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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 – Emergency Medicine – Sharp Chest Pain After Intercourse
On 4/4/2015, a 47-year-old male presented to the emergency department with sharp chest pain after intercourse.
The RN on duty noted taking the patient’s vitals and performing an EKG, chest radiograph, and labs.
In his physician note, the ED physician documented the following: the patient did not take his medication for hypertension or dyslipidemia despite having a history of hypertension and homelessness; the patient reported a history of coronary artery disease and possible coronary artery stent placement; and the patient reported chest discomfort and dyspnea for the week prior to presentation as well as a history of tobacco use.
The ED physician recorded a differential diagnosis including acute myocardial infarction, non-ST segment elevation myocardial infarction (“NSTEMI”), angina, and acute coronary syndrome.
The ED physician did not diagnose the patient with possible cardiac etiology of chest discomfort. He also did not contact the on-call cardiologist. The ED physician did not perform provocative testing or cardiac catheterization. He also did not admit the patient for hospitalization and cardiology consultation. The ED physician discharged the patient without requiring any further evaluation/treatment or serial EKG/troponin. He did not arrange for close outpatient follow-up prior to discharge.
The Board issued a letter of concern against the ED physician’s license and ordered that he pay a fine, reimburse costs for the proceedings, and complete 5 hours of continuing education in risk management.
State: Florida
Date: November 2017
Specialty: Emergency Medicine
Symptom: Chest Pain
Diagnosis: Cardiovascular Disease
Medical Error: Failure to order appropriate diagnostic test, Referral failure to hospital or specialist, Failure to follow up
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
Florida – Family Medicine – Recurrent Chest Pain Diagnosed As Esophageal Spasm
On 8/27/2012 a 47-year-old female presented with complaints of hypertension, possible hyperlipidemia, and pain in her foot. A family practitioner assessed the patient and diagnosed her with poor control of her hypertension and reinforced medical advice for the patient to increase her lisinopril. Additionally, the family practitioner waited for the results of the previous laboratory work and recommended conservative management and stretching for the foot and ankle.
On 4/1/2013, the patient again presented to the family practitioner to address difficulties with concurrent chest pain. The patient stated the chest pains were very severe and “stopped her in her tracks at times.” The patient stated that she felt she was having a heart attack, although she reportedly realized that that was not the case. The family practitioner deemed the chest pain was likely an esophageal spasm, for which he prescribed the patient Librax (chlordiazepoxide/clidinium) and recommended that she see a gastroenterologist for an endoscopy if the medication failed to provide relief. The family practitioner also assessed the patient for hypertension and instructed the patient to stop taking hydrochlorothiazide. The family practitioner provided the patient with a trial of Dyrenium (triamterene).
On 4/12/2013, the patient complained of chest pain and suffered a cardiac arrest. Upon EMS arrival, the patient was unstable and unresponsive. The patient was transported to a hospital where she was later pronounced deceased.
The Board judged the family practitioners conduct to be below the minimal standard of competence given that he failed to conduct an adequate history, which included a risk factor assessment for a patient complaining of chest pain, to order or perform an EKG on a patient complaining of chest pain, and send a patient complaining of chest pain to an emergency room or an expedited outpatient facility for a chest pain evaluation.
The Board ordered that the family practitioner pay a fine of $5,000 against his license and pay reimbursement costs for a minimum of $2,122.00 and not to exceed $4,122.00. The Board also ordered that the family practitioner complete ten hours of continuing medical education in diagnosis in cardiology and five hours of continuing medical education in “Risk Management.”
State: Florida
Date: November 2017
Specialty: Family Medicine
Symptom: Chest Pain, Extremity Pain
Diagnosis: Cardiovascular Disease
Medical Error: Diagnostic error, Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Referral failure to hospital or specialist
Significant Outcome: Death
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Internal Medicine – Retained Guide Wire Found After Replacement Of Dialysis Catheter
On 3/19/2015, a patient presented to a hospital with complaints of chest pain, history of acute stent thrombosis, and renal failure.
On 3/21/2015, a physician referred the patient to an internist for replacement of temporary dialysis catheter to address her acute kidney failure. The internist placed a double-lumen dialysis catheter in the patient’s left subclavian vein.
Due to the catheter not functioning properly, another physician performed a catheter exchange procedure on the patient on 3/23/2015. After the procedure, the inspection of the catheter revealed that the guide wire remained in one of the lumens of the catheter.
Neither the internist nor his staff removed the guide wire from the catheter prior to the insertion of the catheter into the patient’s left subclavian vein.
The Board judged the internist’s conduct to be below the minimum standard of competence given that he left a foreign body in a patient.
The Board ordered that the internist pay a fine of $3,500 against his license and pay reimbursement costs for the case for a minimum of $3,419.35 and not to exceed $5,419.35. The Board also ordered that the internist complete five hours of continuing education in “Risk Management” and complete a lecture/seminar on retained foreign body objects to medical staff.
State: Florida
Date: November 2017
Specialty: Internal Medicine, Nephrology
Symptom: Chest Pain
Diagnosis: Renal Disease
Medical Error: Retained foreign body after surgery
Significant Outcome: N/A
Case Rating: 2
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
Florida – Interventional Radiology – Assigning A Diagnosis To The Wrong Patient Leads To Cardiac Catheterization Performed On The Wrong Patient
On 1/28/2015, Patient A, a 47-year-old male, presented to the hospital with chest pain and was admitted for treatment. A radiological technician was ordered to complete a CT angiogram of the heart for Patient A.
On 1/29/2015, a radiologist received Patient A’s angiogram images to review, as well as heart images for another Patient B. The radiologist assigned a diagnosis of sixty to seventy percent stenosis to Patient A.
The diagnosis of sixty to seventy percent stenosis was intended for Patient B, not Patient A, who did not have any noticeable blockage or stenosis.
On 1/29/2015, subsequent to the radiologist assigning the diagnosis of sixty to seventy percent stenosis to Patient A, Patient A underwent an unnecessary cardiac catheterization without further incident.
On 1/30/2015, the radiologist conducted a corrected review and diagnosis of Patient A’s angiogram.
On 2/3/2015, the radiologist informed Patient A of the error.
The Board judged the radiologist’s conduct to be below the minimal standard of competence given that he assigned a diagnosis to the wrong patient, which resulted in the patient undergoing a medically unnecessary procedure, a cardiac catheterization.
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: Chest Pain
Diagnosis: Cardiovascular Disease
Medical Error: Accidental error, False positive, Unnecessary or excessive treatment or surgery
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
Virginia – Emergency Medicine – Chest Pain Radiating To The Neck, Throat, And Back
On 11/15/2013, a patient presented to the emergency department complaining of chest pain with radiation to the neck, throat, and back. The patient expired the next day due to cardiac arrest. The ED physician failed to perform a CT scan of the patient’s chest and failed to admit the patient for observation. The ED physician discharged the patient with the diagnosis of “musculoskeletal chest pain.”
He was ordered a fine and to complete 5 hours of continuing medical education in each of the topics of medical record keeping and risk management.
State: Virginia
Date: August 2017
Specialty: Emergency Medicine
Symptom: Chest Pain, Back Pain, Head/Neck Pain
Diagnosis: Cardiovascular Disease
Medical Error: Diagnostic error
Significant Outcome: Death
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
Florida – Cardiology – Patient With Serious Hemodynamic Compromise After Receiving A Cardiac Stent For Myocardial Infarction
On 4/5/2012, a patient arrived at a hospital after suffering a heart attack. He received a stent to the left anterior descending artery and was transferred to the intensive care unit.
At 9:00 p.m., the patient began to experience chest pains and lowered blood oxygen. A cardiologist did not report to the hospital to examine the patient at the time.
At 12:00 a.m., the patient began to have serious hemodynamic compromise. The cardiologist did not report to the hospital to examine the patient at the time.
At 3:00 a.m., over three hours after the onset of the patient’s serious hemodynamic compromise, the cardiologist reported to the hospital to examine the patient.
Prior to reporting to the hospital, the cardiologist had been made aware of each of the patient’s clinical status changes. The cardiologist planned to transfer the patient to another hospital where the patient was to undergo a pericardial window, performed by a cardiothoracic surgeon.
Prior to undergoing a pericardial window, the patient expired.
The Board judged the cardiologist’s conduct to be below the minimal standard of competence given that he failed to report to the hospital to attend to the patient’s clinical status changes, to properly recognize the need for an immediate pericardiocentesis, and to perform an immediate pericardiocentesis. Upon arriving at the hospital, the cardiologist failed to recognize that the patient’s clinical deterioration was such that an immediate pericardiocentesis needed to be performed to improve the patient’s blood flow.
The Board issued a letter of concern against the cardiologist’s license. The Board ordered the cardiologist pay a fine of $7,500 against his license and pay reimbursement costs for the case at a minimum of $5,239.98 and not to exceed $7,239.98. The Board also ordered that the cardiologist complete five hours of continuing education in “risk management” and complete five hours of continuing medical education in cardiology.
State: Florida
Date: July 2017
Specialty: Cardiology, Hospitalist, Internal Medicine
Symptom: Chest Pain
Diagnosis: Acute Myocardial Infarction, Acute Myocardial Infarction
Medical Error: Improper treatment, Delay in proper treatment
Significant Outcome: Death
Case Rating: 3
Link to Original Case File: Download PDF
California – Pediatrics – Fourteen-Year-Old Male With A Hemoglobin Of 8.2
On 7/30/2013, a 14-year-old male was seen by a pediatrician for a well-child assessment. The pediatrician reviewed the patient’s height, weight, temperature, and blood pressure and administered hearing and vision tests. She reviewed the patient’s development, including body image, home situation, education, school progress, risk-taking behaviors, sexuality, and mental health. A complete physical examination was performed.
On 7/30/2013, the patient received a routine HPV immunization. Routine diagnostic laboratory tests were ordered, including urinalysis. A hemoglobin test by finger stick was performed. The patient’s urinalysis test result was normal, but his hemoglobin result of 8.2 was significantly lower than normal. The pediatrician repeated the hemoglobin test by finger stick but did not order a complete blood count by venipuncture. The patient’s hemoglobin result was again 8.2. The pediatrician started the patient on iron supplement therapy and instructed him to follow up in three months. No additional diagnostic tests were done during this visit.
On 8/18/2013, the clinic received a report that the patient was experiencing shortness of breath and chest pain. The patient was instructed to go to an emergency room.
At the emergency room, the patient experienced a full cardiac arrest. His complete blood count revealed severe anemia, with a hemoglobin result of 7.5, a hematocrit of 21, 99 atypical lymphocytes, and a critically low platelet count of 39,000. The patient’s cause of death was acute lymphoblastic leukemia/lymphoma.
The Board deemed the pediatrician’s level of conduct to be below the standard of care given failure to order a complete blood count by venipuncture for the follow-up blood test, failure to schedule a visit and lab check at an earlier date, and failure to consider other diagnoses in addition to iron deficiency anemia.
The Board issued a public reprimand against the pediatrician. Stipulations included performing sixty hours of free services to a community or a non-profit organization, conducting 40 hours of continuing medical education, enrolling in a professionalism program, and undergoing a clinical competency assessment program.
State: California
Date: May 2017
Specialty: Pediatrics, Hematology
Symptom: Shortness of Breath, Chest Pain
Diagnosis: Cancer, Hematological Disease
Medical Error: Failure to order appropriate diagnostic test, Delay in proper treatment
Significant Outcome: Death
Case Rating: 5
Link to Original Case File: Download PDF