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Florida – Physician Assistant – Diflucan For Yeast Infection Given With Tacrolimus
A patient received a heart transplant and was on a long-term tacrolimus regimen.
On 10/7/2011, the patient presented to a physician assistant with complaints of an oral yeast infection. The physician assistant prescribed the patient a two-week course of Diflucan and advised him to return for follow-up three weeks after the 10/7/2011 appointment.
Diflucan is known to potentiate tacrolimus, which causes the tacrolimus to reach toxic levels.
The standard of care required that the physician assistant perform serial monitoring of the patient’s drug levels to ensure that they did not reach a toxic level, starting immediately after the physician assistant prescribed Diflucan.
The physician assistant did not schedule blood testing to monitor the patient’s drug levels and advised the patient to return for a follow-up appointment three weeks after the initial appointment.
The physician assistant voluntarily relinquished his license.
State: Florida
Date: August 2017
Specialty: Physician Assistant
Symptom: N/A
Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Infectious Disease
Medical Error: Improper medication management, Failure to properly monitor patient
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
Washington – Physician Assistant – History Of Diabetes And Hypertension With Chest Pain, Left-Sided Weakness, Headache, And Loss Of Vision
On 11/7/2011, a patient presented as a “medical emergency” and was seen by a physician assistant at a correctional facility. The patient was a 62-year-old man whose medical record included a history of arthritis, diabetes, and hypertension for which he was treated with blood pressure medication.
The patient told the physician assistant he thought he had a stroke three days earlier and described symptoms of chest pain, left-sided tingling, left-sided weakness, headache, and loss of vision in the bottom visual field of his left eye. The patient’s presenting blood pressure was 180/94 with a repeat at the end of the visit of 127/82. The physician assistant noted normal pupil, funduscopic, heart and lung exams. Cranial nerves II-XII were intact. The patient’s strength was equal bilaterally. An EKG was done and interpreted as having a normal sinus rhythm. The physician assistant’s diagnosis was “No evidence of stroke.” The patient was given a GI cocktail and released to his unit.
The physician assistant did not verify the patient’s complaint by conducting a visual field exam. The physician assistant did not consider temporal arteritis as a possible cause of the patient’s vision loss. Also, he did not at that time discuss his care of the patient with a supervising physician. The physician assistant failed to recognize the emergent nature of the complaint of sudden vision loss by a patient.
The patient again presented to the physician assistant a week later on 11/14/2011. He reported continued loss of vision in the bottom visual field of his left eye. The physician assistant completed a form recommending the patient be referred to an ophthalmologist.
The patient was seen two weeks later on 11/29/2011 by a local ophthalmologist who ordered a sed rate to help rule out temporal arteritis and placed the patient on clopidogrel. The ophthalmologist diagnosed “[a]cute anterior ischemic optic neuropathy OS.” He stated that at the visit the patient was “already showing signs of superior optic atrophy and inferior visual field loss from superior involvement approximately three weeks previous.”
The Commission stipulated the physician assistant reimburse costs to the Commission and write and submit a paper, with bibliography, on the evaluation of a patient with non-traumatic sudden vision loss.
State: Washington
Date: August 2017
Specialty: Physician Assistant, Family Medicine, Internal Medicine
Symptom: Vision Problems, Headache, Chest Pain, Weakness/Fatigue
Diagnosis: Ocular Disease
Medical Error: Diagnostic error
Significant Outcome: N/A
Case Rating: 5
Link to Original Case File: Download PDF
New York – Physician Assistant – History Of Bipolar Disorder With Concern For Irregular Menses
On 8/13/2007, a 21-year-old female presented to a physician assistant for follow up treatment of bipolar disorder and concern for irregular menses.
During the examination, the patient advised the physician assistant that her most recent period was the prior November and that she had not had a gynecological examination in ten years. The physician assistant examined the patient’s abdomen, which he found to be benign. In regard to the patient’s complaints of irregular menses, the physician assistant ordered a variety of blood work and stated that he would follow up with the patient in three months, unless otherwise indicated. The blood work that he ordered did not include a hCG test.
On 8/16/2007, the patient arrived at the emergency department with a full-term pregnancy and delivered her baby on that same day.
The Board judged that the physician assistant’s medical care deviated from accepted standards of care given failure to perform an adequate physical examination, given failure to order a hCG test, and given failure to recognize signs of pregnancy.
State: New York
Date: July 2017
Specialty: Physician Assistant, Family Medicine, Internal Medicine
Symptom: Gynecological Symptoms
Diagnosis: N/A
Medical Error: Failure to order appropriate diagnostic test, Failure to examine or evaluate patient properly
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
New York – Physician Assistant – Lack Of Lab Work For Routine Visit For A 37-Year-Old Female
On 11/3/2008, a 37-year-old female presented to a physician assistant for a physical and PAP smear. During the examination, the physician assistant performed a pelvic examination and found normal female genitalia without lesion or discharge. A PAP smear was obtained without incident. The physician assistant’s examination of the patient’s abdomen revealed the abdomen was soft and nontender. The physician assistant’s plan was to reassess the patient in three months unless otherwise indicated.
The physician assistant did not order the patient to undergo any lab work, such as an hCG test.
On 11/12/2008, the patient presented to the hospital with a full-term pregnancy and delivered a baby on the same date.
The Board judged that the physician assistant’s medical care of the patient deviated from accepted standards of care given failure to recognize signs of pregnancy.
State: New York
Date: July 2017
Specialty: Physician Assistant, Family Medicine, Internal Medicine, Obstetrics
Symptom: N/A
Diagnosis: N/A
Medical Error: Failure to order appropriate diagnostic test, Failure to examine or evaluate patient properly
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
Florida – Physician Assistant – Patient With Animal Bite Wound Treated With Sutures Only
On 7/13/2011, a 47-year-old female presented to a physician assistant with an animal bite wound. The physician assistant treated the patient’s animal bite wound with sutures.
The physician assistant discussed this wound with an orthopedic specialist, who recommended IV antibiotics and an antibiotic prescription for home.
The physician assistant did not order or administer antibiotics to the patient while the patient was in the hospital. The physician assistant did not order or administer antibiotics to the patient at the time of discharge.
The Board judged the physician assistant’s conduct to be below the minimal standard of competence given that she failed to prescribe antibiotics when assessing and/or treating a patient with the following presentation.
The Board issued a letter of concern against the physician assistant’s license. The Board ordered that the physician assistant pay a fine of $2,000 against her license and pay reimbursement costs for the case at a minimum of $3,867.71 but not to exceed $5,867.71. The Board also ordered that the physician assistant complete five hours of continuing medical education in diagnosing and/or treating patients with wounds and five hours of continuing medical education in “risk management.”
State: Florida
Date: July 2017
Specialty: Physician Assistant
Symptom: N/A
Diagnosis: Trauma Injury, Infectious Disease
Medical Error: Improper treatment
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
Florida – Physician Assistant – Cardiac Catheterization Ordered In The Wrong Patient
On 10/11/2015, Patient A, an 89-year-old male presented to the emergency department with complaints of chest congestion, weakness, and chest pressure.
Lab results revealed that Patient A had elevated troponin levels, and he was admitted and referred for a cardiology consultation.
On 10/11/2015, the patient saw a cardiologist for the cardiology consultation. The cardiologist documented that the patient had an upper respiratory infection and recommended that the patient continue antibiotics, gentle diuresis, and outpatient medical therapy.
At around the same time, on the same date, the cardiologist saw Patient B for a cardiology consultation. Sometime after the cardiac consultations of Patient A and Patient B, the cardiologist contacted a physician assistant and instructed him to order a cardiac catheterization for Patient B.
The physician assistant placed an entry in Patient A’s medical chart instead of Patient B’s chart, ordering the cardiac catheterization. The physician assistant failed to review Patient A’s available medical records, including labs, notes, and imaging studies, before placing the cardiac catheterization order in his chart.
The following morning, cardiac catheterization was unnecessarily performed on Patient A.
The Board judged the physician assistant’s conduct to be below the minimal standard of competence given that he failed to review the patient’s available medical records, including labs, notes, and images studies, before placing the cardiac catheterization order in his chart.
The Board issued a letter of concern against the physician assistant’s license. The Board ordered that the physician assistant pay a fine of $2,000 against his license and pay reimbursement costs for the case at a minimum of $2,611.86 and not to exceed $3,111.86. The Board also ordered that the physician assistant complete five hours of continuing medical education in “risk management.”
State: Florida
Date: June 2017
Specialty: Physician Assistant, Cardiology
Symptom: Weakness/Fatigue
Diagnosis: Infectious Disease
Medical Error: Accidental error, Unnecessary or excessive treatment or surgery
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Emergency Medicine – Pelvic Pain And Vaginal Bleeding With Urinalysis Revealing A Glucose Level >1000
On 8/21/2014, a patient presented with complaints of pelvic pain and vaginal bleeding. The patient was examined by a physician assistant supervised by an ED physician.
The physician assistant ordered laboratory evaluation for the patient, which included bloodwork, cervical/vaginal swabs, pelvic ultrasound, and urinalysis.
The urinalysis revealed the patient’s glucose level to be >1000, which was so high that it could not be measured.
The physician assistant gave the patient a prescription for Flagyl, an antibiotic, gave her education materials on uterine bleeding, bacterial vaginosis, dehydration, and ovarian cysts, and instructed her to follow up with her primary care physician and gynecologist. The physician assistant discussed the patient’s case with the ED physician and the ED physician agreed with the plan of care.
The ED physician did not perform or order a finger stick glucose test or a basic metabolic panel.
The ED physician did not discuss and/or did not order the physician assistant to discuss the patient’s glucose level in relation to her possible new onset of diabetes and did not recommend or order the physician assistant to recommend further evaluation and treatment of her elevated glucose levels.
The ED physician did not administer or order the administration of intravenous fluid and insulin.
On 8/26/2014, the patient expired due to diabetic ketoacidosis.
The Medical Board of Florida judged the ED physician’s conduct to be below the minimal standard of competence give that she failed to administer or order the administration of a finger stick glucose test or basic metabolic panel, discuss or instruct the physician assistant to discuss the patient’s glucose levels in relation to her possible new onset of diabetes and recommend further evaluation and/or treatment of her elevated glucose levels, and failed to administer or order the administration of intravenous fluid and insulin.
It was requested that the Medical Board of Florida order one or more of the following penalties for the ED physician: permanent revocation or suspension of her 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: Emergency Medicine, Endocrinology, Physician Assistant
Symptom: Pelvic/Groin Pain, Abnormal Vaginal Bleeding
Diagnosis: Diabetes
Medical Error: Failure to follow up, Failure to order appropriate diagnostic test, Failure of communication with other providers, Improper supervision, Improper medication management
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF
North Carolina – Physician Assistant – 10-Year-Old With Cough, Fever, High Blood Pressure, and Sore Throat Diagnosed With Strep Throat
The Board was notified of a professional liability payment made on 1/28/2016.
A 10-year-old presented to a physician assistant with a chief complaint of cough, headache, sore throat, and fever. The patient’s blood pressure was elevated, 140/190, and she had a fever of 103.2 degrees F. According to the history, the patient denied nausea, vomiting, or diarrhea. In the physical examination, it was documented a normal respiratory assessment. The patient was diagnosed with strep throat, prescribed amoxicillin, and the patient was discharged home.
The patient died two days later from pneumonia secondary to influenza infection, which was not listed in the differential diagnosis.
The Board expressed concern that the physician assistant did not consider influenza in the differential diagnosis, prescribed an antibiotic without identifying the pathogen responsible for the infection, and did not perform a blood pressure recheck for the patient’s hypertension. The Board noted a failure to document providing adequate follow up instructions to the patient’s family enumerating red flag signs and symptoms which would prompt the family to return the child to a health care facility.
The Board issued a public letter of concern, which was reported to the Federation of State Medical Boards. It was not reported to the National Practitioner Data Bank.
State: North Carolina
Date: April 2017
Specialty: Physician Assistant, Emergency Medicine, Pediatrics
Symptom: Fever, Cough, Headache
Diagnosis: Pneumonia
Medical Error: Diagnostic error, Lack of proper documentation
Significant Outcome: Death
Case Rating: 3
Link to Original Case File: Download PDF
Kansas – Physician Assistant – High Dosing Regimen Of Amitriptyline For A Pediatric Patient With Headache, Vomiting, And Incontinence
On 11/19/2015, a patient presented to a physician assistant at a family care clinic with chief complaints of headache, vomiting, and incontinence since 11/17/2015. The patient’s father reported, in addition to the severe headache, the patient was experiencing involuntary arm jerking. Furthermore, the night prior, the patient experienced hearing voices.
The patient had a history of respiratory problems, was noted to have “poor” functional status, and was noted to be in preschool.
The physician assistant did not complete a neurological examination; however, he diagnosed the patient with pediatric migraine and ordered thirty 10 mg tablets of amitriptyline with instructions for the patient to take one tablet three times daily and the patient was to have one refill. The physician assistant did not perform a thorough workup to include additional studies or tests prior to prescribing amitriptyline.
On 2/3/2016, the Board received a response from the physician assistant wherein he indicated, “I recall little about the episode, except possibly after reviewing his chart and the nurses [sic] report, in investigating his headache and cyclic vomiting and physical exam in UpToDate that the treatment I initiated would have been per the UpToDate recommendations.”
UpToDate is an online website claiming to be an evidence-based, physician-authored clinical decision support resource.
The physician assistant inappropriately prescribed amitriptyline due to the excessive dose and age of the patient.
The Board judged the physician assistant’s conduct to be below the minimum standard of competence given his inappropriate prescribing of amitriptyline.
For this allegation and others, the Board ordered the physician assistant to contact The Center for Personalized Education for Physicians, (“CPEP”) for a competence assessment, follow all recommendations of the CPEP assessment, and complete a medical record keeping seminar.
State: Kansas
Date: April 2017
Specialty: Physician Assistant, Family Medicine, Pediatrics
Symptom: Headache, Nausea Or Vomiting, Psychiatric Symptoms, Urinary Problems
Diagnosis: Neurological Disease
Medical Error: Improper medication management, Accidental Medication Error, Failure to examine or evaluate patient properly
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
Kansas – Physician Assistant – Inappropriate Altering Of Medical Records In A Patient With Diverticulitis
On October 2015, a patient had been hospitalized for eight days with acute sigmoid diverticulitis.
On 11/9/2015, the patient was seen by an internist at a clinic for a hospital follow-up. The internist noted that the patient still had abdominal pain in the left lower quadrant (“LLQ”), but was improved. Further, the internist noted that the patient had tenderness to palpation to the LLQ and the right lower quadrant (“RLQ”) with no guarding or rebound. The internist documented that the patient’s diverticulitis was improved and his plan was for the patient to finish taking his prescribed Levaquin.
On 11/13/2015, the patient presented to the emergency department with abdominal pain rated 10/10. A physician assistant noted that the patient “Does pause episode to speak and answer questions,” and “guards throughout exam.” The physician assistant’s impression was “Non-Acute Long Standing.” The physician assistant ordered a “GI-Cocktail” on the ED physician order sheet and then discharged the patient with a diagnosis of abdominal pain with a plan for a CT in the morning.
It is unclear why the physician assistant did not obtain the CT at that time. At some point, the physician assistant added an untimed order for Dilaudid 2 mg IV to a copy of the original ED physician order sheet.
The patient returned that morning on 11/13/2015 and had a CT scan that indicated bowel perforation and possible entero-colonic fistula.
The physician assistant took the patient to the ED, the patient was crying in pain, and the physician reported that the patient had a CT and needed to be transferred for surgery.
The physician assistant altered the patient’s medical records including the following: altered the time the patient was seen in the ED, changed the diagnosis from “Non-Acute Long Standing” to “Now-Acute/Long Standing” on the emergency physician record, crossed out the checkbox “home” and circled the checkbox “transfer” on the emergency physician record, and crossed out the ED number and wrote “From clinic.” The physician assistant did not initial the alterations, indicate when the alterations were made, nor why the alterations were made.
The Board judged that the physician assistant likely deceived, defrauded, or caused harm to the patient by inappropriately altering the patient’s medical records.
For this allegation and others, the Board ordered the physician assistant to contact The Center for Personalized Education for Physicians, (“CPEP”) for a competence assessment, follow all recommendations of the CPEP assessment, and complete a medical record keeping seminar.
State: Kansas
Date: April 2017
Specialty: Physician Assistant, Emergency Medicine, Internal Medicine
Symptom: Abdominal Pain
Diagnosis: Acute Abdomen
Medical Error: Ethics violation, Delay in proper treatment, Diagnostic error, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF