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California – Neurology – Three EEGs Ordered Without Indication And Diagnosis Of Epilepsy
A 9-year-old girl was referred by her pediatrician to a child neurologist for headaches. The child neurologist first saw the patient on 9/10/2009. The patient’s mother stated that the patient’s headaches started in 7/20/2009. The patient had no episodes of loss of consciousness of any type. The child neurologist’s review of systems revealed headaches, neck pain, and back pain. The child neurologist noted headaches following a viral infection in July 2009 described as constant tension and pressure with nausea, photophobia, and difficulty concentration. The child neurologist’s diagnosis was childhood migraine and prescribed 10 mg amitriptyline. The child neurologist ordered an MRI to rule out neoplasm and aneurysms. The child neurologist also ordered an EEG, which was not indicated for headaches.
On 9/18/2009, the EEG was performed. The technician described the EEG with “sharp and slow waves.” On 9/30/2009, the child neurologist saw the patient for an office visit. The child neurologist read the EEG as showing “generalized polyspike and wave which was synchronous bilaterally over both hemispheres which is highly suggestive of a generalized seizure disorder.” The child neurologist stopped the amitriptyline 10 mg she prescribed at the last visit because of “seizures on EEG.” She ordered a neurosurgery consult and planned a separate meeting with the mother.
The child neurologist next saw the patient on 11/4/2009. The child neurologist prescribed Depakote at 250 b.i.d. The patient’s Depakote level was at 72. The patient reported no seizures or auras, but the child neurologist in her diagnosis documented “seizures, breakthrough.” The child neurologist ordered a second video EEG with computer analysis without medical indication. The EEG was performed on 11/25/2009. The technician report showed no abnormality. The child neurologist’s report was of generalized polyspike and slow waves bilaterally, “highly suggestive of generalized epilepsy,” with localized slowing in the left temporal area.
On 2/11/2010, the child neurologist saw the patient for a follow-up visit. The chief complaint was learning difficulty. The Depakote level was 53. The patient denied experiencing any auras and/or any seizures. On the next visit, on 5/11/2010, the patient still did not report any auras or seizures. The child neurologist’s diagnoses were generalized epilepsy, childhood headaches, adverse effect of medication, and learning disability. The child neurologist ordered a third video EEG with computer analysis to rule out seizures and BAER (brainstem auditory evoked response) to rule out hearing loss, despite no medical indication. The video EEG was performed on 6/28/2010 and was normal. On 7/12/2010, the child neurologist saw the patient for a follow-up visit. The patient denied having headaches and seizures. The child neurologist ordered a 72-hour ambulatory EEG despite the normal EEG.
The child neurologist next saw the patient on 1/19/2011 for a follow-up visit. The patient’s mother complained that the patient’s math and history test results were still low. The patient had no witnessed seizures and was tolerating Keppra well. Despite the negative findings, the child neurologist diagnosed “seizures, breakthrough, rule out.” The child neurologist ordered another video EEG. At this point in time, the 72-hour video EEG she previous ordered on 7/12/2010 had not been performed.
On 2/18/2011, a 72-hour ambulatory EEG was performed. The child neurologist’s last visit with the patient was on 3/14/2011. On the last visit, the child neurologist noted that the 72-hour ambulatory EEG was normal. She discontinued Keppra. She diagnosed the patient with “arachnoid cyst, middle cranial fossa; generalized epilepsy; learning disability; and adverse effect of medication given correctly.”
The Medical Board of California judged that the child neurologist’s conduct departed from the standard of care because she ordered 3 video EEGs and an ambulatory EEG without medical indication, ordered a BAER with no medical indication, misdiagnosed epilepsy on a patient with no medical history of seizures of any type, and made diagnoses of breaththrough seizures with no basis, contrary to her own findings that were no auras or seizures reported.
The Medical Board of California placed the child neurologist on probation and ordered the child neurologist to complete a medical record keeping 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 child neurologist was assigned a practice monitor and was prohibited from supervising physician assistants and advanced practice nurses.
State: California
Date: January 2018
Specialty: Neurology, Pediatrics
Symptom: Headache, Nausea Or Vomiting, Back Pain, Head/Neck Pain
Diagnosis: N/A
Medical Error: Unnecessary or excessive diagnostic tests, False positive
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
California – Neurology – Lack Of Documentation When Diagnosing Neuropathic Pain, RLS, and Carpal Tunnel Syndrome With Normal Neurological Examination
A 43-year-old male was referred by his primary care physician to a neurologist for multiple medical issues, including obesity, chronic post-operative pain following lumbar spine surgery, major depressive disorder, familial tremor, shoulder pain, excessive daytime sleepiness, congestive heart failure, and peripheral neuropathy. The patient had been on Norco and was switched to Tramadol. The dose of Tramadol was 100 mg 4 times a day. Other medications were trazodone 100 mg h.s., zolpidem 10 mg h.s., HCTZ 25 mg, Lasix 40 mg, Flomax 0.5 mg, and topiramate 100 mg twice daily.
On 3/27/2014, the neurologist saw the patient for an office visit. The patient complained of symptoms of foot pain, burning, and restless leg syndrome (RLS) symptoms. The neurologist diagnosed neuropathic pain, RLS, obesity, carpal tunnel syndrome, low back pain, and tremor. She planned to do B12 and ferritin levels, and she recommended an EMG/NCV of both upper and lower extremities. The neurologist noted a normal neurological examination. Despite the normal neurological examination, the neurologist failed to keep adequate documentation to establish her multiple diagnoses. She coded the visit as a level 5 new patient evaluation. The neurologist failed to document her 14-point review of systems and other required examinations to substantiate level 5 billing.
During a subsequent interview with the Medical Board, the neurologist initially stated that she had no recollection of the patient. Her medical report timed the office visit at 9:15, and the encounter ended at 11:11 a.m., approximately 2 hours. She stated that she spent 40 minutes with him. She could not account for the other time. She stated that “the rest was not me” and that she did not know what the time was “in between.” The patient claimed that she asked him only to stand and to try to stand on his heels and to squeeze her fingers. When asked why she ordered the EMG, she answered, “For neuropathy versus radiculopathy versus carpal tunnel syndrome could have CDIP.” She did not know what a Controlled Substance Utilization Review and Evaluation System (CURES) report was.
The Medical Board of California judged that the neurologist’s conduct departed from the standard of care because she failed to keep accurate, timely, complete medical records to support her diagnoses, coded and billed for level 5 services not substantiated in her records, and was not aware of CURES reports and did not utilize it in her practice.
For this case and others, the Medical Board of California placed the neurologist on probation and ordered the neurologist to complete a medical record keeping 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 neurologist was assigned a practice monitor and was prohibited from supervising physician assistants and advanced practice nurses.
State: California
Date: January 2018
Specialty: Neurology
Symptom: Extremity Pain, Back Pain, Joint Pain, Psychiatric Symptoms
Diagnosis: Neurological Disease
Medical Error: Lack of proper documentation, Procedural error
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
Florida – Emergency Medicine – Patient With Chest Pain Radiating To The Neck, Throat, And Back Discharged With Instructions To Follow up In 3-5 Days
On 11/15/2013, a patient complained of chest pain radiating to his neck, throat, and across his back. The patient stated the onset of the pain was noted to be one hour prior to his arrival at the hospital while he was screwing something into the wall, and that the pain was exacerbated by movement.
An ED physician performed an initial EKG, labs, and a chest x-ray on the patient.
The ED physician initially treated the patient with nitroglycerin and a GI cocktail, and subsequently with diazepam, morphine, Toradol, and Dilaudid.
The ED physician’s final assessment of the patient noted that the patient was still complaining of left side neck pain and “trap pain.”
The ED physician discharged the patient with a diagnosis of “musculoskeletal chest pain” and prescribed naproxen, Norco, and diazepam, along with instructions to follow up with him in three to five days.
The patient returned to the hospital the following day in cardiac arrest and expired on 11/16/2013.
The Medical Board of Florida judged the ED physician’s conduct to be below the minimal standard of competence given that he failed to perform a CT of the patient’s chest to evaluate for aortic dissection. He also failed to adequately document bilateral pulses and/or blood pressures in the patient. He failed to pursue other etiologies of the patient’s reported pain. The ED physician failed to admit the patient for further observation.
It was requested that the Medical Board of Florida order one or more of the following penalties for the ED physician: 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 Medical Board of Florida deemed appropriate.
State: Florida
Date: December 2017
Specialty: Emergency Medicine
Symptom: Chest Pain, Back Pain, Chest Pain, Head/Neck Pain
Diagnosis: Aneurysm
Medical Error: Failure to order appropriate diagnostic test, Delay in proper treatment, Failure to examine or evaluate patient properly, Lack of proper documentation
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF
Florida – Obstetrics – Lack Of Maternal Serum Alpha-Fetoprotein Testing With Pregnancy Complications
On 2/24/2014, a 36-year-old female presented to an obstetrician for fatigue, breast tenderness, and absence of menstruation. At the aforementioned visit, the obstetrician diagnosed the patient with amenorrhea and sent her to have blood work.
On 2/25/2014, the patient was notified of her positive pregnancy test.
On 3/10/2014, 3/17/2014, 3/24/2014. 4/24/2014, 8/7/2014, and 9/25/2015, the obstetrician ordered obstetrical ultrasounds and/or sonograms for the patient.
On 4/23/2014 and 8/20/2014, the patient presented to the obstetrician with thick vaginal fluid and blood discharge, morning sickness, nausea, chills, fever, and back pain.
On 5/23/2014, 6/20/2014, 7/16/2014, 8/15/2014, 9/12/2014, 10/13/2014, 10/20/2014, and 10/27/2014, the patient presented to the obstetrician for follow-up visits.
On 11/2/2014, the patient gave birth to her son, who was born with spina bifida/myelomeningocele.
The obstetrician failed to diagnose neural tube defect on imaging studies.
The obstetrician failed to order a maternal serum alpha-fetoprotein (MSAFP) test and did not maintain adequate legible documentation of ordering an MSAFP test.
The obstetrician failed to order an anatomical survey sonogram.
The Board ordered that the obstetrician pay a fine of $7000 against his license. The Board ordered that the obstetrician pay reimbursements costs of a minimum of $3,786.18 and not to exceed $5,786.18. The Board also ordered that the obstetrician complete a course on “Quality Medical Record Keeping for Health Care Professionals” and that he complete five hours of continuing medical education on “Risk Management.”
State: Florida
Date: December 2017
Specialty: Obstetrics
Symptom: Fever, Bleeding, Nausea Or Vomiting, Back Pain
Diagnosis: Obstetrical Complication, Spinal Injury Or Disorder
Medical Error: Failure to order appropriate diagnostic test, Failure to follow up, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
Virginia – Neurosurgery – All-Terrain Vehicle Rollover Accident Causes L1 Compression Fracture
On 1/19/2008, a 32-year-old man suffered an L1 compression fracture following an all-terrain vehicle rollover accident. He saw a neurosurgeon who placed him in a rigid back brace and prescribed pain medications. The patient’s fracture appeared to be clinically stable and appeared to be improving. The Board deemed the long-term risk of developing a kyphotic deformity low in this patient.
On 3/7/2008, the neurosurgeon performed a kyphoplasty of the spine the patient. During the kyphoplasty, the vertebral body was too dense to accept the cement. As a consequence, the cement extruded out of the fracture plans into the epidural space.
The neurosurgeon addressed this complication by performing a posterior laminectomy and decompression of the thecal sac. The Board stated that the laminectomy procedure subjected the patient to a far greater risk for development of kyphosis than had existed prior to the kyphoplasty.
The Board considered the surgery unwarranted and issued a reprimand. The neurosurgeon was ordered to complete 10 hours of continuing medical education in the subject of patient selection for spinal surgery.
State: Virginia
Date: November 2017
Specialty: Neurosurgery
Symptom: Back Pain
Diagnosis: Spinal Injury Or Disorder, Fracture(s)
Medical Error: Unnecessary or excessive treatment or surgery, Procedural error
Significant Outcome: N/A
Case Rating: 5
Link to Original Case File: Download PDF
Florida – Interventional Radiology – Epidural Steroid Injection On A Patient Taking Plavix
On 1/21/2014, an 85-year-old female was admitted to the hospital with complaints of lower back pain and chest pain.
The patient’s medication list, at the time of her admission, listed a prescription for 75 mg of Plavix daily.
On 1/23/2014, a radiologist performed an epidural steroid injection on the patient while she was taking Plavix. Shortly after the procedure, the patient developed an abrupt sudden onset of diffuse abdominal pain with nausea, vomiting, and a large retroperitoneal hematoma extending from the left upper abdomen into the pelvis.
The patient had a stroke, among other complications.
The Board judged the radiologists conduct to be below the minimal standard of competence given that he performed an epidural injection on a patient while the patient had been receiving antiplatelet therapy for a significant period of time.
It was requested that the Board order one or more of the following penalties for the radiologist: 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: October 2017
Specialty: Interventional Radiology
Symptom: Back Pain, Nausea Or Vomiting, Chest Pain
Diagnosis: Drug Overdose, Side Effects, or Withdrawal
Medical Error: Improper medication management
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 4
Link to Original Case File: Download PDF
California – Radiology – Back Pain With Subsequent MRI And Missed Incidental Finding
In 2009, a patient with a history of smoking developed back pain. Her primary care physician sent her to a hospital for two MRIs of her spine: one on 3/9/2009 and another on 4/13/2009. Radiologist A at the hospital obtained the MRI images and sent them to a teleradiology company for review. Radiologist B at the teleradiology company reviewed the MRIs. Neither of his reports mentioned any lung abnormalities.
In 2010, the patient developed a cough and was sent to the hospital for a chest x-ray. Radiologist A reviewed the x-ray and reported that he found no significant pathology.
After suffering from continued bouts of coughing, the patient was sent to the hospital for another chest x-ray in 2012. Radiologist A reviewed the x-ray and reported that he found no significant pathology.
In 2013, Radiologist A received a chest x-ray for asthma. Radiologist A reviewed the x-ray and found a mass on the patient’s right lung. Radiologist A recommended that the patient undergo a computed tomography (CT) scan. The CT scan revealed a 4.8 by 2.5 centimeter mass, which was subsequently identified as cancerous. The patient was diagnosed with unresectable Stage IIIA non-small cell lung cancer metastatic to the lymph nodes. The patient underwent 33 radiation treatments and multiple rounds of chemotherapy.
In January 2014, the patient filed a complaint against Radiologist A and Radiologist B asserting medical malpractice. She claimed that her lung cancer diagnosis was delayed by four years given failure to detect the mass when they reviewed her MRIs and chest x-rays.
In November 2015, prior to the start of the trial, the patient began to have breathing issues, balance problems, dizziness, and difficulty with memory. On 11/3/2015, her primary care physician ordered a CT scan, which revealed that the cancer had metastasized to her brain.
On 11/13/2015, the jury returned a verdict in favor of the patient with liability spread equally among Radiologist A and Radiologist B. The jury awarded the patient a total of $3 million.
The California Board issued a public reprimand against Radiologist B given his failure to report the medical malpractice case to the Hawaiian Board.
State: California
Date: October 2017
Specialty: Radiology
Diagnosis: Lung Cancer
Medical Error: False negative
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
Florida – Obstetrics – Missed Indicators Of A Neural Tube Defect
On 2/24/2014, a 36-year-old female presented to an obstetrician for fatigue, breast tenderness, and absence of menstruation. At the aforementioned visit, the obstetrician diagnosed the patient with amenorrhea and sent her to have blood work.
On 2/25/2014, the patient was notified of her positive pregnancy test.
On 3/20/2014, 3/17/2014, 3/24/2014, 4/24/2014, 8/7/2014, and 9/25/2015, the obstetrician ordered obstetrical ultrasounds and/or sonograms on the patient.
On 4/23/2014 and 8/20/2014, the patient presented to the obstetrician with thick vaginal fluid and bloody discharge and/or morning sickness, nausea, chills, fever, and back pain.
On 5/23/2014, 6/20/2014, 7/16/2014, 8/15/2014, 9/12/2014, 10/13/2014, 10/20/2014, and 10/27/2014, the patient presented to the obstetrician for follow-up visits.
On 11/2/2014, the patient gave birth to her son. The child was born with a neural tube defect called spina bifida/myelomeningocele.
The obstetrician failed to observe on imaging studies, and follow-up on, known indicators that the patient’s child may have had a neural tube defect, or alternatively, did not create, keep, or maintain adequate legible documentation of observing on imaging studies, and following up on known indicators that the patient’s child may have had a neural tube defect.
The obstetrician failed to order maternal serum alpha-fetoprotein (MSAFP) test, or alternatively, did not create, keep, or maintain adequate legible documentation of ordering a MSAFP test.
The obstetrician failed to order an anatomical survey sonogram, or alternatively, did not create, keep, or maintain adequate legible documentation of ordering an anatomical survey sonogram.
It was requested that the Board order one or more of the following penalties for the obstetrician: 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: Obstetrics
Symptom: Weakness/Fatigue, Bleeding, Abnormal Vaginal Discharge, Back Pain
Diagnosis: Neurological Disease
Medical Error: Failure to order appropriate diagnostic test, Failure to follow up, Lack of proper documentation
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 1
Link to Original Case File: Download PDF
Florida – Family Medicine – Improper Prescribing Of Controlled Substances To A Patient With Drug Seeking Behavior, Dependence, and Withdrawals
On 7/13/2006 through 8/6/2013, a family practitioner treated a 37-year-old female for chronic neck and back pain. The patient presented to the family practitioner with a history of hypertension, depression, anxiety, and back pain from a 2004 motor vehicle accident.
The patient’s medical records from her previous treating physicians indicated that the patient was addicted to Xanax, had attempted suicide via overdose of alcohol and Tylenol in 2004, and was a high-risk patient with regards to controlled substances.
Throughout the course of the treatment, the family practitioner prescribed controlled substances to the patient including Nucynta, Percocet, Xanax, Klonopin, Vicodin, and Soma.
On 10/7/2008, the family practitioner noted that the patient exhibited drug seeking behavior, had undergone physical withdrawals, and was having psychological dependence. The family practitioner documented “no further controlled substances after this.”
On 10/7/2008, the family practitioner referred the patient to a pain management specialist.
From 10/17/2008 to 5/6/2010, the patient presented to a pain management specialist for her chronic pain.
Beginning on 5/17/2010, the patient discontinued treatment with the pain management specialist and resumed her treatment with the family practitioner for her chronic pain.
From 9/2/2011 through 8/6/2013, the patient presented to the family practitioner approximately every three months. Despite the patient only presenting every three months, the family practitioner prescribed monthly refills of controlled substances for the patient. The family practitioner prescribed Nucynta, Percocet, Xanax, Klonopin, Vicodin, and Soma to the patient in various combinations and amounts.
The prevailing standard of care requires that a physician treating a patient for chronic pain prescribe controlled substances appropriately. The quantity and/or combination of controlled substances the family practitioner prescribed to the patient on one or more occasions from 9/2/2011 through 8/6/2013 were inappropriate.
The prevailing standard of care requires that a physician treating a high-risk patient for chronic pain create and implement an appropriate treatment plan.
The family practitioner did not create or implement, or did not document creating or implementing, an appropriate treatment plan for the patient. The prevailing standard of care requires that a physician treating a high-risk patient for chronic pain evaluate the patient prior to refilling prescriptions for controlled substances. On one or more occasions, the family practitioner prescribed multiple refills of controlled substances for the patient at a single office visit.
The prevailing standard of care required that a family physician treating a high-risk patient for chronic pain refer the patient to a chronic pain specialist. The family practitioner did not refer, or did not document referring, the patient to a chronic pain specialist on or after 9/2/2011.
It was requested that the Board order one or more of the following penalties for the family practitioner: 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: Family Medicine
Symptom: Head/Neck Pain, Back Pain, Psychiatric Symptoms
Diagnosis: Drug Overdose, Side Effects, or Withdrawal
Medical Error: Improper medication management, Referral failure to hospital or specialist, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
Florida – Neurosurgery – Laminectomy Performed On The Patient’s L3-L4 Level Instead of L4-L5 Level
In March 2016, a 72-year-old male sought treatment from a neurosurgeon for low back pain. The neurosurgeon diagnosed the patient with lumbar spondylosis and lumbar spinal stenosis.
Informed consent was obtained from the patient for an L4-L5 laminoforaminotomy for the decompression of the spinal cord and partial medial facetectomy.
On 3/23/2016, the neurosurgeon performed a laminectomy at the patient’s L3-L4 level (wrong site) rather than at the L4-L5 level (correct site).
Approximately three months after the surgery, the patient saw his primary care physician because his back pain had returned. The patient’s primary care physician obtained an MRI on 7/6/2016. The MRI results revealed spinal stenosis at the patient’s L4-L5 level and post-operative changes at the L3-L4 level.
After reviewing the patient’s post-surgery MRI, the neurosurgeon realized that she performed the procedure at the L3-L4 level.
It was requested that the Board order one or more of the following penalties for the neurosurgeon: 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: Neurosurgery, Orthopedic Surgery
Symptom: Back Pain
Diagnosis: Spinal Injury Or Disorder
Medical Error: Wrong site procedure
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF