Found 35 Results Sorted by Case Date
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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



Kansas – Physician Assistant – Lovenox Prescribed For DVT In A Patient With A History Of GI Bleeding



On 11/19/2015, a patient presented to a family care clinic with complaints of swelling and pain in the right lower extremity (“RLE”).

The patient was seen by the APRN who documented the patient’s history of GI bleeding, noting the patient had experienced a RLE deep vein thrombosis (“DVT”) and pulmonary embolism (“PE”) on October 2015, that had been treated with an IVC filter in a medical center.

The APRN further documented in the patient’s chart, “No [sic] on anticoagulants due to GI Bleed,” and “Recent [history] GI bleed.”

The patient was referred to cardiology for the management of his anticoagulation.  He was to follow up on the morning of 11/20/2015 to have a complete blood count (“CBC”) drawn.

On 11/20/2015, the patient presented to a physician assistant with right leg and foot swelling with new onset pain rated a 1/10.  The physician assistant did not document a patient history and did not review the APRN’s notes from 11/19/2015.  The physician assistant diagnosed the patient with DVT of the right popliteal vein and mild anemia.  The physician assistant improperly prescribed Lovenox 60 mg SQ twice a day for one week with a follow-up to confirm dissolution of the clot.

On 11/23/2015, the patient awoke during the night with chest pain and was transported via ambulance to the emergency department where it was determined the patient had a GI bleed.  The patient’s hemoglobin (“HGB”) dropped abnormally low to 7.7, and his hematocrit (“HCT”) was also abnormally low at 27.4%.

The physician assistant’s response, received by the Board on 3/29/2016, noted, “There was no indication in the note from the previous day, nor in any clinic note that he was not a candidate for anticoagulation therapy.”  However, the original notes received by the Board on 10/6/2016 from the hospital indicated that the patient had a history of GI bleed and no anticoagulants should have been prescribed.

The Board judged the physician assistant’s conduct to be below the minimum standard of competence given his inappropriate prescribing of Lovenox.

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: Blood in Stool, Extremity Pain, Swelling


Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Deep Vein Thrombosis/Intracardiac Thrombus, Pulmonary Embolism


Medical Error: Improper medication management, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Kansas – Pediatrics – Inability To Diagnose Patient And Use of Improper Medications Due To A Lack of Documentation/Diagnostic Testing



On 2/19/2013, a 17-month-old male presented to a pediatrician’s office for his fifteen-month check.  The pediatrician documented a past medical history of transposition of great vessels at three weeks and open heart surgery.  During the appointment, the pediatrician failed to document family history entirely.  The pediatrician’s section is word-for-word the same information as in other patient records.  The pediatrician failed to provide a detail of treatment plan unique to the patient

On 4/10/2013, the patient presented with a chief complaint of progressively worsening cough with concerns for respiratory syncytial virus, and bronchiolitis.  The review of systems documented ENT evaluation and did not assess the heart. No pulse oximetry was performed.  The physical assessment did not document any GI, musculoskeletal, or skin assessments.

On 5/2/2013, the patient presented for nasal congestion and cough for the last two to three days.  No review of systems was documented.  No oximetry was performed.  It is unclear whether budesonide and albuterol were prescribed, although the pediatrician indicated treatments of budesonide and albuterol in his plan.

On 5/13/2013, the patient presented for coughing coupled with wheezing and rales in the chest.  No pulse oximetry was performed.  The pediatrician signed the patient’s record electronically ten days following the patient visit.

On 6/13/2013, the patient presented with chief complaints of croupy cough, very phlegmy, audible wheezing, rales in the chest, and low-grade fever.  No pulse oximetry was performed.  The pediatrician failed to document his impression regarding why the patient has had the same symptoms since 4/10/2013.

The pediatrician signed the patient record electronically on 7/9/2014.

The pediatrician eventually administered Rocephin and IV methylprednisolone, which was identified as being inappropriate.

The Board judged the pediatrician’s conduct to be below the minimum standard of competence given his failure to keep written medical records and given his failure to prescribe appropriate medications for the patient’s diagnosis.

The Board ordered that the pediatrician attend and successfully complete the Medical Record Keeping Seminar at Center for Personalized Education for Physicians (“CPEP”). Also, the Board ordered that the pediatrician hire a medical scribe. Finally, the Board ordered that the pediatrician have another pediatrician monitor his work.

State: Kansas


Date: October 2016


Specialty: Pediatrics


Symptom: Cough, Fever


Diagnosis: Pulmonary Disease


Medical Error: Improper medication management, Failure to order appropriate diagnostic test, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Kansas – Pediatrics – Unnecessary Use of Azithromycin In Viral Infection



On 2/27/2013, a 13-year-old female presented to a pediatrician for follow-up five days after a visit to the emergency department where she had complained of chest pain and had an abnormal D-dimer lab value.  No patient education was documented related to the significance of the finding or the risk of a pulmonary embolism.  The patient record appeared to have been signed with a stamp and not dated.

On 4/24/2013, the patient presented with complains of bilateral ear pain and sore throat.  The patient’s past medical history stated “Significant for allergies.”  However, at her previous appointment, it listed only left knee injury. There was no other information contained in her past medical history.  The record was electronically signed by an advanced practice registered nurse (“APRN”) on 5/23/2013.

On 10/21/2013, the patient was seen by the APRN with complaints of vomiting, diarrhea, and abdominal cramping. At this appointment, the patient’s past medical history stated, “Noncontributory.”  The APRN documented putting the patient on Phenergan 25 mg tablets #40 one by mouth every eight hours as needed, Bentyl 20 mg #40 one by mouth every eight hours as needed, and acidophilus tablets #20 one by mouth twice daily for ten days.  The record was electronically signed by the APRN on 11/15/2013.

On 1/28/2014, the patient presented with cough, sore throat, hoarseness, body aches, and headache.  Vitals were taken and documented within normal limits; however, no blood pressure or heart rate was documented.  The patient was positive for cervical lymphadenopathy and flu A, rhonchi and wheezing were noted, and the pediatrician prescribed azithromycin.  Azithromycin is not indicated for a viral infection and not otherwise justified in the absence of a non-current bacterial infection.

The patient record was signed electronically by the APRN on 3/19/2014.

The Board judged the pediatrician’s conduct to be below the minimum standard of competence given his failure to keep written medical records which accurately describe the services rendered to the patient, including patient histories, pertinent findings, examination results and test results.  Also, the pediatrician prescribed, dispensed, and administered or distributed a prescription drug, in an improper or inappropriate manner.

The Board ordered that the pediatrician attend and successfully complete the Medical Record Keeping Seminar at the Center for Personalized Education for Physicians (“CPEP”). Also, the Board ordered that the pediatrician hire a medical scribe. Finally, the Board ordered that the pediatrician have another pediatrician monitor his work.

State: Kansas


Date: October 2016


Specialty: Pediatrics, Emergency Medicine


Symptom: Cough, Headache, Pain


Diagnosis: Infectious Disease


Medical Error: Improper medication management, Failure of communication with patient or patient relations, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Kansas – Obstetrics – Administering Vaccines In A Pregnant Patient Without Consent



On 3/6/2013, a patient presented for a newborn screening. No pregnancy or labor and delivery history were documented.  A family history was documented; however, no detail of family history was documented.  The patient was not seen until eleven days after discharge.

On 7/3/2013, the patient presented to the obstetrician for her four month well exam.  At that appointment, the patient was administered the following vaccines: Hib, PEDIARIX, PCV 13, and Rota.  No consent form for the aforementioned vaccines was found in the record.

On 9/10/2013, the patient presented to the obstetrician for her six-month exam.  The obstetrician electronically signed the record on 9/27/2013, approximately seventeen days later.

The Board judged the obstetrician’s conduct to be below the minimum standard of competence given his failure to describe the services rendered to the patient.

The Board ordered that the obstetrician attend and successfully complete the Medical Record Keeping Seminar at Center for Personalized Education for Physicians (“CPEP”). Also, the Board ordered that the obstetrician hire a medical scribe. Finally, the Board ordered that the obstetrician have another obstetrician monitor his work.

State: Kansas


Date: October 2016


Specialty: Obstetrics


Symptom: N/A


Diagnosis: N/A


Medical Error: Failure of communication with patient or patient relations, Ethics violation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Kansas – Pediatrics – Improper Documentation In A Patient With Cough, Wheezing, and Runny Nose



On 12/5/2012, a newborn patient presented for his two-week check.  No family history, pregnancy, or labor and delivery history were documented.  The patient was not seen until thirty-three days after discharge.

The patient was seen only a total of three times by six months of age.  The medical record did not discuss why immunizations were late.  The plan/treatment section of the record was word-for-word the same information as in other patient records.

On 8/26/2013 a pediatrician saw the patient.  The pediatrician documented the patient had a cough, wheezing, and a runny nose.  No other information regarding an exam was given outside of the patient’s vitals being taken.  The pediatrician administered Microephrine 0.2 ml in the office.  The record appears to have been stamped in the pediatrician’s signature, but there was no corresponding date.

On 9/3/2013, the patient presented to the pediatrician after being admitted to the hospital the week prior with croup, bronchiolitis, and respiratory distress.  No information regarding the patient’s hospital stay was found in the pediatrician’s record.

The Board judged the pediatrician’s conduct to be below the minimum standard of competence given his failure to keep written medical records which accurately describe the services rendered to the patient, including patient histories, pertinent findings, examination results and test results.

The Board ordered that the pediatrician attend and successfully complete the Medical Record Keeping Seminar at Center for Personalized Education for Physicians (“CPEP”). Also, the Board ordered that the pediatrician hire a medical scribe. Finally, the Board ordered that the pediatrician have a pediatrician to monitor his work.

State: Kansas


Date: October 2016


Specialty: Pediatrics


Symptom: Cough


Diagnosis: N/A


Medical Error: Lack of proper documentation, Failure to examine or evaluate patient properly


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Kansas – Pediatrics – Improper Documentation For Reactive Airway Disease And Improper Use of Bactrim



On 2/4/2013 a 7-year-old female presented to a pediatrician and saw the advanced practice registered nurse (“APRN”).  The patient presented with chief complaints of allergies, congestion, and diarrhea.  The patient was prescribed albuterol, Qvar 40 mcg, Bactrim, and triamcinolone.  The Bactrim was prescribed inappropriately for diarrhea.  The pediatrician agreed but thought that he had perhaps forgotten to document otitis media.

On 2/19/2013, the pediatrician saw the patient for a follow-up appointment.  The pediatrician documented that the patient was there for a follow-up for her asthma, even though the patient previously presented with reactive airway disease.  The pediatrician did not document his thought process in how reactive airway disease developed in asthma.  The pediatrician did not electronically sign the record until 4/11/2013.

On 6/11/2013, the patient presented to the pediatrician for a school physical.  The pediatrician failed to document the patient’s asthma.  In the school health examination, the pediatrician stamped signature appears on the form with the date 6/11/2013.  The pediatrician stamped the document “No” to the question, “Is this student subject to any condition which might cause a possible classroom emergency such as seizures, fainting, diarrhea, diabetes, asthma, allergies, etc.”

The Board judged the pediatrician’s conduct to be below the minimum standard of competence given his failure to keep written medical records, and inappropriately prescribing a medication.

The Board ordered that the pediatrician attend and successfully complete the Medical Record Keeping Seminar at Center for Personalized Education for Physicians (“CPEP”). Also, the Board ordered that the pediatrician hire a medical scribe. Finally, the Board ordered that the pediatrician have a pediatrician monitor his work.

State: Kansas


Date: October 2016


Specialty: Pediatrics


Symptom: Allergic Reaction Symptoms, Diarrhea


Diagnosis: Asthma


Medical Error: Lack of proper documentation, Improper medication management


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Kansas – Cardiothoracic Surgery – Improper Surgical Procedure Of Abdominal Aortic Aneurysm Results In Anuria And Then Death



A 72-year-old male patient was admitted to a medical center with foot ulcer and foot pain. During the patient’s hospitalization, an ultrasound revealed an 8.5 cm large abdominal aortic aneurysm (AAA).  The patient was subsequently scheduled for surgical repair.

On 10/24/2010, a cardiothoracic surgeon admitted the patient to a medical center and completed a history and physical.  The cardiothoracic surgeon also signed pre-operative orders at that time.

On 10/25/2010, the cardiothoracic surgeon performed an endovascular AAA stent repair on the patient using an Endologix stent graft.  After surgery, the cardiothoracic surgeon returned to Wichita, Kansas.  The cardiothoracic surgeon’s first assistant an ARNP, signed the post-operative orders and monitored the patient’s recovery along with other hospital staff.

Post-surgery the patient began to have decreased urine output on 10/26/2010.  The patient was oliguric and then anuric.  The patient failed to respond to large doses of diuretics so a nephrologist was consulted for dialysis.

A CT scan on 10/26/2010 showed bilateral renal artery occlusion and segmental occlusion of the proximal superior mesenteric artery.

Eventually the patient was transferred to Wichita, Kansas for further care where he later died on 10/29/2010.

The Board judged the cardiothoracic surgeon’s conduct to be below the minimum standard of competence given his failure to perform proper endovascular surgery on the patient

The Board ordered that the cardiothoracic surgeon have a cardiac surgeon and/or radiologist with adequate experience in endovascular abdominal aortic aneurysm repair participate and assist the cardiothoracic surgeon on his next ten endovascular abdominal aortic aneurysm repair cases.  Also, the Board ordered that the cardiothoracic surgeon complete at least eight hours of continuing medical education courses with emphasis on endovascular abdominal aortic aneurysm repair.

State: Kansas


Date: June 2016


Specialty: Cardiothoracic Surgery, Nephrology


Symptom: Pain


Diagnosis: Aneurysm, Renal Disease


Medical Error: Procedural error


Significant Outcome: Death


Case Rating: 2


Link to Original Case File: Download PDF



Kansas – Obstetrics – History Of Hypertension And Presentation With Vaginal Bleeding And Cramping



On 2/25/2013, a 26-year-old pregnant female with a history of four prior pregnancies, resulting in four prior premature births, presented to the emergency department with complaints of vaginal bleeding and cramping.  The patient was documented to have a history of hypertension and an ultrasound confirmed an intrauterine pregnancy.

The patient was scheduled to see an obstetrician for follow-up care the following morning but failed to keep the appointment.

On 5/30/2013, the obstetrician saw the patient for an appointment.  He designated the appointment as the patient’s first prenatal visit. At the time of the appointment, the patient’s blood pressure was documented as 198/154.

That same day, the obstetrician sent the patient for a sonogram and lab tests with a follow-up appointment to be scheduled in two weeks.  Lab results showed that the patient had a urinalysis protein of 100, but there was no documentation showing the obstetrician reviewed the results or that the patient was contacted with the results.

On 6/4/2013, the patient returned to the obstetrician’s office.  The patient’s blood pressure was documented as 202/136.

The patient was subsequently admitted to a clinic that same day at approximately 5:00 p.m. with hypertension and severe headache.  The obstetrician’s admission diagnosis was documented as severe chronic hypertension, single intrauterine pregnancy at twenty-nine weeks.

The nursing notes for the patient’s admission to the clinic document that the patient arrived from the obstetrician’s office for a non-stress test and labs.  The nursing staff further documented that the patient was experiencing a severe headache with the right side of her head feeling numb.  Her blood pressure was documented at 208/129.

The obstetrician initially ordered pregnancy-induced hypertension lab testing but canceled the ordered labs.  The patient was given labetalol 400 mg by mouth twice daily with the first dose administered at approximately 5:37 p.m.  Two non-stress tests were also completed.

After the administration of Labetalol, the patient’s blood pressure slowly dropped with systolic measurements in the 160’s and diastolic measurements in the 90-100’s.

At 7:20 p.m., the clinic staff informed the obstetrician of the patient’s high blood pressure and requested medication and parameters.  The obstetrician instructed the staff that the patient was to be left alone and do nothing different.

At 8:00 p.m., orders were obtained by the staff to administer Tylenol for the patient’s continued headache.  However, the Tylenol was not effective as the patient continued to complain of a severe headache.

No new orders were issued for the remainder of 6/4/2013, but staff continued to document the patient’s blood pressure and fetal heart tones. The patient’s systolic measurements remained between 170-220’s and diastolic measurements remained in the 100’s.

At 4:47 a.m. on 6/5/2013,  the patient’s fetal heart tones were documented to have decreased to 125 for approximately 140 seconds, and then returned to baseline.  At 5:38 a.m., the patient was given labetalol 400 mg by mouth.

At 8:55 .m., the patient was documented as resting and denied having a headache or pain.

At 10:13 a.m., the obstetrician saw the patient and ordered a twenty-four hour urine protein.

At 3:25 p.m., the patient again complained of a constant, dull headache.  The patient was given Tylenol 1000 mg orally and later complained that she was feeling “shaky all over.”

At or around 4:03 p.m., the staff notified the obstetrician of the patient’s status, including the fact that the patient had an elevated blood pressure in spite of labetalol.  They asked whether the patient should be on bed rest.  The notified the obstetrician of the patient’s complaint of headache, shakiness, and limited voiding.  They asked if these issues could be related to preeclampsia.  The obstetrician gave no new order or diagnosis and stated that he would be on the OB floor in approximately an hour.

At 4:59 p.m., the patient was documented with a continued complaint of a headache when she moved her eyes.

At 5:20 p.m., the obstetrician was in to see the patient and again wrote orders reiterating the patient’s diagnosis of severe chronic hypertension, and ordered an EKG, echocardiogram, ophthalmology consult, continued twenty-four hour urine protein, and labetalol 20 mg IV bolus with a repeat dose of 40 mg IV if the patient’s blood pressure were to be greater than 160/110 after ten minutes, and to continue Labetalol 400 mg by mouth twice daily.

At 5:40 p.m., the obstetrician dictated the patient’s history and physical for her admission.  The obstetrician documented the patient had severe hypertension; had 100 mg/dl of proteinuria; had no headaches, and had “[n]o sign of preeclampsia at this time.”

The patient received an additional 80 mg of labetalol IV at 8:57 p.m. and her blood pressure remained in the severe level above 160/110, only dropping briefly to 185/115 before returning to the 200’s systolic and 120’s to 130’s diastolic.

On or about 6/6/2013, the patient’s blood pressure remained elevated despite receiving labetalol 40 mg IV at 12:57 a.m., 20 mg IV at 2:00 a.m., and 40 mg IV at 4:12 a.m.

The obstetrician was updated on the patient’s blood pressure status, but was not in to see the patient until 10:35 a.m.  At that time, the obstetrician ordered labetalol 400 mg by mouth every eight hours.

The patient’s previously ordered twenty-four urine protein results was 1953 mg/dl.  The obstetrician was notified by staff of the patient’s results and was documented as saying the patient’s protein was good.

The patient’s blood pressure continued to run in the 210-220’s systolic and 120’s-130’s diastolic

At 6:37 p.m., the obstetrician dictated a progress note for the patient documenting the patient as having severe chronic hypertension.  The obstetrician also noted the patient was on labetalol 400 mg three times daily and that the patient’s blood pressure remained high.  The obstetrician planned to continue the patient’s labetalol.

The patient’s blood pressure remained elevated and at 9:58 p.m. the obstetrician was notified of the situation and the patient’s complaint of a headache.  No new orders were given.

At 10:22 p.m., the obstetrician called to check on the patient’s condition.  The patient continued to complain of a headache and had a documented blood pressure of 221/129.

At 10:25 p.m., the obstetrician ordered “hydralazine 10 mg SIVP over 2 min x 1 Now” for the patient’s symptoms.

At 1:08 a.m. on 6/7/2013, the staff again contacted the obstetrician with the patient’s high blood pressure and headache.  The obstetrician gave orders for repeat a hydralazine 10 mg SIVP and for the patient to be started on magnesium sulfate.  Twenty minutes later the obstetrician ordered the magnesium sulfate to be held.

The patient continued to have a headache and at 1:42 a.m. was documented to complain of blurry vision.  The staff notified the obstetrician of the patient’s symptoms and continued headache.

At 5:34 p.m., the fetal heart rate dropped to sixty for two and a half minutes with recovery to the 120’s.

The patient continued to complain of a headache and at 5:49 p.m. the staff documented the patient as stating, “I feel like there is something wrong with me…I just don’t feel myself…headache is not going away and I feel weird.”

At 6:10 p.m., the obstetrician was in to see the patient who was complaining of upper abdominal pain, increasing headache pain and decreased urine output.  The obstetrician ordered the staff to give the patient hydralazine 10 mg SIVP, and magnesium sulfate 4 gm bolus followed by magnesium sulfate 2 gm/hr and betamethasaone intramuscularly.

The obstetrician also decided to transfer the patient to a different medical center for further care.

At 7:58 p.m., the patient was discharged to EMS care for transfer to a medical center.

In the obstetrician’s discharge summary for the patient, he documented that the patient was admitted with a diagnosis of “severe chronic hypertension with superimposed preeclampsia.”  In addition, he noted that he had given the patient three doses of labetalol, but failed to mention the three previous doses given during the early morning hours on 6/6/2013.

The board judged that the obstetrician failed to adhere to applicable stand of care to a degree constituting ordinary and/or gross negligence due to the following omission: the obstetrician delayed involving other specialists to assist the patient’s care and treatment, failed to acknowledge the patient’s proteinuria and high blood pressure, failed to diagnose and treat the patient’s severe preeclampsia, placed the patient at an increased risk for placental abruption, seizures, and renal damage, and stroke, and the obstetrician delayed to transfer the patient to a facility that could care for the patient and her premature infant.

The Board revoked the obstetrician’s license.

State: Kansas


Date: March 2016


Specialty: Obstetrics


Symptom: Bleeding, Headache, Numbness, Abdominal Pain, Vision Problems


Diagnosis: Preeclampsia


Medical Error: Underestimation of likelihood or severity, Delay in proper treatment, Failure to follow up, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



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