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Florida – Pain Management – Increase In Dosage Of Nature-Throid In A Patient With Normal TSH And T4 Levels
On 6/3/2013, a 67-year-old female presented to a pain management specialist for treatment of her previously diagnosed hypothyroidism. The pain management specialist prescribed the patient 65 mg of Nature-Throid daily and drew blood for lab tests. Each 65 mg Nature-Throid medication consists of 38 mcg of levothyroxine and 9 mcg of liothyronine. The results of the patient’s blood tests showed normal TSH levels, normal T4 levels, and slightly elevated T3 levels.
On 6/18/2013, the pain management specialist increased the patient’s prescription for Nature-Throid to 130 mg daily. The results of the patient’s blood tests did not justify increasing the dosage of Nature-Throid prescribed to the patient. A reasonably prudent physician would only have increased the dosage of Nature-Throid prescribed to the patient with justification. The pain management specialist did not document justification for increasing the dosage of Nature-Throid prescribed to the patient. The blood tests did not justify prescribing the 130 mg of Nature-Throid daily. A reasonably prudent physician would have waited for the patient’s hormone levels to properly balance and reach equilibrium before altering the dosage of Nature-Throid prescribed to the patient.
On 7/16/2013, the pain management specialist increased the patient’s prescription for Nature-Throid to 195 mg daily. A reasonably prudent physician would not have altered the dosage of Nature-Throid prescribed to the patient without having ordered blood tests for the patient. The pain management specialist did not document justification for increasing the dosage of Nature-Throid prescribed to the patient. A reasonably prudent physician would have waited for the patient’s hormone levels to properly balance and reach equilibrium before altering the dosage of Nature-Throid prescribed to the patient.
On 7/16/2013, the pain management specialist informed the patient that he was increasing her dosage of Nature-Throid based on her body temperature. A reasonably prudent physician would not have increased the dosage of Nature-Throid prescribed to the patient based on the patient’s body temperature. Also, a reasonably prudent physician would have ordered blood tests for the patient, and he did not order or document ordering any blood tests for the patient.
The Board issued a letter of concern against the pain management specialist’s license. The Board ordered that he pay a fine of $5,000 against his license and pay reimbursement costs for a minimum of $5,857.09 and not to exceed $7,857.09. The Board also ordered that he complete a records course and complete ten hours of continuing medical education in endocrinology and complete a course in quality assurance consultation/risk management assessment.
State: Florida
Date: June 2017
Specialty: Pain Management, Endocrinology
Symptom: N/A
Diagnosis: Endocrine Disease
Medical Error: Improper medication management
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
Florida – Pain Management – Contrast And Steroid Injected Into The Intrathecal Space Instead Of The Epidural Space
Between February 2006 and September 2012, a patient presented to a pain specialist with complaints of chronic low back pain.
On one or more occasions between February 2006 and September 2012, the pain specialist assessed the patient with, among other things, low back pain, lumbago, osteoarthritis, lumbar failed back surgery syndrome, lumbar radiculopathy, and lumbar muscle spasms.
On 9/28/2012, the patient presented to the pain specialist in order for him to perform a lumbar transforaminal epidural steroid injection with catheter and fluoroscopy. Epidural administration is a medical route of administration in which a drug or contrast agent is injected into the epidural space of the spinal cord.
During the procedure, the pain specialist inserted the tip of the catheter through the patient’s epidural space and into the patient’s intrathecal space. Intrathecal administration is a medical route of administration in which a drug or contrast agent is injected into the spinal canal, or into the subarachnoid space so that it reaches the cerebrospinal fluid.
During the procedure, the pain specialist injected contrast and injectate into the patient’s intrathecal space instead of the patient’s epidural space.
The pain specialist did not obtain an intra-injection lateral view epidurogram to confirm the location of the catheter tip and/or the dispersal pattern of the contrast and injectate.
The pain specialist did not obtain a post-injection lateral view epidurogram to confirm the location of the catheter tip and/or the dispersal pattern of the contrast and injectate.
The pain specialist did not recognize that he had performed an intrathecal injection instead of an epidural injection.
After the procedure, the patient complained of bilateral hip and leg pain, numbness, and paralysis.
The patient was transferred to a hospital where she was ultimately diagnosed with conus medullaris syndrome.
It was requested that the Medical Board of Florida order one or more of the following penalties for the pain specialist: 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: June 2017
Specialty: Pain Management, Anesthesiology
Symptom: Back Pain, Numbness, Extremity Pain, Pelvic/Groin Pain, Weakness/Fatigue
Diagnosis: Post-operative/Operative Complication, Spinal Injury Or Disorder
Medical Error: Wrong site procedure, Lack of proper documentation, Procedural error
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Pain Management – Wrong Concentration Of Hydromorphone Programmed Into Intrathecal Pain Pump
In December 2007, a 55-year-old male had an intrathecal pain pump inserted for pain control at the recommendation of his pain management specialist. He had been prescribing the patient hydromorphone with a concentration of 10 mg/ml.
From 1/31/2012 to 2/15/2012, upon referral by his physician, the patient presented to a new pain management specialist for pain management.
At the initial visit, on 1/31/2012, the pain management specialist ordered a prescription of hydromorphone injectable solution with a concentration of 30 mg/ml to refill the patient’s intrathecal pain pump.
On 2/15/2012, the patient presented to a pain management center to have his intrathecal pain pump refilled with the hydromorphone prescription and reprogrammed.
A physician assistant refilled the patient’s intrathecal pain pump with hydromorphone with a concentration of 30 mg/ml; however, the concentration of the hydromorphone that was programmed into the intrathecal pain pump remained at 10 mg/ml.
The Medical Board of Florida judged the pain management specialists conduct to be below the minimal standard of competence given that he failed to verify that the correct concentration of hydromorphone was administered into the intrathecal pain pump after it was refilled on 2/15/2012 and he failed to verify the correct concentration of the hydromorphone was programmed into the intrathecal pain pump.
The patient expired at his home on 2/15/2012.
It was requested that the Medical Board of Florida order one or more of the following penalties for the pain management specialist: 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: April 2017
Specialty: Pain Management, Anesthesiology
Symptom: Pain
Diagnosis: Drug Overdose, Side Effects, or Withdrawal
Medical Error: Accidental Medication Error, Improper supervision
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF
Florida – Pain Management – Infection Of Left Prosthetic Knee Following Injections Of Zeel And Traumeel With Bupivacaine
On 9/15/2011, a 57-year-old male presented to a pain management specialist with complaints of knee pain in his prosthetic knees.
On 10/13/2011, the pain management specialist established a treatment plan to obtain x-rays of the patient’s knees and refer him to an orthopedic surgeon for evaluation of his prosthetic knees.
The pain management specialist failed to review, or document reviewing, x-rays of the patient’s prosthetic knees. He also failed to refer the patient to an orthopedic surgeon for evaluation of his knee pain, per his treatment plan.
On 2/2/2012, the pain management specialist injected Zeel and Traumeel (both homeopathic products) with bupivacaine into the patient’s prosthetic left knee.
The pain management specialist did not create or maintain records documenting an examination of the patient’s left knee for the 2/2/2012 appointment.
On 2/8/2012, the pain management specialist performed a second injection of Zeel and Traumeel with bupivacaine into the patient’s prosthetic left knee. He did not create or maintain records documenting an examination of the patient’s left knee for the 2/8/2012 appointment.
Shortly after the second injection, the patient’s left knee began to swell, and on 2/21/2012, he presented to an orthopedic institute with complaints of pain, swelling, and redness.
An orthopedic surgeon admitted the patient to a hospital for further evaluation. At the hospital, the patient was diagnosed with acutely infected left total knee arthroplasty and, on 2/25/2012, underwent surgery to remove part of the left knee prosthesis, insert an antibiotic disc and PICC line, and begin IV antibiotics.
The Medical Board of Florida judged the pain management specialists conduct to be below the minimal standard of competence given that he should not have injected homeopathic substances into the patient’s prosthetic left knee and he did not refer the patient to an orthopedic surgeon for evaluation of his left knee pain.
It was requested that the Medical Board of Florida order one or more of the following penalties for the pain management specialist: 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: April 2017
Specialty: Pain Management, Anesthesiology, Orthopedic Surgery
Symptom: Joint Pain, Swelling
Diagnosis: Procedural Site Infection
Medical Error: Unnecessary or excessive treatment or surgery, Failure to examine or evaluate patient properly, Referral failure to hospital or specialist, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
Florida – Family Medicine – Improper Documenting And Other Errors While Treating For Complex Regional Pain Syndrome
On October 2014, a family practitioner began treating the patient, then a minor child, at the patient’s mother’s home for the patient’s complex regional pain syndrome and related insomnia and gastroparesis.
Complex regional pain syndrome is a medical condition characterized by severe regional pain, allodynia, hyperalgesia, autonomic nervous system changes, and loss of limb function.
The family practitioner took over the patient’s care in anticipation of the patient’s eighteenth birthday and her inevitable discharge from the children’s medical services program.
The family practitioner initially only anticipated treating the patient for a short period of time while the patient’s mother located a suitable, long-term healthcare provider for the patient. This search was hindered by difficulty in locating a healthcare practitioner that both accepted the patient’s mother’s insurance and who was willing and able to manage the patient’s condition on an outpatient basis.
When this task of locating a suitable healthcare practitioner proved more complex and time-consuming than previously expected, the family practitioner took over management of the patient’s condition for an interim period of approximately four months.
During the interim treatment period, the family practitioner examined and evaluated the patient, assisted in the management of the patient’s total parenteral nutrition (TPN), managed the patient’s pain, and managed the patient’s insomnia and gastroparesis.
The family practitioner initially attempted to manage the patient’s pain and insomnia through a combination of intravenous hydromorphone, promethazine, and diphenhydramine, but these medications failed to provide adequate and consistent pain and insomnia relief.
The family practitioner next attempted to manage the patient’s pain and insomnia through a combination of intravenous hydromorphone and the benzodiazepine-class drugs midazolam, lorazepam, and diazepam. The combination of medication enabled moderate insomnia relief but failed to provide consistent pain relief.
The family practitioner instructed the patient’s mother on how to administer the patient intravenous medications, and eventually delegated the duty of administering and monitoring these drugs to her.
The family practitioner ultimately settled on a combination of a fentanyl patch for baseline management of the patient’s pain and intranasal fentanyl for breakthrough pain control.
Once the patient’s baseline pain was consistently controlled with a fentanyl patch, the patient no longer required midazolam, lorazepam, and diazepam to sleep.
On January 2015, the patient mother was able to secure long-term treatment providers for the patient, and the family practitioner handed-off treatment duties to these practitioners.
The Medical Board of Florida judged the family practitioner’s conduct to be below the minimal standard of competence given that he failed to create and/or maintain documentation of an adequate patient history for the patient. The family practitioner, during his treatment of the patient, failed to create and/or maintain documentation of an adequate physical examination of the patient. The family practitioner failed to create and/or maintain documentation of a treatment plan for the controlled substances he prescribed to the patient. He failed to create and/or maintain documentation of treatment goals for the controlled substances he prescribed to the patient. He failed to create and/or maintain documentation of his communications with the patient’s past medical providers. He failed to create and/or maintain documentation of a consultation with a pain management specialist.
The prevailing standard of care required that the family practitioner adequately communicates with the patient’s previous healthcare providers regarding the patient’s care. Also, the family practitioner should have personally administered and monitored the patient intravenous benzodiazepine medications and delegated the duty of administering and monitoring the patient’s intravenous benzodiazepine medications to a qualified healthcare practitioner.
It was requested that the Medical Board of Florida order one or more of the following penalties for the family practitioner: 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: December 2016
Specialty: Family Medicine, Internal Medicine, Pain Management
Symptom: Pain
Diagnosis: Neurological Disease
Medical Error: Lack of proper documentation, Failure of communication with other providers, Referral failure to hospital or specialist, Improper medication management
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
Florida – Pain Management – Elevated Erythrocyte Sedimentation Rate And C-Protein Reaction Level After Radiofrequency Ablation Performed For Lumbar Spine Pain
On 6/25/2010, a 51-year-old female presented to a pain specialist for radiofrequency ablation treatment for lumbar spinal pain.
The patient reported her pain to be aching pain in the lumbar area, with pain intensity ranging from two to eight on a scale of zero to ten, and a current pain intensity level of six.
On 6/25/2010, the pain specialist performed left lumbar radiofrequency ablation of dorsal primary ramus blocks at the L3, L4, L5, and S1 levels on the patient.
On 6/27/2010, the patient called the pain specialist’s office and spoke with the on-call physician.
The patient told the on-call physician that she had pain and discomfort, unlike her previous procedures.
On 6/28/2010, the patient stated that she collapsed on her job.
On 6/29/2010, the patient presented to the pain specialist’s office. There were two medical notes for the visit. One of the medical notes stated the patient “almost passed out.” The medical notes provided no vital signs and did not report that the pain specialist looked at the procedure site.
The pain specialist considered infection in his evaluation of the patient and ordered a complete blood count, complete metabolic panel, erythrocyte sedimentation rate, and C-protein reactive tests.
The pain specialist stated that the patient was to continue Lortab and ordered a Medrol Dosepak. The pain specialist ordered that Keflex be started after blood work.
The pain specialist did not inform the patient when to begin her antibiotics.
On 7/1/2010, a physician ordered blood work for the patient. The blood work revealed that the patient’s erythrocyte sedimentation rate and C-protein reaction level were elevated.
On 7/8/2010, the patient called the pain specialist’s office, stating that she was having problems, it was an emergency, and needed to speak with the pain specialist again.
There were two different notes for the patient’s call on 7/8/2010. One of the notes for the patient’s call stated that metaxalone (brand name Skelaxin, an oral drug that relaxes skeletal muscles that control movement of the body) was prescribed and an office visit was scheduled for the next day.
On 7/9/2010, the patient presented to the pain specialist complaining of pain at her injection site that went across her back.
Concerning the patient’s history, the patient did not report chills or fever, and there was no mention of antibiotics.
In the 7/9/2010 medical note, the pain specialist noted “vitals,” but aside from pain, none were noted.
The pain specialist did not document a temperature for the patient during the 7/9/2010 visit. Concerning the patient’s blood work, the pain specialist noted that her C-protein reactive level was normal when it was actually elevated.
The pain specialist’s physical examination of the patient revealed side bend to the left was decreased with pain. The examination further revealed that rotation to the left was decreased, 20 degrees and with pain. His physical examination of the patient further revealed severe tenderness at left L5, left S1, and the left SI joint.
The pain specialist’s plan for the patient was to possibly discontinue hydrocodone/acetaminophen (Lortab), start her on oxymorphone (Opana), have her liver function tested by her primary care providers, and to report to the emergency department if she had a change in mental status or fever greater than 101F.
The pain specialist did not reorder a follow up complete blood count, erythrocyte sedimentation rate test, and C-protein test for the patient.
On 7/21/2010, the patient presented to the emergency department with complaints of pain and swelling in her left buttock, with fever.
The patient was ultimately diagnosed with an abscess in her left paraspinal musculature and staphylococcus aureus-methicillin resistant infection.
The Medical Board of Florida judged the pain specialist’s conduct to be below the minimal standard of competence given that he failed to aggressively pursue the cause of the patient’s pain at the procedure area after the 6/25/2010 left lumbar radiofrequency ablation. He also failed to initiate the appropriate treatment plan when the patient’s erythrocyte sedimentation rate test and C-reactive protein test results returned elevated. The pain specialist failed to inform the patient to start her antibiotics after the 6/29/2010 visit to his office. He failed to order follow up complete blood count, erythrocyte sedimentation rate test, and C-protein test for the patient. He also failed to document the patient’s temperature in her medical records given that he suspected infection.
The Medical Board of Florida issued a letter of concern against the pain specialist’s license. The Medical Board of Florida ordered that the pain specialist pay a fine of $5,000 against his license and pay reimbursement costs for the case that would not exceed $11,000.
State: Florida
Date: December 2016
Specialty: Pain Management, Anesthesiology
Diagnosis: Post-operative/Operative Complication, MRSA, Spinal Injury Or Disorder
Medical Error: Failure to order appropriate diagnostic test, Failure of communication with patient or patient relations, Failure to follow up, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
Virginia – Family Medicine – Long History Of Narcotic Seeking Behavior And Pattern Of Abuse
From 12/01/2010-12/03/2010, a 31-year-old-man with schizophrenia and bipolar disorder was hospitalized. During the hospitalization, a psychiatric consultation revealed that the patient had a significant history of “drug seeking behavior (primarily opiates) and significant paranoid thinking.” It was noted that since July 2010, the patient had presented to the emergency department at least 11 times, “most all of which where he is complaining of pain and seeking some type of medication.”
He had stuck a nail in his ankle and stabbed himself in the thigh in two separate instances, which the mother believed were performed to obtain more pain medications. He had obtained pain medications from other family members. The mother confirmed that he had a “severe drug problem.”
It was also documented that the patient had at least 10 prior psychiatric hospitalizations for the diagnosis of mixed personality disorder (mainly paranoid) and severe opioid dependence. It was noted that the patient was unlikely to take his prescribed psychotropic medications.
On 6/27/2011, the patient’s PCP stated that another physician, who was managing the patient’s pain, refused to prescribe him further narcotics given that his urine drug screen was negative for hydrocodone, which the physician had been prescribing him.
On 7/24/2011, the patient presented to an emergency department for treatment of a re-opened gunshot wound in his right calf. It was documented that the patient had recently been hospitalized at another hospital for an overdose of barbiturates and opiates (which required intubation).
On 10/17/2011, a pain management specialist declined to accept the patient given the patient’s “PMP and UDS results, as well as his record including violent behavior and 2 self-inflicted gunshot wounds…These results and behaviors are highly suggestive of a substance abuse disorder. I would recommend that he be evaluated and treated for addiction…He also likely has rebound headaches given his multiple daily doses of controlled substances. Weaning of the controlled substances would address the rebound headache issue…[and] would be safer from a potential overdose perspective…[F]rom my review of the record, I am very concerned that treatment for his pain would be unsuccessful without first addressing the addiction issue.”
From 2/09/2012 to 2/25/2012, the patient was hospitalized was treated for recurrent infection of his right leg gunshot wound. It was documented that “[u]ltimately, it was felt he had a significant component of pain [medication] seeking behavior…Ultimately, we have recommended to him that he taper and stop all of his pain meds over time. If he cannot do that, I have recommended to him that he seek treatment for substance abuse.”
On 1/6/2012, the surgeon treating the patient’s non-healing gunshot wound was contacted by a pharmacist who reported that the patient was receiving prescriptions for oxycodone/acetaminophen from his PCP at the same time the surgeon was prescribing the medication for him. On 1/25/2012, the patient’s PCP refused to see him anymore after he caused a scene in the waiting room and broke his crutches when his PCP would not write for further narcotics.
The patient reported to the surgeon that his pain medications had been stolen on 2/01/2012 and again on 3/21/2012.
On 3/23/2012, the patient first visited the family practitioner, who subsequently prescribed large quantities of narcotics despite his prior history. The family practitioner testified that she initially did not know of the patient’s prior history. When she knew of his history, she testified that she wanted to gain the patient’s trust first and then she planned to taper the patient off of narcotics.
From March 2012 to August 2015, the family practitioner prescribed fentanyl patches, oxycontin, hydromorphone, Fioricet, and alprazolam for chronic pain from the self-inflicted gunshot wound to the right lower leg, neuropathic pain of the right leg, chronic headaches, chronic left ankle pain, and anxiety.
On 03/29/2013, the family practitioner entered into a controlled substance agreement with the patient. Once executed, the patient failed to enforce provisions of the agreement, such as performing urine drug screens or performing pill counts consistently.
On numerous occasions, the family practitioner documented that the patient reported that his brother, sister, roommate, friends, or others had stolen his pain medications. The family practitioner failed to require a police report proving these alleged thefts and routinely replaced the prescriptions for these stolen medications.
On 4/11/2012, the patient reported that he had run out of his hydromorphone early because he was carrying it with him in the car when the pills fell out of his coat pocket into the back seat. In other instances, he reported that he had lost his pill bottles.
On 6/15/2012, his bottle of hydromorphone again went missing. The patient asserted that his roommate (who allegedly suffered from AIDS) was in possession of the pain medications with blood covering the roommate’s hands as well as several of the pill bottles. He said he could not find the bloody bottle of hydromorphone. When the family practitioner refused to prescribe hydromorphone, he reported that even if he could find the bottle of hydromorphone, he would be afraid to take it, given the risk of HIV exposure.
On 7/5/2012, the pharmacist called the family practitioner stating that the patient had consumed 40 tablets of hydromorphone in just three days. The patient complained that the pharmacist had only given him 40 out of 180 prescribed on 06/29/2012 and requested that the family practitioner provide him with another script. The family practitioner’s nurse practitioner then provided the patient with a prescription for 50 tablets of hydromorphone.
On 10/25/2012, another physician in the family practitioner’s practice saw the patient and noted that the patient was being prescribed “unbelievable doses of opiates along with benzos.”
On 6/12/2013, a blood serum drug test was negative for hydromorphone. On 7/22/2013, the patient explained that he had stopped the hydromorphone 1-2 days prior to the blood test done on 06/12/2013. He stated that he failed to inform the family practitioner of this at his last visit because he thought the medication would still show up in his blood and he did not want the family practitioner to be mad at him for not taking his hydromorphone exactly as prescribed.
On 7/19/2013, he reported that he had run out of a month’s supply of hydromorphone and alprazolam prescribed to him on 06/12/2013 with fill dates of 06/30/2013. Despite the evidence, the family practitioner noted that she would “give him the benefit of doubt and am refilling his meds. for 1 month.”
On 8/1/2013, the patient’s mother told the family practitioner that the patient believed others were stealing his medications secondary to his schizophrenia. The family practitioner and mother agreed that the mother would dispense medications to the patient. On 01/10/2014, the patient reported to the family practitioner that his mother had given back his medications to manage himself.
On 8/16/2013, the family practitioner authorized an early refill given that the patient said his fentanyl patches were falling off, requiring him to increase his hydromorphone usage.
On 11/14/2013, the family practitioner watched a video where the patient secretly recorded his sister stealing a pain patch off of his desk. The patient declined to call the police as recommended by the family practitioner and said her sister had gone into treatment.
On 5/1/2014, the patient received hydrocodone/acetaminophen from his dentist. The family practitioner prescribed the patient more of the same and gave him early scripts for hydromorphone and fentanyl.
On 6/4/2014, the patient reported that he had been hospitalized at a psychiatric facility. His mother admitted that she did not want to manage his medications because the patient kept pestering her for them.
On 6/4/2014, the patient was hurting more than usual and could not take extra medication given that his mother had taken back control.
On 7/9/2014, the patient informed the family practitioner that her mother had not given him any fentanyl patches and he was taking extra hydromorphone in response. The mother had left a message if her son could take an extra hydromorphone pill per day. The family practitioner responded by admonishing the patient not take take an extra hydromorphone per day and prescribed him more fentanyl patches.
On 8/25/2014, the patient was taken to the emergency department after the family practitioner had written prescriptions for hydromorphone (#540), Fioricet (#360), and fentanyl patches (#45) and after the patient had misused these medications.
On 09/25/2014, the family practitioner prescribed further narcotic medications, noting that “this will be [the patient’s] last chance to show his responsibility.”
Despite a pattern of abuse, the family practitioner continued to prescribe narcotics to the patient and in response to the patient’s self-titration upward due to increased pain, she increased the daily dosage of hydromorphone.
On 6/18/2015, the patient reported that he had increased his consumption of hydromorphone to two pills every 6 hours. He justified this increase, saying he would experience suicidal ideation and hallucinations if he failed to do so. In response, the family practitioner noted that she did “not believe that he is abusing the meds. I believe that his pain is uncontrolled.”
On 7/2/2014, the patient reported acute withdrawal symptoms and suicidal thoughts due to being out of hydromorphone for 12 days. The pharmacy had refused to fill the early hydromorphone prescription the family practitioner had given him on 06/28/2015.
The family practitioner testified that she took over care of the patient’s pain management given that other physicians would not and the surgeon did not know what to do with him.
She testified that the patient absolutely refused to see mental health providers during the treatment period. She said that the reason she did not threaten to cut the patient off from his narcotic regime was that she wanted him to buy into the treatment plan.
Based on her treatment of this patient and another, the family practitioner was reprimanded. She was prohibited from treating any patients with chronic pain starting 30 days after the order. Within twelve months of the order, she was to provide proof of completing 15 credit hours in the subject of pain management and 8 hours in the subject of recognizing addiction.
State: Virginia
Date: September 2016
Specialty: Family Medicine, Pain Management, Psychiatry
Symptom: Pain, Psychiatric Symptoms
Diagnosis: Drug Addiction, Drug Overdose, Side Effects, or Withdrawal
Medical Error: Improper medication management
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
California – Pain Management – Stolen Leads Used For Temporary Spinal Cord Stimulator
On 2/17/2011, a pain management specialist percutaneously implanted temporary spinal cord stimulator leads in a patient’s epidural space. The temporary leads were implanted for a trial period to assess whether stimulation would relieve the patient’s intractable back, hip, and lower extremity pain.
The leads themselves were supplied by a terminated employee of Boston Scientific, who had stolen them from that company. The pain management specialist knew that the employee had been terminated and that the leads came from Boston Scientific. The pain management specialist nonetheless purchased the leads (as well as numerous other items) directly from the employee, and not through Boston Scientific, for a sum which was a small fraction of their usual cost.
The pain management specialist never confirmed with Boston Scientific whether the leads were legitimately in the possession of the employee, and in fact, told a Boston Scientific representative that he was using another company’s products in the patient’s implantation procedure. The pain management specialist then allowed the employee, who had no medical license, to assist him in the patient’s procedure, but misrepresented his identity in his operative notes, calling him “John Simpson.” The pain management specialist also used leads that had expired two years before, and allowed a licensed massage therapist, who had no other medical certification or license, to position the C-Arm Fluoroscope during the procedure. He also allowed a licensed Physician Assistant to administer the anesthetic (which was propofol, a potent narcotic) to the patient. The pain management specialist did not sign the anesthesia record indicating that he was the supervising physician.
The following day, the Boston Scientific representative called officers from the police department to go to the pain management specialist’s office to recover medical equipment and supplies worth approximately $143,980. The Boston Scientific Representative had been informed that these were in the pain management specialist’s possession by one of his employees. The pain management specialist initially refused to allow the officers access his premises, but relented when the officers indicated that they would obtain a search warrant if the pain management specialist did not voluntarily allow them to proceed. The items were removed and returned to Boston Scientific.
Allowing the employee with no medical license to assist in the implantation, and implanting expired leads in the patient were an extreme departure from the applicable standard of care and placed the patient’s health and safety at risk.
For this allegation and others, the State Board of California ordered that the pain management specialist be placed on probation for five years and attend a professionalism program (ethics course), as well as a prescribing practices course, be assigned a practice monitor, and maintenance of records of controlled substances. During this time, the pain management specialist was prohibited from supervising physician assistants.
State: California
Date: May 2015
Specialty: Pain Management
Symptom: Back Pain, Extremity Pain, Joint Pain
Diagnosis: N/A
Medical Error: Ethics violation, Improper supervision
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
Wisconsin – Pain Management – Self-Medication With Diazepam Before Ablation Procedure
On 10/24/2012, a patient was scheduled to have a radiofrequency ablation at L3-S1 by a pain management specialist (Physician A). When the patient presented to the procedure, he was noted to be hypotensive (70/36) and difficult to arouse. It was discovered that he had medicated himself with diazepam in preparation for the procedure. The nursing staff recommended IV fluids prior to the procedure. Physician A requested that the procedure start as scheduled and IV fluids given during the procedure.
The Board deemed Physician A to have fallen below the standard of care by initiating a procedure when a patient was hypotensive and potentially critically ill. There was concern that initiating a procedure on a patient that was hypotensive could increase the risk of worsening hypotension, even with administration of fluids during the procedure.
The standard of care would be to stabilize the patient’s blood pressure first, then make a judgment call to proceed with the procedure.
State: Wisconsin
Date: October 2014
Specialty: Pain Management
Symptom: N/A
Diagnosis: Drug Overdose, Side Effects, or Withdrawal
Medical Error: Improper treatment
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
Washington – Pain Management – MRI Study With A Ferrosensitive Implant
In November 2007, a pain specialist assisted to implant a spinal cord stimulator in a patient to relieve intractable low back pain and radiculopathy. The stimulator’s effectiveness diminished over the course of thirty months.
On 1/5/2010, the patient was referred back to the pain specialist for a consult and evaluation. The pain specialist noted that an MRI would be invaluable in order to make a diagnosis to explain the patient’s increased low back pain and failure to thrive. The pain specialist discussed with the patient the pros and cons of low field MRI in patients with ferrosensitive implants. The pain specialist instructed the patient to contact the manufacturer of his implant device for an additional opinion. An MRI and follow-up appointment were both scheduled for 2/9/2010.
The patient contacted the manufacturer of his implant device on 2/8/2010. The manufacturer advised the patient that he should not have an MRI with his implant device and the patient sent an email to the pain specialist’s office regarding the manufacturer’s advice.
On 2/9/2010, the patient went to the pain specialist’s office for his follow-up appointment. The patient was informed that the pain specialist had reviewed the email, but also knew how the MRI could be performed without an adverse incident.
The patient was escorted to the MRI suite at the pain specialist’s office. The patient was resting on an exam table while the equipment powered up when his implant device turned on. The patient was immediately escorted from the room. The pain specialist changed the implant device settings.
After the changes were made, his implant device again turned on before imaging could be initiated. No record was made of the adverse advent. The patient returned to the pain specialist’s upstairs office where the patient’s appointment was rescheduled.
The pain specialist represented that he has voluntarily revised his office protocol, informed consent, and patient intake documents for MRI studies to include the following:
1) Requirement that the implant manufacturer be contacted for each case involving a patient with an implanted device, there be a review of the manufacturer recommendations with the patient, and it is confirmed that the patient understands the recommendations.
2) Requirement that an MRI study be rescheduled if the patient discloses the presence of an implanted device for the first time at the MRI appointment.
3) Notification to patients that manufacturer recommendations regarding implant devices must be received prior to conducting MRI studies.
4) Requirement that the facility attests to whether the conduct of an MRI study is compatible with the implanted device.
The Commission stipulated the pain specialist reimburse costs to the Commission, have his license be placed on probation, allow a representative of the Commission to make a visit to his practice to review compliance with these terms and review patient records, and write and submit a paper of at least 1000 words, plus bibliography, addressing the importance for physicians to directly contact the specific manufacturer of implant devices and to strictly follow manufacturer’s operational recommendations. The pain specialist will also develop and submit a protocol for reporting the conduct and results of MRI studies including the following:
1) Safety screening process for patients with specific reference to patients that have implanted devices.
2) Occurrence of the study, including the date, time, and duration.
3) Indications or clinical problem for which the study is being done.
4) Occurrence of any complications or adverse events and the management of them.
5) Cancellation of any studies and the reasons for cancellation.
6) Maintenance of a record of all MRI studies for a specific scanner.
7) Inclusion of the findings and any complications or adverse events in a patient identified record.
State: Washington
Date: February 2013
Specialty: Pain Management
Symptom: Back Pain
Diagnosis: Neurological Disease
Medical Error: Procedural error, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF