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Florida – Critical Care Medicine – Intensivist Unavailable To Assess Patient With Metabolic Acidosis, Abdominal Pain, And Vomiting
On 10/19/2011 at 5:23 p.m., a 35-year-old male presented to the emergency department at a hospital with a chief complaint of abdominal pain and vomiting, which started approximately five hours before he presented to the hospital.
The patient was admitted to the hospital under the service of an intensivist and was notified of his arrival and condition at 5:35 p.m.
Between the hours of 5:50 p.m. and 7:22 p.m. the intensivist gave verbal orders of Dilaudid and ketorolac to the patient’s nurse.
At 9:20 p.m., the intensivist gave telephonic orders to the patient’s nurse, to place him on his home BIPAP mask.
On 10/20/2011, at 3:15 a.m. a rapid response was called due to an acute change in the patient’s respiratory status.
During the rapid response, an arterial blood gas (“ABG”) was drawn that revealed critical metabolic acidosis.
The intensivist never presented to the emergency room to assess the patient when he demonstrated medically dangerous/life-threatening signs at 3:15 a.m. or any time thereafter.
The intensivist never attended to the patient when his clinical situation was from an unknown cause and when a clear treatment plan had not been determined.
From 3:43 a.m. to 4:15 a.m., the critical care practitioner was contacted approximately five times with information on the patient’s medically unstable and deteriorating condition.
At 3:45 a.m., the patient became short of breath, restless, diaphoretic, and seizure episodes followed. He was then transported to an intensive care unit.
At 5:25 a.m., a second rapid response was called due to a further decline in the patient’s health. The rapid response turned into a code blue.
The patient underwent a cardiopulmonary arrest, and the code team was unable to resuscitate him.
On 10/20/2011, the patient expired at 6:25 am.
The autopsy results were consistent with acute hemorrhagic pancreatitis with diffuse pancreatic necrosis.
The Medical Board of Florida judged the intensivist’s conduct to be below the minimal standard of competence given that he failed to presented to the emergency room to assess the patient when the patient demonstrated medically dangerous/life-threatening signs on 10/20/2011 at 3:15 a.m.
The Medical Board of Florida issued a letter of concern against the critical care practitioner’s license. The Medical Board of Florida ordered that he pay a fine of $7,500 against his license and pay reimbursement costs for the case at a minimum of $4,503.10 and not to exceed $6,503.10. The Medical Board of Florida ordered that the critical care practitioner complete ten hours of continuing medical education in the area of critical care medicine and complete five hours of continuing medical education in “risk management.”
State: Florida
Date: December 2017
Specialty: Critical Care Medicine, Emergency Medicine, Pulmonology
Symptom: Abdominal Pain, Nausea Or Vomiting
Diagnosis: Gastrointestinal Disease
Medical Error: Failure to properly monitor patient
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF
Virginia – Pulmonology – Progression Of Interstitial Lung Disease And Pulmonary Nodules
In 2005, a 71-year-old male was diagnosed with pulmonary fibrosis.
In 2010, the patient began seeing a pulmonologist for follow-up and treatment of interstitial fibrosis with marked progression of interstitial lung disease.
On 5/11/2010, CT imaging identified nodules in the upper and lower left lung and consolidative process in the left lung base.
On 8/5/2010 and 8/302010, follow-up imaging noted significant and progressive increase in the size of the nodule in the left upper lobe, highly suspicious for malignancy. There was also a slight increase in the density in the left lower lobe, concerning for malignancy.
On 10/15/2010, a CT guided lung biopsy was performed, which was complicated by pneumothorax. The biopsy revealed atypical bronchial cells and multinucleated giant cells. The pulmonologist did not follow-up with repeat imaging.
On 9/12/2011, repeat imaging study showed growth of the left lower lobe mass.
On 12/15/2011, follow-up PET scan showed a large hypermetabolic focus in the left lower lobe.
On 4/11/2012, the patient presented to the emergency room with progressive shortness of breath, increasing abdominal distention, and poor appetite.
On 4/16/2012, the patient was diagnosed with stage 4 adenocarcinoma with metastasis to the abdomen, pleural effusion positive for metastatic carcinoma, and possible post-obstructive pneumonia.
In his statement dated 6/8/2016, the pulmonologist stated that the failure to follow up with repeat imaging after the patient’s biopsy on 10/15/2010 was a breach of patient care.
The Board issued the pulmonologist a reprimand.
State: Virginia
Date: June 2017
Specialty: Pulmonology
Symptom: N/A
Diagnosis: Lung Cancer
Medical Error: Failure to follow up
Significant Outcome: N/A
Case Rating: 4
Link to Original Case File: Download PDF
California – Pulmonology – Fecal Matter Noted On PEG Tube
On 9/25/2008, a 38-year-old patient was admitted to the neuro-care unit at a hospital under a pulmonologist’s care. The patient had an extensive medical history, which included diabetes mellitus, prior cerebrovascular accident, bipolar disorder, schizophrenia, ventilator dependent tracheostomy, gastrostomy feeding tube, pituitary tumor, hypertension, and blindness from diabetes. At the time of admission, the patient was ventilator dependent and had a percutaneous endoscopic gastrostomy (PEG) tube.
In January 2009, the patient was weaned off of the ventilator and oral feedings were initiated. Medications were still administered via the PEG tube. After the patient was stabilized, he was transferred to the nursing home, still under the pulmonologist’s care. The pulmonologist evaluated the patient on 1/4/2009, 1/10/2009, 1/18/2009, and 1/22/2009, but there was no documentation by the pulmonologist about the PEG tube on physical examination.
On 2/22/2009, the patient was seen by the pulmonologist. The pulmonologist was advised that the PEG tube, which was still inserted in the patient, may have become loose and may need to be removed. On 2/25/2009, the patient was seen by the pulmonologist.
On 2/27/2009, the pulmonologist consulted with Physician A and a physician assistant about the PEG tube. The patient was seen by the physician assistant, who noted that there was fecal matter on the PEG tube and gave verbal orders for a KUB with Gastrografin to confirm whether the PEG tube was in the stomach.
On 2/28/2009, the pulmonologist gave verbal orders that the patient could receive medication or meals orally or via the PEG tube.
On 3/11/2009, the physician assistant gave another verbal order for a KUB with Gastrografin to confirm that the PEG tube was in the stomach. The pulmonologist signed the verbal orders. The KUB showed that the PEG tube was in the wrong place. During this time, the PEG tube was being used for medicine, meals, and water flushes.
On 3/15/2009, the pulmonologist gave verbal orders not to use the PEG tube until it was clear, but did not document why he gave this order.
On 3/20/2009, a radiology report noted that the patient had “nausea and vomiting” and the feeding tube was in the colon. Physician B, who was covering for the pulmonologist on this date, was notified of the findings and noted this in the patient’s chart. No steps were taken to remove the PEG tube on this date.
On 3/29/2009, the pulmonologist documented a physical examination but did not document any issues or concerns with the PEG tube.
On 3/31/2009, a radiology report from the hospital reported that the patient had mild ileus with moderate constipation.
On 3/31/2009, the patient was seen by the pulmonologist, who noted that the PEG tube was “close to the skin” and transferred the patient to the hospital to have the PEG tube removed. The pulmonologist noted that he had been aware that the PEG tube was in the wrong place since 3/20/2009.
On 4/9/2009, the patient was discharged from the hospital. The discharge summary report was dictated on 6/20/2009.
On 10/31/2011 and 11/22/2011, the pulmonologist saw the patient for routine visits.
The Board judged the patient’s conduct to have fallen below the standard of care given failure to timely intervene when he became aware the PEG tube was misplaced and when the patient had signs and symptoms of a possible ileus; failure to document adequate history and physical examinations including routine abdominal examinations; failure to provide explanations as to why orders were given; and failure to follow-up with consulting providers regarding the status of his patient. He routinely failed to document a plan of care or treatment for the patient.
The Board issued a public reprimand with stipulations to complete a continuing medical education course and a medical record keeping course.
State: California
Date: February 2016
Specialty: Pulmonology, Hospitalist, Internal Medicine
Symptom: Nausea Or Vomiting
Diagnosis: Gastrointestinal Disease
Medical Error: Delay in proper treatment, Failure of communication with other providers, Failure to follow up, Failure to properly monitor patient, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
California – Pulmonology – Treatment For Unconfirmed Mycobacterium Tuberculosis For 7 Months And Resulting Medication Side Effects
A patient was first seen by a pulmonologist for a pulmonary consultation on 11/27/2007 to evaluate abnormal lung sounds. The patient was referred by her surgical oncologist for a pre-operative evaluation before a right breast mastectomy. The pulmonologist ordered pulmonary function studies including a CT scan of the chest, a PET scan, and a bronchoscopy, which occurred on 12/18/2007. On 12/27/2007, the report from the bronchial washings were “2 plus AFB positive on stain” for inflammatory cells.
On 12/31/2007, the “preliminary report 2” from the lab stated that there was a negative DNA probe for Mycobacterium Tuberculosis and that no further workup was performed. For a definitive diagnosis of Mycobacterium Tuberculosis, a culture must be grown over a period of 3-6 weeks. In this case, the pulmonologist did not order any follow-up final culture tests from the lab sample until August 2008.
On 1/8/2008, the pulmonologist initiated treatment for tuberculosis for the patient despite the negative DNA probe result. The pulmonologist prescribed isoniazid (INH), rifampin (RMP), and pyrazinamide (PZA) to the patient even though the pulmonologist’s diagnosis was “atypical mycobacterial disease.’ The pulmonologist claimed he orally asked the patient to have her primary physician monitor her liver blood tests monthly for the prescribed medication. The pulmonologist made no written record regarding this request for another physician to order and monitor liver function tests for the patient.
The pulmonologist next saw the patient on 2/12/2008, where the pulmonoloigst’s impression was again “atypical mycobacterial disease,” and all three TB medications were continued. On 3/15/2008, the patient had blood tests, including a liver panel showing an elevation of the AST to 54 and the ALT to 59. The pulmonologist received these results and did nothing. On 4/29/2008, the pulmonologist saw the patient and wrote in her chart “MAI” (Mycobacterium Avium-intracellulare) and continued the patient on the 3 TB medications. The pulmonologist failed to address the March abnormal liver function tests on this visit with the patient.
From 4/3/2008 through 7/28/2008, the patient had repeated evidence of rising liver function tests, but the pulmonologist claimed not have received them. In June 2008, the patient called the pulmonologist for refills of her TB medications, and the pulmonologist both authorized the refills and advised the patient to continue taking her medication. On 8/4/2008, the patient was admitted to a medical center with liver failure. She was subsequently transferred to another medical center, where she had a liver transplantation.
Despite the fact that the pulmonologist recognized that the bacterium in question was “atypical” mycobacterium and not active TB, he prescribed potentially toxic medications for 7 months that resulted in the patient suffering liver damage. During the 3-month period the pulmonologist saw the patient, he made no attempt to follow-up with the laboratory to get final culture results.
The Medical Board of California judged that the pulmonogist’s conduct departed from the standard of care because he failed to follow up on important laboratory results (to confirm or deny active TB) that could have given him the opportunity to re-evaluate his treatment plan, failed to properly coordinate follow up care for the patient’s liver function tests, and subjecting the patient to toxic medications without appropriate clinical justification.
The Medical Board of California issued a public reprimand and ordered the pulmonologist 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.
State: California
Date: November 2015
Specialty: Pulmonology
Symptom: N/A
Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Liver Disease
Medical Error: Improper medication management, Delay in diagnosis, Failure to follow up
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 5
Link to Original Case File: Download PDF
Washington – General Surgery – Continued Bleeding After Tube Thoracostomy
On 10/6/2011, a 35-year-old female presented to the emergency department with spontaneous right-sided pneumothorax, necessitating placement of a chest tube to allow re-expansion of the affected region of lung. A chest CT showed a small pleural effusion, in addition to the pneumothorax, but did not show the presence of blood in the pleural space.
The patient’s blood pressure was 119/74 and her heart rate was 81. A surgeon placed the chest tube around 9:00 a.m. and the patient was transferred to the inpatient floor at 10 a.m. When the patient was transferred to the inpatient floor, the emergency department physician assistant informed the director of nursing services that bright red blood had “returned” when the chest tube was placed and that this was abnormal. Upon admission to the floor, the nursing staff noted a moderate amount of bleeding from the chest tube site.
At 10:33 a.m., nursing informed the surgeon of moderate bleeding from the patient’s chest tube site and the surgeon recommended a reinforced dressing. The wound continued to bleed and the surgeon changed the dressing and ordered continued reinforced dressings.
At 10:45 a.m., four ABD pads (thick, absorbent pads) were saturated with blood at the patient’s chest tube site. The surgeon was notified and he ordered a platelet count and coagulation labs. The surgeon reassessed the patient, reassured nursing, and recommended continuation of reinforced dressings. The patient’s blood pressure had dropped to 99/67 and a heart rate was not recorded. Nursing notes indicate that at 11:16 a.m., blood had not saturated through the reinforced dressing. At 1:09 p.m., a nursing note recorded “no more blood noted on dressing.”
At 1:58 p.m., the patient appeared pale and diaphoretic, blood pressure had dropped to 80/49, and no drainage was noted from the chest tube site. At 2:19 p.m., blood pressure was 88/56, and diaphoresis was absent. The surgeon was notified of the patient’s low blood pressure readings.
At 3:30 p.m., a new RN came on with the shift change. The patient’s blood pressure was 80/40. The RN reported that the surgeon was aware and had not given any new orders. The patient’s gown and underlying chucks pad were saturated with blood. The dressings were weighed and determined to have 400 ml of blood.
At 4:00 p.m., the RN notified the surgeon of the bleeding and blood pressure readings. The RN note documented, “He informed me that the day shift RN had called him all day and this bleeding was normal for the type of hemothorax she had. He stated he did not know the source of the blood. I stated I would be more comfortable if he could order a CBC (complete blood count). He stated [sic] order an H&H (hematocrit and hemoglobin) and call me with the results. He reassured me that this was nothing. I then stated when we got her up in the chair, the blood pour [sic] out of the chest tube site. He again stated this is normal.” The RN also requested a pressure dressing because the ABD pads were saturating too quickly.
At 4:10 p.m., lab results showed the hematocrit had dropped from 42 to 26 (reflects a blood loss of over 5 units) and the results were called to the surgeon, who ordered an IV fluid bolus and blood transfusion.
At 4:29 p.m., the surgeon arrived to evaluate the patient. He determined the patient needed to be transferred to a higher level of care. Blood transfusions were started and the patient was transferred to another medical center.
The physician at the medical center who assumed the care of the patient noted, “There was bleeding that you could see from a fairly large incision made for the first chest tube in the tissues.” They removed the chest tube and placed a new chest tube through a separate incision and approximately 1000 ml of blood was drained.
Bleeding is a known risk of interventional procedures such as the placement of chest tubes. Continued bleeding would necessitate exploration for a source of the bleeding in an attempt at stopping the actively bleeding site. The surgeon failed to timely respond to reports of continued active bleeding. The surgeon’s failure to timely respond and evaluate the cause of the active bleeding resulted in the patient becoming hemodynamically unstable.
The Commission ordered the surgeon pay a fine, have his license placed on probation for a period of two years, allow a representative of the Commission make semi-annual visits to the surgeon’s practice to review compliance with the Commission’s order, and write and submit a paper of at least 1000 words, with bibliography, on the appropriate response to excessive bleeding at wound care sites. The surgeon will also make a presentation to the medical staff at his workplace on this subject.
State: Washington
Date: January 2015
Specialty: General Surgery, Cardiothoracic Surgery, Emergency Medicine, Pulmonology
Symptom: Bleeding
Diagnosis: Post-operative/Operative Complication, Hemorrhage
Medical Error: Delay in proper treatment, Underestimation of likelihood or severity
Significant Outcome: N/A
Case Rating: 4
Link to Original Case File: Download PDF
Colorado/California – Pulmonology – Reading A STAT Portable Chest Radiograph For Respiratory Decompensation Under Pressure
A patient was admitted to the hospital in February 2011 with shortness of breath, hypoxemia, and progressive bilateral interstitial lung infiltrates. A pulmonologist performed a diagnostic bronchoscopy, a broncho-alveolar lavage in the patient’s right middle lobe, and a trans-bronchial biopsy in the left lower lobe. The patient developed respiratory decompensation after the procedure, and as an iatrogenic pneumothorax was suspected.
The pulmonologist ordered a STAT portable chest radiograph. The radiographic image was unavailable for transmission to the bronchoscopy suite and the radiologist’s reading station. The pulmonologist left the patient in the care of a respiratory therapist and nurse, ran to another floor where the plate reader was located, and hastily reviewed the 90 degree rotated image. The pulmonologist misread the side of the pneumothorax displayed on the chest radiograph, and as a result, he incorrectly placed a chest tube on the left side. The patient did not improve with the insertion of the chest tube, and another portable chest radiograph was requested. The second radiograph image was loaded onto the hospital network, and the radiologist called to report that the chest tube was on the side away from the pneumothorax. The pulmonologist placed a right-sided chest tube, and the patient stabilized. The pulmonologist did not request assistance from a radiologist to read the radiograph initially, but left the patient to read the image himself at a time when the patient was unstable. A delay in correctly placing the chest tube resulted.
The Medical Board of Colorado revoked the pulmonologist’s license. The Medical Board of California ordered the pulmonologist to surrender his license.
State: Colorado, California
Date: January 2014
Specialty: Pulmonology
Symptom: Shortness of Breath
Diagnosis: Pneumothorax, Pulmonary Disease
Medical Error: Accidental error, Diagnostic error, Procedural error
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF