Page 1 of 2
California – Interventional Radiology – Pain And Cold Foot After Arteriogram, Angioplasty, And Atherectomy
On 6/26/2015, a patient presented to an interventional radiologist’s outpatient clinic for a left lower extremity arteriogram and intervention for a thrombosed left lower extremity bypass graft, originally placed in 2007. The patient had an extensive medical history including a renal transplant, diabetes, right leg amputation, and multiple revascularization procedures, including prior thrombectomies of the left lower extremity graft.
The patient reportedly had pain both at rest and with activity, and had a cold left leg prior to and immediately before the procedure. In order to improve blood flow in the patient’s left leg, the interventional radiologist performed an arteriogram, angioplasty, tPA administration, atherectomy, and stent placement within the left lower extremity, including an attempt to revascularize the native superficial femoral artery.
Images show an initially thrombosed femoral artery to popliteal bypass graft and deep femoral artery. Further images show balloons inflated in various parts of the graft and native arteries. Final images show flow through a patent common femoral artery (CFA), bypass graft, and peroneal and anterior tibial arteries. The deep femoral artery appeared occluded shortly beyond its origin.
After the procedure, a nurse noted the patient’s foot was cold. The interventional radiologist also assessed the patient post-procedure and found the foot to be cold, both two (2) and four (4) hours post-procedure. The interventional radiologist recommended to the patient that she travel to the emergency department of a university hospital.
The patient was then driven by her companion two hours to the emergency department, where she was assessed by an ED physician and a vascular surgeon. She was taken to the operating room where she underwent surgery, which included a left leg above-the-knee amputation and a deep femoral artery thrombectomy.
The Board stated that the standard of care for an interventional radiologist when performing an intervention is to recognize complications and to take appropriate steps to manage them. Although the patient’s foot was reportedly cold and painful immediately post-procedure, it can take some time for the foot to warm, and pain could be caused by reperfusion. However, it is clear that two to four hours after the procedure, the interventional radiologist recognized that the patient’s leg had not improved and was worsening and that further care was needed. Thus, when it became clear to the interventional radiologist that the foot was not improving, he recommended that the patient seek more treatment.
The records of the interventional radiologist’s care of the patient were inadequate in that they do not state whether the patient’s clinical status post-procedure was worse than before the procedure. A post-procedure pulse examination was lacking which would have helped in determining the patient’s clinical status.
The patient reported to the ED physician that the pain began after the procedure and steadily worsened, which indicates that the patient rethrombosed her bypass graft and deep femoral artery (source of collateral flow) immediately. This event should have been recognized by the interventional radiologist.
However, the interventional radiologist’s documentation for this patient was inadequate and sparse. The medical records lacked documentation of the change in the patient’s status post-procedure, the discussion with the patient leading up to the discharge from his center, and the patient’s disposition. The interventional radiologist discharged the patient to her own care directly from his clinic instead of calling Emergency Medical Services (EMS), which indicates that the interventional radiologist failed to recognize the gravity of what was occurring.
His conduct did not ensure that the patient would be attended continuously until definitive treatment was given. The patient arrived at the emergency department at approximately 8:00 p.m., two hours after the patient was discharged from the interventional radiologist’s clinic.
Had the process of discharge and transfer occurred earlier, it is possible that the outcome could have been different. The interventional radiologist failed to communicate with the ED physician ahead of the patient’s arrival. The interventional radiologist gave the patient a CD of the procedure, a copy of the medical records, and his phone number, as an attempt of communicating with the emergency department personnel regarding the events that occurred at the interventional radiologist’s clinic.
However, the interventional radiologist failed to telephone the ED physicians at the emergency department to give a verbal report on the patient and to provide a more informative transition and preparation for continued care. In expecting the practitioners at the emergency department to call the interventional radiologist to gain more information, the interventional radiologist improperly sought to shift his responsibility to provide needed information about the patient to the staff at the emergency department.
The interventional radiologist failed to maintain documentation regarding the change in the patient’s status post-procedure, the discussion leading up to the discharge from his center, and the patient’s disposition. He stated that he was not sure if he documented these events, and if he did, he sent them with the patient. Documentation sent with the patient has since been lost. Documentation of a change in the patient’s clinical status was lacking. The medical records lacked documentation of what was discussed regarding the patient’s disposition and where she was told to go for further care.
The Board judged the interventional radiologist’s conduct to have fallen below the standard of care for the following reasons:
1) The interventional radiologist failed to offer to transport the patient by ambulance or EMS services to ensure that she would be attended continuously until definitive treatment was given. His failure to do so indicates that he failed to understand the gravity of the situation which was occurring.
2) The interventional radiologist failed to adequately communicate with the emergency department, to call ahead of time to inform them that the patient was in transit, and to inform them of the circumstances.
3) The interventional radiologist failed to maintain adequate and accurate records.
The Board issued a public reprimand.
State: California
Date: December 2017
Specialty: Interventional Radiology, Vascular Surgery
Symptom: Extremity Pain
Diagnosis: Acute Ischemic Limb, Post-operative/Operative Complication
Medical Error: Diagnostic error, Delay in proper treatment, Underestimation of likelihood or severity, Failure of communication with other providers, Lack of proper documentation
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Interventional Radiology – Guidewire Found In Patient’s Abdomen Following CT-Guided Percutaneous Drainage
On 8/24/2015, a 63-year-old male presented to a medical center for a CT-guided percutaneous aspiration with possible drainage of an abdominal abscess.
During the course of the procedure, an interventional radiologist placed a guidewire into the operative field. Once the procedure was completed the patient had stable vital signs and no immediate complications were known.
On 9/12/2015, the patient was re-admitted to the medical center with complaints of abdominal pain. A subsequent CT scan revealed a foreign body on the left side of the patient’s abdomen.
On 9/15/2015, a general surgeon performed laparoscopic retrieval of the foreign body, at which time a portion of the guidewire, measuring 11.0 centimeters in length, was found and removed intact.
The Board ordered that the interventional radiologist pay a fine of $5,000 against his license and that the radiologist pay reimbursement costs for the case at a minimum of $4,737.16 and not to exceed $6,737.16. The Board also ordered that the interventional radiologist complete five hours of continuing medical education in “Risk Management” and that the interventional radiologist complete a one hour lecture/seminar on retained foreign body objects.
State: Florida
Date: November 2017
Specialty: Interventional Radiology
Symptom: Abdominal Pain
Diagnosis: Post-operative/Operative Complication, Acute Abdomen
Medical Error: Retained foreign body after surgery
Significant Outcome: Hospital Bounce Back
Case Rating: 2
Link to Original Case File: Download PDF
Florida – Interventional Radiology – Epidural Steroid Injection On A Patient Taking Plavix
On 1/21/2014, an 85-year-old female was admitted to the hospital with complaints of lower back pain and chest pain.
The patient’s medication list, at the time of her admission, listed a prescription for 75 mg of Plavix daily.
On 1/23/2014, a radiologist performed an epidural steroid injection on the patient while she was taking Plavix. Shortly after the procedure, the patient developed an abrupt sudden onset of diffuse abdominal pain with nausea, vomiting, and a large retroperitoneal hematoma extending from the left upper abdomen into the pelvis.
The patient had a stroke, among other complications.
The Board judged the radiologists conduct to be below the minimal standard of competence given that he performed an epidural injection on a patient while the patient had been receiving antiplatelet therapy for a significant period of time.
It was requested that the Board order one or more of the following penalties for the radiologist: 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: Interventional Radiology
Symptom: Back Pain, Nausea Or Vomiting, Chest Pain
Diagnosis: Drug Overdose, Side Effects, or Withdrawal
Medical Error: Improper medication management
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 4
Link to Original Case File: Download PDF
Florida – Interventional Radiology – Assigning A Diagnosis To The Wrong Patient Leads To Cardiac Catheterization Performed On The Wrong Patient
On 1/28/2015, Patient A, a 47-year-old male, presented to the hospital with chest pain and was admitted for treatment. A radiological technician was ordered to complete a CT angiogram of the heart for Patient A.
On 1/29/2015, a radiologist received Patient A’s angiogram images to review, as well as heart images for another Patient B. The radiologist assigned a diagnosis of sixty to seventy percent stenosis to Patient A.
The diagnosis of sixty to seventy percent stenosis was intended for Patient B, not Patient A, who did not have any noticeable blockage or stenosis.
On 1/29/2015, subsequent to the radiologist assigning the diagnosis of sixty to seventy percent stenosis to Patient A, Patient A underwent an unnecessary cardiac catheterization without further incident.
On 1/30/2015, the radiologist conducted a corrected review and diagnosis of Patient A’s angiogram.
On 2/3/2015, the radiologist informed Patient A of the error.
The Board judged the radiologist’s conduct to be below the minimal standard of competence given that he assigned a diagnosis to the wrong patient, which resulted in the patient undergoing a medically unnecessary procedure, a cardiac catheterization.
It was requested that the Board order one or more of the following penalties for the radiologist: 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: Interventional Radiology
Symptom: Chest Pain
Diagnosis: Cardiovascular Disease
Medical Error: Accidental error, False positive, Unnecessary or excessive treatment or surgery
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Interventional Radiology – Kyphoplasty Performed On T11 Instead Of T12 Site For T12 Fracture After A Fall
On 10/13/2015, a 70-year-old male was transported to the emergency department after a fall from a hammock when the rope broke.
A CT scan of the lumbar spine was done and a 20% anterior wedge compression fracture on the T12 section was found. An MRI of the lumbar spine, on the same day, showed an acute T12 compression fracture. An MRI of the thoracic spine was done, on the same day, and showed an acute T12 compression fracture with bone marrow edema.
The patient was admitted to the hospital and recommended for T12 kyphoplasty.
On 10/14/2015, an interventional radiologist performed a kyphoplasty on the patient’s T11 vertebrae (wrong site), instead of the T12 vertebrae.
The patient was discharged on 10/19/2015 and began having progressively more pain.
On 10/22/2015, the patient was readmitted to the hospital by ambulance with progressively worsening pain.
On 10/23/2015, a two-view x-ray of the lumbar spine revealed that a T12 compression fracture had remained unchanged despite the 10/12/2015 surgery, and that the T11 vertebrae had been unnecessarily operated upon.
The patient was discharged to a rehabilitation center for two weeks to recover.
The Board issued a letter of concern against the interventional radiologist’s license. The Board ordered that the interventional radiologist pay a fine of $4,000 against his license and pay reimbursement costs for the case at a minimum of $2,009.04 and not to exceed $4,009.04. The Board also ordered that the interventional radiologist complete five hours of continuing medical education in “risk management” and complete a one-hour lecture/seminar on wrong site surgeries.
State: Florida
Date: June 2017
Specialty: Interventional Radiology
Symptom: Pain
Diagnosis: Fracture(s), Spinal Injury Or Disorder
Medical Error: Wrong site procedure
Significant Outcome: Hospital Bounce Back
Case Rating: 2
Link to Original Case File: Download PDF
California – Interventional Radiology – Radiologist Uses Profanity And Hits Patient’s Hand In Anger During Procedure
On 5/4/2015, between 6:00 p.m. and 6:45 p.m., an interventional radiologist entered the hospital’s Room 9 to perform a cerebral angiogram. The interventional radiologist intended to perform a procedure on the patient, a 99-year-old patient who had just suffered a stroke. The cerebral angiogram procedure involves the practitioner gaining access to the patient’s femoral artery, near the patient’s groin, by inserting and threading a catheter from the patient’s femoral artery to the brain. The catheter absorbs and/or extracts any blood clots and can control bleeding in the patient’s brain.
Previously, between 5:30 p.m. and 5:50 p.m., three female ancillary staff, namely Registered Nurse (RN) A, Technician A, and Registered Nurse B, prepared both Room 9 and the equipment in Room 9 for the medical procedure. In addition, ancillary staff prepared the patient by restraining the patient’s head and hands to the surgical table, as well as covering portions of her body with drapes. When the interventional radiologist entered the room, he was immediately upset that the ultrasound machine was not fully ready and had not been placed by the patient’s head. The interventional radiologist yelled, using profanity, at Technician A, regarding the fact that the ultrasound machine was not ready.
As the procedure began, the interventional radiologist started to gain access to the femoral artery to insert a guide wire into the femoral artery, near the patient’s groin, while the patient was lying on a table with her head taped to the table and her right arm was restrained to a board. At that time, the patient managed to move or wriggle her hand toward her groin, a sterile field where the interventional radiologist was trying to insert the guide wire. The interventional radiologist immediately grabbed the patient’s right arm with his hands and yelled at the patient, “God Damn It! Don’t F—— Move! I Said Don’t Move.” The interventional radiologist was standing to the side of the patient when he then took the patient’s right hand and hit it with his closed fist hard. The patient was not yet sedated and she cried out in pain. The interventional radiologist then yelled at Technician A, “Look at what you made me do! This is all your fault.”
After the hitting incident occurred, but during the procedure, a charge nurse came into the room to make her observations. As the charge nurse was Technician A’s supervisor, Technician A wrote on a piece of paper, “He hit the patient” and gave the note to the charge nurse. The charge nurse then left the room. This note exchange occurred approximately between 6:45 p.m. and 6:55 p.m.
Once the procedure was completed, the interventional radiologist requested to look at the patient’s right hand. Staff removed the drape over the hand and observed that the hand was bleeding and bruised. The interventional radiologist ordered that the hand be x-rayed. Later, the interventional radiologist returned to the room and told staff that he had informed the son how his mother had received the injury. However, the interventional radiologist’s version as told to the son was that he had grabbed the patient’s hand and not that he hit her hand with a fist. The interventional radiologist never documented in the patient’s chart that the bruising and bleeding of the hand occurred at all nor how it occurred.
The interventional radiologist’s conduct of swearing at the patient when she moved her hand constituted an extreme departure from the standard of care. The interventional radiologist’s act of hitting the patient’s right hand with his closed fist also constituted an extreme departure from the standard of care.
The Board issued a public reprimand against the interventional radiologist. Stipulations included enrolling in a course on anger management and a course on professionalism.
State: California
Date: February 2017
Specialty: Interventional Radiology
Symptom: N/A
Diagnosis: Ischemic Stroke
Medical Error: Ethics violation, Failure of communication with patient or patient relations
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Interventional Radiology – Patient Given Flumazenil As An Antidote For Fentanyl Overdose
On 11/27/2015, a patient presented to a radiologist for a scheduled thrombectomy of the right upper arm AV fistula.
Over the course of the procedure, the radiologist administered four doses of fentanyl via a sheath in the fistula.
After the final dose of fentanyl, the patient complained of nausea. Shortly thereafter, he stopped responding to questions and showed signs of overdose.
The radiologist administered a dose of flumazenil (Romazicon) in an attempt to counteract the effects of the fentanyl. Flumazenil is a benzodiazepine antagonist and acts as an antidote for the sedative Versed.
Naloxone (Narcan) is the correct antidote for fentanyl overdose.
The Medical Board of Florida judged the radiologist’s conduct to be below the minimal standard of competence given that he failed to give the patient Narcan, the correct antidote for a fentanyl overdose. He also failed to adequately document the thrombectomy, including the method of administering the fentanyl.
It was requested that the Medical Board of Florida order one or more of the following penalties for the radiologist 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: January 2017
Specialty: Interventional Radiology
Symptom: Nausea Or Vomiting
Diagnosis: Drug Overdose, Side Effects, or Withdrawal
Medical Error: Improper medication management, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
Arizona – Interventional Radiologist – Timing Of Angiogram With Peripheral Vascular Disease And Worsening Leg Pain
On 07/12/2012, a 73-year-old man presented to the emergency department with left lower leg pain described as constant, worsening, and exacerbated by movement along with 2 days of left lower back pain radiating into the buttocks and back of the leg. The patient’s history included degenerative disc disease, lower back pain for more than 5 years, chronic pain syndrome on oxycodone/acetaminophen, peripheral neuropathy on gabapentin, and obstructive sleep apnea. The patient reported that during this admission that he had a history of peripheral vascular disease, a previous right leg amputation below the knee, hyperlipidemia, hypertension, coronary artery disease, and a prior coronary artery bypass.
An arterial ultrasound was completed with findings of occlusion of the posterior tibial-peroneal trunk and a patent anterior tibial artery. The interventional radiologist was called to address the occlusion, and he recommended a follow-up in the radiology clinic in 1-2 days. The patient was discharged home with a diagnosis of low back pain with exacerbation.
On 07/13/2012, the interventional radiologist diagnosed the patient with progressive non-acute peripheral vascular disease with worsening left leg rest pain and ordered an angiogram with intervention. The interventional radiologist documented that the patient’s pulses were absent on doppler with three seconds capillary refill.
On 07/19/2012, the patient returned to the emergency department with lower leg pain exacerbated by movement. The physical exam revealed a left lower extremity that was cool, a +1 dorsalis pedal pulse with good capillary refill, and a foot that was pink and warm. The ED physician diagnosed the patient with peripheral vascular complications without neurovascular compromise with good pulses. He ordered a CT angiogram and placed a call to the interventional radiologist who examined the patient. The interventional radiologist performed an examination that was not documented other than that he examined the patient, found that he did not need acute intervention, and recommended outpatient work-up. The interventional radiologist confirmed that the outpatient angiogram was scheduled for 07/26/2012 and re-scheduled it a day later so that he could personally perform it on 07/27/2012.
On 07/25/2012, the patient returned to the emergency department with acute left lower extremity ischemia with a cold, blue, and painful extremity with no pulses. The patient was transferred to a different hospital.
On 08/04/2012, he died with the cause of death listed as shock secondary to severe leg ischemia.
The Board judged the interventional radiologist’s conduct to be below the minimum standard of competence given failure to perform a semi-urgent angiogram on a patient with acute ischemia. He failed to document a vascular examination.
The Board ordered the interventional radiologist to be reprimanded.
State: Arizona
Date: August 2016
Specialty: Interventional Radiology
Symptom: Extremity Pain, Back Pain
Diagnosis: Acute Ischemic Limb
Medical Error: Delay in proper treatment, Lack of proper documentation
Significant Outcome: Death, Hospital Bounce Back
Case Rating: 4
Link to Original Case File: Download PDF
Washington – Interventional Radiology – Kyphoplasty Performed On Incorrect Vertebra
A physician performed a kyphoplasty for a patient but inadvertently performed it at the incorrect vertebra. The procedure was performed at vertebra L1, instead of L2.
Due to the patient’s other health issues and overall decline, the physician was unable to provide an additional kyphoplasty. The patient died approximately one month after the improper kyphoplasty.
The Commission stipulated the physician reimburse costs to the Commission and write and submit a paper of at least 1000 words, with references, discussing risks associated with kyphoplasty procedures, current applicable standards for preventing wrong-site surgery as applied to his practice, lessons learned from this case, and changes made to prevent this type of error from recurring.
State: Washington
Date: January 2016
Specialty: Interventional Radiology, Neurosurgery
Symptom: N/A
Diagnosis: Spinal Injury Or Disorder
Medical Error: Wrong site procedure
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
Wisconsin – Interventional Radiology – Patient On Enoxaparin Undergoes Adrenal Biopsy
A patient was admitted to the hospital with symptoms consistent with pneumonia. The admitting physician prescribed enoxaparin for prophylaxis. When the patient exhibited signs of pulmonary embolism 1 week later, Pulmonologist A increased the enoxaparin.
Imaging studies revealed bilateral lung masses and an adrenal gland mass. The patient’s primary care physician ordered an adrenal biopsy. Interventional radiologist A was consulted. The primary care physician did not mention that the patient was on enoxaparin. The IR nurse told Interventional Radiologist A that the patient was not on any blood thinners. The IR nurse based her belief on the chart and a telephone “handoff report” from the floor nurse. Interventional Radiologist A was unaware that the patient had been on enoxaparin for 10 days and at an increased dose for 3 days. Interventional radiologist A obtained informed consent and reviewed the risks and benefits of the procedure including bleeding. She did not review that enoxaparin would increase the risk of bleeding. The patient developed retroperitoneal hemorrhage after the procedure. An additional procedure and multiple blood transfusions did not stop the bleeding. 6 days after the biopsy, the patient died of multiple organ failure.
The Estate of the patient sued Interventional Radiologist A and Pulmonologist A alleging a lack of informed consent. The Estate dismissed the pulmonologist and settled with the hospital. The hospital was 75% at fault and Interventional Radiologist 25% at fault with total award of $400,000.
State: Wisconsin
Date: December 2012
Specialty: Interventional Radiology
Symptom: N/A
Diagnosis: Post-operative/Operative Complication, Drug Overdose, Side Effects, or Withdrawal
Medical Error: Improper medication management, Failure of communication with other providers
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF