
Diagnosis: N/A
Medical Error: Unnecessary or excessive treatment or surgery, False positive
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 2
Link to Original Case File: Download PDF
Florida – Pediatrics – Deep Laceration Of The Right Knee Treated With Debridement, Irrigation, And Suturing
On 12/7/2011, an 8-year-old male presented to a medical emergency department with a deep laceration to his right knee. The laceration was a full thickness cut with visualization of the capsule. An x-ray revealed air in the knee joint.
A pediatrician examined the patient’s knee and performed debridement, cleaning by irrigation, and suturing of the laceration. Bacitracin and dressing were applied to the patient’s knee.
On 12/10/2011, the patient returned to the emergency department with complaints of right knee swelling, redness, and pain. The patient was admitted to the pediatric floor.
Further examination revealed septic arthritis in the patient’s right knee, which required two operations and the introduction of a PICC line for long-term antibiotic therapy. The patient sustained cartilage damage as a result of the septic arthritis and suffered from significant knee pain.
The Board judged the pediatrician’s conduct to be below the minimal standard of competence given that he failed to refer the patient to an orthopedic surgeon and to fully wash out the patient’s joint by performing an open debridement under anesthesia.
The Board issued a letter of concern against the pediatrician’s license. The Board ordered the pediatrician to pay a fine of $10,000 against his license and pay reimbursement costs at a minimum of $5,496.59 and not to exceed $7,496.59. The Board also ordered that the pediatrician complete ten hours continuing medical education in pediatric orthopedic diagnosis and treatment and complete five hours of continuing medical education in “risk management.”
State: Florida
Date: June 2017
Specialty: Pediatrics, Orthopedic Surgery
Symptom: Joint Pain, Swelling
Diagnosis: Trauma Injury, Septic Arthritis
Medical Error: Improper treatment, Referral failure to hospital or specialist
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 4
Link to Original Case File: Download PDF
Florida – Emergency Medicine – Delayed Response In Spine Immobilization And Ordering X-Rays And CT Scan In Patient With Lumbar Spine Fractures
On 6/22/2012 at 12:30 a.m., a patient was an unrestrained back seat passenger of a taxicab when it was involved in a motor vehicle accident. The patient was intoxicated at the time of the accident.
EMT-Paramedics were dispatched to the scene of the accident and documented that the patient was moving all extremities and had a pulse, motor, and sensation in all four extremities. The EMT-Paramedics transported the patient to the emergency department without back-board or spinal immobilization precautions.
At 12:58 a.m., the patient arrived at the hospital.
At 1:32 a.m., an ED physician performed an exam of the patient’s back and documented equivocal lumbar back tenderness. The ED physician performed an exam of the patient’s pelvis and documented equivocal pelvic tenderness. He also performed a neurologic exam and documented no movement of the patient’s toes or leg muscles. The ED physician performed a rectal exam and documented that the patient exhibited an absence of anal sphincter tone.
AT 1:48 a.m., the ED physician ordered x-rays of the patient’s lumbosacral spine and pelvis. The lumbosacral spine x-ray results showed a comminuted fracture dislocation at T12-L1.
At 2:58 a.m., the ED physician ordered a computed tomography scan of the patient’s lumbar spine. The CT scan of the patient’s lumbar spine also showed a comminuted fracture dislocation at T12-L1.
At 3:17 a.m., the ED physician ordered that the patient be placed on a backboard.
At 4:20 a.m., the patient was transferred by ambulance to a level 1 Trauma Center.
The patient was ultimately diagnosed with paraplegia. A medical malpractice lawsuit was filed against the physician.
The Board judged the ED physician’s conduct to be below the minimal standard of competence given that he failed to immediately perform a full trauma evaluation, immediately immobilize the patient’s spine, immediately order an x-ray of the patient’s chest, immediately order a CT scan of the patient’s abdomen, and immediately order a CT scan of the patient’s pelvis.
The Board issued a letter of concern against the ED physician’s license. The Board ordered that the ED physician pay a fine of $5,000 against his license and pay reimbursement costs for the case at a minimum of $6,452.58 and not to exceed $8,452.58. The Board also ordered that the ED physician complete five hours of continuing medical education of emergency medicine and five hours of continuing medical education in “risk management.”
State: Florida
Date: June 2017
Specialty: Emergency Medicine, Trauma Surgery
Symptom: N/A
Diagnosis: Fracture(s), Spinal Injury Or Disorder
Medical Error: Failure to examine or evaluate patient properly, Delay in proper treatment
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 4
Link to Original Case File: Download PDF
Florida – Pain Management – Contrast And Steroid Injected Into The Intrathecal Space Instead Of The Epidural Space
Between February 2006 and September 2012, a patient presented to a pain specialist with complaints of chronic low back pain.
On one or more occasions between February 2006 and September 2012, the pain specialist assessed the patient with, among other things, low back pain, lumbago, osteoarthritis, lumbar failed back surgery syndrome, lumbar radiculopathy, and lumbar muscle spasms.
On 9/28/2012, the patient presented to the pain specialist in order for him to perform a lumbar transforaminal epidural steroid injection with catheter and fluoroscopy. Epidural administration is a medical route of administration in which a drug or contrast agent is injected into the epidural space of the spinal cord.
During the procedure, the pain specialist inserted the tip of the catheter through the patient’s epidural space and into the patient’s intrathecal space. Intrathecal administration is a medical route of administration in which a drug or contrast agent is injected into the spinal canal, or into the subarachnoid space so that it reaches the cerebrospinal fluid.
During the procedure, the pain specialist injected contrast and injectate into the patient’s intrathecal space instead of the patient’s epidural space.
The pain specialist did not obtain an intra-injection lateral view epidurogram to confirm the location of the catheter tip and/or the dispersal pattern of the contrast and injectate.
The pain specialist did not obtain a post-injection lateral view epidurogram to confirm the location of the catheter tip and/or the dispersal pattern of the contrast and injectate.
The pain specialist did not recognize that he had performed an intrathecal injection instead of an epidural injection.
After the procedure, the patient complained of bilateral hip and leg pain, numbness, and paralysis.
The patient was transferred to a hospital where she was ultimately diagnosed with conus medullaris syndrome.
It was requested that the Medical Board of Florida order one or more of the following penalties for the pain specialist: permanent revocation or suspension of his license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Medical Board of Florida deemed appropriate.
State: Florida
Date: June 2017
Specialty: Pain Management, Anesthesiology
Symptom: Back Pain, Numbness, Extremity Pain, Pelvic/Groin Pain, Weakness/Fatigue
Diagnosis: Post-operative/Operative Complication, Spinal Injury Or Disorder
Medical Error: Wrong site procedure, Lack of proper documentation, Procedural error
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 3
Link to Original Case File: Download PDF
Arizona – Internal Medicine – Managing A Patient Using Alternative Medicine As Opposed To Allopathic Medicine
In November 2009, an 87-year-old man, who was Physician A’s family member, began seeing Physician A for hypotension, autonomic dysfunction syndrome, osteoarthritis, hypothyroidism, and “hormonal imbalance.” Physician A prescribed over-the-counter herbs and supplements, prescription strength hormonal replacement therapy, and acupuncture treatments.
On 02/20/2011, the patient suffered a right frontal hemorrhagic stroke with residual left hemiplegia. Physician A took the patient to the hospital after 12 hours of initial symptoms. Physician A said that no neurologist was available at the local hospital and the weather made it hazardous for him to drive at that time.
On 09/22/2014, an osteopathic provider Physician B saw the patient. He advised that the patient take his blood pressure medications on a regular basis as opposed to as needed as recommended by the Physician A. Physician B recommended albuterol for dyspnea and a follow up spirometry. He also recommended tamsulosin in addition to saw palmetto for benign prostatic hypertrophy.
In August 2016, Physician A was removed as the patient’s primary medical provider.
The Board judged Physician A’s conduct to be below the minimum standard of competence given failure to obtain written consent regarding the treatment plan, which involved over-the counter medicines, herbs, and an absence of allopathic treatment.
Physician A did not monitor the patient’s TSH. He prescribed magnesium when the patient had chronic kidney disease and did not monitor the patient’s magnesium levels. He prescribed iron supplements when there was no documentation that the patient suffered from iron deficiency. He prescribed Natto and other supplements which had blood thinning effects and could have lead to the hemorrhagic stroke along with uncontrolled hypertension.
He prescribed testosterone when the patient had an elevated PSA level and uncontrolled hypertension.
The Board issued a Decree of Censure and placed Physician A on probation for 1 year. He was ordered to complete the Professional/Problem-Based Ethics program offered by the Center of Personalized Education for Physicians for Ethics and Boundaries.
State: Arizona
Date: May 2017
Specialty: Internal Medicine
Symptom: N/A
Diagnosis: Intracranial Hemorrhage
Medical Error: Improper medication management, Failure to properly monitor patient
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 1
Link to Original Case File: Download PDF