Found 19 Results Sorted by Case Date
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Florida – Neurosurgery – Wrong Site Procedure When Performing Surgery On A Subdural Hematoma



On 11/6/2016, a 61-year-old female presented to the emergency department, suffering from confusion and weakness after a fall.  A CT scan revealed that the patient had a large, left-sided subdural hematoma.

That same day, a neurosurgeon was asked to evaluate the patient.  The neurosurgeon correctly documented that the patient was suffering from a left-sided subdural hematoma.  The neurosurgeon further documented his intention to remove a blood clot from the left side of the patient’s subdural space.

Shortly thereafter, the patient was brought to the operating room and preparations were begun for a left-sided craniotomy.  However, at some point during the preparation process, the patient’s head was turned and the neurosurgeon began to operate on the right side.

After the neurosurgeon made an incision through the skin, he removed a bone flap and punctured the dura mater on the right side of the patient’s brain.  The neurosurgeon realized that he was operating on the incorrect side.  The neurosurgeon closed the operating site and proceeded to perform the correct procedure.

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: December 2017


Specialty: Neurosurgery


Symptom: Confusion, Weakness/Fatigue


Diagnosis: Intracranial Hemorrhage, Trauma Injury


Medical Error: Wrong site procedure


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Psychiatry – Lithium Administration With Lisinopril And Hydrochlorothiazide



On 12/7/2016, a 30-year-old female was admitted to University Behavioral Center (“UBC”) while suffering from acute psychotic symptoms and was placed under a psychiatrist’s care.  The patient remained under the psychiatrist’s care at UBC for approximately eleven days.

On the day of the patient’s admission, the psychiatrist began treating the patient with lithium.  The psychiatrist continued treating the patient with lithium until 12/17/2016.

The patient had previously been prescribed lisinopril (an ACE inhibitor) and hydrochlorothiazide (a thiazide diuretic) for hypertension.  The psychiatrist continued treating the patient with hydrochlorothiazide until 12/16/2016.  The psychiatrist continued treating the patient with lisinopril for the duration of her stay at UBC.

During the course of the patient’s confinement at UBC, her condition worsened, and she experienced incontinence and increasing levels of confusion.  After falling in the shower on 12/18/2016, the patient was transferred to a hospital for medical treatment, where it was determined that the patient was experiencing lithium toxicity.  As a result of the lithium toxicity, the patient suffered kidney failure, which required dialysis.

The Board judged the psychiatrist’s conduct to be below the minimum standard of competence given that she should have been aware of the potential drug interactions with lithium and to prescribe alternative antipsychotic drug to a patient taking both a thiazide diuretic and an ACE inhibitor, as each of these drugs has a known interaction with lithium which presents risk of lithium toxicity.  The psychiatrist also failed to monitor the patient for signs of lithium toxicity, and she failed to immediately discontinue treatment with lithium when the patient began experiencing symptoms of lithium toxicity.

It was requested that the Board order one or more of the following penalties for the psychiatrist: permanent revocation or suspension of her 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: December 2017


Specialty: Psychiatry


Symptom: Psychiatric Symptoms, Confusion, Urinary Problems


Diagnosis: Drug Overdose, Side Effects, or Withdrawal


Medical Error: Improper medication management, Failure to properly monitor patient


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Emergency Medicine – Patient With Disorientation And Speech Difficulties Discharged After CT Scan Shows No Abnormalities



On 12/2/2013, a 42-year-old female presented to the hospital with complaints of disorientation and speech difficulties.

An ED physician examined the patient and ordered labs and a CT scan of the brain.  He also documented aphasia in the patient’s chart.  He discharged the patient after the CT scan revealed no abnormalities.

Several hours later, the patient experienced difficulty in chewing and swallowing while attempting to eat and subsequently presented to the emergency department.

The patient was diagnosed with having suffered a stroke.  The ED physician did not diagnose the patient with a possible transient ischemic attack (TIA).  He also did not administer aspirin to the patient.  He did not hospitalize the patient for further evaluation and treatment.

The Medical Board of Florida issued a letter of concern against the ED physician’s license.  The Medical Board of Florida ordered that the ED physician pay a fine against his license for the amount of $5,000 and pay reimbursement costs for the case for a minimum of $6,650.86 and a maximum of $8,650.86.  The Medical Board of Florida also ordered that the ED physician complete five hours of continuing medical education in diagnosing and/or treating stroke patients and five hours of continuing medical education in “risk management.”

State: Florida


Date: April 2017


Specialty: Emergency Medicine


Symptom: Confusion


Diagnosis: Ischemic Stroke


Medical Error: Diagnostic error, Improper medication management


Significant Outcome: Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



Nevada – Nephrology – Potential Overdose Of Aspirin



On 1/27/2012, a patient was transported to the emergency department for a “potential overdose of aspirin.”  According to court documents, the plaintiff alleged that the hospital staff began evaluating and treating the patient when she arrived at the emergency department but failed to recognize that the patient’s “neurological status had been compromised due to her ingestion of aspirin.”

The plaintiff alleged that the nephrologist failed to administer the appropriate medical treatments, which may have included “hemodialysis” and/or “gastric lavage.”  The patient died in the emergency department, nearly eleven hours after she first arrived.

The Board judged the nephrologist’s conduct as having fallen below the standard of care given failure to maintain timely, legible, accurate, and/or complete medical records; failure to document the nature, intensity, and course of treatment for the patient’s overdose of aspirin; failure to act as “captain of the ship” for the patient’s care; failure to instruct the monitoring of strict intake and output to guide treatment; failure to order frequent blood electrolyte levels; and failure to timely perform more frequent blood aspirin levels.

The Board issued a public reprimand.  Stipulations including completion of 3 hours of continuing medical education.

State: Nevada


Date: March 2017


Specialty: Nephrology, Emergency Medicine, Internal Medicine


Symptom: Confusion


Diagnosis: Drug Overdose, Side Effects, or Withdrawal


Medical Error: Improper treatment, Failure to properly monitor patient, Lack of proper documentation


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



Arizona – Internal Medicine – History Of Breast Cancer And Cervical Cancer With Calcium Level At 13.1 On Calcium Supplements And Diuretics



In July 2014, a 58-year-old woman with a history of breast cancer, prior right mastectomy, status post chemotherapy, cervical cancer with prior hysterectomy, and family history of lymphoma was seen by her internist.  The patient had been previously followed by the internist at a different practice since 2012.  Calcium level was noted to be 13.1.  Her records reveal that she had lost a significant amount of weight over the last year.  She was noted to be taking calcium supplements and diuretics.  The calcium level was reported to the internist that evening.  He recommended that she return for a one week follow-up appointment.  There was no management plan located in the chart regarding the elevated calcium level.

In August 2014, the patient returned with confusion, abdominal pain, and diarrhea.  The internist documented that he had advised the patient in July to have her calcium levels rechecked.  However, she had taken an extended trip out of town.  Her calcium was noted to be 14.5 with a low parathyroid hormone.  The internist referred her to the emergency department.  She was treated for severe hypercalcemia with mental status changes and was found to have a large mass in her spleen with retroperitoneal and mesenteric adenopathy.  She was ultimately diagnosed with diffuse large B-cell Non-Hodgkin’s Lymphoma.

At a hearing, the internist testified that he saw the patient and her daughter after office hours and instructed the patient regarding the high calcium levels.  He did not document the encounter.

The Board judged the internist’s conduct to be below the minimum standard of competence given failure to discontinue calcium supplements and diuretics based on the calcium level of 13.1 and given failure to investigate the cause of hypercalcemia.

State: Arizona


Date: January 2017


Specialty: Internal Medicine, Oncology


Symptom: Abdominal Pain, Confusion, Diarrhea


Diagnosis: Cancer


Medical Error: Failure to follow up, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



Arizona – Internal Medicine – Elevated Calcium And Low PTH Accompanied By Confusion, Aching, And Fatigue



On 06/26/2014, a 67-year-old man with a history of hyperlipidemia presented to an internist for management of fatigue and generalized aching.  The patient had been previously followed by the internist at a prior practice.  Records from the internist’s prior practice showed that labs draw on 11/08/2013 revealed a calcium level of 11.5 and PTH of 4.4.  A repeat PTH taken on 11/18/2013 was found to be 3.5.

On 06/27/2014, lab results revealed a calcium of 14.8.  The internist’s plan was to confirm that the on-call physician had referred the patient to the emergency department, and if not, to obtain a PTH, hydrate the patient aggressively, and have the patient follow up in a week.

On 07/03/2016, the patient followed up with the internist.  The internist documented that the patient had been asked to return to discuss abnormal lab results.  The patient denied a change in symptoms but reported mild confusion and intermittent mild generalized aching.  The internist ordered labs including a repeat PTH, but not a repeat calcium level.  The patient’s PTH was low at 3.8.

On 07/15/2014, the patient followed up with the internist to discuss a recent liver MRI.  The patient continued to report fatigue and some difficulty thinking.  The MRI showed a 10 x 12 cm mass to the left lobe of the liver with a satellite nodule.  The patient’s labs revealed a calcium level of 15.3.  The internist’s plan was a liver biopsy and urgent correction of hypercalcemia.  The internist recommended that the patient go to the hospital for immediate treatment.

From 07/16/2014 to 07/18/2014, the patient was admitted for fatigue, lethargy, hypercalcemia, and liver mass.  He was given IV fluids and zoledronic acid.  A CT guided biopsy was performed which revealed intrahepatic bile duct carcinoma.

On 07/31/2014, the patient was again hospitalized.  The history and physical noted that in November 2013, the patient had a baseline calcium level of 11.1 as tested by the internist.  During the hospitalization, the patient underwent a laparoscopic surgical ablation of one or more liver tumors and extensive radiofrequency ablation.

During a hearing and in response to a question from the Board member, the internist stated that when a patient presents with hypercalcemia, there should always be a concern regarding underlying malignancy.

The Board judged the internist’s conduct to be below the minimum standard of competence given failure to address hypercalcemia in a timely fashion leading to a delay in diagnosis.

On 04/2016, an interim order was issued for the internist to complete a competency evaluation.The internist appealed.  On 08/04/2016, the Board denied the internist’s appeal of the interim order.  The provider submitted his intention to retire.  Given concern that the internist had also performed below the standard of care in a multitude of cases, the Board elected to restrict his practice and prohibited from practicing medicine in the state of Arizona.  They ordered that he complete and pass a competency evaluation in order to reverse the practice restriction.

State: Arizona


Date: January 2017


Specialty: Internal Medicine, Oncology


Symptom: Confusion


Diagnosis: Cancer


Medical Error: Failure to follow up


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Hospitalist – Syncope After Cholecystectomy And Wedge Liver Biopsy



On 1/17/2011, a 40-year-old female with a history of hepatitis, gallstones, hypertension, diabetes, and obesity was admitted to a medical center for obstructive jaundice.

On 1/19/2011, a hospitalist performed a pre-operative evaluation of the patient.  The hospitalist noted that the patient had a blood pressure at 91/56, a heart rate at 51 beats per minute, and a hemoglobin level of 11.3 gm/dl.  The hospitalist diagnosed the patient with “Acute on Chronic Cholecystitis” and noted the patient would proceed with a cholecystectomy.

On 1/19/2011, a general surgeon performed a laparoscopic cholecystectomy with intraoperative cholangiogram and wedge liver biopsy on the patient.

At 2:50 a.m. on 1/20/2011, the patient’s hemoglobin level was noted at 11.3 gm/dl.

At 1:10 p.m., the patient fainted on the way out of the bathroom.  Subsequent to this episode, the patient was awake, lethargic, and registered a blood pressure of 80/53 at 1:14 p.m.  The patient was placed in the Trendelenburg position.  The general surgeon was contacted and left orders for one liter of normal saline.  The hospitalist, as the on-duty hospitalist, was also contacted.  He ordered a hemoglobin and hematocrit, cardiac enzymes, and an EKG.  He ordered 125 ml/hr of fluid to be started after the 1 liter bolus ordered by the general surgeon.

At 1:14 p.m., the patient’s hemoglobin was noted to be at 9.3 gm/dl.  It is assumed that this hemoglobin level was obtained prior to 1:14 p.m., as the hemoglobin result obtained after the patient had fainted would have unlikely been available for review by 1:14 p.m.

At 4:25 p.m., the hospitalist saw the patient for persistent low blood pressure and altered mental status.  The hospitalist noted that the previously ordered fluid boluses had not improved the patient’s blood pressure.  The hospitalist documented a blood pressure of 77/50, heart rate of 118, and a hemoglobin of 9.3.  The hospitalist additionally noted that the patient was pale and lethargic.  The hospitalist diagnosed the patient with “shock, possibly hypovolemic.”  The hospitalist made the following orders: transfer to the intensive care unit (ICU), start pressors, initiate a PICC line, start antibiotics, and control blood sugar.  The hospitalist requested a complete blood count and a complete metabolic panel for the following morning.

At 4:50 p.m. on 1/20/2011, a rapid response was called, and the patient was transferred to the ICU.  At approximately 6:32 p.m., the patient coded.

At 7:05 p.m., the hospitalist gave verbal orders for “crossmatch 2 units now; if not available transfuse 2 units uncrossed STAT.”  The patient never received the transfusion and expired at approximately 7:23 p.m.  The hospitalist claimed she contacted the general surgeon after the patient’s transfer to the intensive care unit.  This call is not documented in the patient’s medical records.

On 1/22/2011, the hospitalist dictated a discharge summary that stated, “[w]e think the patient have had a DIC and sepsis.”  The hospitalist does not document the possibility of hemorrhagic shock in her discharge summary.

The Board judged the hospitalist as having committed gross negligence given failure to promptly evaluate the patient in light of her syncope, severe hypotension, and altered mental state; failure to consider the possible causes of hypovolemic shock; and failure to consider hemorrhagic shock as a possibility given the patient’s recent surgery and declining hemoglobin.

The Board placed the hospitalist on probation for three years with stipulations to complete 40 hours annually of continuing medical education in the subjects of hemorrhagic shock and diagnostic medicine, complete a medical record keeping course, and undergo clinical practice monitoring while on probation.

State: California


Date: November 2016


Specialty: Hospitalist, General Surgery, Internal Medicine


Symptom: Syncope, Confusion, Weakness/Fatigue


Diagnosis: Post-operative/Operative Complication, Hemorrhage


Medical Error: Diagnostic error, Delay in proper treatment, Failure of communication with other providers, Improper treatment, Lack of proper documentation


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



California – Cardiology – Confusion, Fever, And Worsening Procedural Site After Right Femoral Artery Graft



On 12/21/2012, a 57-year-old male had a stent procedure.  Complications arose, and on 12/27/2012, the patient returned to the emergency department with complaints of right lower extremity pain, numbness, and increasing inability to move his right lower extremity.  An on-call cardiologist diagnosed a blood clot in the patient’s femoral artery of the right leg and took the patient to surgery in order to place a graft to open the artery to give the leg circulation. During the surgery, the cardiologist also performed a right femoral artery exploration, a right common femoral endarterectomy and patch, and a right femoral to above knee popliteal artery bypass.

On the fourth post-surgical day, 12/31/2012, the patient was noted to be confused and had an atrial fibrillation rhythm, by telemetry, which then returned to a normal rhythm the next day.  On 1/1/2013, the patient had a swollen surgery site and complained of sweats and shakes. A low-grade fever was noted in the record. On 1/2/2013, there was documentation of increased erythema and drainage from the right groin wound.  Wound cultures were obtained, which demonstrated large numbers of gram-negative species present. The patient was again suffering from confusion, which combined with the bacterial culture result, were clues to the patient suffering from systemic and graft infection.

On 1/5/2013, the patient was combative.  A CT scan was performed, which identified fluid collection with bubbles.  On 1/5/2012, the nurse notes documented a worsening wound. On 1/6/2013, the patient had a stroke while attempting to access the bathroom in his hospital room.  Thereafter, from 1/9/2013 through 1/13/2012, the wound continued to worsen without any action by the cardiologist to remove the graft. On 1/14/2013, the patient was transferred to a rehabilitation center, but he had a fever, was delirious, and had an infected site.  The patient had to be transferred back to the hospital on 1/16/2013 because of uncontrollable bleeding from the wound. On 1/17/2013, another vascular surgeon removed the graft from the patient and performed a right Sartorius myoplasty in order to address the infection.

The Medical Board of California judged that the cardiologist’s conduct departed from the standard of care because he failed to recognize and diagnose the signs of serious infection, adequately treat the patient’s graft infection, and remove the graft during the patient’s first hospital stay.

The Medical Board of California placed the cardiac surgeon on probation for 2 years and ordered the cardiac surgeon to complete an education course for at least 40 hours in the first year of probation.

State: California


Date: August 2016


Specialty: Cardiology


Symptom: Numbness, Confusion, Fever, Extremity Pain, Swelling, Weakness/Fatigue, Wound Drainage


Diagnosis: Procedural Site Infection, Acute Ischemic Limb, Cardiac Arrhythmia, Ischemic Stroke


Medical Error: Diagnostic error, Failure to examine or evaluate patient properly, Improper treatment


Significant Outcome: Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



North Carolina – Emergency Medicine – History Of Diabetes, Heart failure, And Aortic Stenosis Presents With Weakness, Difficulty Walking, Nausea, Vomiting, And A Low-Grade Fever



In March 2015, the Board was notified of a professional liability payment.

In October 2009, a 64-year-old female presented to the emergency department for admission due to weakness and difficulty walking.  The patient had a known past medical history of moderate-severe aortic stenosis, congestive heart failure, diabetes, and chronic low back pain.  At the time of this emergency department visit, the patient also presented with a urinary tract infection.  The patient was treated empirically with ceftriaxone for a presumptive urinary tract infection.  After the patient improved, she was discharged with oral levofloxacin to cover both a urinary tract infection and the coagulase-negative staphylococcus bacteremia.

On 12/21/2009, the patient again presented to the emergency department with worsening back pain as well as nausea, vomiting, and a low-grade fever.  All work-up regarding the patient’s fever were negative, her symptoms improved with pain medications and physical therapy, and the patient was discharged.

On 01/17/2010, the patient again presented to the emergency department experiencing falls and confusion.  The patient was started on ceftriaxone for coverage for empiric coverage for a urinary tract infection.  By the next day, the urine cultures were negative and blood cultures were positive for staphylococcus epidermidis.  At this point, a cross-covering physician added vancomycin to the patient’s treatment.  The patient’s condition deteriorated from this point forward, and ultimately, because of the patient’s poor prognosis, the patient’s family withdrew care and she died.

The Board obtained the patient’s records and sent them to a qualified independent medical expert for review.  The independent medical expert judged the hospitalist’s conduct to be below the minimum standard of competence given failure to recognize two positive blood cultures drawn at separate times with the same organism as a likely infective agent.

The Board ordered the hospitalist to be reprimanded.

State: North Carolina


Date: May 2016


Specialty: Emergency Medicine, Internal Medicine


Symptom: Back Pain, Confusion, Fever, Nausea Or Vomiting, Weakness/Fatigue


Diagnosis: Sepsis


Medical Error: Improper treatment, Underestimation of likelihood or severity


Significant Outcome: Death


Case Rating: 2


Link to Original Case File: Download PDF



Wisconsin – Family Medicine – Weight loss, Urinary Incontinence, Lack Of Energy, Unsteady Gait, Irregular Heart Rate, And Memory Deficits



In 1998, a 61-year-old man established primary care with Family Practitioner A.  On 3/10/2014, the patient was noted to be 224 pounds and had a normal neurological exam.  On 6/9/2014, the patient was noted to be 219 pounds and had a normal neurological exam.  On 9/9/2014, the patient was noted to be 210 pounds.  On 12/8/2014, the patient was noted to be 209 pounds and had a normal neurological exam.  On 1/18/2015, the patient and his daughter presented to clinic.  The daughter reported that her father had lost weight, lacked energy, suffered urinary incontinence, and had a mental deficit.  Family Practitioner A noted that the patient weighed 183.5 pounds, documented a normal physical exam, ordered laboratory work, and recommended a colonoscopy.

On 1/21/2015 and 1/22/2015, the daughter contacted the clinic to follow up on the laboratory studies.  These calls were not documented.  The documentation between 3/10/2014, and 1/22/2015 is mostly illegible and deficient.  On 1/22/2015, laboratory work revealed an elevated WBC, elevated BUN, decreased hemoglobin, decreased hematocrit, decreased RBC, decreased platelet count, and decreased Vitamin D level.  On 1/22/2015, the daughter received a voicemail from Family Practitioner A, who conveyed to her that the blood work was normal with the exception of a low vitamin D level.  No further diagnostic studies were recommended.

On 1/26/2015, the daughter took her father to Family Practitioner B for a second opinion.  Family practitioner B noted weight loss, dyspnea on exertion, unsteady gait, memory deficits, irregular heart rhythm, and urinary incontinence.  Laboratory studies, EKG, CT head, CT chest, MRI, neurology, urology, gastroenterology, and surgical consults were ordered.

On 2/2/2015, the patient was diagnosed with stage 4 renal cancer with metastases to the pelvis and brain.  On 2/25/2015, the patient died.

Family practitioner A’s care of the patient was deemed to have fallen below the standard of care.  He was ordered by the Board to complete 16 hours of education with 4 hours education in each of neurology, geriatrics, medical record keeping, and communication.

State: Wisconsin


Date: February 2016


Specialty: Family Medicine, Internal Medicine, Oncology


Symptom: Urinary Problems, Confusion


Diagnosis: Cancer


Medical Error: Diagnostic error


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



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