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The Board was notified of a professional liability payment paid on 3/8/16.

A 48-year-old female presented to the emergency department three times over the course of two days with complaints of severe headache.

During the 7/28/12 visit, she had a non-contrast CT head, which was reported as normal.  The patient’s headache was treated as an acute migraine attack.  She was discharged with anti-migraine, anti-nausea, and anti-anxiety medications.

On 7/29/12, the patient returned with persistent symptoms, was treated symptomatically, and discharged.  Later that day, the patient again returned to the emergency department with continuing headache and persistent nausea and vomiting.

The patient was admitted to the hospital under the care of an internist.  The patient was started on maintenance IV fluids to treat dehydration and was treated for the underlying migraine with analgesics and antiemetic.

During the internist’s care of the patient, the internist did not order a spinal tap or additional CT scan, instead relying on the 7/28/12 emergency department CT scan.

On hospitalization day three, the patient was discharged with anti-migraine and anti-nausea medications, and was advised to follow up with her primary care physician or neurologist within a week.

On 8/2/12, the day after discharge, the patient returned to the emergency department with a continuing headache and a CT scan of her head showed intracranial hemorrhage in the right temporal lobe.

The patient was then airlifted to a tertiary care center and had clipping of a brain aneurysm/hematoma removal and ventriculoperitoneal shunt placement.

The Board obtained the patient’s records and sent them to a qualified independent medical expert for review.

The independent medical expert judged the internist’s conduct to be below the minimum standard of competence given failure to provide adequate care for severe persistent headache with normal neurological exam.  The medical expert found that the internist failed to perform a lumbar puncture and repeat imaging or seek neurology input.

The Board issued a public letter of concern, which was reported to the Federation of State Medical Boards.  It was not reported to the National Practitioner Data Bank.

State: North Carolina

Date: July 2017

Specialty: Internal Medicine, Hospitalist

Symptom: Headache, Nausea Or Vomiting

Diagnosis: Intracranial Hemorrhage

Medical Error: False negative, Delay in proper treatment, Failure to order appropriate diagnostic test, Underestimation of likelihood or severity

Significant Outcome: Permanent Loss Of Functional Status Or Organ, Hospital Bounce Back

Case Rating: 4

Link to Original Case File: Download PDF

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

A 69-year-old male with diffuse systemic sclerosis, interstitial lung disease, end stage renal disease on hemodialysis, anemia, hypertension, hypoalbuminemia, secondary hypothyroidism, and gastric antral vascular ectasia (“GAVE”) had been referred to a gastroenterology clinic for evaluation of recurrent problems with weight loss and dysphagia.  It was assumed that the patient’s disease had progressed to esophageal scleroderma and that a percutaneous endoscopic gastrostomy (“PEG”) would be necessary to bypass his esophagus and would allow him to take in adequate nutrition without swallowing.  The patient was referred to the gastroenterology clinic for evaluation and a PEG.

On 6/25/2012, the gastroenterologist ordered a PEG, and she scheduled an esophagogastroduodenoscopy (“EGD” or upper endoscopy) and esophageal manometry for the afternoon of 6/25/2012, both elective, non-emergent diagnostic procedures, scheduled to be done on an outpatient basis.  On 6/23/2012 or 6/24/2012, the patient had been discharged from the hospital on antibiotics with home oxygen administration after treatment for aspiration pneumonia.

The gastroenterologist performed a pre-endoscopy history and physical examination in the early afternoon of 6/25/2012 and noted that the patient had active diffuse scleroderma complicated by renal crisis, diffuse systemic sclerosis, interstitial lung disease, GAVE with multiple cauterizations, and end stage kidney disease.  In past medical history, she listed “scleroderma renal crisis, “Started dialysis December 30, 2011,” and “Pneumonia. Admitted to er 6/24/12.”  She noted that the patient had had multiple upper endoscopies for gastrointestinal bleeding prior to this EGD.  Her physical examination listed “Lungs: Clear Auscultation. Clear percussion and Normal Symmetry and Expansion.”  She noted that she, not an anesthesiologist, was ordering sedation.

Sedation was to be administered by a registered nurse.  The gastroenterologist listed Airway as Class 2 and ASA Level (American Society of Anesthesiologists physical status classification system) as 3 (severe systemic disease).

On 6/25/2012 at 2:48 p.m. and ending at approximately 3:15 p.m., the gastroenterologist performed an upper endoscopy on the patient and took biopsies.  Nursing records indicate that sedation consisted of midazolam, 7 mg, administered over the 22 minutes; fentanyl, 175 mcg administered over the 22 minutes, and Cetacaine spray applied to the throat prior to the procedure.

The patient was transferred from the endoscopy procedure room to the recovery area under the care of a registered nurse.  The nurse noted that the patient was unresponsive to verbal and painful stimuli, with blood pressure 108/70, heart rate 86, and O2 saturation 89% on 2 liters delivered by nasal cannula.  A face mask was applied at 10 liters O2 and oxygen saturation went up to 97%.  When the gastroenterologist was notified, she ordered reversal medications: flumazenil 0.25 mg IVP over 15 seconds and Narcan 0.4 mg IVP at 3:40 p.m., and the patient was still unresponsive.  A second dose of flumazenil 0.25 mg IVP was given at 3:43 p.m., and the patient became responsive at 3:44 p.m.  Once the patient was responsive, the gastroenterologist performed the esophageal manometry procedure.  No time is entered in the medical record for this procedure although the gastroenterologist acknowledges that it was done and the results are recorded.

The gastroenterologist was later notified by nursing staff of concerns with the patient’s breath sounds, and the gastroenterologist noted stridor at 4:26 p.m.  She was notified at 5:19 p.m. that the patient’s oxygen saturation was 89% on 5 liters oxygen delivered by nasal cannula.  At 5:20 p.m., the gastroenterologist ordered a chest x-ray due to the inability to wean the patient off oxygen after the endoscopy.  A face mask was applied at 10 liters oxygen at 5:21 p.m., and oxygen saturation went up to 93%.  The chest x-ray indicated “a dense retrocardiac opacity and a left pleural effusion” and a “volume loss in the left lung with mild shift of the mediastinum towards the left.”

After the manometry procedure in the recovery room, the patient’s oxygen saturation was monitored, and when the oxygen saturation remained above 90% for 30 minutes on room air, the patient met endoscopy discharge criteria.  The patient was discharged home with instructions concerning any complications that might arise.

The gastroenterologist states that she arranged to admit the patient to the hospital, but the patient left against medical advice (AMA).  Neither notation of this nor a signed AMA release was found in the record.  Pathology results revealed gastritis and the manometry procedure revealed a condition consistent with esophageal scleroderma.

On 6/27/2012, the patient presented to the emergency department with shortness of breath and cough.  Chest x-ray showed new right lung patchy opacities, and the patient was cachectic.  He was admitted to the intensive care unit for treatment of pneumonia.  The admission diagnosis was “most likely persistent pneumonia, likely aspiration due to esophageal dysmotility.”  The patient failed to improve despite intensive hospital care.  Although the gastroenterologist had scheduled a PEG for 7/2/2012, it was decided that the patient would not go through with the procedure.  Instead, it was decided that the medical team would provide palliative care for the patient.

On 7/4/2012, the patient died with the cause of death listed as aspiration pneumonia due to esophageal dysmotility and end-stage scleroderma with severe malnutrition as a contributing factor.

The Board deemed the gastroenterologist’s conduct as falling below the standard of care for the following reasons:

1) The gastroenterologist failed to provide an accurate analysis of the patient’s suitability for the endoscopic and manometry procedures.

2) She classified the patient as an ASA Level 3, which denotes an individual with stable multiple system disease that limits daily activity without immediate danger of death.

3) At the time of the EGD and manometry done by the gastroenterologist, the patient had just been released from another hospital, where he had been treated for aspiration pneumonia and discharged on antibiotics and home oxygen.

4) By reason of the patient’s recent aspiration pneumonia and the necessity for home oxygen administration, his ongoing scleroderma renal crisis which necessitated hemodialysis, his persistent interstitial lung disease, and his frequent bleeding and cauterizations for GAVE, his condition was not stable, and elective procedures at this time were contraindicated.  The patient’s classification was clearly ASA level 4, which denotes an individual with severe, incapacitating disease, poorly controlled or end-stage, at risk for death due to organ failure.

5) The gastroenterologist failed to provide for an anesthesiology consultation, given the patient’s unstable and life-threatening condition, and instead elected to provide conscious sedation directed by the gastroenterologist and administered by a registered nurse.  The level of sedation administered to the patient during the upper endoscopy procedure was relatively large for an individual with so many co-morbid conditions, and an anesthesiologist or nurse anesthetist should have been in attendance.

6) Since both procedures were elective, the gastroenterologist failed to reschedule the procedures for a time when the patient was stable and able to tolerate conscious sedation directed by the gastroenterologist and administered by a nurse.

7) The patient had a very unstable post-procedure course in the recovery room.  He was unresponsive to verbal and painful stimuli and oxygen saturation was below 90%.  Reversal medications had to be administered before the patient became responsive.  When the patient became responsive, the gastroenterologist performed the esophageal manometry in the recovery room.  This procedure was unnecessary to determine the need for a PEG and further endangered the health of the patient.

8) The respondent approved sending the patient home with instructions after his oxygen saturation was above 93% for 30 minutes.  The patient was a very high-risk patient for elective procedures and had had a very unstable post-procedure course in the recovery room, including the development or exacerbation of pneumonia.  Under these circumstances, in conjunction with his numerous co-morbidities, it was unsafe to send the patient home.  There was no record found of the patient leaving the clinic AMA.

The Board issued a public reprimand against the gastroenterologist.  Stipulations included continuing medical education in the topics of pre-operative patient evaluation, informed consent, sedation, and medical record keeping.

State: California

Date: May 2017

Specialty: Gastroenterology, Hospitalist, Internal Medicine

Symptom: GI Symptoms (GERD, Abdominal Distention, Dysphagia), Cough, Shortness of Breath, Weight Loss

Diagnosis: Gastrointestinal Disease, Pneumonia, Pulmonary Disease

Medical Error: Unnecessary or excessive treatment or surgery, Failure of communication with other providers, Lack of proper documentation

Significant Outcome: Death, Hospital Bounce Back

Case Rating: 5

Link to Original Case File: Download PDF

In July 2013, a patient was diagnosed with rectal cancer with metastasis to the liver.  He was treated with chemotherapy.  His course was complicated by colovesical fistula and scrotal abscess.

On 2/4/2014, the patient underwent a laparoscopic diverting colostomy.  He had further chemotherapy after this operation.

On 7/7/2014, the patient went to Internist A’s office.  At that time, the patient’s medication regimen included a fentanyl patch, hydrocodone-acetaminophen, hydromorphone, valium, zolpidem, and oxycodone-acetaminophen.  Adderall was not listed as a prescribed medication in the patient’s medical records.

On 7/22/2014, the patient was admitted to the medical center after a fall at home.  The accompanying diagnosis included syncope, dehydration, volume depletion, generalized weakness, and perineal wound.  During that hospital stay, the patient was found to have streptococcal bacteremia, for which he was treated with intravenous antibiotics.  In the emergency department’s record from the medical center, Adderall was listed in his prior to admission medication list.  It was continued in the inpatient setting and carried over with his discharge orders at the time of transfer to a skilled nursing facility. Internist A did not perform a medication reconciliation when the patient’s care was transitioned.

On 8/2/2014, the patient was discharged from the hospital.  At that time, his medication regimen was as follows:  Adderall 20 mg daily; zolpidem 10 mg at bedtime; fentanyl patch 25 mcg every 72 hours; oxycodone 10-20 mg every 4 hours as needed; and diazepam 5 mg daily as needed.  Based on the patient’s wife’s concern, the physician covering for Internist A discontinued the Adderall and the fentanyl patch.  However, the discharge summary makes no mention of discharge medications.  The patient was transitioned to a skilled nursing facility for continuation of intravenous antibiotics.  He received physical therapy/occupational therapy there and intravenous antibiotics.  He subsequently developed a fever.

On 9/18/2014, the patient was transferred back to the emergency department for tachycardia and was admitted to the hospital.

On 9/25/2014, the patient was discharged home with his spouse under hospice care.  On 10/1/2014, the patient expired at home.

While at the skilled nursing facility, the patient’s wife was concerned that the patient was on too many medications, that he was not required to ambulate, and that is dentures were lost, which impaired his oral intake.  During this period of time, the patient’s wife made multiple phone calls to Internist A, attempting to express her concerns about the care provided to her husband, but was unable to speak to Internist A.  Internist A failed to communicate with the wife regarding her husband’s condition.

The Board felt that Internist A had practiced below the standard of care given failure to perform medication reconciliation at transitions of care.  He failed to fulfill his responsibility as a treating clinician to update the patient’s wife.  He failed to maintain accurate and adequate medical records.  The patient’s perineal wound was not mentioned in his admissions notes or in subsequent follow-up notes.

The Board issued a reprimand against Internist A.  He was ordered to comply with attending a course in medical record keeping.

State: California

Date: February 2017

Specialty: Internal Medicine, Hospitalist

Symptom: Weakness/Fatigue, Fever

Diagnosis: Sepsis, Colon Cancer

Medical Error: Failure of communication with patient or patient relations, Improper medication management, Lack of proper documentation

Significant Outcome: Hospital Bounce Back

Case Rating: 1

Link to Original Case File: Download PDF

On 12/5/2011, a patient underwent knee replacement surgery.  In the course of his post-operative recovery in the hospital, the patient developed a rapid heartbeat.

On 12/6/2011, he was seen by Hospitalist A in the morning.  Hospitalist A attributed the patient’s rapid heart rate to his pre-existing atrial fibrillation and ordered an oral beta-blocker.  The patient’s heart rate was soon restored to a more moderate level.  The patient was transferred to the telemetry unit for closer monitoring at about 11:00 a.m.  Hospitalist A saw the patient again the following morning, noting that the patient was on nasally-administered supplemental oxygen, that his cardiac rhythm was irregular, that he was anemic, and that he had diminished bilateral breath sounds.  The hospitalist ordered chest x-rays and a blood transfusion.  The hospitalist’s order for a chest x-ray read “?chf” under “Indications.”

On 12/8/2017 at 8:40 a.m., nursing notes stated that the patient was receiving 2 liters of oxygen per minute via nasal cannula and his oxygen saturation level was 94%.  Hospitalist A’s chart entries made at about 10:40 a.m. indicate the patient was anemic, displayed some mental confusion, and had abdominal distention.  Hospitalist A opined that the distention “(m)ay be ileus due to oral morphine SR plus PRNs But r/o bleeding.”

Hospitalist A ordered x-rays of the patient’s abdomen, which confirmed the presence of an intestinal ileus.  Hospitalist A did not obtain a CT scan of the patient’s abdomen.  At about 3:50 p.m., Hospitalist A directed a nasogastric tube be placed to decompress the ileus.  Nursing notes from that evening indicate that the patient’s abdomen was “very distended, rounded” with hypoactive bowel sounds.

On 12/9/2017 at 2:30 a.m., a chart entry by Hospitalist B noted that the patient was “extremely uncomfortable with increased abdominal distention.”  She ordered a Harris flush procedure to reduce the patient’s intestinal pressure.

On 12/9/2017 at 3:58 p.m., the patient’s oxygen monitor alarm was sounding.  His oxygen saturation was 74% despite 2 liters per minute of supplemental oxygen.  Nurses repositioned the patient in bed and increased the oxygen flow rate to 5 liters per minute.  The indicated oxygen saturation increased to 88%.  The nasal cannula was moved to the patient’s mouth and the indicated oxygen saturation increased to 91-93%.  Hospitalist A was notified of the patient’s condition.

At 4:30 p.m., the attending nurse again called Hospitalist A to report that the patient was extremely short of breath with “labored” respirations and an indicated oxygen saturation “in the low to mid 80s.”  Hospitalist A directed that the patient be repositioned higher in bed; the nurse informed Hospitalist A that the patient was in the highest possible position.  Hospitalist A gave no new orders regarding the patient’s care.

The attending nurse’s chart entry for 5:10 p.m. states the following:

“(p)t’s condition continues to worsen.  Pt unable to hold O2 sats about low to mid 80’s on 5 liters NC.  Respiratory called to put on non-rebreather mask.  Pt’s LOC is decreased.  Pt repositioned up in bed.  NG tube flushed.  Pt requiring one-to-one nursing care.  Follow-up call to break and relief nurse’s call to [Hospitalist A] to ask that he come to the floor to see pt, d/t pt’s deteriorating respiratory status.  [Hospitalist A] still not answering the phone.”

The attending nurse placed a “Rapid Response” call to summon a physician to assess the patient at 5:20 p.m.  Hospitalist A came to the patient’s room, and his notes state that the patient’s oxygen saturation improved when he was repositioned in bed, “up to the 90s and stayed above 92” per measurement by the respiratory care provider.  Hospitalist A decided to continue with the current treatment on the medical floor rather than transferring the patient to the intensive care unit.

The medical record indicates that at 5:50 p.m., the patient’s oxygen saturation level is “in the 90’s but the O2 sat is variable with sat going down into the 80’s.”  The patient was still receiving supplemental oxygen via the 100% non-rebreathing mask.  The nursing notes for this time state that the patient’s daughter, a nurse, believed the patient should be monitored in the intensive care unit rather than on the medical floor and conveyed that desire for transfer to nursing staff, the nursing supervisor, and to Hospitalist A.

Nursing notes for 6:45 p.m. state the following:

“BP 92/63 HR 120’s.  Pt minimally responsive, respirations increasingly labored.  Telemetry and O2 sat monitors frequently alarming.  Pt requiring RN at bedside at all times.  pt hands cyanotic and remain cool to touch and forehead now appears slightly bluish in color.  [Hospitalist A] aware.  Family tearful, verbalizing anger w/staff regarding pt not being transferred to ICU.”

At 7:05 p.m., Hospitalist B ordered the patient to be transferred to the intensive care unit, apparently in deference to the fact that the “family, rn, supervisor want the pt moved to icu though it was discussed with all by the rounding hbs that there are not criteria for icu…”  The patient was taken to the intensive care unit at about 7:35 p.m.

The intensive care nurse’s notes state that the patient arrived at the ICU unresponsive with his oxygen saturation reading in the 70% range despite being on 15 liters of supplemental oxygen per minute via non-rebreather mask.  The patient’s fingers and toes were cyanotic and his body mottled.

On 12/10/2011 at 3:10 a.m., the patient died despite additional care.

The Board expressed concern that Hospitalist A practiced below the standard of care by failing to order an abdominal CT scan in a patient with an identified bowel obstruction that was not responding to care.  He failed to recognize clinical indicators of early septic shock and make a timely transfer of the patient to a higher level of care.  He failed to recognize and respond to the patient’s acute respiratory distress.

The Board issued a public reprimand.  He was ordered to take a course in early recognition of septic shock.

State: California

Date: January 2017

Specialty: Hospitalist, Internal Medicine

Symptom: Shortness of Breath, GI Symptoms (GERD, Abdominal Distention, Dysphagia)

Diagnosis: Sepsis, Acute Abdomen

Medical Error: Delay in proper treatment, Diagnostic error, Failure to order appropriate diagnostic test, Failure of communication with patient or patient relations, Failure to properly monitor patient

Significant Outcome: Death

Case Rating: 3

Link to Original Case File: Download PDF

On 1/17/2011, a 40-year-old female with a history of hepatitis, gallstones, hypertension, diabetes, and obesity was admitted to a medical center for obstructive jaundice.

On 1/19/2011, a hospitalist performed a pre-operative evaluation of the patient.  The hospitalist noted that the patient had a blood pressure at 91/56, a heart rate at 51 beats per minute, and a hemoglobin level of 11.3 gm/dl.  The hospitalist diagnosed the patient with “Acute on Chronic Cholecystitis” and noted the patient would proceed with a cholecystectomy.

On 1/19/2011, a general surgeon performed a laparoscopic cholecystectomy with intraoperative cholangiogram and wedge liver biopsy on the patient.

At 2:50 a.m. on 1/20/2011, the patient’s hemoglobin level was noted at 11.3 gm/dl.

At 1:10 p.m., the patient fainted on the way out of the bathroom.  Subsequent to this episode, the patient was awake, lethargic, and registered a blood pressure of 80/53 at 1:14 p.m.  The patient was placed in the Trendelenburg position.  The general surgeon was contacted and left orders for one liter of normal saline.  The hospitalist, as the on-duty hospitalist, was also contacted.  He ordered a hemoglobin and hematocrit, cardiac enzymes, and an EKG.  He ordered 125 ml/hr of fluid to be started after the 1 liter bolus ordered by the general surgeon.

At 1:14 p.m., the patient’s hemoglobin was noted to be at 9.3 gm/dl.  It is assumed that this hemoglobin level was obtained prior to 1:14 p.m., as the hemoglobin result obtained after the patient had fainted would have unlikely been available for review by 1:14 p.m.

At 4:25 p.m., the hospitalist saw the patient for persistent low blood pressure and altered mental status.  The hospitalist noted that the previously ordered fluid boluses had not improved the patient’s blood pressure.  The hospitalist documented a blood pressure of 77/50, heart rate of 118, and a hemoglobin of 9.3.  The hospitalist additionally noted that the patient was pale and lethargic.  The hospitalist diagnosed the patient with “shock, possibly hypovolemic.”  The hospitalist made the following orders: transfer to the intensive care unit (ICU), start pressors, initiate a PICC line, start antibiotics, and control blood sugar.  The hospitalist requested a complete blood count and a complete metabolic panel for the following morning.

At 4:50 p.m. on 1/20/2011, a rapid response was called, and the patient was transferred to the ICU.  At approximately 6:32 p.m., the patient coded.

At 7:05 p.m., the hospitalist gave verbal orders for “crossmatch 2 units now; if not available transfuse 2 units uncrossed STAT.”  The patient never received the transfusion and expired at approximately 7:23 p.m.  The hospitalist claimed she contacted the general surgeon after the patient’s transfer to the intensive care unit.  This call is not documented in the patient’s medical records.

On 1/22/2011, the hospitalist dictated a discharge summary that stated, “[w]e think the patient have had a DIC and sepsis.”  The hospitalist does not document the possibility of hemorrhagic shock in her discharge summary.

The Board judged the hospitalist as having committed gross negligence given failure to promptly evaluate the patient in light of her syncope, severe hypotension, and altered mental state; failure to consider the possible causes of hypovolemic shock; and failure to consider hemorrhagic shock as a possibility given the patient’s recent surgery and declining hemoglobin.

The Board placed the hospitalist on probation for three years with stipulations to complete 40 hours annually of continuing medical education in the subjects of hemorrhagic shock and diagnostic medicine, complete a medical record keeping course, and undergo clinical practice monitoring while on probation.

State: California

Date: November 2016

Specialty: Hospitalist, General Surgery, Internal Medicine

Symptom: Syncope, Confusion, Weakness/Fatigue

Diagnosis: Post-operative/Operative Complication, Hemorrhage

Medical Error: Diagnostic error, Delay in proper treatment, Failure of communication with other providers, Improper treatment, Lack of proper documentation

Significant Outcome: Death

Case Rating: 4

Link to Original Case File: Download PDF

On 8/2/2014, a patient presented to the hospital for shortness of breath.  A hospitalist assumed care of the patient and admitted him for inpatient treatment.  Based on the patient’s presentation, the hospitalist ordered multiple labs and radiology studies, including a chest computed tomography scan (CT) with contrast, to rule out serious lung conditions, such as pulmonary embolism.  The 8/2/2014 chest CT report was negative for pulmonary embolism, but did show a 3.3 cm right renal mass highly suggestive of malignancy.  No mention of the renal mass was noted in the hospitalist’s chart notes.  The hospitalist reviewed page one of the CT report which was negative for pulmonary embolism, eliminating the problem from the hospitalist’s differential diagnosis.  The right renal mass suggestive of malignancy was reported on page two of the report; however, the hospitalist was not aware there was a page two.

The hospitalist indicated in her statement to the Commission that she did review the CT report and focused on the findings that addressed the current lung complaints.  She indicated that because the patient did not have complaints suggestive of a renal or bladder issue, she did not order the CT to evaluate renal issues.

The hospitalist continued to follow the patient throughout the hospital admission and prepared the discharge summary.  On 8/6/2014, she discharged the patient.  The discharge diagnoses included bilateral pneumonia, sepsis, and exacerbation of chronic obstructive pulmonary disease (COPD).  The discharge summary recommended that the patient follow up with his primary care provider in one week.  No recommendations were documented regarding the renal mass.

On 8/25/2014, the patient followed up with his primary care provider.  Notes do not indicate that the primary care provider was notified of the renal mass.  The patient continued to follow up with multiple providers for various medical conditions between August 2014 and March 2015.  The patient indicated that on follow-up for psoriasis with a different provider, the renal mass was brought to his attention.  On 3/31/2015, the patient underwent a follow-up CT, which showed that the renal mass had increased in size.  Subsequently, the patient was confirmed to have renal carcinoma and underwent successful treatment.

The Commission stipulated the hospitalist reimburse costs to the Commission, develop and follow a written protocol for the clinic to ensure outside lab and other tests results are promptly reviewed, and write and submit a paper of at least 1000 words, plus bibliography, addressing the standard of care applicable to the ordering provider when reviewing lab/radiology reports and the ordering provider’s responsibility for arranging follow-up of abnormal results.

State: Washington

Date: September 2016

Specialty: Hospitalist, Emergency Medicine, Family Medicine, Internal Medicine, Oncology

Symptom: Shortness of Breath

Diagnosis: Cancer, Pneumonia, Sepsis

Medical Error: Failure to follow up, Diagnostic error

Significant Outcome: N/A

Case Rating: 4

Link to Original Case File: Download PDF

On 8/22/2010, a 42-year-old mentally handicapped male patient presented to a medical center for surgical repair of a broken left arm.

A family practitioner served as the primary care physician and served as the attending physician during the patient’s hospital stay.

The patient was adamantly opposed to treatment and was ultimately intubated and sedated with propofol and morphine prior to surgery.

The patient was kept sedated and intubated for a total of five days in the intensive care unit after surgery.

On 8/27/2010, the patient was extubated.

Upon extubation, the patient immediately became uncooperative and disruptive with the hospital medical staff.

The patient was discharged from the hospital.

The Medical Board of Florida judged the family practitioner’s conduct to be below the minimal standard of competence given that the family practitioner failed to order any pain medication for the patient prior to discharge.  He failed to order a psychiatric consultation for the patient prior to discharge.  He failed to develop a safe and adequate medication regimen for the patient prior to discharge.  The family practitioner failed to develop an appropriate discharge plan that included admission to an appropriate nursing care facility.  He failed to create or maintain records that document any progress notes for the patient from 8/25/2010 through 8/27/2010.

The Medical Board of Florida issued a letter of concern against the family practitioner’s license.  The Medical Board of Florida ordered the family practitioner to pay a fine of $5,000 against his license and pay reimbursement costs for the case at a minimum of $9,107.05 and not to exceed $11,107.05.  The Medical Board of Florida also ordered the family practitioner to complete five hours of continuing medical education in mental health conditions and five hours of continuing medical education in “risk management.”

State: Florida

Date: June 2016

Specialty: Family Medicine, Hospitalist, Internal Medicine

Symptom: N/A

Diagnosis: Fracture(s)

Medical Error: Improper medication management, Referral failure to hospital or specialist, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 1

Link to Original Case File: Download PDF

On 2/20/2010, a patient presented to the emergency department with nausea, vomiting, and severe upper abdominal pain.  A CT scan of the abdomen and pelvis showed pancreatic edema and peripancreatic stranding consistent with pancreatitis.  The CT scan of 2/20/2010 and the gallbladder ultrasound of 2/21/2010 showed the common cystic and common bile ducts as normal in caliber.  Lab reports obtained by the emergency department physicians showed significantly elevated amylase and lipase, at 3739 and 27,055 respectively.  Initial liver enzymes (AST, ALT, alkaline phosphatase) and bilirubin were within normal limits.  The admitting hospitalist ordered a surgery consult for ongoing therapy and possible surgical intervention.

On 2/22/2010, a surgeon evaluated the patient and reviewed the lab reports and imaging.  The gallbladder ultrasound of 2/21/2010 showed a 0.8 cm calculus within the neck of the gallbladder.  The surgeon’s written progress note for the patient on 2/22/2010 concluded with the following: “GI consult for? ERCP, cholecystectomy this admit when panc. stabilizes/resolves.”  The surgeon’s dictated notes included the following: “labs and a CT scan showing significant gallstone pancreatitis likely with a calcified gallstone stuck in the neck of the gallbladder and possibly having recently passed a stone through the duct.”  The surgeon also noted a 1 year history of biliary symptoms.  The surgeon further noted that the patient was responding well to medical treatment and that the patient’s amylase and lipase “are currently improving with amylase and lipase today at 990 and 3200.”  “We do strongly recommend a GI consult for consideration of ERCP.”  The surgeon concluded her dictated assessment with the following: “We do strongly recommend cholecystectomy during this hospital admission to remove all future sources of biliary stones that could lead to recurrent pancreatitis.  If possible we will proceed to laparoscopic cholecystectomy..”

At 7:45 p.m. on 2/22/2010, a gastroenterologist evaluated the patient and noted no urgent need for ERCP, and that he would consider ERCP if the patient’s bilirubin rose to above 3.0.

At 7:15 a.m. on 2/23/2010, the gastroenterologist saw the patient and noted that the patient had moderate mid-abdominal pain with somewhat worsened renal functions and some slight abdominal distention with tenderness and infrequent bowel sounds.  He recorded “consider transfer to PCU for monitoring.”

At 10:40 a.m. on 2/23/2010, the hospitalist saw the patient and noted a T-maximum of 102.8, oxygen saturation of 91 percent on two liters, chest x-ray with increased pulmonary vascular congestion, BUN of 38, creatinine of 2.0, and white count of 20,300.

The surgeon saw the patient later on 2/23/2010 and wrote a brief note indicating that amylase and lipase were improving, suggesting that ERCP may occur and that the cholecystectomy would hopefully be performed the next day, despite her recognition that the patient had a fever of 102.8 degrees and was disoriented.  The surgeon did not recognize nor document the patient’s elevated CRP at 29.6, contained in the same report with the improving amylase and lipase levels, nor did she document the decreased platelets of 81,000 and elevated WBC with the marked left shift.

The gastroenterologist saw the patient again at 4:30 p.m. on 2/23/2010.  He reviewed a chest x-ray for the patient, which was concerning for possible third spacing secondary to pancreatitis along with laboratory indications of worsening renal function.  He noted that, given the patient’s worsening renal function, he would discuss with the hospitalist transfer of the patient to the ICU.

At 5:00 p.m. on 2/23/2010, the hospitalist ordered the transfer of the patient to the ICU as suggested by the gastroenterologist.

The surgeon’s note on 2/24/2010 acknowledges that the patient had a temperature of 102.8 degrees and mentions that the patient had been transferred to the ICU.  The note also states: “OR unable to transfer pt. Wife was under the impression surgery not safe.”  At that time, the patient’s laboratory values showed an elevation of his creatinine to 2.4 (from 1.2 on admission; normal <1.4), which signifies worsening renal function due to severe pancreatitis.  The patient’s deteriorating clinical status was evidenced by the patient’s transfer to a higher level care; the need for ongoing aggressive fluid resuscitation; renal insufficiency; mental status changes; and worsening renal function.  In addition, there was no evidence that biliary obstruction was the cause of the patient’s current clinical status, as his alkaline phosphatase was normal and his direct bilirubin that day was 0.6, which is barely elevated.  The surgeon documented no explanation of the rationale for performing the operation on that day.

At 11:30 a.m. on 2/24/2010, the hospitalist noted the patient was subjectively okay; his pain was decreased; he was requiring five liters of oxygen; he had a temperature of 98.8, a sodium of 150, a white count at 15,200, a BUN of 44, and a creatinine of 2.4.

In the late afternoon of 2/24/2010, the patient did undergo a laparoscopic cholecystectomy.  The surgeon’s operative report noted fluid in the peritoneal cavity, as well as retroperitoneal/peripancreatic edema, as well as a friable, thin-walled gallbladder.  The surgeon did remove the patient’s gallbladder, but did not document why she was unable to perform an intraoperative cholangiogram.  The surgeon placed a Jackson Pratt (JP) drain in the gallbladder bed.  Examination of the gallbladder found “No stones identified within the lumen, cystic duct or specimen container.”

Postoperatively, the patient’s pancreatitis was severe with third spacing and renal dysfunction.  The output from the JP drain, placed at the time of surgery, was concerning for possible biliary leak.  Over time the patient deteriorated, experienced multisystem organ failure, and died on 3/17/2010 of acute respiratory failure secondary to adult respiratory distress syndrome secondary to acute (severe) pancreatitis.

The reports on the CT scan and HIDA scan performed on 2/28/2010 note bile contents in the surgical drain, indicating the presence of a bile leak.  The CT and HIDA scan showed no bile flow through the distal common duct into the duodenum.

The surgeon’s care of the patient was below the standard of care in the following respects:

1) The surgeon failed to recognize the patient’s developing sepsis, respiratory failure, and renal failure; that the patient was becoming gradually sicker over several days; and that laparoscopic cholecystectomy was not indicated at the time the patient underwent surgery.

2) The surgeon did not document any explanation of the rationale for performing the operation on 2/24/2010.

3) The surgeon’s operative report failed to document why she was unable to perform an intraoperative cholangiogram when her primary indication for performing the cholecystectomy was to remove the source of gallstones in the setting of what she believed was retained gallstones in the common bile duct.

4) The surgeon did not document discussions with the patient’s wife about the care of the patient.  The surgeon did not document discussions with the hospitalist or the gastroenterologist about the care of the patient.

5) The surgeon’s documentation was insufficient to discern her clinical thinking.

6) The surgeon failed to document that she considered the possibility of a missed injury to the biliary ductal system at the time of the laparoscopic cholecystectomy when the patient experienced a bile leak.

The Commission ordered the surgeon pay a fine, give a talk to her medical staff regarding this case and the importance of collaborating with the team of physicians taking care of complicated cases, review and keep current with the Commission’s electronic medical record (EMR) guidelines and report in writing how she will use the EMR in her medical practice, complete at least 4 hours of continuing education on pancreatitis (with specific emphasis on the possibility of multisystem organ failure), complete at least 4 hours of continuing education on the importance of documentation of patient changes prior to surgery and the recognized risks of surgery in those situations, and write and submit a paper of at least 1000 words, with bibliography, on the importance of documenting changes in patient status and documenting the recognized risks of surgery.

State: Washington

Date: May 2016

Specialty: General Surgery, Gastroenterology, Hospitalist, Internal Medicine

Symptom: Abdominal Pain, Nausea Or Vomiting

Diagnosis: Acute Abdomen

Medical Error: Improper treatment, Lack of proper documentation

Significant Outcome: Death

Case Rating: 5

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On 9/25/2008, a 38-year-old patient was admitted to the neuro-care unit at a hospital under a pulmonologist’s care.  The patient had an extensive medical history, which included diabetes mellitus, prior cerebrovascular accident, bipolar disorder, schizophrenia, ventilator dependent tracheostomy, gastrostomy feeding tube, pituitary tumor, hypertension, and blindness from diabetes.  At the time of admission, the patient was ventilator dependent and had a percutaneous endoscopic gastrostomy (PEG) tube.

In January 2009, the patient was weaned off of the ventilator and oral feedings were initiated.  Medications were still administered via the PEG tube.  After the patient was stabilized, he was transferred to the nursing home, still under the pulmonologist’s care.  The pulmonologist evaluated the patient on 1/4/2009, 1/10/2009, 1/18/2009, and 1/22/2009, but there was no documentation by the pulmonologist about the PEG tube on physical examination.

On 2/22/2009, the patient was seen by the pulmonologist.  The pulmonologist was advised that the PEG tube, which was still inserted in the patient, may have become loose and may need to be removed.  On 2/25/2009, the patient was seen by the pulmonologist.

On 2/27/2009, the pulmonologist consulted with Physician A and a physician assistant about the PEG tube.  The patient was seen by the physician assistant, who noted that there was fecal matter on the PEG tube and gave verbal orders for a KUB with Gastrografin to confirm whether the PEG tube was in the stomach.

On 2/28/2009, the pulmonologist gave verbal orders that the patient could receive medication or meals orally or via the PEG tube.

On 3/11/2009, the physician assistant gave another verbal order for a KUB with Gastrografin to confirm that the PEG tube was in the stomach.  The pulmonologist signed the verbal orders.  The KUB showed that the PEG tube was in the wrong place.  During this time, the PEG tube was being used for medicine, meals, and water flushes.

On 3/15/2009, the pulmonologist gave verbal orders not to use the PEG tube until it was clear, but did not document why he gave this order.

On 3/20/2009, a radiology report noted that the patient had “nausea and vomiting” and the feeding tube was in the colon.  Physician B, who was covering for the pulmonologist on this date, was notified of the findings and noted this in the patient’s chart.  No steps were taken to remove the PEG tube on this date.

On 3/29/2009, the pulmonologist documented a physical examination but did not document any issues or concerns with the PEG tube.

On 3/31/2009, a radiology report from the hospital reported that the patient had mild ileus with moderate constipation.

On 3/31/2009, the patient was seen by the pulmonologist, who noted that the PEG tube was “close to the skin” and transferred the patient to the hospital to have the PEG tube removed.  The pulmonologist noted that he had been aware that the PEG tube was in the wrong place since 3/20/2009.

On 4/9/2009, the patient was discharged from the hospital.  The discharge summary report was dictated on 6/20/2009.

On 10/31/2011 and 11/22/2011, the pulmonologist saw the patient for routine visits.

The Board judged the patient’s conduct to have fallen below the standard of care given failure to timely intervene when he became aware the PEG tube was misplaced and when the patient had signs and symptoms of a possible ileus; failure to document adequate history and physical examinations including routine abdominal examinations; failure to provide explanations as to why orders were given; and failure to follow-up with consulting providers regarding the status of his patient.  He routinely failed to document a plan of care or treatment for the patient.

The Board issued a public reprimand with stipulations to complete a continuing medical education course and a medical record keeping course.

State: California

Date: February 2016

Specialty: Pulmonology, Hospitalist, Internal Medicine

Symptom: Nausea Or Vomiting

Diagnosis: Gastrointestinal Disease

Medical Error: Delay in proper treatment, Failure of communication with other providers, Failure to follow up, Failure to properly monitor patient, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 1

Link to Original Case File: Download PDF