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North Carolina – Vascular Surgery – Abdominal Aortic Aneurysm 8.3 cm In Size With Large Type I Endoleak
On 3/31/12, a 76-year-old male with a history of heart disease, chronic obstructive pulmonary disease (COPD), prior endovascular repair of a large abdominal aortic aneurysm (AAA) in 2010 at an outside hospital (OSH) presented to the VA Medical Center emergency department with complaints of back, flank, and hip pain.
On 4/1/12 in the early morning, the patient had a CT scan with contrast which revealed an 8.3 cm AAA with large Type I endoleak. There was retroperitoneal stranding consistent with an aneurysm rupture. At 7:45 a.m., these findings were communicated to the emergency department physician.
At 8:00 a.m., the patient was evaluated by a vascular surgeon. Based on the vascular surgeon’s interpretation of the CT films and the patient’s clinical presentation, the vascular surgeon recommended admission for observation with a follow-up consultation with orthopedic surgery and interventional radiology.
The patient was admitted to the medical ward for the next three days during which he continued to have severe ongoing pain that was managed with pain medications.
On 4/4/12, the patient had a precipitous decline in his clinical status with severe hemodynamic compromise. A repeat CT scan demonstrated a ruptured AAA with aortocaval fistula. The patient was taken to the operation room where the vascular surgeon performed an open repair of the aortocaval fistula and ruptured AAA. However, the patient suffered extensive operative blood loss, perioperative myocardial infarction, and neurological injury.
The patient survived the procedure but remained critically ill. Over the next several days, the patient improved to a certain degree, but it was felt that the patient had suffered brain injury with little chance for meaningful recovery.
On 4/9/12, supportive measures were withdrawn, and the patient died.
In January 2017, the Board received information regarding a medical malpractice lawsuit settlement payment related to the care provided by the vascular surgeon to the patient.
The Board obtained the patient’s records and sent them to a qualified independent medical expert for review. The independent medical expert judged the vascular surgeon’s conduct to be below the minimum standard of competence given failure to adequately diagnose and aggressively treat the patient’s symptomatic, ruptured AAA despite evidence of the patient’s life-threatening condition.
The vascular surgeon was reprimanded.
The Board reported the Consent Order to the Federation of State Medical Boards.and the National Practitioner Data Bank.
State: North Carolina
Date: July 2017
Specialty: Vascular Surgery, Emergency Medicine
Symptom: Back Pain, Pelvic/Groin Pain
Diagnosis: Aneurysm, Post-operative/Operative Complication
Medical Error: Delay in proper treatment
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF
North Carolina – Internal Medicine – Three Emergency Department Visits With Persistent Severe Headache And A Negative CT Head Scan
The Board was notified of a professional liability payment paid on 3/8/16.
A 48-year-old female presented to the emergency department three times over the course of two days with complaints of severe headache.
During the 7/28/12 visit, she had a non-contrast CT head, which was reported as normal. The patient’s headache was treated as an acute migraine attack. She was discharged with anti-migraine, anti-nausea, and anti-anxiety medications.
On 7/29/12, the patient returned with persistent symptoms, was treated symptomatically, and discharged. Later that day, the patient again returned to the emergency department with continuing headache and persistent nausea and vomiting.
The patient was admitted to the hospital under the care of an internist. The patient was started on maintenance IV fluids to treat dehydration and was treated for the underlying migraine with analgesics and antiemetic.
During the internist’s care of the patient, the internist did not order a spinal tap or additional CT scan, instead relying on the 7/28/12 emergency department CT scan.
On hospitalization day three, the patient was discharged with anti-migraine and anti-nausea medications, and was advised to follow up with her primary care physician or neurologist within a week.
On 8/2/12, the day after discharge, the patient returned to the emergency department with a continuing headache and a CT scan of her head showed intracranial hemorrhage in the right temporal lobe.
The patient was then airlifted to a tertiary care center and had clipping of a brain aneurysm/hematoma removal and ventriculoperitoneal shunt placement.
The Board obtained the patient’s records and sent them to a qualified independent medical expert for review.
The independent medical expert judged the internist’s conduct to be below the minimum standard of competence given failure to provide adequate care for severe persistent headache with normal neurological exam. The medical expert found that the internist failed to perform a lumbar puncture and repeat imaging or seek neurology input.
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: July 2017
Specialty: Internal Medicine, Hospitalist
Symptom: Headache, Nausea Or Vomiting
Diagnosis: Intracranial Hemorrhage
Medical Error: False negative, Delay in proper treatment, Failure to order appropriate diagnostic test, Underestimation of likelihood or severity
Significant Outcome: Permanent Loss Of Functional Status Or Organ, Hospital Bounce Back
Case Rating: 4
Link to Original Case File: Download PDF
North Carolina – Orthopedic Surgery – Wrong Site Surgery When Performing Arthrodesis Of The Left Great Toe
The Board was notified of a professional liability payment made on 8/30/16.
A patient presented to an orthopedic surgery for arthrodesis of her left great toe. In preparing the patient for surgery, the orthopedic surgeon stated that he did not see the markings on the left leg, given that they had been covered by stockings. The orthopedic surgeon erroneously prepared the patient for surgery on the right toe based on what he believed he saw on the x-ray. Despite performing appropriate timeout procedures, none of the surgical team appreciated the error until the end of the procedure.
The Board expressed concern that the orthopedic surgeon’s conduct was below the standard of care. The Board acknowledged that the orthopedic surgeon implemented several practice improvement procedures in response to this event.
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: June 2017
Specialty: Orthopedic Surgery
Symptom: N/A
Diagnosis: Musculoskeletal Disease
Medical Error: Wrong site procedure
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
North Carolina – Orthopedic Surgery – Wrong Site Surgery Of A Piriformis Tendon Release
The Board was notified of a professional liability payment paid on 6/21/16.
The Board expressed concern that the orthopedic surgeon performed a left sided sciatic neuroplasty and piriformis tendon release on the wrong side of the patient. The orthopedic surgeon indicated that all pre-operative verification procedures and timeouts were conducted, including placing a mark on the intended surgical site. In spite of these precautions, everyone in the room failed to recognize that the patient had been turned on the wrong side. The error was not recognized until the completion of the patient’s procedure.
The Board noted that the orthopedic surgeon implemented several further practice improvement policies in response to the event.
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: June 2017
Specialty: Orthopedic Surgery
Symptom: N/A
Diagnosis: N/A
Medical Error: Wrong site procedure
Significant Outcome: N/A
Case Rating: 1
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
North Carolina – Internal Medicine – Prescribing Opiates Without Checking Controlled Substance Reporting System
In January 2016, a patient presented with a history of anxiety, depression, schizophrenia, bipolar disorder, and drug abuse. The patient also had a history of chronic obstructive pulmonary disease and liver disease. An internist took care of the patient until her death in June 2016 from opiate overdose.
The Board obtained the patient’s records and sent them to a qualified independent medical expert for review. The independent medical expert judged the internist’s conduct to be below the minimum standard of competence given failure to obtain a full medical history, request medical records from other providers, and obtain a current list of medications taken by the patient. During the patient’s first office visit, the internist obtained a blood test that showed evidence of liver disease. In subsequent visits, the abnormal blood test with the possibility of liver disease was not addressed.
In addition, the independent medical expert was concerned that the internist failed to recognize and appropriately address aberrant behavior that may have been an indication of drug abuse or diversion. Urine drug screens were not performed. A controlled substance agreement was not signed. The North Carolina Controlled Substance Reporting System (NCCSRS) was not checked until after the patient’s death.
In February 2016, the internist prescribed hydrocodone to treat the patient for wrist pain associated with an injury. Because he did not search the NCCSRS, the internist did not know that the patient had received three prescriptions for hydrocodone and oxycodone from three providers in less than one month.
In March 2016, the patient reported that she had lost her prescription and needed an early refill. Without checking the NCCSRS, the internist refilled a prescription for oxycodone. If the internist had searched the NCCSRS, he would have seen that the patient had not lost her prescription, but had filled the prescription the same day she received it. Additionally, the internist would have seen that just five days prior to her office visit, the patient had filled a second prescription for oxycodone written in the internist’s name. Finally, the internist would have also seen that the patient had continued to receive oxycodone from another provider.
The Board expressed concern that the physician failed to conform to the standard of care.
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: March 2017
Specialty: Internal Medicine
Symptom: Extremity Pain
Diagnosis: Drug Overdose, Side Effects, or Withdrawal
Medical Error: Improper medication management, Procedural error
Significant Outcome: Death
Case Rating: 3
Link to Original Case File: Download PDF
North Carolina – Gynecology – Hypoxia During Hysteroscopic Resection
On 1/9/2015, a female presented to a gynecologist for a hysteroscopy to resect a large submucosal fibroid, which was in excess of 3 cm, after being treated in the office for several months. The Board noted that the gynecologist recommended a complete hysterectomy for the patient, but the patient refused. Regardless, the gynecologist chose to proceed with a hysteroscopic resection. Because the fibroid was large, the operative time was far in excess of what would be expected. During the operation, hysteroscopic fluid management indicated a significant excess in fluid intake. The excess fluid retention caused the patient to suffer oxygen desaturation as a result of significant pulmonary and laryngeal edema.
The Board expressed concern that the gynecologist failed to stage the operation to avoid prolonged operative time and fluid overload.
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: February 2017
Specialty: Gynecology
Symptom: Mass (Breast Mass, Lump, etc.)
Diagnosis: Post-operative/Operative Complication
Medical Error: Procedural error
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
North Carolina – Nephrology – Deciding To Initiate Vancomycin For Patient With Prior History Of Tachycardia And Dyspnea After Receiving Vancomycin
The Board was notified of a professional liability payment made on 6/5/15.
A 31-year-old male with end-stage renal disease presented to the emergency department with cough, fever, and acute pain. The initial diagnosis was sepsis. He was given cefazolin and gentamicin. The patient’s allergy history was noted to include penicillin and vancomycin.
The patient subsequently underwent two transfers of care. During these transfers, it was indicated by various physicians that the patient would require intravenous vancomycin to treat sepsis. Given the patient’s ambiguous allergy history, the evening hospitalist made the decision to defer to a nephrologist the decision regarding the treatment of the patient with vancomycin as the nephrologist had treated the patient in the past. As the patient’s nephrologist, he was aware that the patient had received vancomycin in the past both intravenously and intraperitoneally. The patient had previously developed tachycardia and dyspnea after receiving vancomycin. The nephrologist had concluded that the patient’s reaction to the most recent exposure to vancomycin was not a true allergic reaction, but rather “red man syndrome” and that the patient now required vancomycin to successfully treat the sepsis. Within minutes of the start of the vancomycin infusion, the patient developed tachycardia, dyspnea, and ultimately cardiac arrest from which he could not be revived.
The Board expressed concern that the nephrologist’s care of the patient fell below the standard of care.
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: February 2017
Specialty: Nephrology
Diagnosis: Sepsis
Medical Error: Improper medication management, Underestimation of likelihood or severity
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF
North Carolina – Urology – Difficult Robotic Assisted Laparoscopic Prostatectomy Leads To Extensive Bleeding And A Prolonged Procedure
On 12/30/2013, a 73-year-old male with prostate cancer underwent a Da Vinci robotic-assisted laparoscopic prostatectomy. The general surgeon encountered various problems with difficult visualization and dissection, leading to extensive bleeding which resulted in a prolonged procedure. After the procedure, the patient was transferred to the ICU in critical condition. The following morning, the patient died despite attempted resuscitation.
The Board obtained the patient’s records and sent them to a qualified independent medical expert for review. The independent medical expert expressed concern that the procedure took longer than would be expected and involved extensive blood loss.
The Board received two Affidavits from physicians knowledgeable about the urologist, which included a urologist who performs robotic laparoscopic prostatectomies and a family medicine practitioner who has referred urology patients to the urologist for thirteen years. Both physicians opined that the complication involving the patient was an aberration.
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: January 2017
Specialty: Urology
Symptom: N/A
Diagnosis: Prostate Cancer
Medical Error: Procedural error
Significant Outcome: Death
Case Rating: 1
Link to Original Case File: Download PDF
North Carolina – Orthopedic Surgery – Radiology Report Diagnoses Medial Supracondylar Fracture
The Board was notified of a professional liability payment made on 01/05/2016.
In April 2014, a six-year-old male was referred to an orthopedic surgeon for a follow-up of an elbow injury. The emergency department radiology report stated that the patient’s injury was a “medial supracondylar fracture.” The orthopedic surgeon took subsequent x-rays of the patient and continued closed treatment of the patient for what was thought to be a “medial supracondylar fracture.
The patient continued to suffer pain and popping at the fracture area during treatment. While the patient was out-of-state, he sought treatment with another orthopedic surgeon, who correctly diagnose the patient’s fracture as a “displaced lateral condyle fracture with non-union” and referred him to another physician for surgical treatment.
The Board obtained the patient’s records and sent them to a qualified independent medical expert for review. The independent medical expert judged the orthopedic surgeon’s conduct to be below the minimum standard of competence given failure to properly diagnose the patient’s “displaced lateral condyle fracture with non-union.”
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: January 2017
Specialty: Orthopedic Surgery
Symptom: Extremity Pain
Diagnosis: Fracture(s)
Medical Error: Diagnostic error
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF