Found 26 Results Sorted by Case Date
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Florida – Neurology – Hammer Falls On Patient Leading To An Open Depressed Skull Fracture And Abnormal EEG Results



A patient had a hammer fall on him at a construction site in January 2014.

On 1/15-16/2014, the patient underwent a right frontal craniotomy for elevation and debridement of an open depressed skull fracture.

The patient started being treated with a neurologist on 9/29/2014, for his headaches and other neurological symptoms.  At that time, the neurologist anticipated that the patient would reach maximum medical improvement from a neurological standpoint in one month’s time.

The patient kept having neurological symptoms and was evaluated via a routine EEG on 11/14/2014.  The routine EEG results were normal, but the patient kept having symptoms.

On 2/6/2015, the neurologist ordered a 48-hour ambulatory EEG on the patient.  The results of the 48-hour ambulatory EEG were abnormal.  The neurologist took no action, despite the patient still having neurological symptoms.

The neurologist gave the patient a permanent impairment rating of zero on 4/29/2015.

The patient then started treatment elsewhere because he was still having neurological symptoms.

The Medical Board of Florida judged the neurologist’s conduct to be below the minimal standard of competence given that he failed to perform follow-up MRI on CT scans, perform or order necessary surgical treatments depending upon the results of MRI or CT scans, perform antiepileptic treatment if indicated by the MRI or CT findings, rule out post-traumatic seizure disorder, order rehabilitation and cognitive therapy, order psychological therapy, and properly evaluate for a permanent impairment rating.

It was requested that the Medical Board of Florida order one or more of the following penalties for the urologist: 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: September 2016


Specialty: Neurology


Symptom: Headache


Diagnosis: Neurological Disease, Fracture(s)


Medical Error: Failure to follow up, Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Improper treatment


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Washington – Family Practice – Accidental Fall With Pain In Hands, Twitching In Extremities, And Muscle Spasms In Legs Months Later



On 2/15/2012, a woman in her late forties met with her family practitioner to address pain in her right knee two days after slipping on the kitchen floor.  The patient reported her knee hurt when bearing weight on it and when turning to the right.  Upon examining the patient’s knee, the family practitioner instructed the patient to wait over the next month for the inflammation to subside and to see if she was able to function as she did before the fall.

On 3/6/2012, the patient sent the family practitioner a secure message requesting a massage prescription, as she had been receiving intermittent massage treatment for many years and felt it helped her with her shoulder pain.  The patient clearly stated the pain was caused by bruxism and caused or increased her tinnitus.  A referral was placed that afternoon by a physician covering for the family practitioner.  The patient responded on 3/12/2012 requesting a prescription, instead of a referral, for insurance purposes.  On 3/13/2012, the family practitioner issued the requested document.  In a subsequent correspondence, the patient also brought up feeling tension in her shoulders when she went down the stairs, feeling nerve pain in her hands and elbows when she sneezed, and walking with numbness in her hands.  The family practitioner did not comment on the patient’s newer symptoms and did not ask her to make an appointment to be seen by the family practitioner.  The family practitioner failed to appreciate the significance of hand numbness and sneeze-induced pain described by the patient.

In May 2012, the patient saw an orthopedic surgeon to further examine her knee.  The orthopedic surgeon’s formal assessment was patellofemoral syndrome.  After the appointment, the patient wrote to the orthopedic surgeon seeking a clear answer regarding the muscle spasms in her legs she was experiencing in about 10-20 times a day and sometimes in her arms.  The orthopedic surgeon told her this issue is not common for someone with her condition and could be a result of a number of things including electrolyte imbalances, dehydration, or neurologic causes and to talk to her primary care provider for further work up.  The orthopedic surgeon provided a report to the family practitioner.

On 6/27/2012, the family practitioner saw the patient to address concerns of increased pain in her hands and how she still felt she had not fully recovered from her fall earlier that year.  She also felt increased pain during exercise and twitching in her extremities.  The patient reported a history of carpal tunnel.  The family practitioner performed an examination of the patient’s wrists and found symptoms consistent with carpal tunnel in the patient’s left wrist.  The family practitioner also noted the patient gained 17 pounds in approximately a year and a half and discussed the long-term importance of staying active.  The family practitioner suspected the patient could be diabetic (as both her parents were diabetic, increasing her risk) and that her possibly having diabetes could be contributing to her neurologic symptoms.  The family practitioner ordered testing for diabetes.  Although diabetes may have been a concern, the symptoms and history are not compatible with a diagnosis of diabetic neuropathy.  Through a secure message two days after the appointment, the family practitioner told the patient that while not yet diabetic, her sugars were higher than before, and that she wanted her to find ways to increase her activity and reduce her weight, and offered to refer her to another provider for a steroid injection in her knee.

On 7/6/2012, the patient sent the family practitioner a secure message in which she described the pain in her hands as “incredible” and when she bent her head down, her left arm went numb.  This symptom is a clear sign of origin in the spinal cord and should have resulted in urgent patient evaluation and prompt referral to neurology or neurosurgery.  The patient reported she wanted to wait six to eight more weeks to see if the pain resolved.  The family practitioner said that six weeks is an appropriate time to wait, and if it was not improving, she would refer the patient for nerve conduction testing and a neurosurgery referral.

On 7/20/2012, after the patient’s pain did not resolve, the family practitioner referred the patient for nerve conduction studies and a neurosurgery referral.  In August 2012, the patient met with a neurologist who confirmed the patient had left-sided carpal tunnel as well as myelopathic symptoms.  Magnetic resonance imaging (MRI) revealed the patient had suffered damage to her spinal cord at C4-C5, C5-C6, and C6-C7 from her fall earlier that year and required surgery.  The patient underwent surgery in late September.

The family practitioner failed to provide an appropriate and timely referral to a specialist.  The patient experiences ongoing symptoms.

The Commission stipulated the family practitioner reimburse costs to the Commission, complete 6 hours of continuing education in the areas of diagnosis and management of spinal cord and nerve root injuries and long-term complications of glucose intolerance and diabetes mellitus, and write and submit a paper of at least 1000 words on the subjects of her continuing education courses and the ways her practice will change based on the experience.

State: Washington


Date: June 2016


Specialty: Family Medicine, Internal Medicine, Neurology


Symptom: Extremity Pain, Numbness


Diagnosis: Spinal Injury Or Disorder


Medical Error: Delay in proper treatment


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 4


Link to Original Case File: Download PDF



California – Neurology – Note In Radiologic Imaging Report Identifying Mass On Skull Unread



A 58-year-old male began experiencing headaches in July 2010.  The patient initially obtained care from his primary care physician (PCP), who discovered, via an MRI and CT scan, a mass developing on the skull of the patient.  After this discovery, the PCP referred the patient to a neurologist. The referral by the PCP included a note written on the PCP’s prescription pad, dated 9/28/2010, which was transmitted to the neurologist’s office stating “CT head reveal destructive mass, pt has HA [headache], please evaluate.”  This note was located in the chart, but apparently not reviewed by the neurologist.

After the referral, the neurologist began treating the patient on 10/11/2010.  On the initial evaluation, a history of hypertension, sleep apnea, and diabetes was obtained.  No cranial nerve deficits were found, and the patient’s neurological exam was considered to be normal according to the neurologist.  The neurologist’s report stated “CT of the head was reviewed.’ The neurologist’s impression was (1) tension headaches, rule out migraine headache and (2) sleep apnea.  The neurologist started the patient on imipramine and wrote “MRI will be considered if the medicine does not work.”

On 11/17/2010, the patient returned to the neurologist with continuing headaches, and again on 12/15/2010.  The imipramine seemed not to be working, so the patient was prescribed topiramate and botox injections were considered.

On 1/24/2011, the patient was evaluated in the emergency department for a severe frontal headache.  A CT of the brain in the emergency department revealed “little change from 9/20/2010 of a large sella/suprasellar mass.”  The discharge instruction handout for cluster headaches was provided, and the patient was told to follow-up with his neurologist in the morning.

The patient returned to the neurologist on 1/26/2011, after the patient had been seen in the emergency department 2 days prior.  The neurologist evaluated the patient, and the neurologist’s impression was (1) migraine with great improvement and (2) meningioma.  The neurologist reassured the patient about the meningioma and suggested Advil for breakthrough pain while continuing imipramine and Topamax.

The neurologist reevaluated the patient again on 5/22/2011, 8/6/2011, and 9/20/2011.  On all these visits, the patient’s headache had not significantly improved, but the neurologist did not identify any structural basis for the patient’s headache.  The neurologist’s examination was nonfocal, and his impression was chronic tension headache. Instead, the neurologist added a sleeping pill, Vicoprofen, continued the Topamax, and added Pamelor, later including the combination of Vicodin and Advil.

On 2/24/2012, the patient was admitted to a hospital for a surgical biopsy and later underwent surgery to remove the tumor to his skull.

The Medical Board of California judged that the neurologist’s conduct departed from the standard of care because he failed to timely diagnose a brain tumor/structural mass in the patient’s skull, which was causing the patient’s medical condition, and which resulted in a delay in obtaining appropriate surgical treatment for the patient’s brain tumor.  The neurologist also failed to seek out the results of the imaging studies and/or other outside records to determine the presence or absence of a mass as a cause of the patient’s presenting symptoms, order additional MRI studies and blood tests for the patient after almost a year of continuing headaches, obtain an adequate history and physical and to provide a rational impression and treatment plan, diagnose and adequately manage the occurrence of new daily headaches, adequately review all outside reports/records, and keep timely, accurate, and complete medical records.

The Medical Board of California placed the neurologist on probation for 4 years and ordered the neurologist to complete a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.  The neurologist was also assigned a monitor and prohibited from supervising physician assistants.

State: California


Date: March 2016


Specialty: Neurology


Symptom: Mass (Breast Mass, Lump, etc.)


Diagnosis: Neurological Disease


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


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Neurology – Geriatric Patient With Dementia And Chronic Pain Treated With Rivastigmine Patches



On 3/16/2005, a 69-year-old female complained of frequent dizziness for many years, off and on, as well as forgetfulness for one to two years, and severe numbness and tingling in her hands for two years.  The patient’s Mini-Mental State Examination score was 20 points out of 30, and there was bilateral atrophy of the abductor pollicis brevis bilaterally.  Her physician’s assessments were, “Dizziness” and “Memory Loss/Dementia?”

In a medical record dated 1/8/2008 at an adult health care center, an LCSW (licensed clinical social worker) reported that the patient was showing “…poor concentration that interferes w/functioning. She has expert memory deficits, e.g. not shutting off water, or locking door and … she may have early vascular dementia.”  The records included a progress noted dated 1/30/2010 signed with initials “AG.”  The note stated that the patient tried rivastigmine (Exelon) 4.6 mg patches with no side effects.  The plan was to restart the Exelon 4.6 mg patches and refer her to a Russian speaker for neuropsychological testing.

Review of medical records revealed the following additional medical problems: hypertension, PUD, appendectomy, leg cramps, joint pain, generalized pain, chest pain, right frontal meningioma, flank pain, hyperlipidemia, chronic headaches, asthma/allergy, insomnia, and hearing loss.  The patient’s medications included reserpine (Adelfan, an anti-hypertensive), pantoprazole (Protonix), pancrelipase (Ultrase), sertraline (Zoloft), mometasone (Nasonex), fenofibrate (Tricor), amitriptyline, aspirin, simvastatin, hydrochlorothiazide, amlodipine, esomeprazole (Nexium), zolpidem, acetaminophen, Advair, Exelon Patch, Caltrate, and loratadine.

The patient was evaluated by a neurologist on at least 5 occasions between 5/4/2010 and 6/29/2012.  On 5/4/2010, the patient complained of acute low back pain radiating to the right leg, without numbness or weakness, after lifting a flowerpot.  The neurologist documented that the patient had “forgot” a pan on the stove, burned it, and firefighters responded.  Her exam showed lumbosacral tenderness and spasm, decreased hearing, and slow and antalgic gait.  Cranial nerves 3-12 were reported to be normal.  The diagnoses were left lumbosacral myofascial pain, dementia, and meningioma.  The treatment was trigger point injection with lidocaine and Kenalog, baclofen, Vicodin, and meningioma was “discussed.”

On 6/17/2010, the patient complained of vertigo, nausea, vomiting, pain in the right lumbosacral region, and right leg with numbness and a question of weakness.  The diagnosis was rule out lumbosacral radiculopathy.  TSH and B12 were ordered.  On 7/23/2010, the patient complained of left periscapular pain and left lumbosacral pain, dizziness, and numbness in the left anterior thigh.  Her gait was described as slow with walker, and there was left thoracic spine spasm and tenderness. Cranial nerves 3-12 were reported to be normal.  Diagnoses included myofascial pain, dizziness, psychogenic, and rule out lumbosacral radiculopathy. Treatment was triggered point injection, walker, and Zoloft at patient’s request.

On 9/8/2010, the patient complained of an episode of “lightning” sensation and numbness in her left head and limbs while walking in the heat on 8/31//2010 that resolved spontaneously in minutes.  At the appointment, the patient complained of left back pain, pain in the hands, aching in the limbs that night, and insomnia.  Her gait was stooped and labored, but cranial nerves 3-12 were reportedly normal.  The assessment was rule out TIA vs. seizure.

On 6/29/2012, the patient complained of pain in the left upper trapezius with radiation to the left upper extremity and left upper extremity numbness.  The exam showed left thoracic spine spasm, decreased left brachioradialis and triceps deep tendon reflexes.  Cranial nerves 3-12 and gait were reportedly normal.  The impression was rule out left cervical radiculopathy, meningioma on the right, and myofascial pain.

In an interview, the neurologist said he performed a straight leg raising test on 5/4/2010 when the patient was complaining of acute low back pain and pain radiating to the right leg.  When asked if he would ordinarily document it in the medical records if he performed a straight leg raising test, the neurologist replied, “I might or might not.”  This was a compelling example of the danger of not properly documenting pertinent negative findings.  Two and a half years after the fact, he could not remember if he had performed a straight leg raising test on that particular day on this particular patient, and it was not his standard procedure to consistently perform that test on a patient with these complaints.

When asked at his interview with the Medical Board of California personnel if he had performed any other motor exam on that day other than watching the patient walk, the neurologist replied, “I don’t remember but most likely I did.”  When asked if the neurologist would ordinarily document if he did a motor exam, the neurologist replied, “Sometimes I do and sometimes I would forego. If it’s normal, I might….”   When asked about the evaluation for vertigo on 7/17/2010, the neurologist stated, “Well, probably had some visual observations that she indeed was…did not display any coordination abnormalities.”  When asked if the neurologist performed a motor exam that day, he replied, “Most likely I did, but I did not mention it.”  When asked about the distribution of the patient’s numbness, the neurologist replied, “Typically if the patient cannot elaborate, I don’t, I may not mention it that they could not elaborate on this. And that is probably what the case.”  When asked if he performed the straight leg raising test, the neurologist replied, “I may or may not have.”  There are many other examples of the neurologist stating that he did not remember whether a particular examination had been performed on a given day.  With respect to the 6/29/2012 visit, when asked if the neurologist would ordinarily document if he tested the Spurling sign, the neurologist replied, “If I…if it’s positive, yes.”

The records showed that the neurologist consistently failed to perform, or failed to document that he performed, pertinent portions of the neurological examination.  By the neurologist’s own description, he would sometimes perform portions of a neurological examination, but not record the findings.  Consequently, there was no way of knowing if that test had been performed.  The consistent deficiency in not performing pertinent examinations, or failing to document pertinent positive and negative findings from the examinations, was a simple departure from the standard of care.

Most of the neurologist’s handwriting was legible, but there were important exceptions.  When attempting to read his 5/4/2010 progress note, the neurologist had difficulty reading the word “firefighter.” “Forgetful, forgetful, four, four, fire, oh firefighter’s visit just fire engines outdoors.”  The standard for a neurologist was to dictate at least some of the report.  Whether dictated or handwritten, the report must be legible enough for another clinician to take advantage of the neurologist’s expertise.  The neurologist’s handwritten notes were much more difficult to read than other records regarding this patient.  The neurologist’s notes were not labeled as neurology notes nor were his name printed or typed on the notes.  His “signature” appears to be an initial.  Thus, unless the reader was already familiar with the neurologist’s handwriting, it is not possible to identify his notes as being from the neurologist.  The neurologist’s failures to provide an easily legible documentation of his assessments, and to identify them as being a neurological evaluation, were a simple departure from the standard of care.

As stated in the summary of the case, it was well-documented that the patient had dementia, with symptoms present by about 2002.  As early as January 2008, healthcare professional had documented a concern about the patient’s safety.  In the neurologist’s 5/4/2010 note, the neurologist documented that the patient had “forgot a pan on the stove, burned it” and that firefighters responded, but there was no documentation that the neurologist made efforts to protect the patient’s safety.  Such efforts could have included attempting to increase the amount of supervision provided to the patient, including moving into an assisted living facility.

In the neurologist’s interview, the neurologist stated that he did not think it was necessary or appropriate to prescribe any treatment for the dementia because the patient was already receiving the Exelon patch, but it was common for patients with moderate or more severe dementia to be prescribed Namenda, an additional FDA-approved treatment for dementia in addition to Exelon (or donepezil or galantamine).  The neurologist also stated in his interview that he “felt” that the dementia was not severe, but there was no documentation that the neurologist administered, or had a third party administer, any type of standardized cognitive testing, such as the Mini-Mental State Examination or even rudimentary “bedside” mental status testing of orientation or memory.

The patient had neuropsychiatric symptoms including anxiety, restlessness, and mood disorder dating to at least 2007.  While under the neurologist’s care in 2010, the patient was still experiencing at least insomnia.  There was no documentation that the neurologist made attempts to improve the treatment of the patient’s insomnia with behavioral/sleep hygiene strategies or pharmacological strategies.  The failure to attempt to ameliorate an unsafe living situation, consider all treatment options for dementia, adequately treat insomnia, and longitudinally measure the cognitive function of a patient with dementia were all simple departures from the standard of care.

The neurologist performed nerve conduction studies and EMGs on the patient on 6/29/2012.  The patient’s chief complaint that day was pain in the left upper trapezius, radiation to the left upper extremity with left upper extremity numbness.  The neurologist’s impression was ‘Rule out left cervical radiculopathy.”  The neurologist didn’t document an adequate history nor did he perform and document any examination of the peripheral nervous system.  There was no documentation to indicate that the results of the EMGs and nerve conduction studies changed the therapy in this patient.  The lack of documentation of an adequate history and examination and the apparent use of neurodiagnostic studies as a substitute for a physical examination rather than as an adjunct to the physical exam constitutes a simple departure from the standard of care.

The Medical Board of California judged that the neurologist’s treatment of the patient was a simple departure from the standard of care because he failed to protect the patient’s safety, consider all treatment options for dementia, adequately treat insomnia, longitudinally measure the cognitive function of a patient with dementia, provide easily legible documentation of his assessments, identify documentation as being a neurological evaluation, and document pertinent positive and negative findings from the examinations.

The Medical Board of California ordered that the neurologist be placed on probation for a period of 3 years, complete a medical record-keeping course, prescribing practices course, and an education course (at least 40 hours per year for 3 years) equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California


Date: January 2015


Specialty: Neurology


Symptom: Dizziness, Headache, Nausea Or Vomiting, Numbness, Pain, Back Pain, Chest Pain, Extremity Pain, Joint Pain, Psychiatric Symptoms, Weakness/Fatigue


Diagnosis: Neurological Disease


Medical Error: Improper treatment, Failure to examine or evaluate patient properly, Improper medication management, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Neurology – Lack Of Proper Examination Due To Assumption That Neurological Symptoms Stemmed From Drug Abuse And Withdrawal



A patient’s medical records showed that the patient’s medical problems included chronic back problems since childhood, seizure disorder, ataxia, left hip pain, low back pain, arthritis, degenerative disease of the spine, hypothyroidism, bipolar disorder, head trauma, fibromyalgia, bronchitis, asthma, anxiety, rule-out obsessive-compulsive disorder, sinusitis, anemia, T&A, traumatic fracture of the right tibia, and cognitive problems including inattentiveness, disorganization, and memory loss.  The patient’s medications have included carisoprodol (Soma), propranolol, levothyroxine, salmeterol/fluticasone (Advair), fluticasone (Flonase), hydrocodone/acetaminophen (Norco), valproic acid (Depakote), buspirone (Buspar), fluoxetine (Prozac), aripiprazole (Abilify), travoprost (Travatan), and clonazepam (Klonopin).

In the patient’s neurologist’s record on 9/20/2008, the only entry that he made in the Motor Exam section of the exam form when examining the patient was “Tremulousness.”  In the neurologist’s interview, the neurologist stated that he would also “check muscle tone, bulk, strength, and armpit.” (Presumably, armpit was mistranscribed and he really said “Arm drift,” because that was what was on the form and it was a more sensible answer than armpit in this context).  In response to the examiner’s query, the neurologist endorsed the statement that the fact that nothing was noted in those sections of the motor exam form meant that those tests were performed and were normal.   The same was true for sensory testing of temperature and vibration.  The consistent deficiency in not performing pertinent examinations, or failing to document pertinent positive and negative findings from the examinations, was a simple departure from the standard of care.

The neurologist stated that he thought the patient was tremulous because she was withdrawing, so he refilled her Klonopin.  The neurologist did not record it and stated, “I would have mentioned it if it had been one of my considerations, but also I was thinking about possibility of overcorrection of her hypothyroidism.”  He did not record his thoughts about the hypothyroidism either.  The neurologist’s failure to document his thought processes and medical decision making regarding important medical problems, such as benzodiazepine withdrawal and overdosing of thyroid medication was a simple departure from the standard of care.  The neurologist’s notes of visits with the patient also lacked legibility and clarity.  The neurologist’s failure to provide an easily legible documentation of his assessments of the patient was a simple departure from the standard of care.

Although the neurologist described the patient as “disorganized” and “inattentive” in his 12/18/2009 report, and he marked the memory category with a plus sign on the form, the neurologist didn’t perform any other bedside/less formal mental status testing or any standardized mental status testing.  At his interview, the neurologist stated that he performed formal mental status testing, “..mostly when there’s a specific complain about memory or, uh, I suspect that dementia is the main, potentially the main issue for this visit.”  This explanation reflected substandard practice.  Patients with substantial memory problems, including patients with dementia, often do not complain of memory problems.  Whether or not memory problems were the main complaint on a particular visit, a patient, who is noted by a neurologist to be disorganized and attentive, should have additional mental status testing documented.  At a minimum, a brief standardized test, such as the Mini-Mental status examination, should be performed.  In fact, the form that the neurologist was using included the Mini-Mental State Exam, but he didn’t administer any of it.

In the interview, the neurologist stated that, “my general impression that she did not have a primary dementing illness from the way she behaved, that she was affected…by her mental condition, and as it turned out later and I suspected, uh, some drug abuse because of my wording for drug abuse was denied, but that, that means I felt that it’s not reliable information.  So there is [sic] conditions, when [a] patient is potentially delirious or has significant mental issues, I don’t find mental health examination of particular use for this etiology.”   The neurologist then went on to say that he strongly suspected that the patient was, “under influence of, of uh substance and/or her behavior is due to her mental status, mental, uh mental health issues.” “Well, my first thought that she was intoxicated.”

These statements by the neurologist raised several concerns. “General impressions” are not substitutes for applying the standard diagnostic workup and diagnostic criteria for dementia.  If a patient was not a reliable source of information, then it is crucial to involve a collateral historian.  If his impression was that the patient was “delirious” and “intoxicated”, then a careful workup for causes of delirium/encephalopathy should’ve been performed, including toxicology testing.  It was not within the standard of care for a neurologist to state that the source of the intoxication was unknown, “because she denied history of alcohol or any drugs.”  It was within the standard of care to order toxicology testing and to interview collateral sources regarding the patient’s use of substances.  The standard of care includes keeping the patient safe.  Prescribing Klonopin to a patient who was thought to be delirious and intoxicated was not safe.  Also, a caregiver should have been identified to be in charge of the patient’s other medication.

The neurologist stated that, “…considering her tremulousness I just assumed that she’s in withdrawal and I refilled her Klonopin. At the time I also gave her Inderal to address tremulousness.”  Assuming that a patient was withdrawing from Klonopin because she was tremulous and adding Inderal in a patient with memory problems was dangerously superficial reasoning and not within the standard of care regarding patient safety.   The neurologist made a simple departure from the standard of care when he failed to perform adequate mental status testing on a patient who was disorganized and inattentive, when he relied on general impressions and drew conclusions about diagnosis without adequate evidentiary data, such as history, exam, and laboratory testing, when he prescribed Klonopin to a disorganized and inattentive patient, and when he failed to take steps to protect the patient’s safety.

When explaining why he didn’t address the patient’s seizure disorder on the 12/18/2009 appointment, the neurologist stated, “My assumption for the reason for Depakote was most likely it was given to her for bipolar and also I thought maybe she actually had seizures for alcohol withdrawal seizures, but in the absence of active seizures I did not see any compelling reason to pursue this…”  Then the neurologist admitted that, “…there was nothing in the prior records to indicate she was alcohol abuser.”  The patient had a history of a seizure disorder, but on the 12/18/2009 appointment, the neurologist “did not address her seizure disorder” because “…that was not the focus of the office appointment” and “…she did not have any active complaints about seizures.”  Failure to review the status of the patient’s seizure disorder in even the most superficial way was a simple departure from the standard of care.  In this instance, the neurologist did not apply a logical, coherent analytical process to diagnosis and treatment.  He postulated theories of treatment for bipolar illness and alcohol withdrawal seizures that were unsupported by objective evidence.  In his record of the patient’s appointment on 1/28/2010, the neurologist documented a complaint of enuresis, but did not do any examination or evaluation with regards to that problem.  The neurologist’s explanation was “I thought it’s most likely because of her alcohol abuse.”  Once again, the neurologist invoked alcohol abuse to explain a medical problem even though there was no support for a diagnosis of alcohol abuse in the medical records.  Repeated failure to apply a logical, coherent analytical process to diagnosis was a simple departure from the applicable standard of care.

The neurologist performed nerve conduction studies and EMGs on the patient on 7/19/2011.  The patient complained of pain in the right knee and left leg cramps.  There were no symptoms documented referable to a radiculopathy or other syndrome that would be an indication for electrophysiologic studies.  The neurologist claimed that the patient had lower back pain radiating to the right lower extremity, but those symptoms were not documented in his progress note.  There was no documentation to indicate that the results of the EMGs and nerve conduction studies changed the therapy in this patient.  The lack of documentation of an adequate history and examination and the apparent use of neurodiagnostic studies as a substitute for a physical examination rather than as an adjunct to the physical exam constituted a simple departure from the standard of care.

The Medical Board of California judged that the neurologist’s treatment of the patient departed from the standard of care because he failed to perform pertinent examinations or failed to document pertinent positive and negative findings from the examination, document his thought processes and medical decision making regarding important medical problems, provide an easily legible documentation of his assessments of the patient, perform adequate mental status testing on a patient who was disorganized and inattentive, review the status of the patient’s seizure disorder, apply a logical, coherent analytical process to diagnosis, and lack of documentation of an adequate history and examination.

The Medical Board of California ordered that the neurologist be placed on probation for a period of 3 years, complete a medical record-keeping course, prescribing practices course, and an education course (at least 40 hours per year for 3 years) equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California


Date: January 2015


Specialty: Neurology


Symptom: Extremity Pain, Urinary Problems


Diagnosis: Neurological Disease


Medical Error: Improper treatment, Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Improper medication management, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Neurology – Attributing Memory Loss To Depression Without Justification And Other Evaluation Errors



A patient’s medical records showed that she had numerous medical problems, including insulin-dependent diabetes mellitus, hypertension, hyperlipidemia, glaucoma, cataracts, depression, insomnia, sleep apnea, CVA, vascular dementia, asthma, osteoarthritis, obesity, urinary incontinence, peripheral neuropathy, diabetic neurogenic bladder, pelvic floor weakness, low back pain, dizziness, and herpes zoster.  Medications included ibuprofen, nitroglycerin, atorvastatin (Lipitor), clopidogrel (Plavix), amlodipine/benazepril (Lotrel), levalbuterol (Xopenex) HFA inhaler, dorzolamide/timolol (Cosopt) Opth. Sol., furosemide, pioglitazone (Actos), insulin glargine (Lantus), albuterol inhaler, aspirin (ASA), ezetimibe (Zetia), brimonidine (Alphagan), tramadol, escitalopram (Lexapro), metoprolol, and metformin.

When asked if the patient had a positive Babinski sign on 1/2/2006, the patient’s neurologist stated, “…no mention of abnormality and that means it was negative.”  The consistent deficiency in not performing pertinent examination, or failing to document pertinent positive and negative findings from the examinations, was a simple departure from the standard of care

The neurologist’s handwritten notes were much more difficult to read than other clinic records regarding this patient.  The neurologist’s notes were not labeled as Neurology notes, and his name was not printed or typed on the notes.  His “signature” appeared to be an initial.  Therefore, it was not possible to identify his notes as being from a neurologist in general, or from him specifically, in the absence of recognizing his writing or “signature” and knowing that he was a neurologist.  The neurologist’s failure to provide an easily legible documentation of his assessments of the patient and to make it clear that these evaluations were neurology evaluations was a simple departure from the standard of care.

The neurologist evaluated the patient on 1/12/2006.  He documented a history of left hemiparesis and slurred speech in 2003, recurrent left-sided weakness, and slurred speech in August 2005, and 10 days prior to that appointment, she had slurred speech, pulling of her mouth to the right, increased left hemiparesis, and numbness in her toes and left fingers.  Despite obtaining a history of strokes and memory loss, the neurologist’s mental status testing was limited to, “Level of consciousness appropriate.”  When asked why the mental status examination was limited to that one observation, the neurologist stated: “It was not the focus of her complaint.  She appeared cognitively preserved.”  It was not clear how the neurologist reached that conclusion because he did not document any mental status testing other than rating the level of consciousness as, “appropriate.”  Also, it was not conventional to apply the word “appropriate” when discussing level of consciousness. “Appropriate” was commonly used to describe a patient’s behavior or conduct, but level of consciousness was conventionally described using terms, such as alert and awake, or somnolent, lethargic.

As to the patient’s memory problems, the neurologist stated, “…it’s a very common complaint, usually subjective, age-related memory problems, depression related.”  The neurologist asserted these impressions without foundation, such as mental status testing or asking the patient about her mood.  This gave the appearance of arbitrarily selecting a diagnosis rather than carefully formulating a diagnosis based on clinical evidence.  The neurologist demonstrated a similar lack of rigor when he evaluated the patient on 1/13/2007.  When asked why the neurologist didn’t do any evaluation of her memory at that visit, he stated, “I felt it is age-related memory which is really normal range because her general behavior was normal. She has no evidence of dementia and she did not focus on this particular complaint. Her general demeanor was kind of depressive, and so that was consistent with the degree of memory complaint.”  Observing “general behavior” was not a substitute for specific mental status testing.  The absence of a complaint of memory problem was not a justification for omitting mental status testing when there was a history of memory problems and multiple cerebral infarctions.

On 5/28/2011, the neurologist administered a Mini-Mental State Exam and the patient earned 20 points out of 30, consistent with moderate dementia.  When asked if that score indicated that she had dementia, he stated, “I felt that it’s mostly depression, but there could be elements of…vascular…dementia.”  Here again, the neurologist reached conclusions without referencing supporting data or applying established diagnostic criteria.  The neurologist did not mention Alzheimer’s disease in the differential diagnosis even though it was by far the most common cause of dementia in this patient’s age group.  Failure to adequately test the patient’s mental status on multiple occasions, failure to apply standard diagnostic criteria to diagnose dementia and to determine the etiology of dementia, and failure to at least consider treatment for dementia, constituted a simple departure from the standard of care.

When asked if the neurologist diagnosed the patient as having peripheral neuropathy, the neurologist stated, “not, not formally, but I, I assumed she, she might have it.”  When asked if it was not his habit to document what kind of a headache he thinks a patient has, he stated, “I wasn’t sure. I was just fishing around.”  This was not a logical coherent analytical process to diagnosis and treatment.  Failing to perform the appropriate neurological testing, failing to use logical diagnostic criteria, and not adequately characterizing this patient’s headache were simple departures from the standard of care.

The neurologist saw the patient on 7/7/2008.  There was a progress note from that date documenting the history of numbness in upper arms, pain in shoulders, and weakness in hands.  The neurologist performed an EMG and nerve conduction studies on that day.  As pointed out in the interview, the records were confusing because the progress note appears to reference the results of the EMG study, but the neurologist stated in the interview that “the order was everything on the progress note and then EMG, and then I would put the finding of the EMG on the progress note as an addition.” However, the statement, “EMG L>R CTS” appears in the body of the progress note, not at the end of the progress note, or as an addendum to the progress note.  At a minimum, the progress note was confusing and called into question the order of the assessments performed that day.  Other than the reference to the EMG results, the progress note contained no evidence that an examination of the peripheral nervous system was performed.  The EMG/nerve conduction report prepared by the neurologist on that day included elements of a peripheral nervous system examination, “(+) Tinel’s on the L. Decrease sens. In L medial, R lateral fingers. No atrophy. DTR’s 2/4 in UE’s.”  Those findings should have been included in the progress note, which would’ve established an indication for doing the studies.  There was no documentation to indicate that the results of the EMGs and nerve conduction studies changed the therapy in this patient.  The lack of documentation of an adequate peripheral nervous system examination in a progress note, and generating a record that gives the appearance that EMGs and nerve conduction studies were performed before the history and physical were complete, is a simple departure from the standard of care.

The Medical Board of California judged that the neurologist’s treatment of the patient departed from the standard of care because he failed to perform pertinent examination or document pertinent positive and negative findings from the examinations, provide an easily legible documentation of his assessments of the patient, make it clear that his evaluations were neurology evaluations, adequately test the patient’s mental status on multiple occasions, apply standard diagnostic criteria to diagnose dementia, determine the etiology of dementia, at least consider treatment for dementia, perform the appropriate neurological testing and use logical diagnostic criteria, adequately characterize this patient’s headache, and document adequately for the patient encounter.

The Medical Board of California ordered that the neurologist be placed on probation for a period of 3 years, complete a medical record-keeping course, prescribing practices course, and an education course (at least 40 hours per year for 3 years) equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California


Date: January 2015


Specialty: Neurology


Symptom: Numbness, Weakness/Fatigue


Diagnosis: Neurological Disease


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


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Neurology – Lack Of Proper Evaluation And Treatment For Chronic Headaches



Medical records documented that a 55-year old female had numerous medical problems, including headache, restless leg syndrome, muscle cramping, musculoskeletal pain, shoulder pain, knee pain, incontinence, uterine prolapse, fibromyalgia, osteoporosis, memory loss, obesity, low back pain, multiple falls, and probably obstructive sleep apnea with daytime hypersomnolence.  The patient’s medications included fluoxetine (Prozac), clonazepam, topiramate (Topamax), ibuprofen, metoprolol (Lopressor), meclizine (Antivert), hydroxychloroquine (Plaquenil), Vicodin, gabapentin, temazepam, benazepril, hydrochlorothiazide, amitriptyline, nortriptyline, simvastatin, ropinirole (Mirapex), baclofen, and zolpidem (Ambien).

On 3/8/2010, the patient complained of pain in the right occiput.  Her neurologist’s impression was right occipital neuralgia, but he didn’t document any physical findings corresponding to that diagnosis.  The neurologist stated that he would typically palpate the patient and document if there was a positive finding, and he stated that he “most likely” did the examination even though it was not documented in the record.  The neurologist’s failure to document pertinent positive and negative findings was a simple departure from the standard of care.

The neurologist’s handwritten notes were much more difficult to read than other clinic records regarding this patient.  The dictated reports of the Rheumatology consultation on 7/28/2005 and the Sleep Medicine consultation on 1/4/2006 were examples of the standard expected of specialists consulting on a patient.  The neurologist’s notes were not labeled as Neurology notes, and his name was not printed or typed on the notes.  The neurologist’s “signature” appears to be an initial.  Thus, it was not possible to identify his notes as being from a neurologist in general or from his specifically, in the absence of recognizing his writing or “signature” and knowing that he was a neurologist.  The neurologist’s failure to provide an easily legible documentation of his assessments of the patient and to clearly identify his records as being neurology evaluations was a simple departure from the standard of care.

When the neurologist saw the patient on 10/5/2011, he obtained a history of decreased memory and forgetfulness, misplacing items, and learning inability.  Nevertheless, he didn’t perform a formal mental status examination because, “it sounded to me that she, those complaints related to fibromyalgia and depressive symptoms.”  That conclusion was unsupported by objective evidence.  The neurologist failed to determine the scope and severity of the cognitive deficits and apply standard diagnostic criteria to exclude other causes of memory loss, such as Alzheimer’s disease.  On 10/5/2011, the neurologist prescribed memantine (Namenda) “…just to meet the patient’s expectations” even though it was contrary to his best medical judgment.  The neurologist stated, “But again, if she responded, why not give what works.”  While treating patients empirically was an acceptable approach, there should at least be a working diagnosis upon which to base that treatment and the treatment should reflect the physician’s best judgment.  The neurologist’s lack of systematic and coherent approach to diagnosis and treatment of memory problems, and his prescription of a medication to meet a patient’s expectations, even though it was contrary to his best judgment, were simple departures from the standard of care.  A neurologist applies a logical coherent analytical process to diagnosis and treatment and does not reach conclusions unsupported by objective data.

The patient had a chronic complaint of headache.  At various points in time, the neurologist’s impressions were migraine, tension headache, and occipital neuralgia.  The record didn’t include an explanation of how those impressions were derived.  The neurologist prescribed medications including Topomax, Klonopin, and Neurontin.  It was not possible to determine from the record which treatment was being prescribed for what diagnosis.   The neurologist did not initiate sequential trials for a treatment for one type of headache, advancing each treatment either until successful or dose-limiting side effects occur.  The diagnoses and treatments changed without well-documented clinical reasons.  The neurologist’s lack of logical and coherent approach to diagnosis and treatment was a simple departure from the standard of care.

On 5/21/2007, the patient complained of vertigo “on turning abrupt movements.”  The neurologist didn’t document any cranial nerve examination, such as testing nystagmus or hearing.  There was no documentation of cerebellar function, such as truncal gait or limb ataxia.  Instead, the neurologist ordered a videoelectronystagmogram and CT simultaneously.  A videoelectronystagmogram is a very low-yield neurodiagnostic test and is either not ordered in standard neurology practice or only ordered after other higher yield diagnostic studies, such as a CT brain scan have been completed and interpreted.  There was no documentation to indicate that the results of the videoelectronystagmogram assisted in the diagnosis or treatment of this patient’s vertigo.  Obtaining a videoelectronystagmogram as one of the initial steps in a work-up of vertigo, before seeing the results of the CT brain scan, was a simple departure from the standard of care.

The Medical Board of California judged that the neurologist’s treatment of the patient departed from the standard of care because he failed to document pertinent positive and negative findings, provide an easily legible documentation of his assessments of the patient, and clearly identify his records as being neurology evaluations.  The neurologist also departed from the standard of care because he lacked a systematic and coherent approach to diagnosis and treatment, his prescription of a medication to meet a patient’s expectations, and obtaining a videoelectronystagmogram before seeing the results of a CT brain scan.

The Medical Board of California ordered that the neurologist be placed on probation for a period of 3 years, complete a medical record-keeping course, prescribing practices course, and an education course (at least 40 hours per year for 3 years) equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California


Date: January 2015


Specialty: Neurology


Symptom: Head/Neck Pain, Dizziness, Headache, Back Pain, Joint Pain, Urinary Problems


Diagnosis: Neurological Disease


Medical Error: Improper medication management, Failure to examine or evaluate patient properly, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Neurology – Pain In Soles Of Feet And Legs Managed Long-Term With Methadone Prescriptions



A 62-year-old patient’s records showed she had hypertension, diabetes mellitus, diabetic polyneuropathy, obesity, asthma, osteoarthritis, leg pain, and depression.  The patient’s medications included duloxetine (Cymbalta), gabapentin (Neurontin), pregabalin (Lyrica), methadone, metoprolol (Toprol), amlodipine/benazepril (Lotrel), naproxen, pioglitazone (Actos), insulin, Vicodin, baclofen, glimepiride, losartan (Diovan), zolpiderm (Ambien), rosuvastatin (Crestor), albuterol, temazepam, esomeprazole (Nexium), and trazodone.

A neurologist saw the patient on 8/13/2009.  The neurologist documented that the patient had decreased sensation in the lower extremities, but the distribution of the sensory loss and the modalities of the sensory loss were not documented.  In the neurologist’s responses to questions, the neurologist stated that the sensory loss was diffuse, meaning that it was “probably above the knees, as well.”  Unless the neurologist had an independent recollection of this examination, he would only be guessing as to the distribution and modalities of sensory loss, and a third party reviewing the medical record would have no way of determining that information.  In response to questions about the 9/29/2009 exam of this patient, the neurologist stated, “At this point I could not tell if it’s positive Tinel’s or negative….”  This was another example of failure to document an important clinical parameter.  Concerning testing the APB muscle on that day, the neurologist was asked, “And do you believe because it doesn’t say anything about weakness of APB that APB was probably normal?”  The neurologist replied, “Normal, probably normal.”  The neurologist’s failure to document pertinent positive and negative findings was a simple departure from the standard of care.

The neurologist’s handwritten notes were much more difficult to read than other clinic records regarding this patient.  The neurologist’s notes were not labeled as neurology notes.  His name was not printed or typed on the notes.  His “signature” appeared to be an initial.  Thus, unless the person was familiar with the physician’s handwriting, it wasn’t possible to identify his notes as being from a neurologist.  The neurologist’s failure to provide an easily legible documentation of his assessments of the patient or to clearly identify them as neurology evaluations was a simple departure from the standard of care.

In the neurologist’s 8/13/2009 Neurology History and Physical for the patient, his history of present complaint was limited to “Pain, burning in feet, cramping at night.”  There was no mention of physical and psychological status or function, severity of pain, quality of pain, exacerbating factors, or ameliorating factors.  There was a history of prior pain treatment, but no documentation of the dose, duration of treatment, degree or response to treatment, or side effects of treatment, no documentation of recognized medical indications for the use of controlled substances in this type of pain, and no statement of objectives.  There was no documentation that informed consent was obtained including a discussion of risks, benefits, and other treatment modalities, and yet the neurologist prescribed methadone, a Schedule 2 controlled substance, at a dose of 5 mg TID.  There was a plan for physical therapy and to see the patient in one month, but there was no documentation of obtaining a pain expert consultation.

When the patient was seen by the neurologist on 9/29/2009, the neurologist documented complains of “pain soles” and finger or fingertip numbness. The methadone dose was doubled, and there was a one-month follow-up ordered.  When the neurologist saw the patient on 11/29/2009, the neurologist documented complaints of right arm tingling only while in bed, pain in feet, and low back pain.  There was no mention of physical and psychological status or function, severity of pain, quality of pain, exacerbating factors (except for lying in bed), or ameliorating factors.  The methadone dose was increased from TID to QID, and there was a one-month follow-up ordered.  When the neurologist saw the patient on 1/13/2012, he documented a complaint of right lateral foot numbness and the report that methadone was still helping the pain in feet.  The methadone dose was not changed, and follow-up was ordered for two months.

The neurologist performed nerve conduction studies and EMGs on the patient on 9/29/2009.  On that day, his impression “was diabetic neuropathy, carpal tunnel syndrome.”  There was no exam of the peripheral nervous system documented.  In the interview, the neurologist stated that he couldn’t tell if the Tinel was positive or negative, and there was no documentation that it was even performed.  The neurologist didn’t document an adequate history or perform and document an examination of the peripheral nervous system relevant to the complaints of numbness in the fingers and pain in the soles.  There was no documentation to indicate that the results of the EMGs and nerve conduction studies changed the therapy in this patient.  The lack of documentation of an adequate history and examination and the apparent use of neurodiagnostic studies as a substitute for a physical examination rather than as an adjunct to the physical exam constituted as a simple departure from the standard of care.

The Medical Board of California judged that the neurologist’s treatment of the patient departed from the standard of care because he failed to document an adequate history and examination including an adequate assessment of the patient’s pain, used neurodiagnostic studies to substitute a physical examination instead of as an adjunct to the physical exam, document recognized medical indications for use of methadone, document objectives, obtain informed consent, consider a pain consultation, provide an easily legible documentation of his assessment of the patient, clearly identify assessments as neurology evaluations, and document pertinent positive and negative findings.

The Medical Board of California ordered that the neurologist be placed on probation for a period of 3 years, complete a medical record-keeping course, prescribing practices course, and an education course (at least 40 hours per year for 3 years) equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California


Date: January 2015


Specialty: Neurology


Symptom: Pain, Numbness, Extremity Pain


Diagnosis: Neurological Disease


Medical Error: Failure to examine or evaluate patient properly, Improper medication management, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Kansas – Neurosurgery – Pneumocephalus And Hemorrhage Following A Burr Hole Procedure



On 2/26/2007, 77-year-old female patient had a magnetic resonance imaging performed which revealed a left-side subdural hematoma.  The patient was admitted to a medical center where she was examined by a neurosurgeon.

On 2/27/2007, the patient underwent surgery for evacuation of a left parietal and frontal subdural hematoma through a burr-hole procedure performed by the neurosurgeon.

The neurosurgeon, as the attending physician and supervisor for all medical personnel assisting with the burr hole procedure, was responsible to the patient for all his actions as well as those who assisted with the procedure.  A traumatic injury to the substance of the patient’s brain occurred, which resulted in hemorrhaging of her brain.

Following surgery, the patient exhibited aphasia and right-sided hemiparesis.  A computed tomography scan was performed on 2/27/2007, which showed new areas of pneumocephalus and hemorrhage in the brain.

The operative report dictated by the neurosurgeon on 2/27/2007, which is the same day the surgery took place, described the neurosurgeon’s placement of two burr holes and the drainage of fluid from each. It also described the placing of a Jackson-Pratt drain and what was variously described as gentle or careful irrigation of the sites.

However, an addendum typed by the neurosurgeon on 6/5/2007 stated that a surgical technician directed what was termed as a “forceful irrigation” into the left-frontal burr hole site while the neurosurgeon had his back turned.  It also stated that when the neurosurgeon inspected the left parietal burr hole site for placement of the drain, he noted a small piece of brain tissue draining out of the site with the residual irrigation.  The addendum further stated that the subdural space was nearly absent when it had been open moments before and the neurosurgeon did not believe he could safely place the drain into that site.  The addendum noted the neurosurgeon’s observation of what was termed “small amount of bleeding” from the surface of the underlying brain.  Finally, the addendum stated that the neurosurgeon believed there was no injury to, or penetration of, the substance of the brain by the neurosurgeon.

On 2/27/2007, after the surgery, the neurosurgeon advised the family of the patient that “everything went great.”

On 2/27/2007, after the surgery, a CT scan was ordered by the neurosurgeon, which indicated a pneumocephalus and associated hemorrhage had developed in the parenchyma of the patient’s left frontal region of the brain.  The neurosurgeon failed to timely advise concurrent and subsequent treatment providers or the patient’s family about the pneumocephalus and associated hemorrhage and he failed to document that an injury had occurred until the neurosurgeon filed his addendum to the operative report filed on 6/5/2007.

On 2/28/2007, an MRI was ordered by the neurosurgeon, which indicated a large hematoma in the left frontal lobe.  Later that day, the neurosurgeon ordered a second post-operative CT scan, which confirmed a pneumocephalus deep in the parenchyma and a growing area of hemorrhage.

On 2/28/2007, the neurosurgeon advised the patient’s family that her condition, which was deteriorating, was likely caused by a stroke.  The neurosurgeon did not mention the incident later described in his own addendum to the operative report or alternative causes for the patient’s deterioration.

Also on 2/28/2007, the patient was seen by an internist.  Upon observing the patient’s condition, the internist suggested the patient be seen by a neurologist.

On 3/1/2007, the patient was seen by a neurologist.  Upon reviewing the imaging scans and examining the patient, the neurologist suspected an injury to the brain had occurred and discussed his suspicion with the neurosurgeon.  Thereafter, the neurologist’s concerns were submitted to risk management in an incident report stating that after surgery there was evidence of a pneumocephalus inside the parenchyma of the brain, which showed progressive hemorrhage.  The incident report requested the surgery department review the case.

Despite his conversation with the neurologist, the neurosurgeon failed to advise any of the patient’s concurrent and subsequent treatment providers about the injury and the neurosurgeon still did not document that an injury or an incident during surgery had occurred until he wrote his addendum on 6/5/2007.

On 3/2/2007, the risk manager at the medical center and the neurosurgeon had a conversation about the patient’s surgery. The risk manager directed the neurosurgeon to inform the patient’s family of the injury that occurred during surgery.  Later that day, the neurosurgeon informed the patient’s son about the injury that had occurred three days earlier.

The Board judged that the neurosurgeon’s conduct to be below the minimum standard of competence give his failure to recognize the significance of the injury that had occurred to the patient during the operation, especially after reviewing the first post-operative CT scan on 2/27/2007, as well as the CT scans and MRI that occurred on 2/28/2007 and 3/1/2007 respectively.  The neurosurgeon failed to timely advise the patient’s concurrent and subsequent treatment providers of the injury that had occurred during the burr hole evacuation surgery.  The neurosurgeon failed to timely advise the patient’s family about the injury to the patient.

The Board also judged that the neurosurgeon’s conduct the be below the minimum standard of competence in that he maintained false records. The neurosurgeon failed to document within his operative report dated 2/27/2007 that a surgical incident had occurred during the burr hole evacuation surgery that he performed.  On 6/5/2007, the neurosurgeon documented within the patient’s medical record that a surgical technician directed what was termed as a “forceful irrigation” into the left-frontal burr hole site while the neurosurgeon had his back turned.  The neurosurgeon failed to document within the patient’s medical record that the surgical incident that had occurred during the burr hole evacuation surgery was causing the patient’s neurological deficits.

The Board ordered the neurosurgeon’s license to be suspended for two years.  Before the neurosurgeon would be reinstated to practice medicine he would have to pay a fine of $20,000.

State: Kansas


Date: February 2014


Specialty: Neurosurgery, Neurology


Symptom: N/A


Diagnosis: Post-operative/Operative Complication, Neurological Disease


Medical Error: Procedural error, Ethics violation, Failure of communication with other providers, Failure of communication with patient or patient relations, Lack of proper documentation


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 4


Link to Original Case File: Download PDF



Colorado – Anesthesiology – Oversedation Using Propofol And Incorrect Needle Placement In A Patient Results in Quadriplegia



On 11/20/2007, an anesthesiologist injured a patient while performing a cervical medial branch nerve procedure.  The anesthesiologist oversedated the patient for the procedure and had incorrect needle placement.  The needle slipped off the lamina and penetrated the patient’s spinal cord.  The anesthesiologist did not stop the procedure to consult with a neurologist.  In the first medical note the anesthesiologist prepared regarding the procedure, the anesthesiologist stated that the patient “suffered no complications.”  Sedation was noted as “480 mg propofol incremental.”  The anesthesiologist did not document motor testing and did not document whether fluoroscopic guidance was used during the patient’s procedure.  When the patient awakened after the procedure, he could not feel his legs.  The anesthesiologist did not seek immediate emergency care for the patient.  The anesthesiologist delayed transporting the patient to the hospital for thirty minutes.  The patient was diagnosed with quadriplegia.  The next day, the anesthesiologist prepared a second medical record concerning the patient’s procedure.  In the second report, the anesthesiologist changed the amount of sedation to “Propofol 260 mg.”  Again, the anesthesiologist did not document motor testing.

The Board ordered the anesthesiologist’s license be put on indefinite probation.  The Board also put a restriction for the anesthesiologist to be a solo practitioner in any practice environment or setting.  The anesthesiologist was required to complete continuing medical education on professional/problem based ethics program and enroll in the Center for Personalized Education for Physicians.  The Board ordered that the anesthesiologist pay a fine of $5,000.

State: Colorado


Date: July 2013


Specialty: Anesthesiology, Neurology


Symptom: Numbness


Diagnosis: Post-operative/Operative Complication, Drug Overdose, Side Effects, or Withdrawal, Spinal Injury Or Disorder


Medical Error: Procedural error, Ethics violation, Failure of communication with other providers, Improper medication management, Lack of proper documentation


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 4


Link to Original Case File: Download PDF



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