Found 5 Results Sorted by Case Date
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Vermont – Emergency Medicine – Suspected Ventricular Tachycardia Not Addressed In A Patient With Respiratory Distress, Fever, And An Elevated Heart Rate



On 2/6/2013 a patient’s father contacted EMS (emergency medical services) because his son had respiratory distress, fever, and an elevated heart rate.

EMS documented a heart rate of 278 and performed a pre-hospital EKG because ventricular tachycardia (VTach) was a concern.  EMS contacted the hospital to report vital signs and their impression of VTach.

The patient presented to the emergency department at 11:29 p.m.  The patient was triaged at 11:42 p.m. and a pulse of 245, blood pressure of 53/39, and a temperature of 101.02 were recorded.  An EKG was performed at 11:43 p.m.  The results were shown to the ED physician at 11:47 p.m.

The ED physician’s notes state that at 12:13 a.m. the patient was examined.  It was documented that the ED physician suspected the patient was in VTach, but no therapy was administered.

The ED physician then contacted the on-call cardiologist, who advised the ED physician to treat the patient for probable sepsis with fluids and Tylenol.  The ED physician then ordered IV antibiotics and spoke to a critical care physician about transfer of the patient.

At 12:29 a.m. the patient had a ventricular fibrillation cardiac arrest.  He was treated with various medications but no shock was given.  At 12:45 a.m. the patient was pronounced dead.

The Board concluded that the ED physician be reprimanded, complete 15 hours of continuing education on Advanced Cardiac Life Support, and pay a fine of $1000.

State: Vermont


Date: September 2017


Specialty: Emergency Medicine, Cardiology


Symptom: Shortness of Breath, Fever, Palpitations


Diagnosis: Cardiac Arrhythmia


Medical Error: Improper treatment, Delay in proper treatment


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



Vermont – Family Practice – Oversight In Anorexia Nervosa Monitoring



A patient was treated by a family practitioner from May 2012 to September 2012.

On the first office visit, the patient presented with symptoms and behaviors that met the DSM-IV criteria of anorexia nervosa, as well as the National Institute for Mental Health criteria of Pediatric Acute Neuropsychiatric Syndrome (PANS).  The patient’s medical records from the patient’s prior primary care physician included a diagnosis of anorexia nervosa and a prior recommendation for inpatient mental health treatment for anorexia.

The family practitioner made the following diagnoses:  systemic inflammatory syndrome with multi-systemic symptoms and marked neuropsychiatric dysfunction with probable underlying infectious triggers; PANS (Pediatric Acute Neuropsychiatric Syndrome); and probable PITANDs (Pediatric Infection-Triggered Autoimmune Neuropsychiatric Disorders).  Anorexia nervosa was not documented as a primary or differential diagnosis.  The family practitioner indicated that he considered the possibility of a purely behavioral syndrome like anorexia nervosa, but felt that the patient’s anorexia was “part of a more complex multi-system picture.”

The family practitioner based his diagnosis on the patient’s history and symptoms meeting the diagnostic criteria for PANS, testing positive to three infectious agents, and an initial response positive response to PITANDs treatment, in addition to a lack of positive response to anorexia nervosa focused management with the patient’s prior primary care physician and other consultants.

The family practitioner saw the patient on three occasions over a four month period, which the Board believes is inadequate for management of anorexia for an adolescent.  The family practitioner relied on his nurse to call the patient on weekly updates and weight checks.

In addition to three office visits, the family practitioner’s treatment included ordering numerous blood tests, and the prescribing of medications, antibiotics, herbal supplements, and vitamins for the infection etiologies and the inflammatory conditions.  However, he did not prescribe any medications for the treatment of anorexia nervosa. While the family practitioner believed that the patient was being treated by his primary care physician, this was not confirmed with any other provider, and the family practitioner did not communicate directly with any other provider beyond sending his initial office visit note and lab results to the patient’s primary care physician.

The Board judged the family practitioner’s medical records and communication with the patient’s primary care physician concerning his treatment of the patient were inadequate. The family practitioner’s office notes did not document past surgical and family history, temperature, height, BMI calculation, and growth curve charting.

Based on review of the family practitioner’s medical records concerning his treatment of the patient and the documentation of his communication with the patient’s parents, it appears that the family practitioner did not clearly explain his role in the patient’s care to the patient’s parents until the end of his treatment.  Is it possible that the patient’s parents believed that the family practitioner had taken over the role as the primary care physician and was actively managing the patient’s care.

The family practitioner’s position was that he believed that he was participating in the care of the patient in the role as a consultant to his primary care physician and that the patient’s primary care physician was concurrently monitoring the patient.  With the exception of the provision of his initial office note and lab results, the family practitioner did not communicate with the patient’s primary care provider during the course of his treatment.  After sending his initial note and lab results, the family practitioner did not communicate with the patient’s primary care provider or any other medical professionals until the patient had an acute worsening of the condition on 9/13/2012.

The Board judged that the family practitioner failed to appropriately monitor, manage, and maintain comprehensive medical records on a juvenile patient with a severe eating disorder.

The Board ordered that the family practitioner be reprimanded, complete one hour of continuing medical education on cognitive bias, and that he shall only practice medicine in a structured, group setting for a period of three years.

State: Vermont


Date: September 2017


Specialty: Family Medicine, Psychiatry


Symptom: Weight Loss


Diagnosis: Psychiatric Disorder


Medical Error: Improper treatment, Failure of communication with other providers, Failure of communication with patient or patient relations, Failure to properly monitor patient, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Vermont – Psychiatry – Pediatrician Prescribes A Combination Of An SSRI And A Benzodiazepine



A pediatrician first met a patient in 2010 when conducting a routine college physical.  In 2011, the pediatrician started the patient on Prozac (fluoxetine) 10 mg daily after the patient started reporting that he was having problems with depression.  After a month, the patient indicated that the medication was working “a little” and denied any side effects, the pediatrician prescribed another 30 tablets of Prozac 20 mg with no refills.

The pediatrician did not see the patient again until 1/30/2014 when the patient came in for a physical exam.  The pediatrician documented that the patient was doing well and was off Prozac.

On 1/22/2015, the patient again came in to see the pediatrician for a physical exam.  The patient was experiencing decreased energy levels, sleeping well, having some difficulty with depression and occasional panic attacks.  The patient was noted as stating that the Prozac he had taken previously did not really help.  The notes document that education and counseling were done, but there was no comment on suicidality.

The pediatrician started the patient on Prozac 40 mg once a day, 30 tablets with no refills, because he had tolerated the 20 mg dose in the past with no side effects.  The patient was also prescribed Xanax (alprazolam), 0.25 mg, 5 tablets with no refills, and was told to take one as needed.

On 1/29/2015, the patient was seen by the pediatrician to follow up on his anxiety and depression.  The patient reported that he was still having panic attacks, for which he took 2 of the 0.25 mg Xanax, and that overall his depression was worse, but that he was dealing more with anxiety than depression.  The patient indicated that he was tolerating the Prozac well.  The patient denied any suicidal ideation or planning.  The pediatrician prescribed the patient Klonopin (clonazepam) 1.0 mg, two times a day, 60 tablets with no refills and increased his Xanax prescription to 0.5 mg as needed, five tablets with no refills.  The pediatrician documented that he provided education and counseling and referred the patient to psychiatry, although the patient indicated that he did not want to go.

On 1/31/2015, the patient reported losing most of his Xanax at work.  The pediatrician advised the patient to stay on Prozac and Klonopin and to save the few Xanax he had for severe panic attacks.  The pediatrician advised the patient that he would look into getting the patient to see a psychiatrist and that he would figure out what to do with the Xanax the following week, but in the meantime, the patient could go to the emergency department or call the pediatrician if he had a panic attack.  The patient agreed to this plan.

During this time, the mother observed changes in the patient’s behavior, including slurring of words, wobbling on his feet, and sleepiness and the patient also became erratic and volatile.  This was not brought to the attention of the pediatrician.

On the morning of 2/2/2015,  the patient called his mother from work and advised they were sending him home because his behavior was similar to someone who was intoxicated.  It was also claimed the patient met with a pharmacist at work, who allegedly told him that the dose of Klonopin was too high and he should cut the dose in half.

The patient returned home and continued to exhibit erratic, volatile, and irrational behavior.  The patient also advised his mother that he tried to cut his wrist and glued it shut.  None of these events were told to the pediatrician and the patient did not show the cut to the pediatrician during the appointment on 1/29/2015 appointment.  The patient made an appointment with another doctor, but could not get in until 2/6/2015.  The patient’s mother asked the patient if he wanted to go to the emergency department but the patient declined, indicating that he had a plan (to cut the dose of Klonopin in half).  That evening the patient had an argument with his girlfriend and committed suicide.

Prozac (fluoxetine) packaging contains a “Black Box” warning for patients up to 21 years of age that indicates there is a very small chance of an adverse reaction that can make the patient more agitated and prone to increased suicidal thoughts.  The patient’s medical chart does not indicate whether the pediatrician explained the Black Box warning to the patient.

The pediatrician retired from the practice of medicine in Fall 2016 as previously planned and for reasons totally unrelated to the allegations in this matter.  He is not currently practicing medicine in the State of Vermont.

The Board judged the pediatrician’s conduct to be below the minimum standard of competence given his failure to maintain adequate and comprehensive medical records, his improper prescribing of an unusually high dose of Prozac, Xanax, and Klonopin, and his failure to conform to the essential standards of acceptable and prevailing practice.

The Board ordered that the pediatrician be reprimanded, pay a fine, and if he applies for a license renewal, he must take a continuing education course on psychotropic medications and retain the services of a practice monitor for a minimum of two years.

State: Vermont


Date: July 2017


Specialty: Psychiatry, Pediatrics


Symptom: Psychiatric Symptoms


Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Psychiatric Disorder


Medical Error: Improper medication management, Lack of proper documentation


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



Vermont – Internal Medicine – Miscommunication Of Dilantin Dosage After Brain Surgery



A patient was admitted on the afternoon of 5/10/2012 from an inpatient hospital where she had recently undergone brain surgery to remove a tumor.  At the time of the admission, an internist saw and examined the patient, went over her history, surgery, and medications, and then wrote orders for her care, including medications.

Sometime in the evening, the internist received a telephone call from the patient’s nurse at a nursing home telling him that she had discovered that the patient had been on Dilantin while hospitalized but it had erroneously been omitted from her nursing home orders.  The internist was indeed concerned that he’d omitted ordering an important medication, as Dilantin, an anti-seizure medication, is frequently prescribed after brain surgery.

The internist told the nurse to write an order for Dilantin.  The nurse inquired what dosage the patient should be placed on, and the internist advised her to inquire of the referring inpatient hospital what dosage she had been on and start her on that.

The nurse later wrote down as a telephone order a dose of Dilantin for the patient and the patient was started on that dose; it is not clear from whom she had obtained the dosing information but she did not call back the internist to discuss the amount with him.

The next time the internist was at the nursing home, on 5/26/2012, he signed a lot of telephone orders. One of them was a telephone order on 5/10/2012 for Dilantin.  The internist signed the order without noticing the dosage was larger than what he was accustomed to prescribing.  Had he noticed the dosage, he would have called the patient’s referring hospital or inpatient attending to determine if the non-standard dose was intentional or a mistake.

On the same day that the internist signed the telephone order, the patient was transferred out of the nursing home to a hospital.  At the hospital, the patient was found to have an excessive Dilantin level, which was eventually corrected by adjustment of the dose.

The Board judged that the internist’s conduct to be below the minimum standard of competence given that he failed to confirm a dose of Dilantin with a nurse calling for a telephone order.

The Board ordered that the internist will hereafter review and sign all telephone orders made by him to a nursing home where he sees patients within ten days of being issued.  This applies to whether the order is for a new medication or is merely an alteration of the dose of an on-going medication.  Before signing any telephone orders, the internist will substantially review all such orders to make sure they are in accordance with the patient’s needs and contain what was transmitted by telephone.  In making a telephone order to a nursing home, the precise dosage will be discussed between the practitioner and the nurse or other on-premises provider and agreed upon before the order will be executed. The internist was also reprimanded and had to pay a fine of $1000.

State: Vermont


Date: October 2013


Specialty: Internal Medicine


Symptom: N/A


Diagnosis: Drug Overdose, Side Effects, or Withdrawal


Medical Error: Accidental Medication Error, Failure of communication with other providers


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



Vermont – Physician Assistant – Wrong Electrocardiogram Reading Used For Diagnosis



On 9/13/2008 a patient presented to the urgent care center at 8:30 a.m. with a chief complaint of shortness of breath.  A nurse administered a 12-lead electrocardiogram (EKG), which indicated an ST segment elevation myocardial infarction.  Neither the treating nurse nor the physician detected the fact that the EKG printout did not include a patient name and was dated 6/15/2007 at 3:00 p.m.  The EKG printout did not document the results of the EKG administered to the patient on 9/13/2008.  Based on the EKG results and the patient’s increased blood pressure and heart rate, the treating physician assistant’s impression was acute coronary syndrome, i.e., acute anteroseptal myocardial infarction.  The treating assistant physician ordered the patient to be transferred to an emergency department at 10:00 a.m. for further evaluation and treatment.

Upon arrival to the emergency department, the ED physician was presented with the EKG from the urgent care center. When the patient arrived at the emergency department, someone had affixed a sticker to the EKG printout that included the patient’s identifying information and was dated 9/13/2008. The date and time of 6/15/2007 at 3:00 p.m. was still visible at the top of the EKG printout.  As a result of the sticker showing the patient’s name and correct date, the ED physician did not notice that the EKG printout had information indicating it was an EKG from the other date of 6/15/2007 at 3:00 p.m.

Two additional EKGs were performed at the hospital and showed rapid atrial fibrillation with runs of ventricular tachycardia, not ST elevation myocardial infarction.

After physically examining the patient, the ED physician called a cardiology fellow at a different medical center for consultation and advised that the patient’s first EKG from the urgent care center showed an ST segment elevation myocardial infarction, but the two additional EKGs that were performed at the ED physician’s hospital showed atrial fibrillation with runs of premature ventricular contractions.  The ED physician did not provide copies of the EKGs to the cardiology fellow to review, and the cardiology fellow did not request them.  The cardiology fellow told the ED physician that the patient was experiencing a rapidly evolving transmural infarction. The cardiology fellow recommended the patient be started on thrombolytics and heparin. The ED physician concurred and started the patient on thrombolytics and heparin. The patient was then transported to the cardiology fellow’s medical center for further treatment. At the medical center, the patient experienced intracranial hemorrhage.

The Board judged that the physician assistant’s conduct to be below the minimum standard of competence given that he failed to recognize that the EKG printout showed a date and time other than the date and time the EKG was administered to a patient and that he diagnosed the patient based on those EKG results.

The Board ordered the physician assistant complete a continuing education course on medical error prevention and pay a fine of $1,000.

State: Vermont


Date: May 2013


Specialty: Physician Assistant, Emergency Medicine


Symptom: Shortness of Breath


Diagnosis: Cardiac Arrhythmia, Intracranial Hemorrhage


Medical Error: Accidental error, Diagnostic error


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 5


Link to Original Case File: Download PDF



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