Found 47 Results Sorted by Case Date
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Washington – Emergency Medicine – COPD, Shortness Of Breath, And Tachycardia With Administration Of Adenosine



On 8/28/2013, a patient who had chronic obstructive pulmonary disease (COPD) was admitted to the emergency department (ED) with shortness of breath.  The patient was transferred to telemetry for COPD exacerbation and persistent tachycardia.  The ED physician conducted various tests and an EKG.  He identified the patient’s medical issue as acute COPD exacerbation secondary to acute bacterial bronchitis with sinus tachycardia.

The patient was admitted to an internist for COPD exacerbation.  The admitting internist misread the EKG as supraventricular tachycardia (SVT).  Based on this, the internist administered adenosine without first consulting a cardiologist.  The internist failed to understand that using adenosine can cause worsening bronchospasm and must be used with caution in COPD patients.  The internist misinterpreted the patient’s severe bronchospastic response to the adenosine as anxiety and gave the patient Ativan, which would be expected to exacerbate this patient’s problem.  Shortly after, the patient experienced respiratory arrest.  Fortunately, the patient was resuscitated successfully.

The patient’s cardiologist felt that the respiratory arrest had been a side effect of the adenosine.  Adenosine has a side effect of causing bronchospasm, which means adenosine is contraindicated in patients with bronchospasm and cautioned for use in any patient with a history of COPD.  The internist failed to identify that the patient may have been suffering from severe bronchospasm or severe COPD.

The internist’s practice fell below the standard of care in the following ways:

1)     The internist misread the EKG.

2)     The internist administered a contraindicated drug.

3)     The internist failed to recognize the expected adverse reaction of that drug.

4)     The internist gave the patient a different drug which potentially exacerbated the adverse reaction.

5)     The internist’s treatment in this case resulted in the patient arresting.

The Commission stipulated the internist reimburse costs to the Commission, allow a Commission representative to audit patient records and review practices related to the internist’s assessment and treatment of patients with COPD, complete 6 hours of continuing education in the area of interpretation and management of cardiac arrhythmias, and write and submit a paper of at least 1000 words, with bibliography, on the subject of arrhythmias and their treatment in COPD patients.

State: Washington


Date: January 2016


Specialty: Hospitalist, Cardiology, Emergency Medicine, Internal Medicine


Symptom: Shortness of Breath


Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Pulmonary Disease


Medical Error: Improper medication management


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



Arizona – Neurosurgery – A Patient With A History Of Chronic Kidney Disease Presenting With Vertigo



A 72-year-old man with a history of chronic kidney disease presented to the hospital with vertigo and dizziness.  He was seen by neurology and cardiology.  Initially, it was felt that he may have had an inner ear problem.  A brain MRI showed bilateral frontal infarcts.  CTA and MRA showed a concern for left internal carotid artery dissection.  A neurosurgeon saw the patient and felt that angiography was appropriate to make a definitive diagnosis, which confirmed the dissection.  The neurosurgeon elected to proceed the following day with stenting of the carotid dissection.  The patient developed crushing subdural chest pain.  He had a coronary angiogram that demonstrated an aortic dissection.  The patient was stabilized, became septic, and was ultimately taken to the operating room for emergency surgery.  The patient was hypotensive and expired in the OR due to the dissection.  The neurosurgeon did not dictate the operative report for 10 days after the procedure.

The patient was noted to have stage III chronic kidney disease.  The Board judged the neurosurgeon’s conduct to be below the minimum standard of competence given failure to treat the patient with medical management instead of proceeding with surgical stenting, which placed the patient at risk secondary to contrast nephropathy.

State: Arizona


Date: December 2015


Specialty: Neurosurgery, Cardiology, Cardiothoracic Surgery


Symptom: Dizziness, Chest Pain


Diagnosis: Post-operative/Operative Complication, Cardiovascular Disease, Neurological Disease


Medical Error: Improper treatment, Diagnostic error


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



California – Internal Medicine – 55-Year-Old Female Who Recently Started An Exercise Program Presents Develops Chest Pain Worsened By Raising Her Arms



On 9/17/2009, a 55-year-old female presented to an internist’s office at 8:45 a.m. for an outpatient visit.  The patient had not previously been seen in that clinic’s affiliated hospital system, so no prior medical records were available.  The patient reported that she had been experiencing a breathing problem for the last three days that was characterized by pain, usually during the evening and at night.  The patient characterized the pain as intermittent sharp, non-radiating pain around the sternum, which became worse when she took a deep breath or pressed on the sternum area.  The internist noted that the patient’s pain was not associated with shortness of breath, fever, chills, cough, nausea, vomiting, or diaphoresis.  The patient reported that the pain was exacerbated when she moved her arms into certain positions, such as raising them.  The patient indicated that she had started an exercise program the previous week that included push-ups.

The patient gave a family history that included the facts that her mother had hypertension and that her sister had heart disease.  No further information concerning this family history of heart disease was in the record. The patient stated that she seldom consulted physicians, and she reported no personal history of heart problems.  The internist described the patient as a “self-professed health care avoider.”  No further social or medical history was obtained.  The internist indicated taking some further family history during her examination, but it was not indicated what additional information was added.  The patient’s vital signs were recorded as blood pressure 130/90, pulse rate 135 bpm, with no notation about rhythm, and temperature 98.3 F.  The patient’s height was 5’5”, and her weight was 172.5 lbs. (overweight).  The internist’s examination consisted of an ear, nose, and throat examination, respiratory auscultation, cardiac findings without mention of jugular venous distention or point of maximal impulse, and notations concerning normal extremity pulses and the absence of edema, clubbing, and cyanosis.  There was no mention of any attempt to reproduce the pain with anterior chest palpation or deep inspiration.  Although the internist noted that the patient’s heart rate was measured at 135 bpm, her electronic progress notes indicated that the heart rate was normal, and the rhythm regular, with no further information.

The internist diagnosed the patient with costochondritis and prescribed ibuprofen (600 mg. t.i.d. for 7 to 10 days, then prn), GI precautions, and push-up cessation, and the patient was sent home.  The tachycardia (135 bpm) was not addressed.  The patient declined immunizations and mammography.  The internist ordered the following tests for the patient: fecal globin, fasting glucose, lipid panel, and alanine transferase.  There is no indication in the record that these tests were taken or completed.  The internist encouraged the patient to make an appointment for a full physical examination and blood work, especially given her family history.  There was no immediate order or plan for further cardiac examination or for an electrocardiogram.

On 9/22/2009, the internist returned a telephone call from the patient.  The patient indicated that her research convinced her that costochondritis was a reasonable diagnosis, but that the ibuprofen prescribed brought only short-duration relief from her chest pain.  The internist then prescribed Relafen (nabumetone, 500 mg 1-2 tablets b.i.d. prn), a long-acting NSAID, and again advised limited activity.

On 9/26/2009, the patient experienced severe shortness of breath and chest pain, and an ambulance was summoned.  The patient was taken to the hospital. While at the hospital’s emergency department, the patient suffered a cardiac arrest and had to be resuscitated.  The patient was admitted to the hospital, and the admitting physician noted that the patient had had continued chest pain and mild shortness of breath for the week before admission.  Diagnosis was a probable ischemic event approximately a week ago, most likely an anterior myocardial infarction, persistent chest pain, and a likely inferior myocardial infarction on arrival at the emergency department as well as development of mitral regurgitation and pulmonary edema.  The patient eventually was diagnosed as having suffered a STEMI.

The admission history taken at the hospital confirmed a negative past medical history, but the family medical history taken included that fact that the patient’s father died of prostate cancer at the age of 77, the patient’s mother died of a myocardial infarction at age 75, and that the patient’s sister had suddenly died of a presume myocardial infarction at age 55.  The social history taken included the facts that the patient did no exercise, had not seen a doctor in 15 years, and drank 4 to 6 beers each night.

On the day of admission to the hospital, the patient underwent a full heart catheterization, including a coronary angiogram.  The results showed diffuse, severe coronary disease of the left anterior descending artery and circumflex and lesser disease of the right coronary artery and multiple smaller vessels.  Collateral flow from the distal right coronary artery supplied at least some of the left circulation.  Pressures were pulmonary artery pressure 45/28, mean 36; pulmonary artery wedge pressure 30/37, mean 30; cardiac output 3.75; and cardiac index 1.96.  A transesophageal echocardiogram revealed an ejection fraction of 30%, several mitral regurgitation, thrombus of the left atrial appendage, and probable ruptured tertiary chordae to the posterior leaflet.

Stenting of the left anterior descending artery and insertion of an intra-aortic balloon pump was done at the hospital, but the patient developed anoxic encephalopathy, so further treatment was curtailed in favor of transferring the patient to another hospital on 10/6/2009 for management of a small right occipital cerebral hematoma.  No surgery was done because the hemorrhage was small and stable.  The patient was transferred to a third hospital on 10/9/2009 for possible cardiac surgery, including mitral valve repair and coronary bypass, but upon arrival, the patient was in heart failure, ventilator-dependent, and agitated, so surgery was not performed.  The patient subsequently developed a fever and cardio-respiratory failure and expired at the third hospital on 10/15/2009. On 10/7/2009, after the internist had been informed of the patient’s admission to the second hospital, cardiac condition, and myocardial infarction, the internist placed an addendum note in her progress notes of 9/17/2009 indicating that the right sternal edge was tender to palpation.

The Medical Board of California judged that the internist’s conduct to be below the minimum standard of competence given that she failed to consider and rule out a cardiac origin for the patient’s pain, garner a detailed history on all cardiac risk factors, including family history, weight, blood pressure, lipids, alcohol consumption, amount of exercise, and diabetes, and perform a complete cardiovascular examination, paying particular attention to vital signs, including jugular venous distention, lung and cardio auscultation, PMI palpation, assessment of vascular bruits, and peripheral pulses.  After learning of coronary artery disease in the patient’s female family members, the internist also failed to take details concerning this familial heart disease, such as type of heart disease, age of onset, type of treatment, outcome, and age of death, if any.  The cardiology failed to do an EKG, take cardiac enzymes, or order a chest x-ray in light of the patient’s symptoms and her family history as well as not ruling out and examining for possible etiologies for the patient’s chest pain other than costochondritis.  The internist failed to explore the pain’s time of day, severity, duration, location, or possible association with activity, stress, food, or other precipitation factors and focused instead on the patient’s report of doing push-ups.  The internist did not pay attention to the patient’s tachycardia (135 bpm) and order an immediate EKG.  The internist ordered some testing for cardiac risk factors and a possible gastrointestinal cause for the patient’s symptoms, but only those useful for risk stratification purposes (ALT, blood sugar, fecal globin, and lipids).  The internist failed to order cardiac enzymes, an EKG, or chest x-ray, or other tests necessary to rule out a cardiac or other more serious cause for the patient’s immediate symptoms, specifically chest pain.  During the internist’s telephone call with the patient on 9/22/2009, the patient reported that ibuprofen provided only short-term relief from her chest pain.  The internist failed to recognize that the temporary efficacy of the ibuprofen could have indicated an etiology for the patient’s chest pain other than costochondritis.  The internist failed to inquire about the patient’s general condition and her chest pain, whether it had changed in character or duration.  The internist assumed costochondritis was the correct diagnosis, noting that the patient corroborated the diagnosis, and the internist missed the opportunity to ask questions about her general condition and her pain or to arrange for further examination or testing.

The Medical Board of California issued a public reprimand and ordered that the internist complete 8 hours of continuing medical education course in the diagnosis and treatment of heart disease.

State: California


Date: November 2015


Specialty: Internal Medicine, Cardiology, Emergency Medicine


Symptom: Chest Pain, Shortness of Breath


Diagnosis: Acute Myocardial Infarction, Intracranial Hemorrhage


Medical Error: Diagnostic error, Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Ethics violation, Lack of proper documentation


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Virginia – Cardiology – Failed Wire Guide Into Left Anterior Descending Artery Leads To Complication



On 4/4/2012, a 44-year-old female was admitted complaining of chest pain radiating to her left shoulder and to her back.  She was diagnosed with acute coronary syndrome.  Cardiac catheterization revealed a 99% exceptionally long stenosis of the proximal left anterior descending artery (“LAD”).  The cardiologist attempted to advance a guide wire in the LAD, but concluded that the LAD was too small for coronary stenting and abandoned the effort after a number of attempts.

Seven hours after the procedure, the patient’s blood pressure suddenly dropped and an echocardiogram indicated pericardial effusion, which was due to a micro-puncture of the patient’s coronary artery during angioplasty.  The patient required emergent pericardiocentesis.

The Board issued a reprimand.

State: Virginia


Date: October 2015


Specialty: Cardiology


Symptom: Chest Pain, Back Pain


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


Medical Error: Procedural error


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Virginia – Cardiology – Nitroprusside And Furosemide For Shortness Of Breath, Tachycardia, Diaphoresis, Hypertension, And 5-7 mm Of ST Elevation



On 10/16/2012, a 51-year-old male presented to the emergency department with shortness of breath, tachycardia, diaphoresis, a blood pressure of 240/193, and a pulse of 151.  The patient denied chest pain on admission, but he had experienced brief chest pain when his shortness of breath began, and his EKG showed 5-7 mm of ST elevation in the precordial leads.

Cardiologist A treated the patient with nitroprusside and furosemide that evening and admitted the patient to the intensive care unit.  Over the next several hours, the Cardiologist A neither re-examined the patient nor re-evaluated him for cardiac catheterization.  The following morning, the patient’s troponin was 185.66 versus 0.87 the prior evening.  He underwent emergency stenting of his left anterior descending artery by Cardiologist B.

Cardiologist A testified that he believed the patient’s hypertension, pulmonary edema, and inability to lie flat for the procedure increased the risk of performing cardiac catheterization and angioplasty.  He stated that the patient had not met criteria for emergency catheterization given that the patient had not experienced 30 minutes of constant chest pain.

The Board issued a reprimand.

State: Virginia


Date: October 2015


Specialty: Cardiology


Symptom: Shortness of Breath


Diagnosis: Acute Myocardial Infarction, Hypertensive Emergency


Medical Error: Delay in proper treatment, Failure to properly monitor patient


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Cardiology – Difficulty Placing Pacemaker With Subsequent Hypotension



On 8/10/2009, a 78-year-old female was admitted to the hospital due to chest discomfort, weakness, and slow heart rate.  During the work-up, the patient was diagnosed as having bradycardia. At the time of admissions, she also had a diagnosis of hypertension.  The patient also had a history of a cerebrovascular accident (stroke), for which she was maintained on antiplatelet medications Plavix (clopidogrel) and aspirin to decrease the incidence of a recurrent cerebrovascular accident.

A cardiologist decided that the patient should have a permanent pacemaker inserted, and the patient agreed.  The patient was taken to the cardiac catheterization lab in stable condition. On 8/12/2009 at 9:14 a.m., the cardiologist started the procedure to insert the pacemaker.  The cardiologist did not use a venogram of the subclavian vein prior to his attempted cannulation of the left subclavian vein.

The cardiologist inserted a sheath into a blood vessel at 9:19 a.m., but he was unable to advance the pacemaker lead after multiple failed attempts.  The cardiologist removed the sheath and lead wire, and pressure was applied. The cardiologist then made additional attempts to access the left subclavian vein without success.  A venogram was then performed, and a vascular consult with a cardiac surgeon was called. Following these attempts to access the subclavian vein, the patient became hypotensive and was noticed to be pale.  An attempt was made to normalize her blood pressure with vasopressor, dopamine, elevation of the legs, and boluses of saline.

The cardiac surgeon arrived at the catheterization lab within 5-10 minutes after being called.  Immediately after arriving at the catheterization lab, the cardiologist told the cardiac surgeon that he had punctured the subclavian artery about 2 to 3 times in his attempts to access the subclavian vein, and that he had put the needle, wire, and sheath in the artery.  The cardiologist further told the cardiac surgeon that he performed a fluoroscopy with dye, realized he was not in the right place, and then removed the needle, wire, and sheath.

In spite of the patient being extremely unstable, the cardiologist decided to continue with the pacemaker insertion.  After the cardiac surgeon inserted the pacemaker lead without difficulty, the cardiologist then inserted the pacemaker.  During this time, the patient was noted to have diminished breath sounds on the left side and was extremely pale and hypotensive.

After insertion of the pacemaker, the cardiac surgeon inserted a chest tube with an initial diagnosis of pneumothorax.  Blood was noticed from the chest tube, which indicated that the patient actually had hemopneumothorax. The patient’s condition remained unstable, and her blood pressure remained low on the vasopressor.  The patient was given a blood transfusion and fresh plasma. One unit of platelets was ordered, but the patient apparently did not receive it.

The pacemaker was rechecked, and then a cardiac surgery consultation was obtained.  A decision was made to observe the patient in the ICU and hold vascular intervention.  The patient continued to be unstable. At 2:45 p.m., the patient was transferred to the ICU in a hypotensive state.

At 3:09 p.m., the cardiologist dictated his operative report.  In that report, he stated, “Initially, left subclavian artery was entered by Sedlinger technique. This was recognized, guidewire was removed along with introducing sheath. Subsequently, multiple attempts were made to enter the left subclavian vein. Assistance was requested from the cardiac surgeon who entered left subclavian vein by Seldinger technique. Subsequently, pacemaker procedure was completed. The patient was found to be hypotensive, responded to fluid administration, dopamine infusion, was on supplemental oxygen. After pacemaker procedure was completed, the patient developed hypoxemia, hypotension. Fluoroscopy revealed suggestion of pneumothorax…”

At 5:00 p.m., the patient was experiencing worsening hypotension with fresh bleeding noted in the chest tube.  The patient became unresponsive, CPR was initiated without success, and the patient died.

A postmortem study was performed, which revealed multiple puncture wounds in the left subclavian artery and significant bruising and hematoma resulting in hemopneumothorax.  The cause of death was determined to be from hemorrhagic shock resulting from exsanguination due to complications associated with placement of the pacemaker.

The Medical Board of California judged that the cardiologist’s conduct departed from the standard of care because he inserted a sheath into the subclavian artery without knowing the location of the guidewire, removed the sheath after inserting it into the subclavian artery and prior to calling for a surgical consult,  after inserting and removing the sheath from the subclavian artery, decided to proceed with the pacemaker insertion rather than focusing on taking immediate interventional action to stop the patient’s bleeding from the subclavian artery, failed to use a venogram prior to insertion of needle into the blood vessel, and failed to provide adequate platelet transfusion.

The Medical Board of California ordered the cardiologist to surrender his license. The cardiologist was deemed incompetent after suffering a stroke in 2014.

State: California


Date: September 2015


Specialty: Cardiology, Cardiothoracic Surgery


Symptom: Chest Pain, Weakness/Fatigue


Diagnosis: Post-operative/Operative Complication, Hemorrhage, Ischemic Stroke


Medical Error: Procedural error


Significant Outcome: Death


Case Rating: 5


Link to Original Case File: Download PDF



Washington – Physician Assistant – EKG Read As “very mild ST elevation in the inferior leads” In Patient With Chest Pain



On 3/19/2014, a patient presented to a physician assistant at a family practice clinic complaining of chest pain that had persisted for five days.  The physician assistant’s examination of the patient revealed normal vital signs, normal cardiovascular examination, and a normal heart rate.  The physician assistant ordered an electrocardiogram (EKG) to further evaluate the patient’s chest pain.  The physician assistant interpreted the patient’s EKG as showing “very mild ST elevation in the inferior leads.”

The physician assistant failed to meet the standard of care when she did not identify the inverted T-waves on the EKG, which in the face of ongoing chest pain, suggested anterior cardiac ischemia and unstable angina pectoris.  Most significantly, the physician assistant also failed to meet the standard of care when she did not take emergency action in response to the patient’s situation.  The patient’s plan of care included orders for a stat troponin, complete metabolic panel (CMP), complete blood count (CBC), hemoglobin A1C, and chest x-rays.  On 3/19/2014, the physician did make an outpatient cardiology referral for an “ASAP appointment but there was no indication of when that appointment would occur.

The physician assistant kept insufficient records in that she did not document her discussions and plan with the “admitting provider.”  She claimed to have discussed and reviewed the EKG and plan with the admitting provider, an MD.  She further claimed the admitting provider agreed with her plan of care and EKG interpretation.  There is no documentation of this discussion in the patient’s medical records.

The physician assistant failed to meet the standard of care as the patient’s history of chest pain and EKG indicated an emergency situation.  The physician assistant should not have discharged the patient from her office on 3/19/2013, but should have recommended immediate transfer of the patient to the emergency department, preferably by an advanced cardiovascular life support (ACLS) capable transport, for further evaluation and therapy as necessary.

On 3/27/2014, eight days later, the patient returned to the clinic with worsening chest pain.  He was transferred to the emergency department and underwent emergent coronary catheterization that confirmed a left anterior descending (LAD) coronary lesion and a stent was successfully placed.

The Commission stipulated the physician assistant reimburse costs to the Commission, complete continuing education courses in EKG interpretation, the recognition and treatment of unstable angina/acute coronary syndrome, and advanced cardiac life support (ACLS), and write and submit a paper of at least 2000 words, with references, regarding the evaluation and management of unstable angina/acute coronary syndrome.  The paper should also contrast how she managed this case with how it ought to have been handled and will detail the changes she will make in her practice as a result of her coursework and experience in this case.

State: Washington


Date: February 2015


Specialty: Physician Assistant, Cardiology, Emergency Medicine, Family Medicine, Internal Medicine


Symptom: Chest Pain


Diagnosis: Acute Myocardial Infarction


Medical Error: Diagnostic error, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Cardiology – Chest Pain, Shortness Of Breath, And Heart Palpitations With Stress Test Read As Negative



On 7/15/2007, a 42-year-old male was taken by ambulance to the emergency department for chest pain.  The patient reported having left arm numbness and chest pain on a scale of 6 out of 10.  The patient had no prior history of heart disease, but his medical records indicated he reported that he had high blood pressure, smoked marijuana, and had similar episodes over the prior two weeks that included sweating, shortness of breath, and heart palpitations.  Hospitalist A evaluated and admitted the patient to the hospital in the telemetry unit for observation and a more complete medical work-up.  The patient did well overnight and showed no evidence of myocardial necrosis (heart attack) with normal electrocardiography (ECG) and troponin blood levels (cardiac damage marker in the blood).  Hospitalist A ordered a stress exercise echocardiogram (also known as a stress test).

A stress test was completed on 7/16/2007.  A cardiologist was only asked to interpret the stress test and not to provide a cardiology consultation or evaluate the patient.  The cardiologist interpreted the stress test approximately three hours after the test.  During the test, the patient showed good exercise tolerance, but he complained of chest pain.  Medical staff present during the test stopped it before completion due to the patient’s complaint of fatigue.  The test showed abnormal ECG’s, which suggested significant coronary artery disease.  The stress test also showed frequent premature ventricular contractions (PVC’s) and couplets (two in a row) in recovery, which was a possible marker for heart irritability from a blocked artery.  There was also stress-induced wall motion abnormality, which indicated that part of the heart was not getting enough blood flow due to a blocked coronary artery.

Despite these conditions, the cardiologist reviewed the stress test, and accompanying stress test worksheet, and found that there was no evidence of a heart problem in the patient.  The cardiologist dictated the following notes in the patient’s medical record: “This exercise echocardiographic study reveals no evidence for myocardial ischemia.  The patient did have chest discomfort and fatigue.  Note that frequent premature ventricular contraction was noted as described above.  Appropriate heart rate slowing did occur at one minute into recovery.  The patient achieved 117% of the predicted exercise capacity for age.”  At 6:08 p.m., the cardiologist wrote the following notes in the patient’s medical record: “EXE [exercise] (-) [negative] for ischemia. Freq. PVC’s in Recovery. Excellent exercise tolerance.”  The cardiologist determined that the patient’s stress test showed no heart problems or a blocked artery, when in fact, there were obvious signs of a blocked artery.

During the stress test, only an echocardiographic technician and nurse were present.  Despite the normal stress test results received from the cardiologist, the patient remained in the cardiac care unit overnight for continued monitoring.  The medical records for the patient indicated that he continued to complain to the nursing staff of chest pain, and he requested to speak with a doctor about the chest pain.  Also, the medical records reflected that the patient was afraid of being released from the hospital without knowing why he was having chest pain.  On the “Plan of Care” form in the patient’s medical records, the nursing staff wrote that the patient’s concerns were relayed to Hospitalist B on 7/17/2007.

On 7/17/2007 at 2 p.m., a physician assistant made the following handwritten note in the patient’s medical record: “stress test MNL [within normal limits], Lytes [electrolytes] OK. PVC’s during stress test OK.”  Hospitalist B ordered a lung test (spirometry) for the patient to determine if the chest pain was due to pulmonary issues, but the patient was discharged on 7/17/2007, before the spirometry tests were available, with instructions to see his primary care provider.  At no time did the cardiologist see the patient or review the medical chart from the patient’s admission date of 7/16/2007.

On 7/28/2007, the patient’s medical records, including from a coroner’s office, indicated that he was suffering from chest pains and called 911.  The patient was transported to the emergency department after suffering a heart attack.  The patient died in the emergency department. The subsequent autopsy listed the cause of death as “critical coronary artery stenosis due to coronary arterio and atherosclerosis.”  “Clinical history of hypertension” was also listed as another significant condition affecting the cause of death.

Investigators interviewed the cardiologist on 2/28/2012.  During this interview, the cardiologist admitted to making a mistake in how he read the patient’s stress test results.  He also admitted that he made a mistake in reading that there was no ischemia because it was in fact present.  Finally, the cardiologist denied that he needed to change his practice of supervision during stress tests.

The Medical Board of California judged that the cardiologist committed repeated negligent acts in his care and treatment of the patient and demonstrated a lack of knowledge and skill in his care and treatment of the patient given that he failed to identify an abnormality in the patient’s stress echocardiogram test results, which included a failure to recognize several high-risk indicators in the patient’s stress test and on the stress test worksheet.  Specifically, the high risk indicators were that the patient was a hospitalized patient in the cardiac care unit; was a marijuana smoker; was suffering from chest pain; developed chest pain rated a 4 out of 10 during the stress test; had a family history of coronary artery disease; developed PVC’s and couplets after the test; and developed ECG changes during exercise and during the recovery period.

For this case and another, the Medical Board of California issued a public reprimand and ordered that the cardiologist complete a clinical training or educational program equivalent to the Physician Assessment and Clinical Education Program (PACE) offered at the University of California, San Diego School of Medicine (Program) within 6 months after initial enrollment.

State: California


Date: December 2014


Specialty: Cardiology, Hospitalist


Symptom: Chest Pain, Numbness, Palpitations, Shortness of Breath, Weakness/Fatigue


Diagnosis: Acute Myocardial Infarction, Cardiovascular Disease


Medical Error: False negative


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



California – Cardiology – PCI Procedure Takes Over Six Hours As Stent Fails To Progress Resulting In Dye Overload And Excessive Fluoroscopy Time



A 77-year-old male patient with a history of diabetes and chest pain underwent elective cardiac catheterization on 3/13/2006 to assess any blockages.  On 3/13/2006 at 9:47 a.m., a cardiologist performed a cardiac catheterization. The cardiologist noted critical lesions in the LAD proximal and mid and in the circumflex coronary artery.  Specifically, there was a 90% proximal, and 70%, 80%, and 90% lesions of the mid left anterior descending coronary artery identified. There was also 80% lesion of the mid circumflex coronary artery.

A PCI procedure was undertaken at 10:18 a.m.  The patient underwent stenting in the proximal LAD, with dissection of the mid LAD.  The patient was treated with PCI only. The patient was given 6000 units of intravenous heparin.  The patient was started on an Integrilin bolus dose followed by continuous infusion. The catheter and guidewire were subsequently introduced.  At 11:22 a.m., the cardiologist attempted to advance a Cypher 2.5 x 28 mm stent, which was too difficult to pass. The stent was removed, and a Guidant PowerSail balloon catheter was advanced.  The balloon was unable to advance and was removed at 11:34 a.m. At 11:36 a.m., the cardiologist inserted a Guidant voyager OTW 2.4 x 15 mm and was inflated and removed between 11:44 a.m.-12:08 p.m.

Further attempts were made by the cardiologist to advance the stent, which was noted by the cardiologist to be difficult due to a tortuous midcourse of the left anterior descending coronary artery.  Further dilations were performed by the cardiologist.

Because of attempts to open a calcified artery by balloon rather than rotablator, multiple complications occurred including dissection, extremely excessive radiation time, and dye overload.  The procedure ended at 4:01 p.m., lasting 6 hours and 13 minutes with dye loads over 1000 ml and fluoro time of over 170 minutes.

The cardiologist noted that the lesions were heavily calcified, resulting in excessive procedure time, fluoro time, dye load, and inability to insert a stent in the dissected LAD. Post-catheterization, the patient displayed evidence of ischemia and possible anterior MI.  The cardiologist did not order cardiac enzymes. The cardiologist interpreted the definite EKG changes and possible MI as nonspecific ST changes. At this point of discharge, the patient’s creatinine levels were still above the normal range. This was, however, not documented by the cardiologist.  The cardiologist noted postoperatively that the plan was to follow up post-procedure with the circumflex coronary artery intervention at a later date to prevent any acute renal failure secondary to large amounts of dye used with the initial procedure. However, on follow up, no labs were ordered for renal function assessment.

The cardiologist’s conduct constituted gross negligence in that: the fluoro time and catheterization time were excessive.  The unsuccessful multiple dilations over 6 hours resulted in dissection, which the cardiologist could not properly stent. The patient was consequently subjected to multiple dye loads, which could result in renal complications.  The cardiologist failed to use a rotablator in a patient with heavily calcified arteries with multiple lesions, which were resistant to dilation and difficult to pass a stent. The cardiologist failed to rule out MI and order cardiac enzymes despite the fact that there was a documented dissection, prolonged catheterization time, evidence of ischemia, and possible MI by EKG.

For this allegation and others, the Medical Board of California ordered that the cardiologist be placed on probation for five years, attend a medical record keeping course, a clinical training program, be assigned a practice monitor for the duration of the probation, and be prohibited from supervising physician assistants for the duration of the probation.

State: California


Date: July 2014


Specialty: Cardiology


Symptom: Chest Pain


Diagnosis: Cardiovascular Disease


Medical Error: Procedural error, Failure to order appropriate diagnostic test, Failure to properly monitor patient, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Cardiology – Excessive Dye Loads And Fluoroscopy Time During Catheterization



A 68-year-old male was admitted to a medical center with known heart disease, coronary artery disease, and had undergone a previous bypass surgery.  He also had poor heart muscle function. His ejection fraction was 36%.

The patient had chest pain and underwent cardiac catheterization to assess any blockage and to improve his heart function by opening the artery.  The cardiologist spent about 69.4 minutes in fluoro time, which meant an extremely high indication of radiation exposure. The cardiologist also used dye excessively during the cardiac catheterization.

The cardiologist’s failure to use rotablator in heavily calcified arteries was a departure from the standard of care. His conduct of engaging in excessive fluoroscopy radiation time and using excessive dye loads was a departure from the standard of care.

For this allegation and others, the Medical Board of California ordered that the cardiologist be placed on probation for five years, attend a medical record keeping course, a clinical training program, be assigned a practice monitor for the duration of the probation, and be prohibited from supervising physician assistants for the duration of the probation.

State: California


Date: July 2014


Specialty: Cardiology


Symptom: Chest Pain


Diagnosis: Cardiovascular Disease


Medical Error: Procedural error


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



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