Found 7 Results Sorted by Case Date
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Kansas – Pediatrics – Improper Documentation For Reactive Airway Disease And Improper Use of Bactrim



On 2/4/2013 a 7-year-old female presented to a pediatrician and saw the advanced practice registered nurse (“APRN”).  The patient presented with chief complaints of allergies, congestion, and diarrhea.  The patient was prescribed albuterol, Qvar 40 mcg, Bactrim, and triamcinolone.  The Bactrim was prescribed inappropriately for diarrhea.  The pediatrician agreed but thought that he had perhaps forgotten to document otitis media.

On 2/19/2013, the pediatrician saw the patient for a follow-up appointment.  The pediatrician documented that the patient was there for a follow-up for her asthma, even though the patient previously presented with reactive airway disease.  The pediatrician did not document his thought process in how reactive airway disease developed in asthma.  The pediatrician did not electronically sign the record until 4/11/2013.

On 6/11/2013, the patient presented to the pediatrician for a school physical.  The pediatrician failed to document the patient’s asthma.  In the school health examination, the pediatrician stamped signature appears on the form with the date 6/11/2013.  The pediatrician stamped the document “No” to the question, “Is this student subject to any condition which might cause a possible classroom emergency such as seizures, fainting, diarrhea, diabetes, asthma, allergies, etc.”

The Board judged the pediatrician’s conduct to be below the minimum standard of competence given his failure to keep written medical records, and inappropriately prescribing a medication.

The Board ordered that the pediatrician attend and successfully complete the Medical Record Keeping Seminar at Center for Personalized Education for Physicians (“CPEP”). Also, the Board ordered that the pediatrician hire a medical scribe. Finally, the Board ordered that the pediatrician have a pediatrician monitor his work.

State: Kansas


Date: October 2016


Specialty: Pediatrics


Symptom: Allergic Reaction Symptoms, Diarrhea


Diagnosis: Asthma


Medical Error: Lack of proper documentation, Improper medication management


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Washington – Allergy And Immunology – Injections Administered To The Wrong Patients



On 1/9/2014, Patient A, a 34 year old male who suffers from allergies to pollen and pet dander and is asthmatic, presented to a physician’s allergy and asthma center for an allergy shot.

The allergist administered an allergy shot to Patient A.  Shortly after administering the shot, the allergist realized she had injected Patient A with another patient’s dose.  The other patient had a similar name to Patient A, and the allergist had confused the two patients.  The allergist observed Patient A, and after thirty minutes noted he had developed hives on his abdomen and hands but experienced no difficulty with breathing, wheezing, or throat constriction.  The allergist administered 0.4 mg epinephrine (EpiPen) to Patient A.  The allergist further monitored Patient A, ensuring the treatment was adequate, and released Patient A home with an additional EpiPen.

Later that day, Patient A phoned the allergist stating he felt generally unwell and dizzy.  Patient A told the allergist he had used the EpiPen at home and felt severe cramping in his arm from it.  The allergist visited Patient A at his home, examined his lungs, and provided him with additional EpiPens.  The allergist stayed with Patient A to ensure he was doing well.

On 6/27/2014, eight year old Patient B presented to the allergist’s clinic along with his father. Patient B’s father had been receiving allergy shots by the allergist for about one year when Patient B began treatment.  The allergist gave Patient B an allergy shot, however, the dose she administered was his father’s dose which was over a thousand times more than the dose Patient B should have been given.  About five minutes later, Patient B experienced shortness of breath.  The allergist administered 0.3 ml EpiPen, noted progressed symptoms, and administered another 0.4 ml EpiPen.  Patient B had a sensation of his throat tightening and experienced some wheezing.  Ten minutes following the injections, the allergist called 911 and Patient B was transported to the emergency department (ED). The ED diagnosed Patient B with anaphylaxis due to inappropriate immunotherapy.  Patient B’s condition stabilized and he was discharged a few hours later.

The allergist has since sold her clinic and now works as a hospitalist in a nearby hospital.

The Commission stipulated the allergist reimburse costs to the Commission, submit semi-annual reports to the Commission from her supervising physician on the quality of her clinical practice and any documented medicine errors, write and submit a paper of at least 2000 words, with references, concerning medication errors and how they can be prevented and how to ensure patients get the correct medication at the correct dose at the correct time, and present this paper to a group of her peers at a hospital which she has privileges.

State: Washington


Date: February 2016


Specialty: Allergy and Immunology


Symptom: Allergic Reaction Symptoms


Diagnosis: Drug Overdose, Side Effects, or Withdrawal


Medical Error: Accidental Medication Error


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



North Carolina – Psychiatry – Dosing Of Psychiatric Medications For A Three Year Old



On 05/14/2014, a three-year-old patient presented to a psychiatrist for an evaluation.  The patient’s mother complained of problems with attention, erratic sleep schedule, and aggression towards the patient’s younger sibling.

The psychiatrist diagnosed the patient with attention deficit hyperactivity disorder (ADHD) and prescribed two psychostimulant medications with a recommendation for a follow-up within a month.

On 09/16/2014, the psychiatrist saw the patient, who presented with complaints of trouble sleeping, diminished appetite, and diminished energy level.  The patient’s mother had consulted another physician, who discontinued one of the ADHD medications, because the dosage was considered too high for the patient.  The psychiatrist then discontinued both of the medications that the psychiatrist had initially prescribed for the patient and started the patient on a third psychostimulant medication for ADHD.

On 10/28/2014, the patient returned to the psychiatrist, who discontinued the third medication he had prescribed and prescribed a fourth psychostimulant medication for ADHD.  The psychiatrist also prescribed two new antidepressant medications at dosages recommended for an adult.  Within 48 hours of taking these three prescriptions, the patient became ill and was hospitalized due to an altered mental status.

In November 2014, the Board received complaints regarding the care provided by the psychiatrist.  The complaints were from two of the patient’s treating physicians.  The patient’s medical records were sent to an independent medical expert who specializes in child psychiatry.  This independent medical expert opined that all aspects of the psychiatrist’s care for the patient were below the acceptable and prevailing standard of care in North Carolina.

The medical expert opined that the psychiatrist did not conduct a complete and thorough evaluation of the patient.  The diagnosis of ADHD in a three year old requires collateral information which was not obtained.  The expert opined that the medication choices for the patient were below the standard of practice.  Stopping one medication and starting a combination of three medications at adult dosage levels in a three year old lead to serious iatrogenic side effects requiring hospitalization.

The Board required that the psychiatrist complete 15 hours of Category 1 CME in the diagnosis and treatment of ADHD with a 6 month time limit.

State: North Carolina


Date: May 2015


Specialty: Psychiatry


Symptom: Allergic Reaction Symptoms


Diagnosis: Autoimmune Disease


Medical Error: Improper medication management


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Family Medicine – Recurring Hemorrhoids And Blood In the Stool



A family practitioner saw a patient for various medical reasons from 1986 to 2009 with the first visit on 8/24/1984.  During the period of 1986-2009, the patient also saw the family practitioner at least once a year for treatment of seasonal allergies.  The family practitioner treated the patient’s allergies with non-sedating antihistamines and nasal steroids.  During the period of 1986-2009, the family practitioner gave the patient yearly injections of steroids.

On 5/16/2000, the patient, who was 56-years-old, presented to the hospital complaining of chest pain.  Another physician noted that his physical examination was unremarkable.  A rectal examination showed external hemorrhoid, normal sphincter tone, mildly enlarged prostate, and a “ring” appreciated on rectal exam as well as heme-positive stool.  The physician recommended a colonoscopy.  The family practitioner saw the patient on 10/21/2003 for an evaluation.  The family practitioner noted that the patient had been going to an outpatient clinic for a period of time and was not back under the care of the family practitioner.  The family practitioner noted to recheck his blood studies in about a week.

On 11/5/2003, the family practitioner saw the patient and noted that the patient “has some rectal bleeding, appears to be hemorrhoidal.”  The family practitioner also noted that “[the patient] is quite spooky and it is difficult to do a rectal on him”  The family practitioner administered Procto-HC Cream for hemorrhoids and scheduled the patient for a colonoscopy for 12/8/2003 at 7:45 a.m.  On 11/11/2003, the family practitioner saw the patient for an injured right toe. The x-rays were negative.

The colonoscopy scheduled for 12/8/2003 was canceled by the family practitioner.  The family practitioner did not communicate to the patient why the colonoscopy was canceled nor did he try to reschedule the colonoscopy.  On 7/2/2004, the family practitioner saw the patient for a complete physical examination.  At this time, the patient was 61-years-old and presented with a chief complaint of “arthritis, recent shoulder surgery.”  The physical examination was unremarkable.  The family practitioner documented an enlarged prostate that was “typical for age and no other masses.”

On 2/18/2005, the family practitioner saw the patient, who presented with allergies, which began in the spring.  The family practitioner noted that the review of systems was unremarkable.  The family practitioner noted that the patient denied abdominal pain, melena, or bright red blood, nausea, vomiting, diarrhea, or constipation.  The family practitioner didn’t document that he performed a rectal examination at this visit.  The family practitioner noted: “Assessment: Allergic Rhinitis. Plan: Depo Medrol 80mg IM.”

The family practitioner next saw the patient on 2/23/2005.  He documented that the “exam shows some hemorrhoid tissue. Prostate is slightly enlarged but palpates smoothly.”  Lab work showed that the patient was positive for occult blood.  On 3/25/2005, the family practitioner noted “patient in for review of lab studies. He is feeling better than he has in years.”  The family practitioner didn’t discuss the positive occult blood report.

On 4/17/2006, the family practitioner saw the patient for a complete physical examination.  The patient presented with a chief complaint of “some hemorrhoid irritation and bleeding at times and mild hypertension that is well controlled.”  The physical examination was unremarkable.  The family practitioner noted that the rectal examination was “negative, except for some hemorrhoidal tissue and somewhat enlarged prostate. No other masses.”  The family practitioner prescribed Procto-HC cream to use for hemorrhoids.

On 5/8/2007, the family practitioner saw the patient for a complete physical examination.  At this time, the patient was 64-years-old and had elevated lipids and a decrease in urinary stream.  The family practitioner suspected the decrease in urinary stream was caused by allergy medication and noted the rectal examination was “negative, except for slightly enlarged prostate, but smooth and PSA was normal.”  On 5/8/2008, the family practitioner saw the patient for a complete medical examination.  The patient’s note for this visit listed in the rectal examination that the patient “shows very tight sphincter with perhaps some slight enlargement of prostate.”  The patient next saw the family practitioner on 4/13/2009 for strain of the right knee related to playing softball.

On 7/16/2009, the family practitioner saw the patient at which time the patient’s chief complaint was chronic pain and swelling on the right knee and some erection difficulties.  The family practitioner noted the rectal examination was “Negative exam. No masses noted.”

On 1/1/2010, the patient saw Physician A for rectal pain.  Physician A noted that the patient “…just got back from Las Vegas and he feels like he has to go to the bathroom six to eight times a day and does not completely void very well, though he does get the stool out without too much difficulty.”  Physician A noted that he suspected a “thrombosed hemorrhoid,” but did not see any evidence of that and, instead, on the rectal exam, observed a “nearly, if not circumferential firm mass that has reddish ting [sic] on it.”  Physician A noted that he suspected rectal cancer and thought it was past being able to do a colonoscopy.

On 2/1/2010, the patient was seen in consultation by Physician B after the referral from Physician A.  The patient had a chief complaint of probable rectal cancer adenocarcinoma.  On the note under “history of present illness,” Physician B wrote that the patient reported that he had suffered from intermittent bleeding rectally for a long time, attributed to hemorrhoids.  The patient had never had a colonoscopy.  For several months, there was more frequent bleeding with bowel movements and some mid-sacral pain.  Physician B performed a rectal exam and noted that there was an “annular ulcerating firm lesion starting at the top of the sphincter, highly suspicious for a lower third rectal cancer.”  Physician B scheduled the patient for a colonoscopy and biopsy within the week.

On 2/2/2010, the patient underwent a CT scan of the abdomen and pelvis with contrast.  The findings were “rectal cancer in a 55-year-old.”  Impressions were noted as “circumferential thickening of the rectosigmoid junction.  Suggestion of infiltrate change in the perirectal fat. Small nodularity seen with one node slightly enlarged suggesting the possibility of early adenopathy to the left pelvic sidewall area.”

On 2/5/2010, Physician B performed a colonoscopy and discovered a mass in the rectum that was 6 cm long and was palpated 4-10 cm from the anal verge.  The mass was circumferential with residual lumen around 1.5 cm in diameter.  The mass was biopsied.  The pathology report on the biopsy reported “a poorly differentiated adenocarcinoma, focus suspicious for lymphovascular invasion.”  A lower endoscopic ultrasound was done on 2/19/2010.  A rectal mass was found.  There was an extension of the mass into adjacent structures including internal and external anal sphincter muscles and prostate.  Multiple malignant-appearing lymph nodes in the perirectal region, in the left iliac region and adjacent to the rectal mass, were also observed.  The patient underwent preoperative radiation to shrink his tumor.  The patient later required diverting colostomy in May 2010 and later hemodialysis.  At the time of surgery, his cancer was noted to have invaded the local tissues and was deemed unresectable.  The patient passed away on 6/22/2010.

The Medical Board of California judged that the family practitioner committed gross negligence in his care and treatment of the patient because he failed to provide appropriate colon cancer screening despite multiple opportunities to do so, diagnose colon cancer, evaluate and document undiagnosed rectal bleeding as a problem on the medical history form provided for that purpose, reschedule a colonoscopy that was ordered for rectal bleeding, properly address allergies on serial evaluations, and refer the patient to an allergy specialist despite non-response of the patient to daily nasal steroid and antihistamines.

The Medical Board of California ordered the family practitioner to surrender his license.

State: California


Date: March 2015


Specialty: Family Medicine, Internal Medicine


Symptom: Blood in Stool, Allergic Reaction Symptoms, Chest Pain, Extremity Pain, Joint Pain, Pelvic/Groin Pain, Urinary Problems


Diagnosis: Colon Cancer


Medical Error: Failure to order appropriate diagnostic test, Failure to examine or evaluate patient properly, Referral failure to hospital or specialist, Failure of communication with patient or patient relations, Failure to follow up, Lack of proper documentation


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



California – Pediatrics – Allergies With Ear And Nose Congestion, Along With Motor And Behavioral Problems



On 1/11/2008, parents of a patient presented their son, then three and a half years old, to a pediatrician for medical treatment.  The patient was a product of a twin pregnancy.  His brother did not present with any of the health issues suffered by the patient.  At the time, the patient suffered from allergies with ear and nose congestion as well as motor and behavior problems.  The pediatrician presented himself as a specialist in learning disorders, cognitive dysfunction, and neuro-immune disorders, notwithstanding his lack of subspecialty training or board certification in these areas.  During the initial visit, the pediatrician told the patient’s mother that he, the pediatrician, used to be a general pediatrician, but now only treated special needs/neuro-immune dysfunctional children.  The pediatrician told the patient’s mother that her son exhibited some symptoms considered on the autistic spectrum, due to neuro-immune issues.  The patient had not previously been diagnosed as autistic and was not tested for autism by the pediatrician.

The pediatrician, who is the author of The Myth of Autism: How a Misunderstood Epidemic Is Destroying Our Children (Skyhorse Publishing, 2011), placed the patient on a similar regimen as children being treated for autism by other physicians – namely, antihistamines, antivirals, and Selective Serotonin Reuptake Inhibitors (SSRI) medication.  The pediatrician diagnosed the patient with elevated EBV titer and neuro-immune cognitive dysfunction/NIDS (Neuro Immune Dysfunction Syndrome).

The pediatrician did not inform the patient’s parents of the known risks of the medications that he was recommending for the patient or did not document that he had done so in his medical records for the patient.

After beginning the medication prescribed by the pediatrician, the patient became agitated and sleepless.  He experienced “leg kicking and early waking.”  The patient remained on the medication regime for eleven months.  The medications were changed or adjusted in response to the patient’s reactions.  The pediatrician did not refer the patient to another physician and surgeon for his neuro-immune issues and did not recommend that the patient’s parents consult with another physician or surgeon.

The pediatrician saw the patient on frequent occasions and recommended numerous blood and ear tests.

A food allergy panel showed that the patient was potentially sensitive to eggs.  The pediatrician did not advise the patient’s parents and dismissed the test results or did not document that he had advised the patient’s parents of the test results in the patient’s medical records.

The patient’s parents eventually transferred their son’s care to another physician and surgeon upon referral by the pediatrician.  The subsequent physician successfully treated the patient’s allergies with ear and nose congestion by inserting tubes in the child’s ears one year later.

While under the pediatrician’s care, treatment, and management, the patient had periodic problems with balance and motor issues.

The Board judged the pediatrician’s conduct as having fallen below the standard of care for this patient and another given the inappropriate prescription of antiviral and antifungal medications; the administration of unapproved treatment without advising the patients’ parents; the representation of himself as a specialist in learning disorders, cognitive dysfunction, and neuro-immune autism; and the failure to diagnose the patients in accordance to commonly accepted guidelines.  For the above specific patient, he failed to advise the patient or his parents of the patient’s positive result for potential egg allergy.

State: California


Date: November 2013


Specialty: Pediatrics, Otolaryngology


Symptom: Allergic Reaction Symptoms


Diagnosis: Neurological Disease, Ear, Nose, or Throat Disease


Medical Error: Improper medication management, Ethics violation, Failure of communication with patient or patient relations, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Wisconsin – Urology – Failure To Review Allergies Leading To Medication Error



On 09/21/2009, a patient underwent an abdominal ultrasound for epigastric right upper quadrant pain which revealed bilateral hydronephrosis.  The patient was referred to a urologist, who saw the patient on 09/21/2009.  The urologist documented: “We discussed the definitive workup for this and she desires to proceed with a cystoscopy and bilateral retrograde pyelograms under local with MAC in ASC.  The procedure was described in detail.  Potential complications, including but not exclusive of burning with urination, postoperative pain, infection, bleeding, DVTs, PEs, Mis [sic], CVAs, intraoperative or postoperative death.  Despite the above, she desires to proceed.  It is explained to the patient if there is correctable etiology found, such as a stricture, this would be high-pressure balloon-dilated and a stent placed.  She understands stents can cause significant discomfort to outright pain until they are removed…”

On 10/19/2009, the patient presented to the urologist for a cystoscopy with retrograde pyelogram, high-grade pressure balloon dilation of right UPJ stricture, and right double J stent placement.  The urologist used contrast dye for the high-pressure balloon dilation.

The patient then experienced an “anaphylactic reaction secondary to extravasated contrast at high-pressure balloon dilated UPJ stricture site.”  The urologist documented: “…On recognition of the extravasation, I immediately ordered IV Solu-Medrol which was administered by Anesthesia.  Despite this, within 3-5 minutes of the extravasation, the patient’s systolic blood pressures dropped into the 50 range and O2 sats dropped into the 70% range and resuscitation efforts were immediately began with intubation of the patient and administration if (sic) IV epinephrine.  This restored her blood pressures to normal…”

The urologist had not discussed with the patient the risk of anaphylactic reaction with the use of IV contrast.  It was noted in the patient’s chart: “Contrast media: Allergic reaction/anaphylaxis (CT dye)” and “Ivp dye, iodine containing: Allergic reaction/anaphylaxis, history of (CT dye).”

The Board judged that the urologist had fallen below the minimum acceptable standards of care by failing to discuss the risks of using IV contrast in a patient with a prior history of anaphylaxis to IV contrast and failing to pre-medicate the patient with steroids.  It was deemed inappropriate for Solu-Medrol to have been administered when the patient developed an anaphylactic reaction given that it takes hours for it to work.

The Board ordered the urologist be reprimanded and complete  2 hours of medical education for the management of allergic reactions and anaphylactic shock.

State: Wisconsin


Date: November 2012


Specialty: Urology, Allergy and Immunology


Symptom: Allergic Reaction Symptoms


Diagnosis: Drug Overdose, Side Effects, or Withdrawal


Medical Error: Accidental Medication Error


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



California – Family Medicine – Elevated Blood Pressure Elevation Attributed To Clonidine And Chlorpheniramine Interaction



A family practitioner was employed by a prison from October 2003 to July 2007.  The family practitioner’s primary duty at the prison was to perform health assessments on newly arrived inmates and to provide urgent care at the prison’s Triage and Treatment Area (TTA).  On 4/10/2008, the California Department of Corrections and Rehabilitation (CDCR) filed a report with the California Medical Board stating that the family practitioner resigned from employment with the CDCR effective 7/20/2007 during peer review of his care and treatment of several patients.

On 5/27/2007, a 39-year-old patient presented to the TTA complaining that he could not sleep due to nasal congestion and a noisy cellmate.  He was referred to the TTA due to hypertension, his blood pressure being 217/137. The TTA nurse noted that the patient had a chronic inability to sleep, had a problem with snoring, and was feeling sad.  At his initial evaluation in the TTA, his blood pressure was 188/131.

The family practitioner ordered a dose of clonidine, which slows the heart rate and relaxes the blood vessels, to address the patient’s high blood pressure.  30 minutes later, the patient’s blood pressure was reduced to 177/113; 90 minutes later, it was 152/91. The family practitioner ordered a second dose of clonidine and discontinued the patient’s chlorpheniramine, an antihistamine the patient took for his nasal congestion.  The nurse’s notes stated that the blood pressure elevation was due to “mixing antihistamines with BP meds.” The family practitioner ordered the patient to see the primary care provider in 2 days.

The Medical Board of California judged that the family practitioner’s conduct departed from the standard of care because he failed to perform an adequate history and physical for the patient, examine the patient for signs of hypertensive damage, and address in his progress notes that patient’s complaints of inability to sleep, snoring, or feelings of sadness.  The family practitioner’s examination and progress notes were not sufficient to provide the subsequent primary care physician detail to understand the issues the patient presented and to continue appropriate treatment. The family practitioner also failed to document a differential diagnosis for the patient. The patient’s poorly controlled hypertension, presenting with a blood pressure of 217/137, called upon the family practitioner to consider and address other issues including medication non-compliance, malignant hypertension, and hypertensive urgency.  The family practitioner erroneously assumed that the patient’s elevated blood pressure was caused by the interaction between the BP meds and the antihistamines he was taking. The family practitioner discontinued the antihistamines even though elevated blood pressure is not a side effect of antihistamines. The family practitioner also failed to properly treat the patient’s conditions. He did not increase nor add any other antihypertensive medication to address the patient’s uncontrolled blood pressure. The family practitioner also discontinued the patient’s antihistamine without prescribing an alternative to treat the patient’s nasal congestion.

For this case and others, the Medical Board of California placed the family practitioner on probation for 5 years and ordered the family practitioner to complete a medical record keeping course, a prescribing practices course, a professionalism program (ethics course), an education course (at least 40 hours per year for each year of probation), and a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.  The family practitioner was also prohibited from practicing solo and supervising physician assistants. The family practitioner’s license was later revoked due to a failure to successfully complete the clinical training program.

State: California


Date: July 2012


Specialty: Family Medicine, Internal Medicine


Symptom: Allergic Reaction Symptoms, Psychiatric Symptoms


Diagnosis: Cardiovascular Disease


Medical Error: Failure to examine or evaluate patient properly, Diagnostic error, Failure of communication with other providers, Improper treatment, Improper medication management, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



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