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Florida – Critical Care Medicine – Intensivist Unavailable To Assess Patient With Metabolic Acidosis, Abdominal Pain, And Vomiting
On 10/19/2011 at 5:23 p.m., a 35-year-old male presented to the emergency department at a hospital with a chief complaint of abdominal pain and vomiting, which started approximately five hours before he presented to the hospital.
The patient was admitted to the hospital under the service of an intensivist and was notified of his arrival and condition at 5:35 p.m.
Between the hours of 5:50 p.m. and 7:22 p.m. the intensivist gave verbal orders of Dilaudid and ketorolac to the patient’s nurse.
At 9:20 p.m., the intensivist gave telephonic orders to the patient’s nurse, to place him on his home BIPAP mask.
On 10/20/2011, at 3:15 a.m. a rapid response was called due to an acute change in the patient’s respiratory status.
During the rapid response, an arterial blood gas (“ABG”) was drawn that revealed critical metabolic acidosis.
The intensivist never presented to the emergency room to assess the patient when he demonstrated medically dangerous/life-threatening signs at 3:15 a.m. or any time thereafter.
The intensivist never attended to the patient when his clinical situation was from an unknown cause and when a clear treatment plan had not been determined.
From 3:43 a.m. to 4:15 a.m., the critical care practitioner was contacted approximately five times with information on the patient’s medically unstable and deteriorating condition.
At 3:45 a.m., the patient became short of breath, restless, diaphoretic, and seizure episodes followed. He was then transported to an intensive care unit.
At 5:25 a.m., a second rapid response was called due to a further decline in the patient’s health. The rapid response turned into a code blue.
The patient underwent a cardiopulmonary arrest, and the code team was unable to resuscitate him.
On 10/20/2011, the patient expired at 6:25 am.
The autopsy results were consistent with acute hemorrhagic pancreatitis with diffuse pancreatic necrosis.
The Medical Board of Florida judged the intensivist’s conduct to be below the minimal standard of competence given that he failed to presented to the emergency room to assess the patient when the patient demonstrated medically dangerous/life-threatening signs on 10/20/2011 at 3:15 a.m.
The Medical Board of Florida issued a letter of concern against the critical care practitioner’s license. The Medical Board of Florida ordered that he pay a fine of $7,500 against his license and pay reimbursement costs for the case at a minimum of $4,503.10 and not to exceed $6,503.10. The Medical Board of Florida ordered that the critical care practitioner complete ten hours of continuing medical education in the area of critical care medicine and complete five hours of continuing medical education in “risk management.”
State: Florida
Date: December 2017
Specialty: Critical Care Medicine, Emergency Medicine, Pulmonology
Symptom: Abdominal Pain, Nausea Or Vomiting
Diagnosis: Gastrointestinal Disease
Medical Error: Failure to properly monitor patient
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF
Florida – Emergency Medicine – Patient With Chest Pain Radiating To The Neck, Throat, And Back Discharged With Instructions To Follow up In 3-5 Days
On 11/15/2013, a patient complained of chest pain radiating to his neck, throat, and across his back. The patient stated the onset of the pain was noted to be one hour prior to his arrival at the hospital while he was screwing something into the wall, and that the pain was exacerbated by movement.
An ED physician performed an initial EKG, labs, and a chest x-ray on the patient.
The ED physician initially treated the patient with nitroglycerin and a GI cocktail, and subsequently with diazepam, morphine, Toradol, and Dilaudid.
The ED physician’s final assessment of the patient noted that the patient was still complaining of left side neck pain and “trap pain.”
The ED physician discharged the patient with a diagnosis of “musculoskeletal chest pain” and prescribed naproxen, Norco, and diazepam, along with instructions to follow up with him in three to five days.
The patient returned to the hospital the following day in cardiac arrest and expired on 11/16/2013.
The Medical Board of Florida judged the ED physician’s conduct to be below the minimal standard of competence given that he failed to perform a CT of the patient’s chest to evaluate for aortic dissection. He also failed to adequately document bilateral pulses and/or blood pressures in the patient. He failed to pursue other etiologies of the patient’s reported pain. The ED physician failed to admit the patient for further observation.
It was requested that the Medical Board of Florida order one or more of the following penalties for the ED physician: 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: December 2017
Specialty: Emergency Medicine
Symptom: Chest Pain, Back Pain, Chest Pain, Head/Neck Pain
Diagnosis: Aneurysm
Medical Error: Failure to order appropriate diagnostic test, Delay in proper treatment, Failure to examine or evaluate patient properly, Lack of proper documentation
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF
Florida – Emergency Medicine – Patient With Intussusception Involving Loop Of Small Bowel Discharged Home With Magnesium Citrate
At 1:45 a.m. on 7/26/2014, a 46-year-old female presented to the emergency department with complaints of severe abdominal pain. Upon arrival at the emergency department, the patient was evaluated by the ED physician.
The patient complained of severe abdominal pain and stated the pain was “10 out of 10.” The patient then underwent laboratory studies and a CT scan of the abdomen/pelvis with intravenous and oral contrast.
A radiologist reviewed the CT scan at some time before 4:16 a.m., when he read and signed the preliminary report. Upon review of the CT scan results the radiologist recorded in the preliminary report “intussusception involving loop of small bowel in the left lower quadrant with involved loops appearing edematous.” The radiologist relayed the results of the CT scan to the ED physician via teleradiology.
The ED physician recorded the results of the CT scan in the patient’s emergency provider report and noted “thickened loop of small bowel in the left lower quadrant, [m]ay be intussuception [sic].”
At 4:32 a.m. the ED physician discharged the patient to her home with a magnesium citrate prescription and no additional discharge instructions.
At 8:28 a.m. a physician signed the final radiology report and noted “[i]ntussesception involving loop of small bowel in the left lower quadrant” and “preliminary report related to referring physician teleradiology at the time of the exam by the radiologist.”
Later that day, the patient developed worsening pain, and presented to another emergency department, and underwent an emergency surgery for resection of necrotic bowel.
The Board judged the ED physician’s conduct to be below the minimum standard of competence given his failure obtain emergent surgical consultation for further evaluation and treatment and continue hospitalization for operative intervention or ongoing evaluation of abdominal pain.
The Board ordered the ED physician to pay an administrative fine in the amount of $8,000. Also, the Board ordered the ED physician to complete five hours of continuing medical education in the area of emergency medicine.
State: Florida
Date: December 2017
Specialty: Emergency Medicine
Symptom: Abdominal Pain
Diagnosis: Acute Abdomen
Medical Error: Improper treatment, Referral failure to hospital or specialist
Significant Outcome: Hospital Bounce Back
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Emergency Medicine – Sharp Chest Pain After Intercourse
On 4/4/2015, a 47-year-old male presented to the emergency department with sharp chest pain after intercourse.
The RN on duty noted taking the patient’s vitals and performing an EKG, chest radiograph, and labs.
In his physician note, the ED physician documented the following: the patient did not take his medication for hypertension or dyslipidemia despite having a history of hypertension and homelessness; the patient reported a history of coronary artery disease and possible coronary artery stent placement; and the patient reported chest discomfort and dyspnea for the week prior to presentation as well as a history of tobacco use.
The ED physician recorded a differential diagnosis including acute myocardial infarction, non-ST segment elevation myocardial infarction (“NSTEMI”), angina, and acute coronary syndrome.
The ED physician did not diagnose the patient with possible cardiac etiology of chest discomfort. He also did not contact the on-call cardiologist. The ED physician did not perform provocative testing or cardiac catheterization. He also did not admit the patient for hospitalization and cardiology consultation. The ED physician discharged the patient without requiring any further evaluation/treatment or serial EKG/troponin. He did not arrange for close outpatient follow-up prior to discharge.
The Board issued a letter of concern against the ED physician’s license and ordered that he pay a fine, reimburse costs for the proceedings, and complete 5 hours of continuing education in risk management.
State: Florida
Date: November 2017
Specialty: Emergency Medicine
Symptom: Chest Pain
Diagnosis: Cardiovascular Disease
Medical Error: Failure to order appropriate diagnostic test, Referral failure to hospital or specialist, Failure to follow up
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
Florida – Emergency Medicine – A Patient With Diabetes Presents With Hyperglycemia, Nausea, Vomiting, And A Bicarbonate Level
On 4/28/2015, a 69-year-old female presented to the emergency department with complaints of nausea and vomiting, which had persisted for two to three days.
The patient reported that members of her family had recently experienced similar symptoms.
The patient presented with a history of diabetes and high blood pressure.
An ED physician ordered a general chemistry lab. The patient’s lab work revealed a high blood glucose level of 383 with a reference range of 65-99. The patient’s lab work also showed that her bicarbonate level was low at 15 with a reference range of 21-32. The low bicarbonate level indicated possible acidosis.
The ED physician treated the patient with insulin and antinausea medications and discharged her. The ED physician did not further investigate the patient’s low bicarbonate level. The ED physician did not assess the patient for diabetic ketoacidosis.
On 4/29/2015, the patient returned to the emergency department with recurrent nausea, vomiting, and worsening shortness of breath.
The patient was diagnosed with diabetic ketoacidosis and severe sepsis.
The patient’s condition deteriorated and she expired in the hospital on 5/4/2015.
The Board judged the ED physician’s conduct to be below the minimal standard of competence given that he failed to further investigate a low bicarbonate level by ordering additional laboratory studies such as a serum ketone, serum beta-hydroxybutyrate, or serum pH.
It was requested that the Board order one or more of the following penalties for the ED physician: 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: Emergency Medicine
Symptom: Nausea Or Vomiting, Shortness of Breath
Medical Error: Failure to order appropriate diagnostic test
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF
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 – Pediatrics – Cough, Post-Tussive Emesis, Fever, Elevated Heart Rate, And Elevated Respiratory Rate
On 6/8/2012, a 16-year-old female presented with complaints of tactile fever for the previous four days, coughing, and one incident of post-tussive emesis.
A pediatrician performed an examination and documented that the patient’s temperature was 98.3, her heart rate was 98, and her respiratory rate was 22. The patient’s weight was also documented to be 209 pounds.
The pediatrician assessed the patient was suffering from an upper respiratory infection (URI) and recommended that she continue over-the-counter medication to manage her symptoms.
On 6/9/2012, the patient again presented to the pediatrician. She presented with the same complaints of fever and coughing, but additionally complained of a sore throat.
The pediatrician performed an examination and documented that the patient’s heart rate was 106 and her respiratory rate was 32. She was also running a temperature of 100.8.
The pediatrician assessed that the patient had a URI and pharyngitis. The pediatrician provided the patient with respiratory instruction and advised that she should return in two days if her temperature persisted.
Despite the increase in the patient’s heart rate and respiratory rate from the 6/8/2012 and 6/9/2012 visit, the pediatrician did not order a STAT chest x-ray for the patient. Despite the increase in the patient’s heart rate and respiratory rate from the 6/8/2012 and 6/9/2012 visit, the pediatrician did not check the patient’s oxygen saturation.
On 6/10/2012, the patient expired in her home. The medical examiner documented the patient’s cause of death as pneumonia with sepsis due to haemophilus influenzae.
The Medical Board of Florida judged the obstetrician’s conduct to be below the minimal standard of competence given that he failed to order a STAT chest x-ray and check the patient’s oxygen saturation.
The Medical Board of Florida issued a letter of concern against the pediatrician’s license. The Medical Board of Florida ordered that the pediatrician pay a fine of $5,000 against his license and pay reimbursement cost at a minimum of $1,408.03 and a maximum of $3,408.03. The Medical Board of Florida ordered that the pediatrician complete five hours of continuing medical education in pediatric medicine and complete three hours of continuing medical education in diagnosis and treatment of pneumonia.
State: Florida
Date: August 2017
Specialty: Pediatrics, Emergency Medicine, Family Medicine, Internal Medicine
Symptom: Fever, Cough, Nausea Or Vomiting
Diagnosis: Pneumonia
Medical Error: Failure to order appropriate diagnostic test
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF
Virginia – Emergency Medicine – Chest Pain Radiating To The Neck, Throat, And Back
On 11/15/2013, a patient presented to the emergency department complaining of chest pain with radiation to the neck, throat, and back. The patient expired the next day due to cardiac arrest. The ED physician failed to perform a CT scan of the patient’s chest and failed to admit the patient for observation. The ED physician discharged the patient with the diagnosis of “musculoskeletal chest pain.”
He was ordered a fine and to complete 5 hours of continuing medical education in each of the topics of medical record keeping and risk management.
State: Virginia
Date: August 2017
Specialty: Emergency Medicine
Symptom: Chest Pain, Back Pain, Head/Neck Pain
Diagnosis: Cardiovascular Disease
Medical Error: Diagnostic error
Significant Outcome: Death
Case Rating: 1
Link to Original Case File: Download PDF
North Carolina – Vascular Surgery – Abdominal Aortic Aneurysm 8.3 cm In Size With Large Type I Endoleak
On 3/31/12, a 76-year-old male with a history of heart disease, chronic obstructive pulmonary disease (COPD), prior endovascular repair of a large abdominal aortic aneurysm (AAA) in 2010 at an outside hospital (OSH) presented to the VA Medical Center emergency department with complaints of back, flank, and hip pain.
On 4/1/12 in the early morning, the patient had a CT scan with contrast which revealed an 8.3 cm AAA with large Type I endoleak. There was retroperitoneal stranding consistent with an aneurysm rupture. At 7:45 a.m., these findings were communicated to the emergency department physician.
At 8:00 a.m., the patient was evaluated by a vascular surgeon. Based on the vascular surgeon’s interpretation of the CT films and the patient’s clinical presentation, the vascular surgeon recommended admission for observation with a follow-up consultation with orthopedic surgery and interventional radiology.
The patient was admitted to the medical ward for the next three days during which he continued to have severe ongoing pain that was managed with pain medications.
On 4/4/12, the patient had a precipitous decline in his clinical status with severe hemodynamic compromise. A repeat CT scan demonstrated a ruptured AAA with aortocaval fistula. The patient was taken to the operation room where the vascular surgeon performed an open repair of the aortocaval fistula and ruptured AAA. However, the patient suffered extensive operative blood loss, perioperative myocardial infarction, and neurological injury.
The patient survived the procedure but remained critically ill. Over the next several days, the patient improved to a certain degree, but it was felt that the patient had suffered brain injury with little chance for meaningful recovery.
On 4/9/12, supportive measures were withdrawn, and the patient died.
In January 2017, the Board received information regarding a medical malpractice lawsuit settlement payment related to the care provided by the vascular surgeon to the patient.
The Board obtained the patient’s records and sent them to a qualified independent medical expert for review. The independent medical expert judged the vascular surgeon’s conduct to be below the minimum standard of competence given failure to adequately diagnose and aggressively treat the patient’s symptomatic, ruptured AAA despite evidence of the patient’s life-threatening condition.
The vascular surgeon was reprimanded.
The Board reported the Consent Order to the Federation of State Medical Boards.and the National Practitioner Data Bank.
State: North Carolina
Date: July 2017
Specialty: Vascular Surgery, Emergency Medicine
Symptom: Back Pain, Pelvic/Groin Pain
Diagnosis: Aneurysm, Post-operative/Operative Complication
Medical Error: Delay in proper treatment
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF
California – Radiology – Epidural Injection With Subsequent Lower Extremity Pain And Sensory And Motor Function Loss
On 1/15/2010, a 61-year-old female underwent an epidural injection. Following the procedure, she complained of sharp pain in the lower extremities, followed by sensory and motor function loss below the T10 and T11 level. The patient was transferred by ambulance to the emergency department.
A thoracic and lumbar MRI was performed and interpreted by a radiologist. The final report for the lumbar spine states “Mild desiccation and degenerative changes of the disc but no disc bulge or herniation is noted.” His final report of the thoracic spine demonstrates “normal MRI of the thoracic spine…A repeat study of the thoracolumbar spine is recommended without contrast infusion in both projections to better evaluate this area as this is on the edge of the study on the current images both lumbar and thoracic is not well delineated.” Although the images were suboptimal, the epidural hematoma of the lower thoracic spine was evident in the axial images.
On 1/19/2010, a repeat MRI was performed. The radiologist interpreted the MRI stating there is “abnormal signal focus demonstrated in the spinal canal from approximately the T10-T11 disc space inferiorly through the T12-L1 disc space located mostly in the posterior and posterolateral aspect of the spinal canal displacing the cords slightly anteriorly and causing a slight mass effect on the cord and subarachnoid sac. This is consistent with a subdural or epidural hematoma.”
The Board judged the radiologist’s conduct as having fallen below the standard of care given failure to observe and document all pertinent findings on diagnostic imaging studies, failure to discuss findings requiring urgent treatment with the referring physician, failure to diagnose the abnormality found on MRI, and failure to document his discussion with the referring physician regarding the abnormality on MRI.
A public reprimand was issued against the radiologist.
State: California
Date: June 2017
Specialty: Radiology, Emergency Medicine
Symptom: Extremity Pain, Numbness, Weakness/Fatigue
Diagnosis: Spinal Injury Or Disorder
Medical Error: False negative, Failure of communication with other providers, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF