Page 1 of 7
Arizona – Internal Medicine – Managing A Patient Using Alternative Medicine As Opposed To Allopathic Medicine
In November 2009, an 87-year-old man, who was Physician A’s family member, began seeing Physician A for hypotension, autonomic dysfunction syndrome, osteoarthritis, hypothyroidism, and “hormonal imbalance.” Physician A prescribed over-the-counter herbs and supplements, prescription strength hormonal replacement therapy, and acupuncture treatments.
On 02/20/2011, the patient suffered a right frontal hemorrhagic stroke with residual left hemiplegia. Physician A took the patient to the hospital after 12 hours of initial symptoms. Physician A said that no neurologist was available at the local hospital and the weather made it hazardous for him to drive at that time.
On 09/22/2014, an osteopathic provider Physician B saw the patient. He advised that the patient take his blood pressure medications on a regular basis as opposed to as needed as recommended by the Physician A. Physician B recommended albuterol for dyspnea and a follow up spirometry. He also recommended tamsulosin in addition to saw palmetto for benign prostatic hypertrophy.
In August 2016, Physician A was removed as the patient’s primary medical provider.
The Board judged Physician A’s conduct to be below the minimum standard of competence given failure to obtain written consent regarding the treatment plan, which involved over-the counter medicines, herbs, and an absence of allopathic treatment.
Physician A did not monitor the patient’s TSH. He prescribed magnesium when the patient had chronic kidney disease and did not monitor the patient’s magnesium levels. He prescribed iron supplements when there was no documentation that the patient suffered from iron deficiency. He prescribed Natto and other supplements which had blood thinning effects and could have lead to the hemorrhagic stroke along with uncontrolled hypertension.
He prescribed testosterone when the patient had an elevated PSA level and uncontrolled hypertension.
The Board issued a Decree of Censure and placed Physician A on probation for 1 year. He was ordered to complete the Professional/Problem-Based Ethics program offered by the Center of Personalized Education for Physicians for Ethics and Boundaries.
State: Arizona
Date: May 2017
Specialty: Internal Medicine
Symptom: N/A
Diagnosis: Intracranial Hemorrhage
Medical Error: Improper medication management, Failure to properly monitor patient
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 1
Link to Original Case File: Download PDF
Arizona – Cardiology – Multiple Complications During Cardiac Catheterization With Repeat Thrombosis Of The Right Coronary Artery
On 05/30/2014, a 56-year-old man presented with acute onset chest pain. The cardiologist discovered that the left anterior descending (LAD) and right coronary artery (RCA) had significant stenosis. The cardiologist first intervened up on the LAD with a stent, but found the proximal edge had “haziness” so he did not intervene further. The cardiologist then focused on the RCA. The first stent was deployed, but had a dissection for which the cardiologist deployed multiple other stents to correct. Brisk flow in all coronaries was reported at the conclusion of these procedures.
The patient experienced a sudden thrombosis of the RCA two days later. The cardiologist placed 3.5 diameter stents and used 2.0 and 2.5 mm balloons to reopen the RCA. The patient also developed cardiogenic shock and acute respiratory failure from probably aspiration and required emergency intubation, which was described as traumatic. The patient was on pressors and an intra-aortic balloon pump (IABP) was placed.
On 06/02/2014, the patient was noted to be improving with decreased dependence on pressors. The IABP was removed the following day, but the patient became progressively agitated and experienced increased ST changes.
On 06/05/2014, the patient became hypoxic with ST elevation and was taken back to the catheterization lab where it was determined that the RCA was thrombosed. The cardiologist performed balloon angioplasty on the RCA during which a perforation of the posterior descending (PDA) branch occurred. The cardiologist made several attempts to stop the bleeding, including prolonged balloon inflations, which failed, and an attempt to completely occlude the PDA branch by placing a covered stent. The stent could not be placed or withdrawn in the location of concern and was deployed more proximally. A wire was left in the mid-RCA, which was ultimately coiled by an interventional radiologist due to ongoing bleeding. The cardiologist noted a pericardial effusion, which did not demonstrate tamponade and did not require pericardiocentesis.
Over the next several days, the patient continued to experience worsening abdominal distention, right heart failure, episodes of bradycardia (which the Board deemed was not adequately addressed by the cardiologist), mottling of the lower extremities, liver congestion, and acute renal failure. On 06/08/2014, the IABP was removed.
On 06/10/2014, the patient went into multi-organ system failure. The decision was made to make the patient comfortable. The patient had runs of ventricular arrhythmias and passed away that evening.
The Board judged that while there was no single defined even in the cardiologist’s treatment of the patient that would be considered a deviation of a standard of care, there were several areas of concern regarding his treatment of the patient.
The Board ordered the cardiologist to be placed on probation given complications among several patients he had managed. He was prohibited from performing interventional cardiology until the Board granted him permission. The cardiologist must provide evidence that he is able to safely perform interventional cardiology before the Board would consider lifting the prohibition.
State: Arizona
Date: April 2017
Specialty: Cardiology
Symptom: Chest Pain
Diagnosis: Acute Myocardial Infarction
Medical Error: Procedural error
Significant Outcome: Death
Case Rating: 3
Link to Original Case File: Download PDF
Arizona – Cardiology – Hypotension, Tachycardia, Respiratory Distress, And Hypovolemic Shock During Pericardiocentesis
A 67-year-old woman with a history of Crohn’s disease presented to a cardiologist in consultation for a pericardial effusion.
On 04/10/2014, the cardiologist performed a pericardiocentesis. 1400 ml of bloody drainage had been removed when the patient developed hypotension, tachycardia, respiratory distress, and hypovolemic shock. She required intubation. The cardiology removed another 2000 ml of fluid before he removed the catheter used for the pericardiocentesis. The patient required 6 units of PRBC’s, 4 units FFP, and 2 liters of NS to get stabilized. In the intensive care unit, the patient was on phenylephrine and dopamine before she was gradually weaned off of pressors and the ventilator. The patient was discharged in good condition.
The Board judged the cardiologist’s conduct to be below the minimum standard of competence given failure to recognize that he was not in the pericardial space and failure to use echocardiography to verify proper placement. The cardiologist deviated from the standard of care by continuing to withdraw fluid from the patient and failing to verify that he was in the pericardial space.
The Board ordered the cardiologist to be placed on probation given complications among several patients he had managed. He was prohibited from performing interventional cardiology until the Board granted him permission. The cardiologist must provide evidence that he is able to safely perform interventional cardiology before the Board would consider lifting the prohibition.
State: Arizona
Date: April 2017
Specialty: Cardiology
Symptom: N/A
Diagnosis: Post-operative/Operative Complication
Medical Error: Procedural error
Significant Outcome: N/A
Case Rating: 4
Link to Original Case File: Download PDF
Arizona – Cardiology – Cardiac Catheterization With Questionable Indications Results In Complications
A 76-year-old woman was diagnosed with severe aortic stenosis.
On 03/20/2014, the cardiologist performed cardiac catheterization which consisted of left and right coronary angiograms and left ventriculogram. The patient experienced chest pain and syncope after the catheterization. A STAT echocardiogram was performed and revealed aortic stenosis, normal LV function, and no pericardial effusion. Troponins were elevated after the cardiac catheterization.
On 03/22/2014, the patient was taken to the operating room and was reported to have a pericardial effusion with non-clotting blood and evidence of early tamponade. The aortic valve was replaced. After surgery, the patient had difficulty weaning from the cardiopulmonary bypass machine and an intra-aortic balloon pump was required. The patient was subsequently weaned off pressors and the IABP, and she was extubated one day postoperatively. The patient had episodes of atrial fibrillation postoperatively and was discharged on 03/27/2014.
The Board judged the cardiologist’s conduct to be below the minimum standard of competence given failure to perform a left heart catheterization and left ventriculogram without proper indications. Further details are unclear as to why the Board focused on this concern (given that left heart catheterization is often done in a patient with severe aortic stenosis to evaluate for coronary artery disease in case bypass graft surgery is required during aortic valve replacement, although one could argue the left ventriculogram was not warranted).
The main concern appeared to be that the cardiologist had a pattern of complications with concern that the complication of hemopericardium after cardiac catheterization indicated a deficiency of skills that increased the risk of complications among his patients.
The Board ordered the cardiologist to be placed on probation given complications among several patients he had managed. He was prohibited from performing interventional cardiology until the Board granted him permission. The cardiologist must provide evidence that he is able to safely perform interventional cardiology before the Board would consider lifting the prohibition.
State: Arizona
Date: April 2017
Specialty: Cardiology
Symptom: Chest Pain, Syncope
Diagnosis: Post-operative/Operative Complication
Medical Error: Procedural error
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
Arizona – Pediatrics – Pediatrician Suddenly Resigns And Leaves Without Prior Arrangements Or Warning
A pediatrician held the position of Chief Medical Officer.
On 10/22/2014, the pediatrician was scheduled to see patients, but informed his Chief Operating Officer that morning that he was resigning effective immediately. The pediatrician was asked to stay 48 hours to allow the employer to seek a locum tenens to replace him, but he declined, and provided a letter of resignation for himself and another physician employed by his Employer.
Consequently, the Employer’s clinic did not have any physicians to see the patients scheduled that day. The Employer was ultimately unable to secure a locum tenens for 10 days following the resignations and appointments for pediatric patients had to be cancelled, rescheduled, or the patients were referred elsewhere during that time period. The pediatrician did provide prescription refills for established patients for a period of time following his resignation.
The standard of care requires a physician to give a reasonable amount of time before resigning from a practice to assure seamless care of the patients in that practice setting.
The Board judged the pediatrician’s conduct to be below the minimum standard of competence given failure to allow for a seamless transition of patient care, which ultimately increased the risk of patient harm.
The Board ordered the pediatrician be reprimanded.
State: Arizona
Date: April 2017
Specialty: Pediatrics
Symptom: N/A
Diagnosis: N/A
Medical Error: Ethics violation
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
Arizona – Dermatology – Failure To Adequately Conduct Mohs Surgery
The Board received a complaint alleging failure to adequately conduct Mohs surgery. During the Board’s investigation, the Medical Consultant reviewed the charts of three patients regarding the dermatologist’s performances of Mohs surgery for a patient with basal cell carcinoma of the left ear, a patient with squamous cell carcinoma of the left ear and preauricular face, and a patient with basal cell carcinoma of the right ear. The Mohs histology slides prepared for each patient were reviewed. The Medical Consultant concluded that in each case the dermatologist’s removal of either the basal cell carcinoma or squamous cell carcinoma was incomplete. It was noted that there was insufficient tissue present on the histology slides to represent a complete margin of a 2 cm tumor of the ear. The dermatologist’s Medical Consultants disagreed.
The Medical Consultants noted in that the patient with the basal cell carcinoma of the right ear, there was poor correlation with Mohs Map, the operative report, and the findings in the histology slides. In addition, there was no documentation discussing adjuvant therapies, further staging work up, or the persistent tumor with the patient at the time of Mohs surgery.
These patients had documented recurrences of their skin cancers that required additional Mohs surgery and in some cases, lead to tissue loss, nerve damage, and the need for reconstruction.
The Board judged the dermatologist’s conduct to be below the minimum standard of competence given failure to completely remove the tumor for three patients.
The Board ordered dermatologist be reprimanded.
State: Arizona
Date: April 2017
Specialty: Dermatology
Symptom: Dermatological Abnormality
Diagnosis: Cancer, Dermatological Issues
Medical Error: No error found
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
Arizona – Anesthesiology – Cardiac Arrest During Elective Face And Brow Lift After Administration Of Propofol, Fentanyl, And Lidocaine
The Board was notified that an anesthesiologist had his privileges suspended.
On 08/25/2015, a 52-year-old woman presented for an elective face and brow lift.
At 8:13 a.m., on the morning of the surgery, the anesthesiologist administered anesthesia to the patient. When the surgeon began to inject lidocaine around the patient’s face, the anesthesiologist began injecting propofol on a regular basis during the local injection and supplemented it with fentanyl boluses. Based on the patient’s medical records, it appeared that the anesthesiologist administered at least 200 mg of propofol and 100 mcg of fentanyl during this time.
During the first 2-3 hours of the surgery, the patient was responding more than usual, and the anesthesiologist administered regular boluses of propofol and fentanyl. Based on the patient’s medical records, it appears that the anesthesiologist administered approximately 2000 mg of propofol and 500 mcg of fentanyl during this time period.
The anesthesiologist documented in the patient’s records that the patient experienced short periods of apnea, which caused the pulse oximetry readings to decrease. The anesthesiologist recognized that he was using significantly more propofol and fentanyl during the 2-3 hour time period after the surgery began. Because a portion of the procedure involved the use of an endoscope, which is painful, the anesthesiologist requested the surgeon to inject the patient with additional lidocaine. The patient continued to respond and reach for her face in response to the painful stimulus.
At approximately 11:30 a.m., the patient unexpectedly and violently reached towards her face and nearly sat up. The anesthesiologist gave the patient a 50 mg dose of propofol. However, the patient’s pulse oximetry readings began to fall and her heart rate dropped. The patient’s color became blue around her mouth. The anesthesiologist placed a laryngeal mask airway, but the patient’s pulse oximeter readings and heart rate continued to drop.
The surgery was halted and the anesthesiologist elected to intubate the patient. After intubation, the patient went into cardiac arrest and a full code was called. The patient was given atropine, IV epinephrine, and chest compressions.
The anesthesiologist used a video laryngoscope to determine whether the endotracheal tube was properly positioned and realized that the intake tube was still connected to the nasal oxygen tubing and not the anesthesia circuit, which resulted in not getting a CO2 reading.
After two rounds of chest compressions, the patient’s heart rate started to increase. The anesthesiologist claims that the patient’s heart rate and blood pressure returned to reassuring levels and that the whole episode transpired within approximately 3-5 minutes of coding.
The surgeon and the anesthesiologist agreed that the patient would spend the night in the hospital, which the anesthesiologist believed was only precautionary. The anesthesiologist and the surgeon discussed if the patient’s surgery should be continued, if the extensive excision should be closed, or if the patient should be transferred to a different hospital for a higher level of care.
They elected to proceed with the surgery, but not perform the endoscopic brow lift. At the same time, arrangements were made to transfer the patient to a hospital with a higher level of care. The surgery took approximately 2 hours and 45 minutes to complete.
After the patient was brought to the recovery room, her vital signs were stable with minimal chin lift required. After the anesthesiologist gave a report to the PACU staff, he went to participate in a short surgical case with the same surgeon.
During the second surgery, the PACU nurses reported to the anesthesiologist that the patient did not appear to be waking up from the anesthesia normally and needed a nasal airway because her breathing was obstructed without constant chin lift. The anesthesiologist evaluated the patient and agreed that her emergence from anesthesia was not normal. The patient then started to demonstrate seizure-like activity. The anesthesiologist inquired about the status of the patient’s transport to the hospital. He was informed that a transport team had not been called to the surgery center. The anesthesiologist immediately instructed the staff to call for transport.
After the patient’s transfer, the anesthesiologist received a call from the intensive care physician at the hospital who reported that the patient had suffered profound brain damage with a very poor prognosis. The intensive care physician initiated hypothermia protocol.
On 09/3/2015, the patient expired. The discharge diagnosis included diffuse anoxic encephalopathy related to the outpatient cardiac arrest; recurrent seizures related to global brain injury; cardiomyopathy with an ejection fraction of 45-50% presumed related to the cardiac arrest; and abnormal troponin levels consistent with myocardial infarction.
The Board judged anesthesiologist’s conduct to be below the minimum standard of competence given several failures. He failed to switch to another form of anesthesia when the patient was not responding to the current anesthesia plan. He failed to immediately send a patient who had had a code to a hospital with a higher level of care. He failed to immediately make arrangements for the patient to be transferred to a hospital with a higher level of care. He failed to stay with a patient who had had a code and manage the transfer to a hospital to ensure that there is no miscommunication between the facilities. The Board finds that the anesthesiologist deviated from the standard of care by electing to participate in another surgery case instead of staying with the patient.
The Board ordered the physician to be reprimanded.
State: Arizona
Date: March 2017
Specialty: Anesthesiology, Plastic Surgery
Symptom: N/A
Diagnosis: Post-operative/Operative Complication
Medical Error: Improper medication management, Procedural error
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF
Arizona – Family Medicine – Unaddressed Cervical Issue And Unnecessary Genetic Testing
A 26-year-old woman made an appointment for a well woman exam and refill of her birth control medications at a clinic. When the woman arrived, she was told that the physician with whom she had made an appointment was not available and that she would be seen by another physician.
Two MAs saw the patient. One performed an examination, the other acted as a translator. The patient requested a PAP smear and an STD test. The patient was not offered a breast exam. A detailed history was not obtained. The patient underwent a PAP smear performed by the MA. A urine sample was requested for the performance of a pregnancy test. The patient again requested an STD test and was told that she would have to return for another visit for that test, and that she would have to return for a third visit to discuss the results of the lab tests and the PAP smear. At that time, another MA entered the room and suggested that the patient complete genetic testing. She reassured the patient that it would be covered by her insurance. The patient agreed to proceed with the test and submitted to a cheek swab for the testing.
The physician arrived after the examination was completed and asked the patient if she had any questions. The patient was given a three month prescription for birth control with no refills at the front desk. The patient asked for additional refills and was told she would have to return for additional appointments. After consultation with the physician, staff members told the patient that she would not be receiving additional refills because she was probably sterile due to the length of time she had been on birth control. The patient cancelled her labs, informed the staff that she would not come back, and requested reimbursement and return of her registration fee and paperwork. The physician returned the patient’s registration paperwork, refunded the registration fee, and called the police due to the patient’s agitated behavior.
The documentation for the examination indicated that the patient’s cervix was “red” or inflamed; however, there is no record that this was addressed or treated during the patient’s visit.
The physician’s office subsequently sent the patient’s sample for genetic testing. The patient’s insurance denied coverage for the test, and the patient received an explanation of benefits from her insurer stating that she owed $3,800 for it.
In his response to the Board, the physician denied that he allowed his MA to perform the PAP smear on the patient and stated that he entered into the treatment room after the patient was prepped, draped, and “with her legs in the ‘up position’…With her head down and her legs up, the patient was unable to see me perform the Pap smear.”
The Board judged physician’s conduct to be below the minimum standard of competence given failure to obtain a medical and family history, a medication list, an allergy list, a review of systems, and a complete physical examination. The abnormal finding on exam was not addressed. The patient had to pay for unnecessary genetic testing.
The Board ordered the physician to be reprimanded and take 10 of continuing medical education on well-woman examinations.
State: Arizona
Date: March 2017
Specialty: Family Medicine, Gynecology
Symptom: Gynecological Symptoms
Diagnosis: N/A
Medical Error: Failure to examine or evaluate patient properly
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
Arizona – Neurosurgery – Identifying A Dural Arteriovenous Fistula In A Cerebral Angiogram
The Board received notification of a malpractice settlement regarding the care and treatment of a 57-year-old woman.
The suit alleged misdiagnosis of an arteriovenous fistula in the left transverse sinus of the brain and unnecessary performance of procedures. A Medical Consultant who reviewed the neurosurgeon’s care asserted that the neurosurgeon failed to correctly identify a dural arteriovenous fistula on a diagnostic cerebral angiogram with subsequent unnecessary performance of procedures.
The neurosurgeon admitted that he was unable to comply with the terms of the probationary agreement due to his absence from the country and current financial situation.
The Board ordered that he immediately surrender his license.
State: Arizona
Date: March 2017
Specialty: Neurosurgery
Symptom: N/A
Diagnosis: Neurological Disease
Medical Error: Diagnostic error
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
Arizona – Obstetrics – Pregnancy With Elevated Blood Pressure And Proteinuria
On 02/02/2015, a 37-year old-woman was evaluated for vaginal bleeding in the emergency department.
On 02/04/2015, she established care with an obstetrician. She had received prenatal care on two prior occasions from other providers. An ultrasound was performed and a sub-chorionic hemorrhage was identified along with fibroids. Blood pressure was noted to be 139/79.
On 03/18/2015, she was noted to have elevated blood pressure at an appointment with the obstetrician.
On 04/14/2015, the blood pressure was elevated and 2+ protein was present. The obstetrician sent the patient to her family practitioner for evaluation, and the family practitioner then sent the patient to the hospital, where she was treated with labetalol and discharged with no further evaluation.
On 04/16/2015, the patient was seen at the obstetrician’s office with continued significantly high blood pressure. The obstetrician ordered a 24-hour urine and pregnancy induced hypertension labs. The patient then went home.
On 04/17/2015, the lab studies showed significant abnormalities consistent with severe pregnancy induced hypertension. The patient went to the hospital. She subsequently had an intrauterine fetal death at approximately 22 weeks gestation with delivery.
The Board judged obstetrician’s conduct to be below the minimum standard of competence given failure to evaluate the patient for preeclampsia with a history and physical, serial blood pressure evaluations, and laboratory studies. He failed to admit the patient to a hospital for treatment.
The Board ordered the obstetrician be reprimanded, be placed on probation for a period of 6 months, and take 5 hours of CME in hypertensive disorders in pregnancy.
State: Arizona
Date: February 2017
Specialty: Obstetrics
Symptom: Gynecological Symptoms
Diagnosis: Preeclampsia
Medical Error: Diagnostic error
Significant Outcome: Death
Case Rating: 3
Link to Original Case File: Download PDF