Found 47 Results Sorted by Case Date
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California – Cardiology – Patient With Dizziness And Trivial Mitral Insufficiency Diagnosed With Mitral Valve Prolapse



A 13-year-old female was initially seen by a pediatric cardiologist on 10/28/2009 for frequent dizzy episodes.  She had an echocardiogram, which showed trivial mitral insufficiency. The patient also underwent a stress echocardiogram.  The pediatric cardiologist noted that he felt the patient did not have any cardiac condition. There was no clinical or echocardiographic suggestion of mitral valve prolapse.  The pediatric cardiologist, however, diagnosed the patient with mitral valve prolapse. He did not explore any other diagnoses.

The consultation letter to the patient’s primary care physician for the 10/28/2009 visit was not generated until 11/7/2009 and was not signed by the pediatric cardiologist until 11/9/2009.  The pediatric cardiologist saw the patient on 1/4/2012. The consultation letter, however, was not generated until 3/4/2012 and not signed by the pediatric cardiologist until 3/7/2012.

The Medical Board of California judged that the pediatric cardiologist’s conduct departed from the standard of care because he diagnosed the patient with mitral valve prolapse in the absence of clinical or echocardiographic indication, failed to explore alternative diagnoses, delayed the production of the consultation letters, and ordered a stress echocardiogram work-up for pre-syncope in a teenager with a normal cardiac examination.

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: Dizziness


Diagnosis: N/A


Medical Error: Diagnostic error, Unnecessary or excessive diagnostic tests, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Cardiology – Decreased LV Systolic Function Misinterpreted As Normal



A pediatric cardiologist followed a patient after surgery for a congenital heart defect with poor LV systolic function.  The patient underwent an echocardiogram on 1/15/2010, 2/12/2010, 3/12/2010, 3/17/2010, and 4/9/2010. The narrative in the pediatric cardiologist’s reports stated “normal LV systolic motion” and/or “normal LV systolic and diastolic function.”  The reported quantitative function was anywhere between 10% and 24%, which should have been stated as decreased rather than normal.

The Medical Board of California judged that the pediatric cardiologist’s conduct departed from the standard of care because he misinterpreted the echocardiograms as normal rather than decreased LV systolic function.

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: False negative


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Emergency Medicine – Chest Pain, Shortness Of Breath, Left Bundle Branch Block On EKG



On 1/19/2014 at 4:40 a.m., a patient arrived at the emergency department complaining of shortness of breath and weeks of intermittent chest pain.

At 4:50 a.m., an ED physician evaluated the patient.  The patient was hypotensive, mildly tachycardic, tachypneic, and hypothermic.  He had rales, rhonchi, and a few wheezes.  The ED physician documented “Today, his pain is less,” but otherwise did not document any further description of the patient’s pain.

In his dictated note, the ED physician explained that he was concerned with the patient suffering septic shock.  In a subsequently written narrative, the differential diagnosis was expanded to include cardiac causes.

Laboratory studies were ordered along with an EKG, a troponin level, and a brain natriuretic peptide level.  The EKG was performed timely and was abnormal.  While the ED physician identified a left bundle block pattern (“LBBP”) in his dictated notes, he neither offered further interpretation of the EKG nor referenced criteria known to be helpful in identifying myocardial infarction in those with an LBBP on EKG.  The ED physician wrote that the EKG showed an LBBP “consistent with a myocardial infarction…”

The small community hospital where the patient presented had an ST-elevated myocardial infarction (“STEMI”) protocol in collaboration with a larger regional hospital better equipped to handle patients with cardiac emergencies.  Once activated, the protocol provides for rapid transportation of the patient to the larger hospital by ambulance.  The ED physician did not activate this protocol.

45 minutes after the EKG was performed, the troponin and BNP results indicated myocardial infarction and congestive heart failure.  A subsequent chest x-ray revealed pulmonary edema.  At this point, the ED physician called the on-call cardiologist to discuss transfer of the patient for treatment at a larger regional hospital.

The Board issued a reprimand and expressed concern that the ED physician departed from the standard of care by failing to obtain and document a more robust history and failing to more promptly consult cardiology regarding the patient’s abnormal EKG.

The Board ordered 40 hours of continuing medical education.

State: California


Date: October 2016


Specialty: Emergency Medicine, Cardiology, Internal Medicine


Symptom: Chest Pain, Shortness of Breath


Diagnosis: Acute Myocardial Infarction, Heart Failure


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


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Arizona – Cardiology – Nighttime Bradycardia And Pacemaker Implantation



In October of 2012, a 48-year-old obese man with a history of cardiomyopathy presented to Cardiologist A with dizziness.  An echocardiogram revealed normal left ventricular (LV) function and no significant valvular disease.  A nuclear scan showed normal LV function with an apical perfusion defect.  On an exercise stress test, the patient achieved 12 METS and reached a peak heart rate of 164 beats per minute.  An EKG revealed sinus rhythm with a rate of 60 beats per minute.  A Holter monitor revealed nighttime bradycardia.  Cardiologist A recommended a pacemaker and was referred to Cardiologist B.  Cardiologist B implanted a pacemaker.

The Board judged Cardiologist B’s conduct to be below the minimum standard of competence given failure to conduct a thorough evaluation prior to pacemaker implantation and given failure to justify implantation of a pacemaker.

On review of other patient charts, the Board noted that Cardiologist B lacked fundamental EKG reading skills.

The Board ordered the cardiologist be reprimanded and take 6 hours of continuing education in EKG interpretation.

State: Arizona


Date: August 2016


Specialty: Cardiology


Symptom: Dizziness


Diagnosis: Cardiovascular Disease


Medical Error: Unnecessary or excessive treatment or surgery, Failure to order appropriate diagnostic test


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Arizona – Cardiology – Supraventricular Tachycardia And Pacemaker Implantation



In July of 2012, an 83-year-old man with hypertension and COPD presented to Cardiologist A with dizziness and fall of unknown etiology.

In 2008, the patient had a normal EKG.  In 2009, he had a normal nuclear perfusion scan.

In May 2012, the patient’s primary care physician ordered a Holter monitor, which revealed sinus rhythm of 60-70 beats per minute during the daytime and 50 minutes during the nighttime.  No critical bradycardia was noted.

In August 2012, a follow-up EKG was performed, which revealed an episode of supraventricular tachycardia (SVT) at a rate of 130 beats per minute.  Cardiologist A recommended a pacemaker and referred the patient to Cardiologist B.

The Board judged Cardiologist B’s conduct to be below the minimum standard of competence given failure to conduct a thorough evaluation prior to pacemaker implantation and given failure to justify implantation of a pacemaker.

On review of other patient charts, the Board noted that Cardiologist B lacked fundamental EKG reading skills.

The Board ordered the cardiologist to be reprimanded and take 6 hours of continuing education in EKG interpretation.

State: Arizona


Date: August 2016


Specialty: Cardiology


Symptom: Dizziness


Diagnosis: Cardiovascular Disease


Medical Error: Unnecessary or excessive treatment or surgery


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Cardiology – Confusion, Fever, And Worsening Procedural Site After Right Femoral Artery Graft



On 12/21/2012, a 57-year-old male had a stent procedure.  Complications arose, and on 12/27/2012, the patient returned to the emergency department with complaints of right lower extremity pain, numbness, and increasing inability to move his right lower extremity.  An on-call cardiologist diagnosed a blood clot in the patient’s femoral artery of the right leg and took the patient to surgery in order to place a graft to open the artery to give the leg circulation. During the surgery, the cardiologist also performed a right femoral artery exploration, a right common femoral endarterectomy and patch, and a right femoral to above knee popliteal artery bypass.

On the fourth post-surgical day, 12/31/2012, the patient was noted to be confused and had an atrial fibrillation rhythm, by telemetry, which then returned to a normal rhythm the next day.  On 1/1/2013, the patient had a swollen surgery site and complained of sweats and shakes. A low-grade fever was noted in the record. On 1/2/2013, there was documentation of increased erythema and drainage from the right groin wound.  Wound cultures were obtained, which demonstrated large numbers of gram-negative species present. The patient was again suffering from confusion, which combined with the bacterial culture result, were clues to the patient suffering from systemic and graft infection.

On 1/5/2013, the patient was combative.  A CT scan was performed, which identified fluid collection with bubbles.  On 1/5/2012, the nurse notes documented a worsening wound. On 1/6/2013, the patient had a stroke while attempting to access the bathroom in his hospital room.  Thereafter, from 1/9/2013 through 1/13/2012, the wound continued to worsen without any action by the cardiologist to remove the graft. On 1/14/2013, the patient was transferred to a rehabilitation center, but he had a fever, was delirious, and had an infected site.  The patient had to be transferred back to the hospital on 1/16/2013 because of uncontrollable bleeding from the wound. On 1/17/2013, another vascular surgeon removed the graft from the patient and performed a right Sartorius myoplasty in order to address the infection.

The Medical Board of California judged that the cardiologist’s conduct departed from the standard of care because he failed to recognize and diagnose the signs of serious infection, adequately treat the patient’s graft infection, and remove the graft during the patient’s first hospital stay.

The Medical Board of California placed the cardiac surgeon on probation for 2 years and ordered the cardiac surgeon to complete an education course for at least 40 hours in the first year of probation.

State: California


Date: August 2016


Specialty: Cardiology


Symptom: Numbness, Confusion, Fever, Extremity Pain, Swelling, Weakness/Fatigue, Wound Drainage


Diagnosis: Procedural Site Infection, Acute Ischemic Limb, Cardiac Arrhythmia, Ischemic Stroke


Medical Error: Diagnostic error, Failure to examine or evaluate patient properly, Improper treatment


Significant Outcome: Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



Arizona – Emergency Medicine – Recent Cardiac Catheterization With Subsequent Presentation Of Right Groin Pain



The Board received notification of a malpractice settlement.

On 07/20/2011, a 66-year-old male presented to the emergency department.  He reported bleeding of his right groin status post cardiac catheterization performed 2 days prior.  The patient was evaluated by ED physician A, who noted that the bleeding had improved and that the right groin swelling had not gotten worse.  The patient reported taking enoxaparin and warfarin for his mechanical aortic valve.  The remainder of the examination was unremarkable with the exception of some noted bruising to the right groin.  The patient was discharged home after prolonged observation in the ED.

On 07/23/2011, the patient returned to the same ED and was evaluated by a resident.  The patient complained of right groin pain that radiated into the right lower back and was associated with numbness and tingling of his anterior right thigh.  ED physician B was supervising the resident.  The resident noted that the patient had developed a “knot” over the insertion site the night before, which was followed by increased pain into the right back.  At the time of the second ED visit, the patient reported that the pain was more persistent, and he was having difficulty walking.

The resident noted that the patient was taking blood thinners and that he “bruises/bleeds easily” secondary to the blood thinning medications.  Tenderness to palpation of the right groin was noted as well as a 3 x 6 cm oval area of ecchymosis with a small palpable round mass underneath and a 3 cm long longitudinal mass that was extremely tender.

There was no documentation of a back examination.  The neurologic portion of the examination was limited to the patient’s mental status.  A blood analysis and a CT scan were ordered.  The CT scan revealed a small to moderate retroperitoneal bleed on the right side consistent with right psoas hematoma as well as enhancement of the right common femoral artery and vein concerning for an aneurysm.

The reading radiologist recommended an ultrasound and the findings were discussed with the resident.  No ultrasound was available at that time.  The patient was subsequently discharged home with instructions to return with any worsening pain, fevers, chest pain, or shortness of breath, and to follow up with his cardiologist.  The ED physician submitted an addendum to the medical record noting that he examined the patient with the resident and agreed with the care plan.

Later that same day, the patient was taken to a different ED by ambulance complaining of shortness of breath.  The patient was noted to be in significant respiratory distress and was subsequently intubated for pending respiratory failure.  A blood analysis showed a hemoglobin of 4.2, creatinine of 3.4, potassium of 6.6, and an INR of 2.2.  The patient was severely anemic with hyperkalemia from acute renal failure.  When treatment was initiated to correct hyperkalemia, the patient went into cardiac arrest.

At 5:45 a.m. on 07/24/2011 and despite aggressive treatment efforts, the patient was pronounced dead.

An autopsy performed revealed the immediate cause of death was a massive right-sided retroperitoneal hematoma likely resulting from an intimal tear in the right femoral artery with dissection and adventitial hemorrhage.

The Board judged the ED physician’s conduct to be below the minimum standard of competence given failure to obtain an ultrasound to determine if an aneurysm was present.  He also failed to appreciate the risks of sending a patient home who has a bleed and who is on blood thinners.

The ED physician testified that the recommendation to obtain further ultrasound imaging was not communicated to him.  The ED physician expressed deep remorse for the error in judgment and stated that it would never be repeated.

The Board ordered the ED physician be reprimanded.

State: Arizona


Date: June 2016


Specialty: Emergency Medicine, Cardiology, Internal Medicine


Symptom: Bleeding, Numbness, Back Pain, Pelvic/Groin Pain, Swelling


Diagnosis: Hemorrhage


Medical Error: Failure to order appropriate diagnostic test, Underestimation of likelihood or severity, Failure of communication with other providers, Failure to follow up, Improper supervision


Significant Outcome: Death, Hospital Bounce Back


Case Rating: 5


Link to Original Case File: Download PDF



Arizona – Cardiology – Failure To Interrogate Pacemaker



The Board initiated an investigation into a cardiologist’s practice after receiving a report from the hospital where the cardiologist worked. He had resigned during a review of multiple patient charts and concerns regarding poor clinical judgment and inattention to details.

An 80-year-old man was admitted to the hospital with near syncope.  The hospital records did not contain any reference to a pacemaker interrogation.  However, the cardiologist responded that the pacer interrogation was “normal” when checked several months prior.  The Medical Consultant found that the patient’s pacer Holter function should have been reviewed to exclude concerns regarding interactions between neurostimulators and pacers that can lead to tachycardias and bradycardias.

The cardiologist said that he had checked the pacemaker.

From 06/06/2014-06/07/2014, the cardiologist underwent Phase I of the Physician Assessment and Clinical Education (“Pace”) Program.  The initial report stated that his performance was variable and recommended that the cardiologist complete a neuropsychological fitness for duty evaluation prior to completion of Phase II.

On 03/09/2015, the cardiologist presented to Phase II of PACE without undergoing the neuropsychological evaluation recommended in the Phase I report.  The cardiologist did not complete Phase II due to alleged unprofessional conduct during the clinical evaluation portion of the program, resulting in the cardiologist being “indefinitely barred” from returning to complete Phase II without a neuropsychological evaluation.

On 06/25/2015, the cardiologist completed a neuropsychological evaluation, although he failed to ensure the evaluator was approved by the Board.  The evaluator found that the cardiologist exhibited areas of poor performance compared to a younger population, but he was deemed not to have a cognitive disorder and his difficulties during the test did not account for his episodes of poor judgment.

The Board questioned the cardiologist’s unprofessional conduct during the interview of the cardiologist.  They remained concerned that allowing him to practice would not be safe for his patients’ safety.  He was placed probation with recommendation for him to complete a neuropsychological evaluation, CME, and practice monitoring.

On 0923/2016, the physician informed the Board that he was planning to retire.

State: Arizona


Date: February 2016


Specialty: Cardiology


Symptom: N/A


Diagnosis: N/A


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


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Arizona – Cardiology – Left Ventricular Dysfunction With Event Monitoring Showing Monomorphic Ventricular Tachycardia



The Board initiated an investigation into a cardiologist’s practice after receiving a report from the hospital where the cardiologist worked. He had resigned during a review of multiple patient charts and concerns regarding poor clinical judgment and inattention to details.

A 56-year-old man presented for a follow-up to address multiple episodes of near syncope and chest discomfort.  He was seen by the cardiologist to review results of outpatient testing.  A transesophageal echocardiogram revealed severe left ventricular dysfunction, event monitoring revealed episodes of monomorphic ventricular tachycardia, and nuclear stress imaging revealed an inferior wall infarct.  The patient was admitted, and the cardiologist performed cardiac catheterization, which revealed normal coronary arteries and severe global LV dysfunction.  The cardiologist diagnosed the patient with non-ischemic cardiomyopathy and treated him with intravenous and oral amiodarone.  It is assumed that the plan was for implantation of an implantable cardioverter-defibrillator, but the hospital did not perform that procedure.  For this presumed reason, the patient was subsequently discharged and transported by car to another hospital for implantation of an implantable cardioverter-defibrillator.

The Medical Consultant noted that VT ablation should have been considered.  Furthermore, the Medical Consultant did not think it was safe for the patient to be transferred to another hospital without cardiac monitoring given the risk of ventricular tachycardia.

The cardiologist said that the patient had declined transfer.

The Board judged the cardiologist’s conduct to be below the minimum standard of competence given failure to transfer the patient by ambulance.

From 06/06/2014-06/07/2014, the cardiologist underwent Phase I of the Physician Assessment and Clinical Education (“Pace”) Program.  The initial report stated that his performance was variable and recommended that the cardiologist complete a neuropsychological fitness for duty evaluation prior to completion of Phase II.

On 03/09/2015, the cardiologist presented to Phase II of PACE without undergoing the neuropsychological evaluation recommended in the Phase I report.  The cardiologist did not complete Phase II due to alleged unprofessional conduct during the clinical evaluation portion of the program, resulting in the cardiologist being “indefinitely barred” from returning to complete Phase II without a neuropsychological evaluation.

On 06/25/2015, the cardiologist completed a neuropsychological evaluation, although he failed to ensure the evaluator was approved by the Board.  The evaluator found that the cardiologist exhibited areas of poor performance compared to a younger population, but he was deemed not to have a cognitive disorder and his difficulties during the test did not account for his episodes of poor judgment.

The Board questioned the cardiologist’s unprofessional conduct during the interview of the cardiologist.  They remained concerned that allowing him to practice would not be safe for his patients’ safety.  He was placed probation with recommendation for him to complete a neuropsychological evaluation, CME, and practice monitoring.

On 0923/2016, the physician informed the Board that he was planning to retire.

State: Arizona


Date: February 2016


Specialty: Cardiology


Symptom: N/A


Diagnosis: Cardiovascular Disease


Medical Error: Improper treatment, Lack of proper documentation, Procedural error


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Arizona – Cardiology – Patient With Chest Pain And Elevated Troponin Requesting Transfer To The VA



The Board initiated an investigation into a the cardiologist’s practice after receiving a report from the hospital where the cardiologist worked. He had resigned during a review of multiple patient charts and concerns regarding poor clinical judgment and inattention to details.

A 59-year-old man presented to the hospital with chest pain.  Cardiac markers suggested myocardial infarction.  EKG’s were unremarkable.  The patient initially wanted to leave the hospital and seek care at the Veterans Administration Hospital (VA), but he was convinced to stay.  Though he was clinically stable, his cardiac markers increased and was strongly suggestive of a non-ST elevation myocardial infarction.  He was treated with low molecular weight heparin, aspirin, beta blockade, and nitrates.  The patient insisted on going to the VA.  After a day of clinical stability that included a ten minute walk on the ward, he was then discharged from the hospital by the cardiologist.  An ambulance was not used to transfer the patient to the VA.  The cardiologist was unable to contact cardiology at the VA.  For this reason, the patient did not have an established VA cardiologist that knew of his medical history and the reason for transfer.

The Medical Consultant stated that the patient should have been transferred by a resuscitation-capable transport.  Medical therapy for acute coronary syndrome should have been interrupted.  The cardiologist at the VA should have been contacted to accept the patient as a cardiology admission.

The cardiologist that he could not find any cardiologist at the VA facility.

The Board judged the cardiologist’s conduct to be below the minimum standard of competence given failure to transfer the patient by ambulance and reach a cardiologist at the outside hospital to transfer care.

From 06/06/2014-06/07/2014, the cardiologist underwent Phase I of the Physician Assessment and Clinical Education (“Pace”) Program.  The initial report stated that his performance was variable and recommended that the cardiologist complete a neuropsychological fitness for duty evaluation prior to completion of Phase II.

On 03/09/2015, the cardiologist presented to Phase II of PACE without undergoing the neuropsychological evaluation recommended in the Phase I report.  The cardiologist did not complete Phase II due to alleged unprofessional conduct during the clinical evaluation portion of the program, resulting in the cardiologist being “indefinitely barred” from returning to complete Phase II without a neuropsychological evaluation.

On 06/25/2015, the cardiologist completed a neuropsychological evaluation, although he failed to ensure the evaluator was approved by the Board.  The evaluator found that the cardiologist exhibited areas of poor performance compared to a younger population, but he was deemed not to have a cognitive disorder and his difficulties during the test did not account for his episodes of poor judgment.

The Board questioned the cardiologist’s unprofessional conduct during the interview of the cardiologist.  They remained concerned that allowing him to practice would not be safe for his patients’ safety.  He was placed probation with recommendation for him to complete a neuropsychological evaluation, CME, and practice monitoring.

On 0923/2016, the physician informed the Board that he was planning to retire.

State: Arizona


Date: February 2016


Specialty: Cardiology


Symptom: Chest Pain


Diagnosis: Cardiovascular Disease


Medical Error: Procedural error, Failure of communication with other providers


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



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