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New Jersey – Gastroenterology – Pathology Diagnoses Polyp Removed During Colonoscopy As Adenocarcinoma
A payment of $775,000 had been made on the gastroenterologist’s behalf to settle a civil malpractice action brought against him by a patient.
It was alleged the gastroenterologist failed to follow-up on pathology results that revealed cancer after he had performed a colonoscopy on the patient, which led to a delay in the diagnosis of colorectal cancer.
On 8/12/2009, a 55-year-old woman presented to a gastroenterologist with complaints of abdominal pain and rectal bleeding. The patient’s medical history revealed a family history of colon cancer. The gastroenterologist recommended that the patient have a diagnostic colonoscopy to evaluate her persistent rectal symptoms.
On 9/17/2009, the gastroenterologist performed a colonoscopy on the patient. During the procedure, the gastroenterologist identified internal hemorrhoids associated with a sessile polyp in the mid-rectum. The gastroenterologist removed the polyp and submitted the specimen for pathologic analysis. The patient was discharged from the hospital on 9/17/2009.
On 9/18/2009, pathology diagnosed the polyp to be a moderately differentiated adenocarcinoma arising within a tubular adenoma. On 10/6/2009, the gastroenterologist entered a progress note in the patient’s hospital chart directly documenting the finding of adenocarcinoma made in the pathology report. Despite entering that chart note, the gastroenterologist never advised the patient of the finding of adenocarcinoma that had been made.
The gastroenterologist thereafter had no further contact with the patient until he saw her in his office on 8/23/2010, approximately eleven months after the colonoscopy had been performed. At that visit, the gastroenterologist diagnosed the patient with hemorrhoids and prescribed steroid suppositories; however, he once again failed to inform her of the finding of cancer that had been made following the September 2009 colonoscopy. Additionally, the gastroenterologist did not then recommend that the patient schedule a repeat colonoscopy.
The patient ultimately had a repeat colonoscopy performed by another physician on 4/27/2011. Following that procedure, she was found to have an invasive carcinoma of the mid-rectum, and she commenced receiving treatment for colon cancer.
When appearing before the panel, the gastroenterologist testified that he was aware of the pathology findings that had been made following the colonoscopy but did not specifically advise the patient of those findings because he considered the pathology findings to be “benign.” The gastroenterologist further testified that he was confident that he had removed the entirety of the rectal polyp at the time of the colonoscopy. The gastroenterologist maintains that, after completing the colonoscopy, he advised the patient that she would need to see him again in “about” a year, but there is no documentation in either the gastroenterologist’s medical record or the hospital chart which memorializes respondent’s having advised the patient to have a repeat colonoscopy within one year. Further, although the gastroenterologist entered a note in the patient’s hospital chart on 10/6/2009 documenting the pathology findings, he failed to record the pathology findings in his office medical record, and he failed to obtain and/or maintain a copy of the pathology report in his office record.
The Board judged the gastroenterologist’s conduct to have fallen below the standard of care given failure to document that he advised the patient to have a repeat colonoscopy performed within one year of the date on which the original colonoscopy was performed and failure to have documented the pathology findings of adenocarcinoma in his office record.
The Board assessed a fine against the gastroenterologist with stipulations to complete courses in medical record keeping and medical ethics.
State: New Jersey
Date: March 3017
Specialty: Gastroenterology
Symptom: Blood in Stool, Abdominal Pain
Diagnosis: Colon Cancer
Medical Error: Failure to follow up, Failure of communication with patient or patient relations, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Critical Care Medicine – Intensivist Unavailable To Assess Patient With Metabolic Acidosis, Abdominal Pain, And Vomiting
On 10/19/2011 at 5:23 p.m., a 35-year-old male presented to the emergency department at a hospital with a chief complaint of abdominal pain and vomiting, which started approximately five hours before he presented to the hospital.
The patient was admitted to the hospital under the service of an intensivist and was notified of his arrival and condition at 5:35 p.m.
Between the hours of 5:50 p.m. and 7:22 p.m. the intensivist gave verbal orders of Dilaudid and ketorolac to the patient’s nurse.
At 9:20 p.m., the intensivist gave telephonic orders to the patient’s nurse, to place him on his home BIPAP mask.
On 10/20/2011, at 3:15 a.m. a rapid response was called due to an acute change in the patient’s respiratory status.
During the rapid response, an arterial blood gas (“ABG”) was drawn that revealed critical metabolic acidosis.
The intensivist never presented to the emergency room to assess the patient when he demonstrated medically dangerous/life-threatening signs at 3:15 a.m. or any time thereafter.
The intensivist never attended to the patient when his clinical situation was from an unknown cause and when a clear treatment plan had not been determined.
From 3:43 a.m. to 4:15 a.m., the critical care practitioner was contacted approximately five times with information on the patient’s medically unstable and deteriorating condition.
At 3:45 a.m., the patient became short of breath, restless, diaphoretic, and seizure episodes followed. He was then transported to an intensive care unit.
At 5:25 a.m., a second rapid response was called due to a further decline in the patient’s health. The rapid response turned into a code blue.
The patient underwent a cardiopulmonary arrest, and the code team was unable to resuscitate him.
On 10/20/2011, the patient expired at 6:25 am.
The autopsy results were consistent with acute hemorrhagic pancreatitis with diffuse pancreatic necrosis.
The Medical Board of Florida judged the intensivist’s conduct to be below the minimal standard of competence given that he failed to presented to the emergency room to assess the patient when the patient demonstrated medically dangerous/life-threatening signs on 10/20/2011 at 3:15 a.m.
The Medical Board of Florida issued a letter of concern against the critical care practitioner’s license. The Medical Board of Florida ordered that he pay a fine of $7,500 against his license and pay reimbursement costs for the case at a minimum of $4,503.10 and not to exceed $6,503.10. The Medical Board of Florida ordered that the critical care practitioner complete ten hours of continuing medical education in the area of critical care medicine and complete five hours of continuing medical education in “risk management.”
State: Florida
Date: December 2017
Specialty: Critical Care Medicine, Emergency Medicine, Pulmonology
Symptom: Abdominal Pain, Nausea Or Vomiting
Diagnosis: Gastrointestinal Disease
Medical Error: Failure to properly monitor patient
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF
Florida – Emergency Medicine – Patient With Intussusception Involving Loop Of Small Bowel Discharged Home With Magnesium Citrate
At 1:45 a.m. on 7/26/2014, a 46-year-old female presented to the emergency department with complaints of severe abdominal pain. Upon arrival at the emergency department, the patient was evaluated by the ED physician.
The patient complained of severe abdominal pain and stated the pain was “10 out of 10.” The patient then underwent laboratory studies and a CT scan of the abdomen/pelvis with intravenous and oral contrast.
A radiologist reviewed the CT scan at some time before 4:16 a.m., when he read and signed the preliminary report. Upon review of the CT scan results the radiologist recorded in the preliminary report “intussusception involving loop of small bowel in the left lower quadrant with involved loops appearing edematous.” The radiologist relayed the results of the CT scan to the ED physician via teleradiology.
The ED physician recorded the results of the CT scan in the patient’s emergency provider report and noted “thickened loop of small bowel in the left lower quadrant, [m]ay be intussuception [sic].”
At 4:32 a.m. the ED physician discharged the patient to her home with a magnesium citrate prescription and no additional discharge instructions.
At 8:28 a.m. a physician signed the final radiology report and noted “[i]ntussesception involving loop of small bowel in the left lower quadrant” and “preliminary report related to referring physician teleradiology at the time of the exam by the radiologist.”
Later that day, the patient developed worsening pain, and presented to another emergency department, and underwent an emergency surgery for resection of necrotic bowel.
The Board judged the ED physician’s conduct to be below the minimum standard of competence given his failure obtain emergent surgical consultation for further evaluation and treatment and continue hospitalization for operative intervention or ongoing evaluation of abdominal pain.
The Board ordered the ED physician to pay an administrative fine in the amount of $8,000. Also, the Board ordered the ED physician to complete five hours of continuing medical education in the area of emergency medicine.
State: Florida
Date: December 2017
Specialty: Emergency Medicine
Symptom: Abdominal Pain
Diagnosis: Acute Abdomen
Medical Error: Improper treatment, Referral failure to hospital or specialist
Significant Outcome: Hospital Bounce Back
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Family Medicine – Patient With Kidney Stone Started On Morphine Along With Fluoxetine And Promethazine
A 27-year-old female was a patient of a family practitioner. On 2/11/2014, the patient started complaining to the family practitioner about a potential kidney stone.
The family practitioner had records indicating that the patient was being treated with tramadol, Percocet, fluoxetine, and promethazine.
On 5/12/2014, the family practitioner prescribed morphine 60 mg, extended release, to the patient, to be taken twice a day, but the family practitioner never adequately documented medical justification for the prescription. The standard starting dose for morphine is 15 mg every eight to twelve hours.
The patient was also taking fluoxetine and promethazine and the family practitioner signed a CVS form indicating the patient could start morphine despite possible contraindications.
The family practitioner did not take additional precautions to monitor the patient, despite her taking fluoxetine and promethazine in combination with morphine.
At 5:25 p.m. on 5/14/2014, the patient’s husband found her unresponsive in the bedroom and 911 was called immediately.
The patient ultimately was transported to a hospital and diagnosed with poisoning by opiates and related narcotics.
The Board judged the family practitioners conduct to be below the minimum standard of competence given his failure to prescribe morphine for medically justified reasons. The family practitioner failed to start with an initial dose of morphine at 15 mg every eight to twelve hours. The family practitioner failed to take additional precautions regarding monitoring for central nervous system or respiratory depression when the morphine was prescribed with the fluoxetine and promethazine. The Board judged that the family practitioner failed to adequately create or maintain medical records that justified the course of treatment for the patient.
The Board ordered that the family practitioner have a reprimand against his license. The Board ordered that the family physician pay a fine against his license of $7,500 and that the family practitioner pay reimbursement costs for the case between a minimum of $820.04 and a maximum of $2,820.04. The Board ordered that the family practitioner complete a drug prescribing course and a medical records course and that the family practitioner complete five hours of continuing medical education in nephrology.
State: Florida
Date: November 2017
Specialty: Family Medicine, Internal Medicine
Symptom: Abdominal Pain
Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Renal Disease
Medical Error: Improper medication management, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Interventional Radiology – Guidewire Found In Patient’s Abdomen Following CT-Guided Percutaneous Drainage
On 8/24/2015, a 63-year-old male presented to a medical center for a CT-guided percutaneous aspiration with possible drainage of an abdominal abscess.
During the course of the procedure, an interventional radiologist placed a guidewire into the operative field. Once the procedure was completed the patient had stable vital signs and no immediate complications were known.
On 9/12/2015, the patient was re-admitted to the medical center with complaints of abdominal pain. A subsequent CT scan revealed a foreign body on the left side of the patient’s abdomen.
On 9/15/2015, a general surgeon performed laparoscopic retrieval of the foreign body, at which time a portion of the guidewire, measuring 11.0 centimeters in length, was found and removed intact.
The Board ordered that the interventional radiologist pay a fine of $5,000 against his license and that the radiologist pay reimbursement costs for the case at a minimum of $4,737.16 and not to exceed $6,737.16. The Board also ordered that the interventional radiologist complete five hours of continuing medical education in “Risk Management” and that the interventional radiologist complete a one hour lecture/seminar on retained foreign body objects.
State: Florida
Date: November 2017
Specialty: Interventional Radiology
Symptom: Abdominal Pain
Diagnosis: Post-operative/Operative Complication, Acute Abdomen
Medical Error: Retained foreign body after surgery
Significant Outcome: Hospital Bounce Back
Case Rating: 2
Link to Original Case File: Download PDF
Florida – Urology – Stent Placed For Kidney Stone Placed In Wrong Ureter
On 7/16/2016, a 50-year-old male presented to the medical center emergency department with abdominal pain.
The patient was diagnosed with renal kidney stones and admitted to the hospital.
The patient was taken to the operating room for a planned cystoscopy, right ureteroscopy, and placement of right ureteral stent.
Informed consent was obtained from the patient for the placement of the right ureteral stent.
On 7/20/2016, a urologist placed a stent in the patient’s left ureter (wrong site), rather than the right ureter (correct site). The patient was then discharged home.
On 7/25/2016, the patient returned to the hospital with complaints of abdominal pain.
A CT scan of the patient’s abdomen and pelvis revealed right distal ureteral stones with moderate right hydronephrosis. The CT scan also revealed a left ureteral without left hydronephrosis.
On 7/26/2016, the patient was informed by the Chief Medical Officer of the hospital that the surgery was performed on the wrong side.
On 7/26/2016, the patient underwent a second procedure to remove the foreign body (left stent) and right ureteroscopy with laser lithotripsy and placement of right ureteral stent.
The second surgery was performed without incident and the patient was discharged home on 7/27/2016.
It was requested that the Board order one or more of the following penalties for the urologist: permanent revocation or suspension of his license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Board deemed appropriate.
State: Florida
Date: August 2017
Specialty: Urology
Symptom: Abdominal Pain
Diagnosis: Renal Disease
Medical Error: Wrong site procedure
Significant Outcome: Hospital Bounce Back
Case Rating: 3
Link to Original Case File: Download PDF
California – Gynecologist – Complications After A Laparoscopic Assisted Vaginal Hysterectomy For Irregular Bleeding And Abdominal Pain
Sometime prior to 2011, a gynecologist began treating a patient with a history of a prior myomectomy in 2011, pre-diabetes, and fibromyalgia.
On 3/8/2011, the patient presented to the gynecologist with complaints of irregular vaginal bleeding with some pain in her right lower quadrant that worsened when she was on her period. The patient informed the gynecologist that she was “ready for a hysterectomy.” Medical records for this visit do not document the extent of the bleeding, whether or not the bleeding contributed to any other symptoms, the patient’s level of pain, or whether or not the pain interfered with the patient’s lifestyle. At the conclusion of this visit, the gynecologist referred the patient for a pelvic ultrasound with plans to follow up after the ultrasound.
On 4/5/2011, the patient had a pelvic ultrasound which showed the uterus was oriented anteverted and located midline. A fibroid was visualized in the right lateral aspect of the uterus that measured 5.3 by 4.2 by 5.3 centimeters. The endometrial stripe measured 12 millimeters. No other fibroids were seen. The left and right ovary were normal. There was no fluid in the cul-de-sac. The fibroid had increased in size compared to a prior ultrasound in 2010.
On 4/11/2011, the patient presented to the gynecologist for a follow-up. The gynecologist went over the results from the ultrasound and discussed possible treatment options. The gynecologist did not recommend or perform an endometrial biopsy to determine the reason for endometrial thickening or repeat the ultrasound to watch this condition. The gynecologist did not consider or document that the irregular bleeding could be caused by endometrial thickening, endometrial hyperplasia, or endometrial polyp. She did not recommend a dilation and curettage. At the conclusion of this visit, a decision was made for the patient to undergo a hysterectomy, which was scheduled to occur on 6/27/2011. The patient indicated that she wanted a bilateral salpingo-oophorectomy, but the gynecologist advised her to leave in the ovaries.
On 6/24/2011, the patient presented to the gynecologist for a preoperative evaluation. The gynecologist offered the patient medical and surgical options and the patient chose a hysterectomy. The gynecologist explained various surgical options, including risk factors and complications. During the physical examination of the patient, the gynecologist noted the patient’s uterus was bulky and that it did not descend well. The gynecologist did not document any observable vaginal bleeding or any pelvic pain with palpation of the pelvic organs. At the conclusion of this visit, the gynecologist had formed a surgical plan to include a total vaginal hysterectomy and depending on whether the uterus was mobile in the operation room, possible laparoscopic assisted vaginal hysterectomy, possible exploratory laparotomy, and possible cystoscopy.
On 6/27/2011, the gynecologist performed a laparoscopic assisted vaginal hysterectomy, bilateral salpingo-oophorectomy, cystoscopy, and lysis of adhesions on the patient. The medical records do not document a specific clinical reason for this choice in surgical technique versus a laparotomy approach.
During the surgery, the gynecologist encountered a web of filmy adhesions that were abundant along the back of both ovaries and continued along the back of the uterus. The adhesions connected the bowel to the uterus and ovaries.
There were also adhesions from the ovaries to the side walls. The gynecologist considered converting to an open procedure but opted to continue with laparoscopic dissection. After dissection of all of the adhesions, the gynecologist obtained a general surgery consultation as a precaution to review the small bowel, which had been adherent, especially near the right ovary. After observation through the monitor only, neither the surgeon nor the gynecologist noted any bowel injuries.
The gynecologist then proceeded with the vaginal hysterectomy portion of the surgery, which progressed “a bit more difficult than average but not remarkably so.”
Upon completion of the vaginal portion of the surgery, the gynecologist returned to the abdominal cavity. Upon doing so, she noted a slight oozing from the round ligament on the left, which she cauterized. The gynecologist then irrigated the pelvis and looked for any bleeding or injury but found none.
Prior to closing, the gynecologist requested a urology consultation. After cystoscopy and examination revealed no injury to the bladder or ureter, the gynecologist completed the procedure. The gynecologist’s detailed operative report does not specifically document the difficulties or complexities she encountered during the over eight-hour operation.
During the first three post-operative days, the patient experienced complications from the surgery that began to worsen. The patient’s symptoms included abdominal pain, distention, lack of appetite, bowel dysfunction, fever, tachycardia, weakness, emesis, and anemia.
After attempting to treat the patient with antibiotics and observation, on 7/5/2011, the patient was taken in for an exploratory laparotomy.
During the surgery, several liters of feces were found in the patient’s abdomen, which were suctioned out. Then, the abdomen was irrigated. Further into the surgery, a 1-centimeter tear in the distal sigmoid and another 3-centimeter tear in the proximal rectum were identified, repaired, and treated with a colostomy.
From 7/5/2011 to 8/1/2011, the patient remained hospitalized and experienced complications including but not limited to nausea, vomiting, fatigue, fever, tachycardia, wound infection, anemia, and significant leukocytosis. During this time period, the patient had to undergo radiological drainage of intraabdominal collections and was on several courses of antibiotics. The patient was discharged from the hospital on 8/1/2011, approximately thirty-five days after her total hysterectomy.
Per the Board, the gynecologist committed gross negligence in her care and treatment of the patient by continuing with a long and complicated abdominal and pelvic surgery through laparoscopy without converting to laparotomy to prevent multiple intraoperative injuries.
In addition, the Board judged the gynecologist’s conduct to be below the minimum level of competence given the performance of a total abdominal hysterectomy and bilateral salpingo-oophorectomy without definitive clinical indication and without consideration of alternative treatments, prior to consideration of a major surgery, and given failure to maintain adequate and accurate records relating to her care and treatment of the patient.
The Board issued a public reprimand with stipulations to complete a medical record keeping course.
State: California
Date: July 2017
Specialty: Gynecology, General Surgery
Symptom: Abdominal Pain, Fever, Gynecological Symptoms, Nausea Or Vomiting, Weakness/Fatigue
Diagnosis: Post-operative/Operative Complication, Gynecological Disease
Medical Error: Procedural error, Unnecessary or excessive treatment or surgery, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Gynecology – MRI Reveals Two Adjacent Large Intraperitoneal Complex Cystic Masses With Plan For Removal
On 11/19/2013, a 44-year-old female presented to a gynecologist for abdominal/pelvic discomfort.
The gynecologist performed an ultrasound and reported a “large ovarian cyst 14 cm in greatest extent… simple in nature.” The gynecologist ordered additional imaging of the patient’s abdomen and pelvis to further evaluate the cyst.
The patient was scheduled for surgical removal of the cyst to be performed by the gynecologist on 11/27/2013.
On 11/22/2013, an MRI of the patient’s pelvis was performed, which indicated the presence of “two adjacent large intraperitoneal complex cystic masses.”
On 11/27/2013, preoperatively, the gynecologist indicated that he read the history and physical and examined the patient and that there were “no changes.”
After receiving and reviewing the MRI report, the gynecologist failed to further evaluate, or alternatively, did not create, keep, or maintain adequate legible documentation of evaluating, whether a malignancy was present.
Prior to the surgery on 11/27/2013, the gynecologist failed to discuss, or alternatively, did not create, keep, or maintain adequate legible documentation of discussing, with the patient her desired plan-of-care in the event that the cysts contained malignant cells.
The gynecologist attempted to remove the cysts laparoscopically, by intentionally puncturing and aspirating the cysts. Prior to intentionally puncturing the cysts, the gynecologist did not place the cysts into a specimen bag to prevent contamination in the event that the cysts contained malignant cells. During the procedure, the contents of the cysts spilled into the patient’s abdominal cavity.
Intraoperatively, the procedure was converted to a laparotomy and the gynecologist removed the patient’s left ovary in its entirety and sent it to pathology. The pathology report indicated that the specimen was “of at least low malignant potential” indicating possible higher grade abnormality.
Accordingly, the gynecologist performed a total abdominal hysterectomy and removal of the right ovary.
The Board judged the gynecologist’s conduct to be below the minimal standard of competence given that he failed to further evaluate, preoperatively, to determine whether a malignancy was present, proceed with the correct surgical approach on 11/27/2013, by performing a laparotomy and removing the cysts intact, or by placing a specimen bag around the cysts prior to intentionally puncturing and aspirating the cysts, and discussing with the patient, preoperatively, to determine the patient’s desired plan-of-care for the possibility of malignancy.
It was requested that the Board order one or more of the following penalties for the gynecologist: permanent revocation or suspension of his license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Board deemed appropriate.
State: Florida
Date: July 2017
Specialty: Gynecology
Symptom: Abdominal Pain, Mass (Breast Mass, Lump, etc.)
Diagnosis: Gynecological (Endometrial, Ovarian, Cervical) Cancer
Medical Error: Underestimation of likelihood or severity, Failure of communication with patient or patient relations, Procedural error
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Internal Medicine – Use Of Diltiazem In A Tachycardic And Hypotensive Patient
On 2/20/2012, a 31-year-old female presented to the medical emergency department with abdominal pain and shortness of breath.
On 2/20/2012 at 2:06 p.m., the patient had a blood pressure of 147/81 and a heart rate of 165 beats per minute. At 2:52 p.m., the patient had a heart rate of 153 beats per minute. At 3:24 p.m., the patient had a blood pressure of 94/40 and a heart rate of 132 beats per minute. At 4:08 p.m., the patient had a heart rate of 157 beats per minute. At 6:04 p.m., the patient had a blood pressure of 98/50 and a heart rate of 145 beats per minute.
From 2:06 p.m. until 6:04 p.m., the patient was sinus tachycardic and hypotensive.
At 6:52 p.m., an internal medicine practitioner on the unit was advised of the patient’s consistent elevated heart rate. From 6:52 p.m., the internist was the physician treating the patient.
At 7:00 p.m., the internist ordered the administration of 10 mg of diltiazem to the patient one time, over two minutes.
At 7:10 p.m., the patient had a palpated systolic pressure of 80 and a heart rate of 125 beats per minute. The patient’s medical records indicated that due to the patient’s low blood pressure, 5 mg of diltiazem was administered over five minutes.
Diltiazem is not indicated for the treatment of sinus tachycardia. Diltiazem is contraindicated in the setting of hypotension. Diltiazem is contraindicated in the setting of hypotension and sinus tachycardia.
The patient’s medical records include a correction that indicates that additional vital signs were obtained at 6:43 on 2/20/2012. According to that record, the patient had a blood pressure of 186/76 and a heart rate of 82 beats per minute.
Diltiazem is not indicated for a patient with a blood pressure of 186/76 and a heart rate of 82 beats per minute.
Ultimately, the patient died after a hospitalization lasting 4 weeks. A lawsuit was filed alleging the patient was not transferred to an ICU in a timely fashion. There were no ICU beds available at the hospital where she had been treated. The suit alleged the hospital should have transferred the patient to another hospital with an available ICU bed.
In the lawsuit, it was noted that the patient had developed diabetic ketoacidosis, severe metabolic acidosis, and pancreatitis. After she was administered the doses of diltiazem mentioned above, she went into cardiac arrest before transfer to an ICU. It was noted that the patient was held in the emergency department from the time of her arrival at 1:52 p.m. until her transfer at 12:10 a.m. the following day (for a total of over 10 hours). On 3/18/2012, she died.
The Board judged the internists conduct to be below the minimal standard of competence given that he ordered the administration of diltiazem to a patient when diltiazem was not indicated and/or was contraindicated.
The Board issued a letter of concern against the internist’s license. The Board ordered that the internist pay an administrative fine of $5,000 against his license and pay reimbursement costs for the case for $10,000. The Board also ordered that the internist complete ten hours of continuing medical education in “internal medicine” and five hours of continuing medical education in “risk management.”
State: Florida
Date: June 2017
Specialty: Internal Medicine, Emergency Medicine, Endocrinology
Symptom: Palpitations, Abdominal Pain
Diagnosis: Cardiovascular Disease
Medical Error: Improper medication management
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF
California – Gastroenterology – Complication During Endoscopy With Colonoscopy For Nausea, Vomiting, And Epigastric Pain After Bone Marrow Transplant
On 11/17/2011, a 56-year-old female underwent a colonoscopy performed by a gastroenterologist. The patient had undergone a bone marrow transplant for chronic lymphocytic leukemia. After the procedure, the patient complained of nausea, vomiting, and epigastric pain. An endoscopy was performed the prior day to rule out graft versus host disease or cytomegalovirus infection and the colonoscopy was a part of that procedure.
The gastroenterologist performed the coloscopy to the terminal ileum. The patient was sedated with midazolam 8 mg IV, fentanyl 175 micrograms IV, and diphenhydramine 50 mg IV in divided doses as the patient exhibited any signs of discomfort. Biopsies and cultures were obtained and submitted for evaluation. Pathology results indicated apoptosis of the ileum and right colon, but negative findings for CMV.
During the course of the colonoscopic procedure, full sedation was not achieved. The patient became drowsy, but she became fully awake during the procedure more than once, complained of pain, and asked that the procedure be stopped. The gastroenterologist continued and completed the procedure despite the patient’s urgent requests.
The Board issued a public reprimand against the gastroenterologist. Stipulations included continuing medical education in the topics of pre-operative patient evaluation, informed consent, sedation, and medical record keeping.
State: California
Date: May 2017
Specialty: Gastroenterology, Anesthesiology, Hematology
Symptom: Abdominal Pain, Nausea Or Vomiting
Diagnosis: Post-operative/Operative Complication, Hematological Disease
Medical Error: Procedural error
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF