Found 26 Results Sorted by Case Date
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Wisconsin – Pain Management – Nerve Root Block Injections Performed Without Radiographic Guidance



A 53-year-old male was seen by a pain specialist for his chronic pain.  In 1992, the patient had undergone fusion of L3, L4, and L5; in 2002, he had his right knee replaced.  On five occasions between 1/15/2003, and 7/22/2003, in conjunction with exercise, mobilization, and medical treatment, the pain specialist performed nerve root block injections on the patient.  The pain specialist did not use radiographic guidance in performing the injections.  The pain specialist continued to treat the patient through 10/29/2004, and then referred him to an anesthesiologist for further evaluation and treatment.

The pain specialist has stopped performing nerve root block injections without radiographic guidance, and has agreed that he will not resume performing nerve root block injections without radiographic guidance.  The Board considers that the pain specialist’s agreement to permanently cease of the practice or performing nerve root block injections without radiographic guidance adequately protects the public health, safety, and welfare.

State: Wisconsin


Date: March 2007


Specialty: Pain Management, Neurology


Symptom: Pain


Diagnosis: Spinal Injury Or Disorder


Medical Error: Procedural error


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Wisconsin – Emergency Medicine – Determination Of Discharge When Evaluating Stability Of Spinal Fracture



On 3/25/2000 at 3:30 p.m., a patient arrived at the emergency department after being involved in a rollover motor vehicle accident.  The patient was up and walking at the scene of the accident but complained of back pain. She was transported to the hospital emergency department on a backboard with a cervical collar.

The patient’s vital signs were normal, and a baseline neurological examination showed that she was able to move all extremities and had no tingling or numbness at the time of the evaluation.   At 4:00 p.m. plain film x-rays were taken of the patient’s thoracic and lumbar spine.  ED Physician A read the films and determined that the patient had suffered a compression fracture of her spine involving T12 and T11.

After reading the x-ray ED Physician A prepared the patient for discharge, stating that her fracture was stable and would not cause injury to the spinal cord or nerves.  As a nurse was helping the patient get up to go home, the patient experienced severe pain that caused her to cry out.  Because of her extreme pain, ED Physician A decided to admit her to the hospital for pain control.

ED Physician A did not re-institute the use of the backboard or any other spine stabilization measures.  He wrote in his admission orders that the patient could be up with assistance and recommended a physical therapy consultation the next morning. ED Physician A claims that these admitting orders were dictated by the ED Physician B, who was the admitting physician. ED Physician B denies that he even saw the patient until the next day.

The next morning it was noted that the patient had not emptied her bladder since her admission. A nurse got her up to the commode, but after 20 minutes she was unable to void.  ED Physician B believed the urinary retention was due to the pain medication and ordered a Foley catheter.  The same day, it was noted that the patient had tingling numbness in her buttocks and bilaterally in her feet.

The next day, the patient was incontinent of bowel, with no sensory knowledge that it had occurred.  At this point, ED Physician B ordered a CT scan and immobilized the patient.  He transferred her to another hospital for a neurological/neurosurgical evaluation.

The patient was immediately taken to surgery at the hospital for removal of the T12 vertebra and fusion of the T11-L1 section.

The patient suffered nerve damage due to the incident which may have been prevented or minimized had she been immobilized and if a CT scan had been ordered sooner to determine whether the spinal cord had been compromised.

The Board ordered that ED Physician B pay the costs of the proceeding and complete 18 hours of continuing education in neurological emergencies.

State: Wisconsin


Date: April 2006


Specialty: Emergency Medicine, Neurology


Symptom: Back Pain


Diagnosis: Spinal Injury Or Disorder


Medical Error: Diagnostic error, Failure of communication with other providers


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 4


Link to Original Case File: Download PDF



Wisconsin – Pediatrics – Impaired Cognitive Development And A Large Head



A physician was the pediatrician for a patient from 11/29/1990, at two weeks old, until 4/5/2001 at 10 years old.

In 1991, when the patient was 1 year old, the pediatrician observed the patient had a large head size, which he believed was normal for the rest of his body proportions.  He observed that the patient was developing within normal limits.

After the patient was 2 years old, the pediatrician’s office no longer routinely measured and recorded the patient’s head circumference even though his head was over the 95th percentile. At two years of age, the patient’s weight was about 92nd percentile and his length was over the 95th percentile.

In 1994, when the patient was 3 years old, the pediatrician noted significant speech delays, mild motor delays, and some cognitive delays which he noted in his records may have been due to megacephaly.  He noted that his head circumference was two standard deviations above the 95th percentile.  He requested early childhood classes for speech, language, socialization, and physical therapy through the school special services.

In January 1997, when the patient was 6 years old, the school occupational therapist wrote in her report provided to the pediatrician, dated 1/15/1997, “Parents reveal concerns regarding his need for all the current intervention due to his delays that he exhibits.  What may be some of the causes and how can we all better support & service his needs presently and in the future when the academic demands increase?”

In a letter dated 1/16/1997 to the school occupational therapist, the pediatrician wrote that the patient had megacephaly.  “He does not suffer from hydrocephalus nor does he show any characteristics of physical syndromes which would entail a genetics intervention.  What megalencephaly means is a large head, which, in turn, means a large brain.  In general, these children will have motor delays much more commonly than cognitive delays, although cognitive delays may also be noted.  These children do not show neurologic deterioration.  Rather, they show continued gradual progress but in a delayed fashion.”

In May 1999, at 8 years old, the patient was having difficulty in school with being distracted and could not follow through on a list of items.  He was inattentive and daydreaming.  There was also a concern about fatigue.  The pediatrician assessed possible attention deficit disorder.

In April 2000, at 9 years old, the pediatrician saw the patient for possible depression.  He noted that there was concern he was not processing verbal language very well, but did process reading pretty well.  He generally took 3 hours to do what should be one hour of homework. The pediatrician did not assess depression.

In January 2001, the patient’s parents took him to a neurologist for a second opinion about arm and leg tremors which they called the pediatrician about initially. The parents alleged the pediatrician told them it was an involuntary tremor disorder which would not get better.  The neurologist did MRI testing and found that the patient actually had hydrocephalus. The patient was later evaluated by neurological surgeons who diagnosed him with aqueductal insufficiency and aqueductal stenosis.

The Board ordered that the pediatrician pay the costs of the proceeding, be reprimanded, and complete 24 hours of continuing education in pediatric neurology.

State: Wisconsin


Date: April 2006


Specialty: Pediatrics, Neurology


Symptom: Psychiatric Symptoms


Diagnosis: Neurological Disease


Medical Error: Diagnostic error


Significant Outcome: N/A


Case Rating: 5


Link to Original Case File: Download PDF



Wisconsin – Emergency Medicine – 5 Days Of Severe Headache With A History Of Cryptic Arteriovenous Malformation



A patient presented to the emergency department with a severe headache of 5 days duration.  He reported a history of cryptic arteriovenous malformation which had resulted in a left frontal intracerebral bleed, leading to the patient’s hospitalization on 11/26/1994.  This left frontal intracerebral bleed had resolved without surgical intervention.

The ED physician discharged the patient from the emergency department on 9/6/1995 without seeking a further evaluation of the patient by his treating neurologist or another competent neurologist, without obtaining a CT scan of the patient’s head, and without admitting the patient to the hospital for further evaluation and observation.  The ED physician advised the patient to see his neurologist the next day.  The patient made the appointment for the next following day, 9/8/1995, but had a major subarachnoid hemorrhage with significant edema in the left frontal lobe and left to right shift on the morning of 9/8/1995, and died.

The Board ordered that the ED physician pay the costs of the proceedings and complete 30 hours of continuing education in the evaluation of patients presenting with acute neurological events.

State: Wisconsin


Date: March 1999


Specialty: Emergency Medicine, Neurology


Symptom: Headache


Diagnosis: Intracranial Hemorrhage


Medical Error: Improper treatment


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Wisconsin – Family Practice – Dexamethasone For Patient With Weakness And Numbness After A Fall



On 11/12/1979, a patient made an appointment to see a family practitioner.  He was able to see the family practitioner on the same day.  It was the first time the patient saw this family practitioner.  He told the family practitioner that he had fallen down some steps at a construction site where he was working 2 days before.  He had landed on his back, but was able to get up and walk away from the fall.  The patient complained of numbness and weakness in both hands and legs.  In addition, he reported difficulties with his balance.

The family practitioner did not document the patient’s medical history.  An adequate physical examination was not documented. However, a physical exam was performed, which revealed weakness in the right hand.  Weakness or numbness of the other extremities was not documented.

The family practitioner ordered cervical spine x-rays for the patient, but did not document the results.  The family practitioner did not conduct any other diagnostic studies.  There was soft tissue swelling (location unclear), for which the family practitioner prescribed dexamethasone.

The family practitioner did not document a follow-up plan.  No instructions for physical restrictions were given.

On 11/27/1979, the patient returned to the family practitioner’s office.  The family practitioner performed a physical examination of the patient and noted that the patient had developed ataxia and had developed weakness of the right arm.  The family practitioner’s complete notes stated:

“No improvement from above symptoms.  Medscreen basic and hemogram.  Sed. rate to hospital.  Objective – as above.  Assessment – etiology unknown.  Plan – outpatient work-up.  SMA-12, CBC and sed. rate.  Refer to neurologist.  Send report.  Appointment to see [a neurologist], December 10, 10:45 a.m.”

On 12/10/1979,  a neurologist performed a neurological examination and documented that the patient likely had a cervical disc problem at the C5 level.

On 12/16/1979, the patient was admitted to the hospital by the neurologist.

On 12/21/1979, a neurosurgeon performed cervical hemilaminectomy.  The final diagnosis of the patient was noted to be cervical spondylosis with cervical myelopathy.

The Board judged the family practitioner’s conduct to be below the standard of care given failure to document findings of the cervical x-ray and failure to adequately assess the patient’s symptoms for a neurological cause.

He was ordered to complete a continuing medical education in neuroanatomy and neurophysiology at the University of Wisconsin Medical School.  He was ordered to adopt office procedures to ensure every patient of his has a medical history taken and an appropriate physical examination documented.  A reviewing physician was to be monitoring the family practitioner and reviewing his medical records every three months to ensure compliance.  The reviewing physician was to submit written reports.

State: Wisconsin


Date: March 1989


Specialty: Family Medicine, Internal Medicine, Neurology


Symptom: Weakness/Fatigue, Numbness, Swelling


Diagnosis: Spinal Injury Or Disorder


Medical Error: Diagnostic error, Delay in proper treatment, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



Wisconsin – Family Practice – Pseudoephedrine For Dizziness, Plugged Ears, Nausea, And Difficulty Walking



On 06/11/1980, a patient presented to a family practitioner with dizziness, plugged ears, nausea, and difficulty walking.  The family practitioner did not document the patient’s medical history and his family history.  He did not conduct a physical examination of the patient other than his ears.  The family practitioner flushed the patient’s right ear canal, but did not document the results.  The family practitioner did not take his blood pressure.  He did not conduct further studies or order any lab tests.  He prescribed pseudoephedrine.  There was no plan for a follow-up.

The patient worsened, developed slurred speech, began favoring his left hand over his right hand (despite being right-handed), and had even more difficulty walking.

On 06/14/1980, the patient’s wife called the family practitioner’s office, given that the patient had not improved.  The family practitioner was not in the office that day.  The family practitioner’s partner told the patient’s wife to bring the patient to the emergency department.

On 06/14/1980, the patient presented to the emergency department.  At 11 a.m., his blood pressure was 250/178.  At 11:20 a.m., his blood pressure had increased to 290/190.

On 07/07/1980 despite continued medical treatment, the patient eventually succumbed to his illness and died.  The final pathologic diagnoses included thrombosis of bilateral vertebral arteries with infarction of the right cerebellum and thrombosis of the right coronary artery.  The patient had been treated for hypertension in 1971 and 1972, but was not taking any medication for hypertension when he was treated by the family practitioner in 1980.

The Board judged the family practitioner’s conduct to be below the standard of care given failure to check the patient’s blood pressure prior to administering pseudoephedrine and failure to diagnose cerebellar stroke in a patient with difficulty walking.

He was ordered to complete a continuing medical education in neuroanatomy and neurophysiology at the University of Wisconsin Medical School.  He was ordered to adopt office procedures to ensure every patient of his has a medical history taken and an appropriate physical examination documented.  A reviewing physician was to be monitoring the family practitioner and reviewing his medical records every three months to ensure compliance.  The reviewing physician was to submit written reports.

State: Wisconsin


Date: March 1989


Specialty: Family Medicine, Internal Medicine, Neurology


Symptom: Dizziness, Nausea Or Vomiting


Diagnosis: Ischemic Stroke, Acute Myocardial Infarction


Medical Error: Failure to examine or evaluate patient properly, Diagnostic error, Improper medication management


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



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