Found 143 Results Sorted by Case Date
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Washington – Internal Medicine – Proper Monitoring Of Thyroid Dysfunction And High Blood Pressure



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



Washington – Physician Assistant – History Of Diabetes And Hypertension With Chest Pain, Left-Sided Weakness, Headache, And Loss Of Vision



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



Washington – Orthopedic Surgery – Complex Wrist Fracture After A Fall With A Screw Within The Radiocarpal Joint



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



Washington – Physician Assistant – Groin Rash, Swelling, And Hard Left Testicle Found On Infant



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



Washington – Orthopedic Surgery – Bilateral Shoulder Pain After A Motor Vehicle Accident And Repair Attempt Of Os Acromiale



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



Washington – Neurosurgery – Misplaced Pedicle Screws



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



Washington – Orthopedic Surgery – iO-Flex Use For Spinal Decompression



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



Washington – General Surgery – History Of Obesity And Myocardial Infarction With Hypoxia After Laparoscopic Ventral Hernia Repair



On 4/14/2011, a surgeon performed a laparoscopic ventral hernia repair on a 70-year-old female.  The patient had a history of hypertension, an increased body mass index of 41, coronary artery disease with a past history of myocardial infarction, and a previous coronary angioplasty procedure with stent placement.

A pre-operative cardiac test determined that the patient had a normal cardiac ejection fraction.  The patient had reported pre-surgical symptoms of shortness of breath with exertion that was of undetermined etiology.  She had not previously required home oxygen therapy and her resting room air oxygen saturation on the morning of the surgery was 95%.

The patient’s post-anesthesia note indicated that she had some mild wheezing after completion of the surgical procedure.

Postoperatively, on 4/14/2011 at 8:00 p.m., the patient had a low oxygen level 87% after standing at her bedside, despite being on oxygen at 2 liters per minute at the time.  Her oxygen levels on the night of 4/14/2011 subsequently improved.

On 4/15/2011 at 9:00 a.m., the surgeon evaluated the patient, determined she was ready for discharge, wrote discharge orders, and requested the patient follow up in his office in two weeks.

On 4/15/2011 at 1:24 p.m., nursing staff attempted to wean the patient off oxygen in preparation for hospital discharge but found that the patient’s oxygen level was low at 88% on room air and dropped to 82% with ambulation.  Nursing staff informed the surgeon of the patient’s abnormal oxygenation.  The surgeon reportedly indicated that the patient’s respiratory status was her “norm” and that she had no heart problems or chronic lung disease, and that she needed to be discharged.

The nurse then asked whether the surgeon wanted to send the patient home with oxygen treatment.  Chart notes document that the surgeon stated he was not concerned about the poor oxygenation and he advised nursing to discharge the patient without oxygen therapy.  The nurse, who remained concerned about the patient’s respiratory status, discussed the situation with the nursing supervisor.  Nursing then contacted the patient’s primary care provider who did order home oxygen therapy and asked for the patient to be evaluated in their clinic the following day.  The patient left the hospital at 4 p.m. on 4/15/2011 on 2 liters per minute of oxygen.

Patients with room air oxygen saturation equal or less than 89% qualify for home oxygen therapy.  The patient’s oxygen level of 82% while on 2 liters of oxygen supplementation was markedly worse than this qualifying criterion.  The patient’s low oxygen saturation should have been of concern to the surgeon and warranted further evaluation by the surgeon.

The Commission ordered the surgeon pay a fine, have his license placed on probation for a period of two years, allow a representative of the Commission make semi-annual visits to the surgeon’s practice to review compliance with the Commission’s order, and write and submit a paper of at least 1000 words, with bibliography, on appropriate use of supplemental oxygen when discharging patients.  The surgeon will also make a presentation to the medical staff at his workplace on this subject.

State: Washington


Date: January 2017


Specialty: General Surgery


Symptom: Shortness of Breath


Diagnosis: Gastrointestinal Disease


Medical Error: Improper treatment


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Washington – Neurology – Neuromonitoring During Decompression Surgery With iO-Flex



On 8/15/2012, a neurologist was the physician in charge of supervising the intraoperative neuromonitoring aspect of a patient’s spinal decompression surgery.  The neurologist was not present in the operating room during the patient’s surgery.  He was at his off-site office supervising the neuromonitoring technician who was present in the operating room during the patient’s surgery.  The neurologist was remotely reviewing data from the patient’s surgery on his desktop and laptop in real-time while an orthopedic surgeon was performing the surgery.

In addition to monitoring the patient’s surgery, the neurologist was also simultaneously acting as a supervisor for the intraoperative monitoring of two other patients.  He was seeing patients in his office in addition to neuromonitoring.

Prior to the patient’s surgery, there was a lack of clear communication about the nature of the case and the use of a new device.  The neurologist understood the operation to be a routine L4/L5 hemilaminectomy as opposed to an operation with a new and unproven device with significant risk of complication.

During the patient’s surgery, the orthopedic surgeon inserted the newly marketed device, the iO-Flex, a micro-blade shaver, into the patient’s back.  During the surgery, on two separate occasions, there was a significant drop in the patient’s nerve signals.  The signals never returned to baseline but the surgery continued.  The neuromonitoring technician informed the neurologist of the signal changes, and documented she informed the surgeon of the changes.  The neurologist did not independently communicate with the surgeon or the neuromonitoring technician.  The neurologist was not in the operating room and had no awareness of what the surgeon was doing or the use of the iO-flex device.  The patient’s cauda equina (bundle of spinal nerves and spinal nerve roots) was damaged.

It took over one month for the neurologist to finalize his report relating to the surgery.  The neurologist’s report, dating 9/14/2012, stated that the patient suffered spinal cord damage, which is inaccurate as there is no spinal cord where the cauda equina is located.  The neurologist’s report is inaccurate when he wrote, “there is no nerve root injury” when the patient actually did suffer severe nerve root damage.  The patient suffered damage to his cauda equina that required additional surgery and resulted in ongoing neurological deficits.

Communication between the remote monitor and the neuromonitoring technician and surgeon is critical to the neuromonitoring process.  The pathways of communication were not mutually understood and did not work as a result.  Communication between the neurologist, the neuromonitoring technician, and the surgeon was less than satisfactory.

The Commission stipulated the neurologist reimburse costs to the Commission, complete a continuing education course on ethics, complete a continuing education course on communication, 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: Neurology, Neurosurgery, Orthopedic Surgery


Symptom: N/A


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


Medical Error: Failure of communication with other providers


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 3


Link to Original Case File: Download PDF



Washington – Internal Medicine – High Dose Phentermine Prescribing



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



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