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Beginning in June 2014, a physician began treating Patients A and B for thyroid dysfunction and Patient C for high blood pressure. The physician communicated with Patient A and B through phone consultation and met Patient C in social situations and during at least two office visits. The physician reviewed previous lab work on thyroid functions for Patients A and B. The physician based Patient C’s treatment upon his physical observation of her conditions, two Zytoscans (device that measures electrical currents in the skin), and taking her blood pressure. Patient A and B’s lab work indicated both patients having lower than normal thyroid function. The physician started both Patients A and B on a thyroid hormone supplement. He prescribed medication commonly used for treating high blood pressure for Patient C based upon his observations, oral reports of Patient C, and the Zytoscans. The physician failed to do lab work, took minimal chart notes, and did not schedule follow-up examinations for Patients A, B, or C.

For several months, the physician continued prescribing for Patients A, B, and C without ever seeing the patients in person for further work up. The physician’s interactions with Patients A and B were solely over the phone, while the physician notes state that he had two office visits with Patient C. The physician did not order thyroid stimulating hormone (TSH) testing to further verify if continuing the thyroid hormone supplement would be appropriate in managing Patient A and B’s conditions.

In June 2015, Patient A presented to another provider with concerns of heart palpitations. Patient A told the provider he noticed the palpitations reduced when he reduced his thyroid hormone supplement dosage. During this consultation, Patient A disclosed his treatment with the physician which alerted the provider to have Patient A’s TSH levels checked. Patient A’s lower than normal TSH result prompted the provider to immediately begin weaning Patient A off of his thyroid hormone supplement.

Patient B also presented to the same provider in June 2015. At her visit, Patient B presented with a rash on her chest which she had for over a month. The new provider assessed the rash being unrelated to her treatment with the physician; however, due to her receiving similar treatment as Patient A, the provider had Patient B’s TSH level tested. Patient B’s results indicated her TSH level was below the normal range.

On 8/26/2015, the physician saw Patient C for what he thought was a urinary tract infection. The physician first prescribed Keflex but changed it to ciprofloxacin based upon the results of a Zytoscan. Caution is required when giving ciprofloxacin to patients with hypokalemia.

On or about 9/9/2015, Patient C presented to the hospital emergency department where she was diagnosed with significant hypokalemia (lowered levels of potassium in the blood) and hyponatremia (lowered levels of sodium in the blood) which caused Patient C to suffer fatigue and heart palpitations. Patient C went immediately from the emergency department to a new care provider. After an oral interview with Patient C, the new care provider learned that Patient C was taking a number of medications prescribed by the physician. The new care provider attempted to contact the physician a number of times to obtain the physician’s chart notes, lab studies, and other medical records for Patient C but was unsuccessful. Patient C told her new care provider that the physician had been giving her medications for a number of years. She stated, “I tell him what I need.” In the physician’s response to the Commission, he stated that “if [Patient C] called me to have a prescription filled, I would do that for her.”

The Commission stipulated the physician reimburse costs to the Commission and write and submit a paper of at least 2000 words, with references and annotated bibliography, regarding Washington State rules for physicians forming and maintaining patient/physician relationships, the differential diagnosis of hyperthyroidism and hypothyroidism, the proper monitoring of electrolyte levels for patients with high blood pressure, and the importance of complying with Commission sanctions.

State: Washington

Date: November 2017

Specialty: Internal Medicine, Family Medicine

Symptom: Palpitations, Rash

Diagnosis: Endocrine Disease

Medical Error: Failure to follow up, Failure to properly monitor patient, Improper medication management

Significant Outcome: N/A

Case Rating: 1

Link to Original Case File: Download PDF

On 11/7/2011, a patient presented as a “medical emergency” and was seen by a physician assistant at a correctional facility.  The patient was a 62-year-old man whose medical record included a history of arthritis, diabetes, and hypertension for which he was treated with blood pressure medication.

The patient told the physician assistant he thought he had a stroke three days earlier and described symptoms of chest pain, left-sided tingling, left-sided weakness, headache, and loss of vision in the bottom visual field of his left eye.  The patient’s presenting blood pressure was 180/94 with a repeat at the end of the visit of 127/82.  The physician assistant noted normal pupil, funduscopic, heart and lung exams.  Cranial nerves II-XII were intact.  The patient’s strength was equal bilaterally.  An EKG was done and interpreted as having a normal sinus rhythm.  The physician assistant’s diagnosis was “No evidence of stroke.”  The patient was given a GI cocktail and released to his unit.

The physician assistant did not verify the patient’s complaint by conducting a visual field exam.  The physician assistant did not consider temporal arteritis as a possible cause of the patient’s vision loss.  Also, he did not at that time discuss his care of the patient with a supervising physician.  The physician assistant failed to recognize the emergent nature of the complaint of sudden vision loss by a patient.

The patient again presented to the physician assistant a week later on 11/14/2011.  He reported continued loss of vision in the bottom visual field of his left eye. The physician assistant completed a form recommending the patient be referred to an ophthalmologist.

The patient was seen two weeks later on 11/29/2011 by a local ophthalmologist who ordered a sed rate to help rule out temporal arteritis and placed the patient on clopidogrel.  The ophthalmologist diagnosed “[a]cute anterior ischemic optic neuropathy OS.”  He stated that at the visit the patient was “already showing signs of superior optic atrophy and inferior visual field loss from superior involvement approximately three weeks previous.”

The Commission stipulated the physician assistant reimburse costs to the Commission and write and submit a paper, with bibliography, on the evaluation of a patient with non-traumatic sudden vision loss.

State: Washington

Date: August 2017

Specialty: Physician Assistant, Family Medicine, Internal Medicine

Symptom: Vision Problems, Headache, Chest Pain, Weakness/Fatigue

Diagnosis: Ocular Disease

Medical Error: Diagnostic error

Significant Outcome: N/A

Case Rating: 5

Link to Original Case File: Download PDF

On 1/3/2015, a seven-month-old patient was brought to an urgent care facility where he was seen by a physician assistant.  His history included over several months of groin rash that was being treated with steroid cream.  The patient’s mother reported that the patient’s left testicle was hard.  Over the past two days, his symptoms had worsened.  The physician assistant examined the patient and found a rash and swelling at the scrotum only.  He diagnosed the patient with a diaper rash.

On 1/4/2015, the patient’s grandparents brought the patient to the emergency department, where he was examined by a second provider.  The patient’s grandparents reported that the patient seemed uncomfortable and that his left scrotum appeared red, swollen, and firm.  An ultrasound found the patient’s left testicle with decreased blood flow.  The patient was transferred to another facility and testicular torsion was confirmed.  The patient underwent emergency surgery where his testicle was found nonviable and removed.

The physician assistant did not consider testicular torsion in the differential diagnosis and failed to order an ultrasound to rule out this condition.

The Commission stipulated the physician assistant reimburse costs to the Commission, complete a continuing medical education course in assessment and diagnosis of acute scrotal conditions, and submit a paper of no less than one thousand words, with references, on the subject of acute scrotal conditions.

State: Washington

Date: April 2017

Specialty: Physician Assistant, Pediatrics, Urology

Symptom: Rash, Swelling

Diagnosis: Testicular Torsion

Medical Error: Failure to order appropriate diagnostic test

Significant Outcome: Permanent Loss Of Functional Status Or Organ

Case Rating: 3

Link to Original Case File: Download PDF

On 5/26/2012, a patient presented to an emergency department after falling and fracturing the distal radius, at his right wrist.  The operating room was unavailable so the orthopedic surgeon opted for a non-surgical (closed reduction) procedure, aligning the patient’s wrist and arm into a splint until he could return for surgery the following week

On 6/1/2012, the patient presented to the orthopedic surgeon for open reduction surgery and internal fixation.  This type of surgery involves surgically aligning the broken bones and using items like plates and screws to hold broken bones together to encourage healing in the correct position.  The orthopedic surgeon positioned a plate adjacent to the fracture and secured the plate to the fracture area with screws.

On 6/13/2012, the patient returned to the orthopedic surgeon for a follow-up.  Imaging found one of the plate’s screws appeared to be within the patient’s radiocarpal joint (where the wrist and palm meet).  The orthopedic surgeon told the patient of the potential for hardware to intrude into the joint.  The orthopedic surgeon noted that if the positioning of the hardware continued to remain a concern, then further imaging and hardware removal would be discussed.

On 7/11/2012, the orthopedic surgeon contacted the patient to discuss the findings of a CT scan performed two days prior.  He assessed the patient’s wrist to be healing nicely, but the CT scan confirmed one of the screws was protruding through the radiocarpal joint.  The orthopedic surgeon decided to go forward with removing the screws and hardware.

On 7/26/2012, the orthopedic surgeon performed his second open surgery on the patient’s wrist, this time removing all of the hardware.  A significant amount of scar tissue and new bone formation had to be cleared in order to reach the hardware.  The orthopedic surgeon found the fracture reasonably stable with gentle flexion-extension movements.  The fracture itself seemed to move as a single unit when doing this, and he felt no further hardware was necessary.

On 8/28/2012, the patient returned to the orthopedic surgeon.  The orthopedic surgeon found the patient’s distal radius had healed abnormally with some displacement of the wrist joint.  The orthopedic surgeon proposed the patient get a specialist’s opinion regarding feasibility for further constructive work.

On 9/27/2012, the patient saw a hand specialist for a second opinion.  The patient described having diminished nerve sensation near the wound area.  The specialist discovered that the patient’s July 2012 CT scan showed the plate had partially dislodged itself.  Upon examination, the specialist noted a displacement deformity at the hand on the forearm.  The patient’s wrist had healed improperly, leaving a significant dorsal prominence of the joint surface and the remaining part of his wrist displaced at the palm.  The patient’s right wrist had limited motion.

The Commission stipulated the orthopedic surgeon reimburse costs to the Commission and write and submit a paper of at least 1000 words, with an annotated bibliography, on knowing his limitations, especially with complex wrist fractures, and complete a continuing education course on complex wrist fractures.

State: Washington

Date: April 2017

Specialty: Orthopedic Surgery

Symptom: N/A

Diagnosis: Fracture(s)

Medical Error: Procedural error

Significant Outcome: Permanent Loss Of Functional Status Or Organ

Case Rating: 2

Link to Original Case File: Download PDF

On 1/4/2011, a patient was involved with a head on motor vehicle collision.  The patient sought care the following day at a hospital.

On 1/20/2011, the patient followed up with his primary care provider (PCP).  A magnetic resonance imaging (MRI) of the patient’s right shoulder was performed.  The MRI showed an abnormal rotator cuff, areas of a partial tear, and an injury to the tendon.

On 2/3/2011, the patient presented to an orthopedic surgeon’s clinic with complaints of right shoulder pain.  The orthopedic surgeon reviewed the previous MRI and performed a physical examination.  The orthopedic surgeon diagnosed the patient with rotator cuff tendinosis with possible tear, degenerative arthritis of the acromioclavicular joint, and inflammation of the tendon around the biceps muscle.

For the following four months, the orthopedic surgeon continued to see the patient.  Though the orthopedic surgeon encouraged the patient to engage in conservative treatment, including physical therapy, the patient’s pain did not completely resolve.

On 6/1/2011, the patient complained of pain in both of his shoulders.  The orthopedic surgeon discussed surgical options with the patient.  The patient consented to have surgery.

On 6/9/2011, the orthopedic surgeon performed right shoulder surgery.  During the surgery, the orthopedic surgeon discovered the patient had an unfused os acromiale (a developmental aberration in which the acromion fails to fuse).  Without the patient’s consent, the orthopedic surgeon decided to attempt to repair the os acromiale.  The orthopedic surgeon claims he placed two pins within the acromion and a screw down the center.  K wires (stainless steel sharpened pins) were cut and placed.

On 7/6/2011, the patient had x-rays taken of his right shoulder.  The orthopedic surgeon believed the x-rays showed the hardware was placed appropriately in the patient’s shoulder.  Later, the patient saw a different physician, who took a new set of x-rays and believed the hardware was angled inappropriately and the wires were loose.  He also believed based on the new x-rays that the screw thread appeared to be just barely in the bone.

Following the patient’s surgery, the patient continued to experience varying degrees of shoulder pain and soreness. On 9/9/2011, the orthopedic surgeon took x-ray images of the patient’s left shoulder, which revealed the patient had bilateral os acromiale.

On 11/21/2011, x-rays were taken of the patient’s right shoulder and showed the screw had pulled out, the bone had not fused, and the wire was broken.  The orthopedic surgeon had allegedly failed to appropriately place the original fixation and should have been aware of this when reviewing earlier x-ray images.

The Commission stipulated the orthopedic surgeon reimburse costs to the Commission and write and submit a paper of at least 1000 words with annotated bibliography on the diagnosis and proper treatment of os acromiale.

State: Washington

Date: February 2017

Specialty: Orthopedic Surgery

Symptom: Extremity Pain

Diagnosis: Musculoskeletal Disease

Medical Error: Procedural error, Diagnostic error, Ethics violation

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

A 55-year-old woman with long-standing lower back pain, Patient A, was diagnosed with slipping vertebral bones that resulted in lumbar stenosis and foraminal stenosis.

On 6/26/2014, a neurosurgeon performed lumbar fusion surgery on Patient A.  Patient A’s post-operative course was marked by considerable pain and slow recovery.  Patient A was referred to an orthopedic surgeon at another hospital when her pain did not diminish as expected.  Radiologic images were interpreted as showing misplaced pedicle screws from the lumbar fusion surgery performed by the neurosurgeon.

On 10/22/2014, Patient A underwent a repeat fusion operation with replacement screws.  The operative report notes detailed screw misplacement from the initial surgery.  Patient A underwent a third surgery on 11/4/2014, because of ongoing pain, after which she made improvement.

Patient B was a 19-year-old man with chronic low back and leg pain caused by a collapsed disc.  On 2/13/2014, the neurosurgeon performed lumbar fusion surgery on Patient B.  Patient B’s post-operative course was marked by some relief, but he experienced new pain in his left leg.

Patient B was also referred to the orthopedic surgeon at the other hospital.  Patient B underwent a repeat fusion operation with replacement screws.  Radiologic images and operative report notes documented misplaced pedicle screws from the lumbar fusion surgery performed by the neurosurgeon.

The Commission stipulated the neurosurgeon reimburse costs to the Commission, complete fifty hours of continuing education covering the subject of spine surgeries, including the interpretation of imaging studies of pedicle screw replacement, attend two spine conferences, and complete a total of one hundred proctored spine instrumentation procedures with Commission approved surgeons.

State: Washington

Date: February 2017

Specialty: Neurosurgery, Orthopedic Surgery

Symptom: Back Pain

Diagnosis: Spinal Injury Or Disorder

Medical Error: Procedural error

Significant Outcome: N/A

Case Rating: 1

Link to Original Case File: Download PDF

Between 2007 and 2011, a physician who was a board certified general surgeon treated over 16 patients for weight loss by prescribing phentermine in doses that exceeded the recommended adult daily dose of 37.5 mg.  The recommended dose should not be exceeded in an attempt to increase the effect of weight loss since increased doses do not demonstrate greater efficacy for weight loss.

Adrenergic activation is the primary concern with long-term phentermine therapy, including increases in blood pressure (BP), development of hypertension, and increases in pulse rate.  The obese are at higher risk for cardiovascular disease, increases in pulse and BP, and even increases that remain below current thresholds for the definition of hypertension may increase oxygen demand in the heart and cardiovascular wall pressure, putting obese patients at risk for a vascular event.

The Food and Drug Administration (FDA) has approved phentermine for short-term weight loss, interpreted as three to six weeks.  The standard of clinical practice, however, is to continue phentermine indefinitely if all of the following conditions are met: 1) documentation of continued efficacy in the form of sustained weight loss maintenance; 2) absence of side effects that result in patient intolerance; 3) careful monitoring for emergence of tachycardia or hypertension; and 4) continued absence of conditions considered contraindications, such as heart disease or peripheral cardiovascular disease.  During his treatment of his patients, the physician consistently failed to monitor the absence or presence of side effects, conduct a complete review of systems, and record patients’ vital signs, including blood pressure and heart rate.  The physician’s failure to appropriately monitor these patients while prescribing high doses of phentermine on a long-term basis potentially exposed these patients to prolonged risk for a vascular event.  Here is one such patient case:

A 52 year old female was treated by the physician for obesity between April 2008 and August 2009.  The patient had gastric banding revised to gastric bypass surgery that was performed by the physician; however, records do not indicate when the patient had the surgery.  The records also do not contain chart notes for the initial consult with the patient regarding weight loss treatment.

During the 15 months that the physician treated the patient, he prescribed phentermine at irregular and increased doses that exceeded the recommended daily maximum amount of 37.5 mg for an adult in the treatment of obesity.  The patient’s highest prescribed dosage was an astonishing two 37.5 mg tablets, three times a day, for a total 225 mg per day, or five times the recommended dose.  The physician prescribed phentermine at high doses continuously and without documenting any medical justification for the excessive doses.  After 15 months, the patient’s total weight loss was less than 10% of her starting weight, and her resulting BMI status still indicated that she was overweight.

The Commission judged the physician’s conduct to be below the minimum standard of competence given failure to conduct a review of systems and monitor for side effects during follow-up appointments, and despite knowing that the patient would take irregular and increased doses.  Of the twelve appointments with the patient, the physician conducted only two reviews of systems even though the patient believed that the phentermine caused her mouth ulcers and that it did not work to stop her hunger.  The physician was also aware that the patient chose to stop and restart phentermine on her own and would take irregular high doses throughout her treatment, but the physician continued to prescribe high doses.  He also failed to regularly monitor and document the patient’s basic vital signs such as blood pressure and pulse, potentially exposing her to prolonged risk for a vascular event.  The physician documented the patient’s blood pressure only twice in fifteen months of treatment, and he never noted her pulse.

The Commission ordered the physician surrender his physician license and that he should not resume the practice in the state of Washington, including temporary, emergency or volunteer practice.

State: Washington

Date: January 2017

Specialty: Internal Medicine

Symptom: N/A

Diagnosis: Drug Overdose, Side Effects, or Withdrawal

Medical Error: Improper medication management, Failure to properly monitor patient, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

A physician was the co-owner and medical director of a dermal spa.  A patient received hair removal, photofacial, and skin tightening treatments at the dermal spa from 8/4/2014 through 9/10/2014.  These treatments were performed using an intense pulsed light (IPL) device.  The use of IPL devices, among other devices, is regulated by WAC 246-919-605 – commonly referred to as the “laser rules,” though that title is under-inclusive.

Contrary to laser rules, prior to initiating treatment with the IPL device, the physician failed to document or perform a history and physical examination.  The physician performed and supervised the patient’s treatments without creating a sufficient medical record or ensuring that a sufficient medical record was created.  The physician failed to provide or document the provision of instructions for emergency and follow-up care, as required by the laser rules.

The informed consent document signed by the patient, prior to her treatment, did not record that the patient was informed that a non-physician may operate the IPL device, as required by the laser rules.  Contrary to laser rules, the physician failed to ensure the existence of a quality assurance program and failed to have written office protocols for supervised professional staff to follow before delegating the use of the IPL device.

The physician delegated the performance of the final three treatments to an esthetician.  Following the final treatment on 8/4/2015, the dermal spa records indicated that the patient developed slight burns on her chest and forearms.  The notes further indicated that the patient “said she had sun exposure before treatments.”  The physician indicated that patients are advised to avoid sun exposure prior to treatment and advised to inform the dermal spa staff if they are exposed to the sun before treatment so that adjustments can be made to the IPL device.  However, there was no further documentation regarding this potential complication, or regarding the physician’s involvement or availability to treat potential complications or provide consultation.

The Commission stipulated the physician write and submit a paper of at least 1000 words, with annotations, regarding the Washington State “Laser Rules” and her plan for ensuring that she is in compliance with the laser rules, write and implement a quality assurance program at the dermal spa, ensure that each patient receiving treatment with the IPL has a complete medical record, and reimburse costs to the Commission.

State: Washington

Date: January 2017

Specialty: Dermatology

Symptom: Dermatological Abnormality

Diagnosis: Post-operative/Operative Complication, Dermatological Issues

Medical Error: Procedural error, Failure to follow up, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 1

Link to Original Case File: Download PDF

A patient’s primary care physician (PCP) referred her to a general surgeon for a right upper quadrant mass after suspecting a hernia.  In his written referral to the general surgeon, the PCP stated that the patient’s present illness was “Abdominal pain in RUQ from hernia…Refer to surgeon to evaluate RUQ mass/pain.”

In October 2008, the general surgeon examined the patient and noted that the patient presented with “a painful bulge in the R lateral abdominal wall,” she was 75 years old, 5’4” tall, 240 pounds, and suffered from hypertension.  The pre-operative note also indicated that the patient would not accept a blood transfusion.  This is significant considering that the patient’s pre-operative laboratory report showed a low platelet count of 84,000.

Although the patient had been experiencing significant pain and her PCP had suspected and noted the likelihood of a hernia, the general surgeon believed the abdominal mass to be a lipoma.  The general surgeon did not obtain any pre-operative image studies.  Instead, the general surgeon scheduled the patient for surgery at an outpatient, ambulatory surgery center, where he works.  The general surgeon did not take into account that complex hernia repairs that require bowel repair or resection are not appropriate for same day surgical procedures and outpatient centers are not equipped for such procedures.  At a minimum, without a preoperative image study, the general surgeon should have scheduled the patient for surgery at the hospital so that whatever issue was encountered could be properly addressed.

In November 2008, the general surgeon attempted surgery on the patient at the ambulatory surgery center.  The general surgeon used the subcostal approach and discovered that in fact, the patient had a hernia and not the lipoma he had anticipated.  A hernia was stuck to the undersurface of the abdominal area where the general surgeon found dense adhesions.

The surgery had to be stopped 25 minutes after its start because the surgery center lacked the instrumentation and equipment for hernia surgery.  As a result of the more difficult and involved surgery required, the conscious sedation started by the anesthesiologist was insufficient to control the patient’s discomfort, and a laryngeal mask airway was needed and provided.  The patient was immediately transferred by ambulance to the hospital.

The surgery center’s anesthesiologist’s report stated that the patient had a “likely bowel perforation.” If the anesthesiologist’s note is correct, the requisite delay in repairing the perforation could potentially expose the patient to an increased risk of wound infection.  A bowel perforation requires emergent repair, and any delay poses serious consequences.

The general surgeon denied perforating the patient’s bowel during the surgery at the surgery center but his own hospital admission report states that the patient had “a probable perforation of the hepatic flexure.”  The hospital’s report also contains a contradicting note where the general surgeon states that the patient had begun outpatient surgery to remove a right-sided abdominal mass which “ended up perforating bowel.”  This hospital’s report further acknowledged that the patient was admitted for “bowel resection as this could not be done at the surgery center.”

At the hospital, the general surgeon undertook the more extensive surgery which confirmed that the bowel was perforated.  The general surgeon performed this second surgery with a subcostal retroperitoneal approach despite his recognition of dense adhesions and presumed bowel injury, as well as the earlier difficulty in exposing the large hernia in the morbidly obese patient.

The general surgeon’s discharge summary states that the patient had experienced purulent drainage from her incision.  However, the general surgeon did not document his evaluation of the patient’s wound prior to discharging the patient from the hospital, nor did the general surgeon document the patient’s complaint of pain.  The general surgeon discharged the patient to a rehabilitation center.

Within 24 hours of discharge, the patient immediately returned to the hospital by ambulance with a grossly infected wound.  The patient appeared septic, experienced constant, intense pain, with fever, chills and brown, bilious-colored material draining from her surgical incision.

A CT scan showed draining fecal matter in her right abdomen.  The patient stated that her abdominal pain and wound drainage began three days prior to discharge from the hospital.  The scan also revealed the patient had a significant intra-abdominal process that likely festered for some time.  This fact raises the possibility that the drainage in the abdominal wound was the continuum of a process that was occurring intra-abdominally.

The patient returned for a third surgery.  The general surgeon again performed the surgery, this time using a midline incision.  The general surgeon described the surgery as mildly bloody.  During this surgery, in a purulent area in the right side of the abdomen, the general surgeon identified a perforation in the patient’s colon which was leaking air.  The general surgeon resected the patient’s colon and broke down some hard adhesions.  Because of the extensive peritonitis that had developed, the patient had to have a colostomy.  The patient’s health rapidly declined following the third surgery.

The patient died less than thirty days after the general surgeon’s initial surgery.  The general surgeon prepared the death certificate, and he failed to accurately reflect that the patient died of multi-organ system failure as a consequence of a bowel perforation that occurred from his abdominal surgery to repair a hernia.  There was no mention for reason of organ failure and the only pathology mentioned were various organ system failures that occurred just before death.  A death certificate should accurately reflect the course of events leading up to a patient’s demise.  The general surgeon neglected to properly document the actual cause of the patient’s death.

The Commission stipulated the general surgeon reimburse costs to the Commission, arrange for the manager of the Quality Review Committee at all facilities where he provides patient care to submit quarterly reports addressing whether any surgical cases involving the general surgeon were discussed at the Quality Review Committee meetings,  and write and submit a paper of at least 1500 words, with annotated bibliography, discussing the Communication and Resolution Program (CRP) principles and the importance of integrating these principles into practice.

State: Washington

Date: January 2017

Specialty: General Surgery

Symptom: Abdominal Pain

Diagnosis: Post-operative/Operative Complication, Sepsis, Procedural Site Infection

Medical Error: Underestimation of likelihood or severity, Failure to examine or evaluate patient properly, Lack of proper documentation, Procedural error

Significant Outcome: Death, Hospital Bounce Back

Case Rating: 5

Link to Original Case File: Download PDF

On 7/24/2012, a patient saw an orthopedic surgeon for a preoperative appointment concerning the decision for unilateral decompression surgery at L4-5 secondary to chronic lower back pain radiating to the right lower extremity with numbness and tingling.  The orthopedic surgeon failed to document in his preoperative report his intention to use the iO-flex (minimally invasive micro-blade shaver), a newly-marketed surgical device, during the patient’s upcoming surgery.  The orthopedic surgeon did not disclose to the patient that he had never used this device before.  Specifically, the orthopedic surgeon did not obtain the patient’s informed consent to use the iO-flex.

On 8/9/2012, the patient returned to the orthopedic surgeon’s clinic presenting with a sudden onset of back pain radiating to the left lower extremity.  Magnetic resonance imaging (MRI) revealed a new large disc herniation at L4-5.  This newly discovered injury caused the original surgical plan to change, which the orthopedic surgeon failed to document in his preoperative report and failed to tell the patient.

On 8/15/2015, the orthopedic surgeon began the patient’s decompression with the iO-flex and the progress was being observed by a remote neuromonitoring physician and an on-site neuromonitoring technician.  The neuromonitoring technician informed the orthopedic surgeon that there was a decrease in some of the patient’s sensory nerve signals.  In response, the orthopedic surgeon removed all of the iO-Flex tools and waited for improvement.

While waiting for improvement, there was a lack of clear communication between the orthopedic surgeon, the neuromonitoring physician, and the neuromonitoring technician about a drop in neuromonitoring function.  The orthopedic surgeon had a duty to make sure the information received from the neuromonitoring physician and the neuromonitoring technician was correct.  The changes in function should have been noted in the orthopedic surgeon’s operative report, but were not included.  Due to this omission, the orthopedic surgeon’s report incorrectly implied there were no complications.  When the orthopedic surgeon inserted the iO-flex micro-blade shaver into the patient’s spine and performed about sixty reciprocations for decompression, the orthopedic surgeon unknowingly damaged the patient’s cauda equina (bundle of spinal nerves and spinal nerve roots).

On 8/16/2012, the orthopedic surgeon examined the patient in the recovery room.  The patient had weakness and numbness in both feet.  On 8/17/2012, based on the patient’s presentation of weakness in both feet and a newly experienced loss of bladder control, an MRI was ordered and the orthopedic surgeon recommended exploratory surgery.

On 8/18/2012, the orthopedic surgeon performed the exploratory surgery.  The exploratory surgery revealed cauda equina damage and a tear in the patient’s dura (a watertight sac of tissue that covers the spinal cord and spinal nerves).  Given the seriousness of the neurological complications (weakness, numbness, bladder dysfunction), the exploratory operation should have been completed when those symptoms were first noted, not two days later.

The orthopedic surgeon treated the patient’s dural tear with a sealant. The orthopedic surgeon failed to document fluid leaking in the patient’s spine in his post-operative report and there was no documentation of an appearance of fluid collection in the patient’s exploratory MRI report.  The orthopedic surgeon should have documented these complications.

The Commission stipulated the orthopedic surgeon reimburse costs to the Commission, complete a continuing education course on ethics, complete a continuing education course on medical record keeping, and write and submit a paper of at least 1000 words on what he learned from the courses and how information he learned applies to this case.

State: Washington

Date: January 2017

Specialty: Orthopedic Surgery, Neurosurgery

Symptom: Back Pain, Numbness, Extremity Pain

Diagnosis: Post-operative/Operative Complication, Spinal Injury Or Disorder

Medical Error: Procedural error, Delay in proper treatment, Ethics violation, Failure of communication with other providers, Failure of communication with patient or patient relations, Lack of proper documentation

Significant Outcome: Permanent Loss Of Functional Status Or Organ

Case Rating: 1

Link to Original Case File: Download PDF