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Florida – Internal Medicine – Retained Guide Wire Found After Replacement Of Dialysis Catheter
On 3/19/2015, a patient presented to a hospital with complaints of chest pain, history of acute stent thrombosis, and renal failure.
On 3/21/2015, a physician referred the patient to an internist for replacement of temporary dialysis catheter to address her acute kidney failure. The internist placed a double-lumen dialysis catheter in the patient’s left subclavian vein.
Due to the catheter not functioning properly, another physician performed a catheter exchange procedure on the patient on 3/23/2015. After the procedure, the inspection of the catheter revealed that the guide wire remained in one of the lumens of the catheter.
Neither the internist nor his staff removed the guide wire from the catheter prior to the insertion of the catheter into the patient’s left subclavian vein.
The Board judged the internist’s conduct to be below the minimum standard of competence given that he left a foreign body in a patient.
The Board ordered that the internist pay a fine of $3,500 against his license and pay reimbursement costs for the case for a minimum of $3,419.35 and not to exceed $5,419.35. The Board also ordered that the internist complete five hours of continuing education in “Risk Management” and complete a lecture/seminar on retained foreign body objects to medical staff.
State: Florida
Date: November 2017
Specialty: Internal Medicine, Nephrology
Symptom: Chest Pain
Diagnosis: Renal Disease
Medical Error: Retained foreign body after surgery
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
Florida – Internal Medicine – Daily Dose Of 1200 Milligrams Of Gabapentin For Patient With End Stage Renal Disease
On 5/8/2014, a 74-year-old female presented to an internist for the purpose of establishing care. The patient had multiple medical problems, including diabetes, end-stage renal disease, and recurrent C. difficile infections.
At all times pertinent to this complaint, the patient was undergoing chronic hemodialysis treatment.
On 6/10/2014, the patient presented to the internist for a follow-up visit. The internist prescribed 600 mg tablets of gabapentin to the patient to treat her diabetic neuropathy. The patient’s prescription directed her to take the 600 mg of gabapentin twice daily, totalling 1200 mg of gabapentin per day.
On 6/14/2014, after taking her prescribed dosage of gabapentin, the patient lost control of her leg muscles and fell, resulting in a fracture of the T12 vertebrae in her back.
The prevailing professional standard of care required the internist to prescribe the patient a dosage of gabapentin not to exceed 150 mg per day, due to her end-stage renal disease. The internist prescribed the patient an inappropriate and/or excessive dosage of gabapentin.
According to the internist, he verbally instructed the patient and/or her family members to modify the gabapentin prescription.
The internist failed to document and/or accurately document the alleged verbal instruction to the patient and/or her family members to modify the patient’s gabapentin prescription.
The Board issued a letter of concern against the internist’s license. The Board ordered that the internist pay a fine of $5,000 against his license and pay reimbursement costs for the case at a minimum of $30,433.57 and not to exceed $32,433.57. The Board also ordered that the internist complete a medical records course and complete five hours of continuing medical education in clinical pharmacology and drug dosing.
State: Florida
Date: June 2017
Specialty: Internal Medicine, Nephrology
Symptom: Weakness/Fatigue
Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Diabetes, Neurological Disease, Spinal Injury Or Disorder, Renal Disease, Fracture(s)
Medical Error: Improper medication management, Accidental Medication Error, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
Nevada – Nephrology – Potential Overdose Of Aspirin
On 1/27/2012, a patient was transported to the emergency department for a “potential overdose of aspirin.” According to court documents, the plaintiff alleged that the hospital staff began evaluating and treating the patient when she arrived at the emergency department but failed to recognize that the patient’s “neurological status had been compromised due to her ingestion of aspirin.”
The plaintiff alleged that the nephrologist failed to administer the appropriate medical treatments, which may have included “hemodialysis” and/or “gastric lavage.” The patient died in the emergency department, nearly eleven hours after she first arrived.
The Board judged the nephrologist’s conduct as having fallen below the standard of care given failure to maintain timely, legible, accurate, and/or complete medical records; failure to document the nature, intensity, and course of treatment for the patient’s overdose of aspirin; failure to act as “captain of the ship” for the patient’s care; failure to instruct the monitoring of strict intake and output to guide treatment; failure to order frequent blood electrolyte levels; and failure to timely perform more frequent blood aspirin levels.
The Board issued a public reprimand. Stipulations including completion of 3 hours of continuing medical education.
State: Nevada
Date: March 2017
Specialty: Nephrology, Emergency Medicine, Internal Medicine
Symptom: Confusion
Diagnosis: Drug Overdose, Side Effects, or Withdrawal
Medical Error: Improper treatment, Failure to properly monitor patient, Lack of proper documentation
Significant Outcome: Death
Case Rating: 3
Link to Original Case File: Download PDF
North Carolina – Nephrology – Deciding To Initiate Vancomycin For Patient With Prior History Of Tachycardia And Dyspnea After Receiving Vancomycin
The Board was notified of a professional liability payment made on 6/5/15.
A 31-year-old male with end-stage renal disease presented to the emergency department with cough, fever, and acute pain. The initial diagnosis was sepsis. He was given cefazolin and gentamicin. The patient’s allergy history was noted to include penicillin and vancomycin.
The patient subsequently underwent two transfers of care. During these transfers, it was indicated by various physicians that the patient would require intravenous vancomycin to treat sepsis. Given the patient’s ambiguous allergy history, the evening hospitalist made the decision to defer to a nephrologist the decision regarding the treatment of the patient with vancomycin as the nephrologist had treated the patient in the past. As the patient’s nephrologist, he was aware that the patient had received vancomycin in the past both intravenously and intraperitoneally. The patient had previously developed tachycardia and dyspnea after receiving vancomycin. The nephrologist had concluded that the patient’s reaction to the most recent exposure to vancomycin was not a true allergic reaction, but rather “red man syndrome” and that the patient now required vancomycin to successfully treat the sepsis. Within minutes of the start of the vancomycin infusion, the patient developed tachycardia, dyspnea, and ultimately cardiac arrest from which he could not be revived.
The Board expressed concern that the nephrologist’s care of the patient fell below the standard of care.
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: February 2017
Specialty: Nephrology
Diagnosis: Sepsis
Medical Error: Improper medication management, Underestimation of likelihood or severity
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF
Arizona – Urology – Hepatic Artery, Portal Vein, and Common Bile Duct Transected During Partial Nephrectomy
The Board was notified of a malpractice settlement regarding the treatment of a 76-year-old woman.
On 02/14/2012, a woman was evaluated by a urology regarding a renal lesion that had been found on a CT scan. The urologist ordered a CT scan which was performed on 11/28/2012 and which revealed no no significant change in size of the 0.9 cm lesion located on the upper pole of the right kidney. The lesion had a slightly thickened and irregular enhancing wall. There was a small ventral wall hernia. The urologist documented the renal lesion as being complex and enhancing with no significant enlargement. It was around 1 cm in diameter and was not causing the patient any symptoms. The urologist recommended a biopsy.
On 01/24/2013, the patient underwent a right renal biopsy. Pathology revealed probable clear cell renal cell carcinoma Fuhrman grade 2.
On 01/30/2013, the urologist documented that he discussed the risks and benefits with the patient regarding surgery. The urologist offered a hand assisted approach to allow for repair of the patient’s hernia. The patient gave consent for the procedure.
On 04/17/2013, the patient was admitted for right nephrectomy via hand assisted laparoscopy. Per the anesthesia record, the anesthesia start time was 1:51 p.m. and surgery start time was 2:26 p.m. The surgery end time was 5:54 p.m. The urologist’s operative note documented adhesions and significant bleeding he initially thought was due to injury of the inferior vena cava. The patient received two packed red blood cell transfusions and the operation was converted to an open procedure.
At 3:00 p.m., the anesthesia record stated that the blood pressure was 60/30.
At 3:47 p.m., a general surgeon was consulted and arrived in the operating room. The surgeon noted that there was bleeding along the anterolateral edge of the patient’s duodenum and pancreas. The portal vein, common bile duct, and hepatic artery were transected. The urologist stated that he proceeded with a radical nephrectomy prior to liver vascular repair to avoid further liver vascular damage. Per the general surgeon’s note, hepatic warm ischemia time was one hour and fifteen minutes. After the nephrectomy was completed, the hepatic artery, portal vein, and common bile duct were repaired, including graft replacement.
At 5:30 a.m. on 04/18/2013, the urologist dictated his operative report.
On 04/18/2013, the patient was taken back to surgery after sanguineous fluid was found in the drain output. The general surgeon’s intraoperative findings included 1500 ml of intra-abdominal blood along with bleeding from a gonadal vessel and from the insertion of the renal vein on the vena cava. The family requested DNR status for the patient. The patient subsequently died.
The Board judged urologist’s conduct to be below the minimum standard of competence given failure to use proper surgical technique with correct tissue transection/ligation, failure to timely convert to an open procedure, and failure to consider hepatic artery and portal vein repair prior to proceeding with the performance of the nephrectomy.
The Board ordered the urologist to be reprimanded.
State: Arizona
Date: November 2016
Specialty: Urology, General Surgery, Nephrology, Oncology
Symptom: N/A
Diagnosis: Post-operative/Operative Complication, Cancer
Medical Error: Procedural error
Significant Outcome: Death
Case Rating: 3
Link to Original Case File: Download PDF
Kansas – Cardiothoracic Surgery – Improper Surgical Procedure Of Abdominal Aortic Aneurysm Results In Anuria And Then Death
A 72-year-old male patient was admitted to a medical center with foot ulcer and foot pain. During the patient’s hospitalization, an ultrasound revealed an 8.5 cm large abdominal aortic aneurysm (AAA). The patient was subsequently scheduled for surgical repair.
On 10/24/2010, a cardiothoracic surgeon admitted the patient to a medical center and completed a history and physical. The cardiothoracic surgeon also signed pre-operative orders at that time.
On 10/25/2010, the cardiothoracic surgeon performed an endovascular AAA stent repair on the patient using an Endologix stent graft. After surgery, the cardiothoracic surgeon returned to Wichita, Kansas. The cardiothoracic surgeon’s first assistant an ARNP, signed the post-operative orders and monitored the patient’s recovery along with other hospital staff.
Post-surgery the patient began to have decreased urine output on 10/26/2010. The patient was oliguric and then anuric. The patient failed to respond to large doses of diuretics so a nephrologist was consulted for dialysis.
A CT scan on 10/26/2010 showed bilateral renal artery occlusion and segmental occlusion of the proximal superior mesenteric artery.
Eventually the patient was transferred to Wichita, Kansas for further care where he later died on 10/29/2010.
The Board judged the cardiothoracic surgeon’s conduct to be below the minimum standard of competence given his failure to perform proper endovascular surgery on the patient
The Board ordered that the cardiothoracic surgeon have a cardiac surgeon and/or radiologist with adequate experience in endovascular abdominal aortic aneurysm repair participate and assist the cardiothoracic surgeon on his next ten endovascular abdominal aortic aneurysm repair cases. Also, the Board ordered that the cardiothoracic surgeon complete at least eight hours of continuing medical education courses with emphasis on endovascular abdominal aortic aneurysm repair.
State: Kansas
Date: June 2016
Specialty: Cardiothoracic Surgery, Nephrology
Symptom: Pain
Diagnosis: Aneurysm, Renal Disease
Medical Error: Procedural error
Significant Outcome: Death
Case Rating: 2
Link to Original Case File: Download PDF
North Carolina – Nephrology – Abdominal Pain And Hypotension After Renal Biopsy
In December 2011, a nephrologist performed a renal biopsy on a patient, a 70-year-old male with a diagnosis of temporal arteritis and presumed acute tubular necrosis. The procedure was uncomplicated and the nephrologist provided care of the patient following the procedure.
Approximately two hours after the procedure, the patient developed abdominal pain. After receiving a call from the nursing staff, the nephrologist ordered hydromorphone 2 mg and ondansetron 4 mg for pain and nausea. The nursing staff contacted the nephrologist two hours later to notify the nephrologist that the patient’s blood pressure had dropped. The nephrologist ordered an ampule of intravenous naloxone and normal saline bolus for the patient. One hour later the patient was transferred to the ICU, where he suffered a cardiopulmonary arrest, but was resuscitated. The patient became hemodynamically unstable and, despite aggressive resuscitation, died.
The Board obtained the patient’s records and sent them to a qualified independent medical expert for review. The independent medical expert judged the nephrologist’s conduct to be below the minimum standard of competence given failure to sufficiently appreciate the significance of post-biopsy pain; failure to recognize the significance of the patient’s drop in hemoglobin; and failure to order appropriate follow-up laboratory evaluation to assess the patient’s status when he began to complain of abdominal pain which was treated with what was thought to be an excessive dose of hydromorphone.
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: January 2016
Specialty: Nephrology
Symptom: Abdominal Pain, Bleeding
Diagnosis: Hemorrhage, Renal Disease
Medical Error: Diagnostic error
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF
California – Urology – Fever, Hypotension, Tachycardia, And Darkening Urine Develops During Kidney Stone Removal Operation
On 11/14/2012 at 6:30 a.m., a 60-year-old female presented to the emergency department with a five-day history of intermittent abdominal pain located in the right lower quadrant, which was severe at time of presentation. She also presented with chills without fever. Two days prior, the patient had developed nausea and vomiting, which eventually became blood-streaked. The patient was placed on morphine for the pain, and the pain eased. The patient was prophylactically placed on intravenous antibiotics for suspected infection. A CT scan of the abdomen and pelvis revealed a 5 mm kidney stone at the right ureterovesical junction (UVJ) with moderate hydronephrosis above it. A urologist was called in on consult, and the patient was admitted to the hospital.
The urologist read the emergency department records and laboratory results and scan, examined the patient, and affirmed that she had a 5 mm obstructive UVJ ureteral stone, which was symptomatic with hydronephrosis and creatinine and glomerular filtration rate dysfunction. After discussing his findings and recommendations with the patient and obtaining consent, the urologist schedule the patient for a right ureteroscopy, possible stone basketing or laser lithotripsy of the stone, and insertion of a right double-J ureteral stent for the evening of 11/14/2012.
The patient entered the operating room at 5:40 p.m. on 11/14/2012. The operative procedure with the patient under general anesthesia commenced at 6:20 p.m. and concluded at 8:50 p.m. The urologist commenced the cystoscopy and ureteroscopy and had difficulty inserting the Glidewire to place surgical implements due to fluid retention and edema in the kidney. The placement of the initial Glidewire took 45 minutes. Once the catheter and other implements were in place, an anesthesiologist reported to the urologist that the patient had developed a fever of 38.6 C (101.48 F) and that a large amount of darker urine was issuing from the right ureteral orifice. The urologist elected to continue and complete the stone removal and stent placement. Approximately 6 liters of IV fluid resuscitation were administered intraoperatively. The patient’s temperature fell to near normal, but hypotension and tachycardia continued. The urologist completed the ureteroscopy, stone retrieval, and placement of a right ureteral stent despite the development of signs of sepsis in the patient. Postoperatively, the patient’s infection was diagnosed as sepsis, presumably urosepsis. It required IV fluid boluses, IV antibiotics, pressors, and ICU admission for treatment of septic shock.
Ureteral stones can cause sepsis if there is an infection trapped behind a ureteral stone. Many times, the urine culture is clear, despite having an infection building behind an impacted stone. Any sign of infection, including an elevated white blood cell count, fever, blood pressure abnormality, tachycardia, or purulence behind the stone, should warn the urologist of impending infection and sepsis. A patient with an impacted ureteral stone and infection should be treated with either percutaneous nephrostomy tube or ureteral stent placement, and the stone should be treated only after the infection has resolved.
The Medical Board of California judged that the urologist committed negligent acts in his care and treatment of the patient given that he completed the operative procedure, instead of aborting it or placing a stent only and treating the infection first, despite the presence of signs and symptoms of serious infection.
For this case and others, the Medical Board of California issued a public reprimand and ordered that the urologist complete a clinical training or educational program equivalent to the Physician Assessment and Clinical Education Program (PACE) offered at the University of California, San Diego School of Medicine (Program) within 60 calendar days.
State: California
Date: October 2015
Specialty: Urology, Nephrology
Symptom: Abdominal Pain, Bleeding, Fever, Nausea Or Vomiting
Diagnosis: Sepsis, Post-operative/Operative Complication, Urological Disease
Medical Error: Improper treatment, Procedural error
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
North Carolina – Internal Medicine – Oral Lesions, Odynodysphagia, Weight Loss, And Poor Appetite
On March 2007, a patient with a history of diabetes, hypertension, and hyperlipidemia presented to a primary care physician who was board certified in internal medicine and nephrology for management of his medical issues.
On 07/16/2013, the patient presented to the nephrologist with oral lesions and painful swallowing. The patient was on lisinopril, clonidine, triamterene/hydrochlorothiazide, and metformin. The patient was diagnosed as having oral and possibly esophageal candidiasis. The patient was initiated on clotrimazole and fluconazole. The patient returned the next week with poor appetite and weight loss.
Labs were not reviewed by the nephrologist until two days later. They revealed elevation of BUN, creatinine, and potassium as well as a low TSH. The nephrologist requested the patient present to the hospital.
When the patient arrived to the emergency department, she was told she required transfer to another hospital for treatment. While en route, the patient coded. She stayed on life support for nine days before passing away secondary to acute renal failure and thyroid storm.
The Board expressed concern that the nephrologist’s conduct was below the minimum standard of competence. They noticed disorganized documentation and missing information along with failure to obtain an adequate history and failing to document relevant physical findings.
The Board issued a public letter of concern and reported the letter to the Federation of State Medical Boards.
State: North Carolina
Date: January 2015
Specialty: Internal Medicine, Emergency Medicine, Endocrinology, Family Medicine, Internal Medicine, Nephrology
Symptom: Weakness/Fatigue, GI Symptoms (GERD, Abdominal Distention, Dysphagia)
Diagnosis: Endocrine Disease, Renal Disease
Medical Error: Failure to follow up, Delay in proper treatment, Referral failure to hospital or specialist
Significant Outcome: Death
Case Rating: 3
Link to Original Case File: Download PDF
Virginia – Internal Medicine – Cardiac Arrest Shortly After Beginning Endoscopy
On 10/20/1997, a nephrologist admitted a 56-year-old male with a history of insulin dependent diabetes mellitus and chronic renal failure with complaints of shortness of breath, abdominal pain, and bloated abdomen. On the date of admission, a chest x-ray showed bilateral pleural effusions suggesting pulmonary edema, and an electrocardiogram was abnormal, showing ST and T wave abnormality; however, the patient was taken for endoscopy on 10/21/1997, where cardiac arrest occurred shortly after initiation of the procedure.
After a careful review of the records of his care regarding multiple patients and other information provided, and following a discussion with the nephrologist, the Committee found that he had no violations. The physician provided evidence that in July 1999, after a six-month review of his medical records found no deficiencies, he was granted full staff privileges at a hospital. Based on the foregoing, the Committee voted unanimously to dismiss this matter with no action.
State: Virginia
Date: June 1999
Specialty: Internal Medicine, Nephrology
Symptom: Shortness of Breath, Abdominal Pain
Diagnosis: Cardiovascular Disease
Medical Error: No error found
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF