Found 47 Results Sorted by Case Date
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Vermont – Emergency Medicine – Suspected Ventricular Tachycardia Not Addressed In A Patient With Respiratory Distress, Fever, And An Elevated Heart Rate



On 2/6/2013 a patient’s father contacted EMS (emergency medical services) because his son had respiratory distress, fever, and an elevated heart rate.

EMS documented a heart rate of 278 and performed a pre-hospital EKG because ventricular tachycardia (VTach) was a concern.  EMS contacted the hospital to report vital signs and their impression of VTach.

The patient presented to the emergency department at 11:29 p.m.  The patient was triaged at 11:42 p.m. and a pulse of 245, blood pressure of 53/39, and a temperature of 101.02 were recorded.  An EKG was performed at 11:43 p.m.  The results were shown to the ED physician at 11:47 p.m.

The ED physician’s notes state that at 12:13 a.m. the patient was examined.  It was documented that the ED physician suspected the patient was in VTach, but no therapy was administered.

The ED physician then contacted the on-call cardiologist, who advised the ED physician to treat the patient for probable sepsis with fluids and Tylenol.  The ED physician then ordered IV antibiotics and spoke to a critical care physician about transfer of the patient.

At 12:29 a.m. the patient had a ventricular fibrillation cardiac arrest.  He was treated with various medications but no shock was given.  At 12:45 a.m. the patient was pronounced dead.

The Board concluded that the ED physician be reprimanded, complete 15 hours of continuing education on Advanced Cardiac Life Support, and pay a fine of $1000.

State: Vermont


Date: September 2017


Specialty: Emergency Medicine, Cardiology


Symptom: Shortness of Breath, Fever, Palpitations


Diagnosis: Cardiac Arrhythmia


Medical Error: Improper treatment, Delay in proper treatment


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Cardiology – Patient With Serious Hemodynamic Compromise After Receiving A Cardiac Stent For Myocardial Infarction



On 4/5/2012, a patient arrived at a hospital after suffering a heart attack.  He received a stent to the left anterior descending artery and was transferred to the intensive care unit.

At 9:00 p.m., the patient began to experience chest pains and lowered blood oxygen.  A cardiologist did not report to the hospital to examine the patient at the time.

At 12:00 a.m., the patient began to have serious hemodynamic compromise.  The cardiologist did not report to the hospital to examine the patient at the time.

At 3:00 a.m., over three hours after the onset of the patient’s serious hemodynamic compromise, the cardiologist reported to the hospital to examine the patient.

Prior to reporting to the hospital, the cardiologist had been made aware of each of the patient’s clinical status changes.  The cardiologist planned to transfer the patient to another hospital where the patient was to undergo a pericardial window, performed by a cardiothoracic surgeon.

Prior to undergoing a pericardial window, the patient expired.

The Board judged the cardiologist’s conduct to be below the minimal standard of competence given that he failed to report to the hospital to attend to the patient’s clinical status changes, to properly recognize the need for an immediate pericardiocentesis, and to perform an immediate pericardiocentesis.  Upon arriving at the hospital, the cardiologist failed to recognize that the patient’s clinical deterioration was such that an immediate pericardiocentesis needed to be performed to improve the patient’s blood flow.

The Board issued a letter of concern against the cardiologist’s license.  The Board ordered the cardiologist pay a fine of $7,500 against his license and pay reimbursement costs for the case at a minimum of $5,239.98 and not to exceed $7,239.98.  The Board also ordered that the cardiologist complete five hours of continuing education in “risk management” and complete five hours of continuing medical education in cardiology.

State: Florida


Date: July 2017


Specialty: Cardiology, Hospitalist, Internal Medicine


Symptom: Chest Pain


Diagnosis: Acute Myocardial Infarction, Acute Myocardial Infarction


Medical Error: Improper treatment, Delay in proper treatment


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Physician Assistant – Cardiac Catheterization Ordered In The Wrong Patient



On 10/11/2015, Patient A, an 89-year-old male presented to the emergency department with complaints of chest congestion, weakness, and chest pressure.

Lab results revealed that Patient A had elevated troponin levels, and he was admitted and referred for a cardiology consultation.

On 10/11/2015, the patient saw a cardiologist for the cardiology consultation.  The cardiologist documented that the patient had an upper respiratory infection and recommended that the patient continue antibiotics, gentle diuresis, and outpatient medical therapy.

At around the same time, on the same date, the cardiologist saw Patient B for a cardiology consultation.  Sometime after the cardiac consultations of Patient A and Patient B, the cardiologist contacted a physician assistant and instructed him to order a cardiac catheterization for Patient B.

The physician assistant placed an entry in Patient A’s medical chart instead of Patient B’s chart, ordering the cardiac catheterization.  The physician assistant failed to review Patient A’s available medical records, including labs, notes, and imaging studies, before placing the cardiac catheterization order in his chart.

The following morning, cardiac catheterization was unnecessarily performed on Patient A.

The Board judged the physician assistant’s conduct to be below the minimal standard of competence given that he failed to review the patient’s available medical records, including labs, notes, and images studies, before placing the cardiac catheterization order in his chart.

The Board issued a letter of concern against the physician assistant’s license.  The Board ordered that the physician assistant pay a fine of $2,000 against his license and pay reimbursement costs for the case at a minimum of $2,611.86 and not to exceed $3,111.86.  The Board also ordered that the physician assistant complete five hours of continuing medical education in “risk management.”

State: Florida


Date: June 2017


Specialty: Physician Assistant, Cardiology


Symptom: Weakness/Fatigue


Diagnosis: Infectious Disease


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


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Arizona – Cardiology – Cardiac Catheterization With Questionable Indications Results In Complications



A 76-year-old woman was diagnosed with severe aortic stenosis.

On 03/20/2014, the cardiologist performed cardiac catheterization which consisted of left and right coronary angiograms and left ventriculogram.  The patient experienced chest pain and syncope after the catheterization.  A STAT echocardiogram was performed and revealed aortic stenosis, normal LV function, and no pericardial effusion.  Troponins were elevated after the cardiac catheterization.

On 03/22/2014, the patient was taken to the operating room and was reported to have a pericardial effusion with non-clotting blood and evidence of early tamponade.  The aortic valve was replaced.  After surgery, the patient had difficulty weaning from the cardiopulmonary bypass machine and an intra-aortic balloon pump was required.  The patient was subsequently weaned off pressors and the IABP, and she was extubated one day postoperatively.  The patient had episodes of atrial fibrillation postoperatively and was discharged on 03/27/2014.

The Board judged the cardiologist’s conduct to be below the minimum standard of competence given failure to perform a left heart catheterization and left ventriculogram without proper indications.  Further details are unclear as to why the Board focused on this concern (given that left heart catheterization is often done in a patient with severe aortic stenosis to evaluate for coronary artery disease in case bypass graft surgery is required during aortic valve replacement, although one could argue the left ventriculogram was not warranted).

The main concern appeared to be that the cardiologist had a pattern of complications with concern that the complication of hemopericardium after cardiac catheterization indicated a deficiency of skills that increased the risk of complications among his patients.

The Board ordered the cardiologist to be placed on probation given complications among several patients he had managed.  He was prohibited from performing interventional cardiology until the Board granted him permission.  The cardiologist must provide evidence that he is able to safely perform interventional cardiology before the Board would consider lifting the prohibition.

State: Arizona


Date: April 2017


Specialty: Cardiology


Symptom: Chest Pain, Syncope


Diagnosis: Post-operative/Operative Complication


Medical Error: Procedural error


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Arizona – Cardiology – Multiple Complications During Cardiac Catheterization With Repeat Thrombosis Of The Right Coronary Artery



On 05/30/2014, a 56-year-old man presented with acute onset chest pain.  The cardiologist discovered that the left anterior descending (LAD) and right coronary artery (RCA) had significant stenosis.  The cardiologist first intervened up on the LAD with a stent, but found the proximal edge had “haziness” so he did not intervene further.  The cardiologist then focused on the RCA.  The first stent was deployed, but had a dissection for which the cardiologist deployed multiple other stents to correct.  Brisk flow in all coronaries was reported at the conclusion of these procedures.

The patient experienced a sudden thrombosis of the RCA two days later.  The cardiologist placed 3.5 diameter stents and used 2.0 and 2.5 mm balloons to reopen the RCA.  The patient also developed cardiogenic shock and acute respiratory failure from probably aspiration and required emergency intubation, which was described as traumatic.  The patient was on pressors and an intra-aortic balloon pump (IABP) was placed.

On 06/02/2014, the patient was noted to be improving with decreased dependence on pressors.  The IABP was removed the following day, but the patient became progressively agitated and experienced increased ST changes.

On 06/05/2014, the patient became hypoxic with ST elevation and was taken back to the catheterization lab where it was determined that the RCA was thrombosed.  The cardiologist performed balloon angioplasty on the RCA during which a perforation of the posterior descending (PDA) branch occurred.  The cardiologist made several attempts to stop the bleeding, including prolonged balloon inflations, which failed, and an attempt to completely occlude the PDA branch by placing a covered stent.  The stent could not be placed or withdrawn in the location of concern and was deployed more proximally.  A wire was left in the mid-RCA, which was ultimately coiled by an interventional radiologist due to ongoing bleeding.  The cardiologist noted a pericardial effusion, which did not demonstrate tamponade and did not require pericardiocentesis.

Over the next several days, the patient continued to experience worsening abdominal distention, right heart failure, episodes of bradycardia (which the Board deemed was not adequately addressed by the cardiologist), mottling of the lower extremities, liver congestion, and acute renal failure.  On 06/08/2014, the IABP was removed.

On 06/10/2014, the patient went into multi-organ system failure.  The decision was made to make the patient comfortable.  The patient had runs of ventricular arrhythmias and passed away that evening.

The Board judged that while there was no single defined even in the cardiologist’s treatment of the patient that would be considered a deviation of a standard of care, there were several areas of concern regarding his treatment of the patient.

The Board ordered the cardiologist to be placed on probation given complications among several patients he had managed.  He was prohibited from performing interventional cardiology until the Board granted him permission.  The cardiologist must provide evidence that he is able to safely perform interventional cardiology before the Board would consider lifting the prohibition.

State: Arizona


Date: April 2017


Specialty: Cardiology


Symptom: Chest Pain


Diagnosis: Acute Myocardial Infarction


Medical Error: Procedural error


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



Arizona – Cardiology – Hypotension, Tachycardia, Respiratory Distress, And Hypovolemic Shock During Pericardiocentesis



A 67-year-old woman with a history of Crohn’s disease presented to a cardiologist in consultation for a pericardial effusion.

On 04/10/2014, the cardiologist performed a pericardiocentesis.  1400 ml of bloody drainage had been removed when the patient developed hypotension, tachycardia, respiratory distress, and hypovolemic shock.  She required intubation.  The cardiology removed another 2000 ml of fluid before he removed the catheter used for the pericardiocentesis.  The patient required 6 units of PRBC’s, 4 units FFP, and 2 liters of NS to get stabilized.  In the intensive care unit, the patient was on phenylephrine and dopamine before she was gradually weaned off of pressors and the ventilator.  The patient was discharged in good condition.

The Board judged the cardiologist’s conduct to be below the minimum standard of competence given failure to recognize that he was not in the pericardial space and failure to use echocardiography to verify proper placement.  The cardiologist deviated from the standard of care by continuing to withdraw fluid from the patient and failing to verify that he was in the pericardial space.

The Board ordered the cardiologist to be placed on probation given complications among several patients he had managed.  He was prohibited from performing interventional cardiology until the Board granted him permission.  The cardiologist must provide evidence that he is able to safely perform interventional cardiology before the Board would consider lifting the prohibition.

State: Arizona


Date: April 2017


Specialty: Cardiology


Symptom: N/A


Diagnosis: Post-operative/Operative Complication


Medical Error: Procedural error


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



California – Cardiology – Inferior Wall Myocardial Infarction With Wire Placed In Small Side Branch And Balloon Dilated



On 7/5/2013, a 67-year-old female was brought by ambulance to a medical center for severe chest pains.  An electrocardiogram (EKG) was obtained and was consistent with inferior wall myocardial infarction.  The patient was immediately brought to the cardiac catheterization lab for angiography and angioplasty.

A cardiologist was noted to by the Board to have placed a wire in a small side branch and not in the distal right posterior descending artery, where the culprit lesion was located.  He inflated the balloon in the small side branch leading to a small perforation.  He then moved his wire and made another inflation, which resulted in a larger perforation.  After causing these four perforations and a large pericardial effusion, the cardiologist proceeded to inflate the balloon an additional four times.

At 7:47 p.m., the pericardial effusion was documented.  However, pericardiocentesis was not performed until 8:21 p.m.  The delay occurred even though the patient’s blood pressure continued to decline.

The Medical Board of California judged the cardiologist’s conduct as having fallen below the standard of care given failure to perform a pericardiocentesis in a timely manner, failure to identify the pericardial effusion in a timely manner, failure to place the wire in the correct location, and failure to address the culprit lesion.

The Medical Board of California placed the cardiologist on probation with stipulations to complete 40 hours annually while on probation of continuing medical education in the areas of deficiency, complete a clinical competence assessment program, and complete a professional enhancement program.  The professional enhancement program would include a quarterly chart review, semi-annual practice assessment, and semi-annual review of professional growth and education.

State: California


Date: April 2017


Specialty: Cardiology


Symptom: Chest Pain


Diagnosis: Acute Myocardial Infarction, Post-operative/Operative Complication


Medical Error: Wrong site procedure, Delay in proper treatment, Diagnostic error, Procedural error


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Cardiology – CT Coronary Angiogram On Hemodynamically Compromised Patient For Chest Pain, Abnormal Electrocardiogram, Right Atrial Enlargement, And Elevated Cardiac Enzymes



On 4/16/2012, a 23-year-old female presented to the emergency department with chest pain, acute nausea, vomiting, and diarrhea.  The patient had a history of pulmonary hypertension. Laboratory measurements were taken that revealed a hemoglobin of 17.2, hematocrit of 49.9, an acidotic pH of 7.12, an elevated WBC count of 15,900, potassium of 6.6, BUN of 31, and creatinine level of 1.4.  These measurements were consistent with mild renal insufficiency. An electrocardiogram test revealed sinus tachycardia, which was consistent with the findings of an electrocardiogram performed on the patient approximately 1 year earlier.

On 4/17/2012, the patient was admitted to the hospital.  The patient was initially treated with sodium bicarbonate to treat her lactic acidosis and IV fluids for dehydration.  The patient also received a dialysis catheter in her right femoral artery due to the increase in the BUN/creatinine measurements.  However, this catheter was never used.

On 4/17/2012, a cardiologist performed a telephonic cardiology consult with the hospitalist and ordered a CT coronary angiogram due to the patient’s chest pain, abnormal electrocardiogram, right atrial enlargement, and elevated cardiac enzymes (troponin).  The cardiologist also ordered 100 ml of ionic contrast to facilitate the CT angiogram despite the patient’s continued elevated BUN and creatinine levels. The cardiologist also ordered 50 mg of metoprolol orally and 5 mg intravenously to improve visualization on the CT angiogram despite the patient’s clinical condition.  The cardiologist did not perform a physical examination of the patient, measure the patient’s pulmonary pressure, or review the patient’s diagnostic or laboratory tests prior to ordering ionic contrast, CT angiogram, or administering metoprolol.

On 4/17/2012, the patient deteriorated and became hypotensive approximately 90 minutes after the CT angiogram and administration of metoprolol.  At approximately 8:00 p.m., the patient expired due to cardiac arrest.

The Medical Board of California judged that the obstetrician’s conduct departed from the standard of care because he failed to physically examine the patient prior to ordering a potentially dangerous procedure and drugs, review the patient’s previous diagnostic testing and laboratory testing prior to ordering a potentially dangerous procedure and drugs, and order a pulmonary artery catheter to measure pulmonary pressure in a hemodynamically compromised patient.

The Medical Board of California placed the cardiologist on probation for 3 years and ordered the cardiologist to complete a medical record keeping course and an education course (at least 40 hours per year for each year of probation).  The cardiologist was also assigned a practice monitor.

State: California


Date: March 2017


Specialty: Cardiology


Symptom: Chest Pain, Diarrhea, Nausea Or Vomiting


Diagnosis: Cardiovascular Disease, Renal Disease, Sepsis


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


Significant Outcome: Death


Case Rating: 5


Link to Original Case File: Download PDF



California – Cardiology – Echocardiogram For Heart Murmur Misinterpreted



On 10/10/2012, a 2-month-old child presented to a pediatric cardiologist with a heart murmur.  The pediatric cardiologist ordered an echocardiogram and a Holter test. He then sent the child home.  The pediatric cardiologist interpreted the results of the echocardiogram that day as “large ASD with left to right shunt, probable membranous VSD, marked right atrial and right ventricular and pulmonary artery dilatation.”  The following day, the patient returned to have the Holter removed. The child was noted to have a bluish tint to his skin caused by oxygen-poor blood. The patient was immediately sent to the emergency department, where a cardiologist reinterpreted the echocardiogram and found critical congenital heart disease, cor triatriatum with severe pulmonary hypertension.  The patient was immediately transferred to a tertiary care center via helicopter.

On 10/12/2012, the pediatric cardiologist amended his initial echocardiogram report of the patient to include the possibility of Ebstein anomaly and to state that the images transmitted over the internet were poor.

The Medical Board of California judged that the pediatric cardiologist conduct departed from the standard of care because he failed to admit the patient with significant pulmonary hypertension and ordered a Holter test for the evaluation of a heart murmur in the absence of an irregular heart rhythm.

For this case and others, the Medical Board of California ordered the pediatric cardiologist to surrender his license.

State: California


Date: January 2017


Specialty: Cardiology, Pediatrics


Symptom: N/A


Diagnosis: Cardiovascular Disease


Medical Error: Diagnostic error, Unnecessary or excessive diagnostic tests


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Cardiology – Discrepancy Between Echocardiogram Interpretation And Progress Note



On 4/7/2010, a pediatric cardiologist started following a patient for a small atrial communication, a patent foramen ovale (PFO).  On examination, the patient had a heart murmur with normal splitting of the second heart sound. An echocardiogram revealed the PFO.  He was asked to return in 1 year.

On 4/6/2011, the patient underwent a subsequent echocardiogram.  The results were normal. The pediatric cardiologist’s interpretation was “spontaneous closure of a PFO/ASD.”  His progress note of the same day stated “today’s echo/Doppler confirms the PFO is still present.”

The Medical Board of California judged that the pediatric cardiologist’s conduct departed from the standard of care because his progress note did not reflect the results of the echocardiogram from 4/6/2011.

For this case and others, the Medical Board of California ordered the pediatric cardiologist to surrender his license.

State: California


Date: January 2017


Specialty: Cardiology, Pediatrics


Symptom: N/A


Diagnosis: N/A


Medical Error: Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



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