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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 – Pediatrics – Cough, Post-Tussive Emesis, Fever, Elevated Heart Rate, And Elevated Respiratory Rate
On 6/8/2012, a 16-year-old female presented with complaints of tactile fever for the previous four days, coughing, and one incident of post-tussive emesis.
A pediatrician performed an examination and documented that the patient’s temperature was 98.3, her heart rate was 98, and her respiratory rate was 22. The patient’s weight was also documented to be 209 pounds.
The pediatrician assessed the patient was suffering from an upper respiratory infection (URI) and recommended that she continue over-the-counter medication to manage her symptoms.
On 6/9/2012, the patient again presented to the pediatrician. She presented with the same complaints of fever and coughing, but additionally complained of a sore throat.
The pediatrician performed an examination and documented that the patient’s heart rate was 106 and her respiratory rate was 32. She was also running a temperature of 100.8.
The pediatrician assessed that the patient had a URI and pharyngitis. The pediatrician provided the patient with respiratory instruction and advised that she should return in two days if her temperature persisted.
Despite the increase in the patient’s heart rate and respiratory rate from the 6/8/2012 and 6/9/2012 visit, the pediatrician did not order a STAT chest x-ray for the patient. Despite the increase in the patient’s heart rate and respiratory rate from the 6/8/2012 and 6/9/2012 visit, the pediatrician did not check the patient’s oxygen saturation.
On 6/10/2012, the patient expired in her home. The medical examiner documented the patient’s cause of death as pneumonia with sepsis due to haemophilus influenzae.
The Medical Board of Florida judged the obstetrician’s conduct to be below the minimal standard of competence given that he failed to order a STAT chest x-ray and check the patient’s oxygen saturation.
The Medical Board of Florida issued a letter of concern against the pediatrician’s license. The Medical Board of Florida ordered that the pediatrician pay a fine of $5,000 against his license and pay reimbursement cost at a minimum of $1,408.03 and a maximum of $3,408.03. The Medical Board of Florida ordered that the pediatrician complete five hours of continuing medical education in pediatric medicine and complete three hours of continuing medical education in diagnosis and treatment of pneumonia.
State: Florida
Date: August 2017
Specialty: Pediatrics, Emergency Medicine, Family Medicine, Internal Medicine
Symptom: Fever, Cough, Nausea Or Vomiting
Diagnosis: Pneumonia
Medical Error: Failure to order appropriate diagnostic test
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF
California – Gastroenterology – Endoscopy In High Risk Patient With Esophageal Scleroderma Results In Complications
A 69-year-old male with diffuse systemic sclerosis, interstitial lung disease, end stage renal disease on hemodialysis, anemia, hypertension, hypoalbuminemia, secondary hypothyroidism, and gastric antral vascular ectasia (“GAVE”) had been referred to a gastroenterology clinic for evaluation of recurrent problems with weight loss and dysphagia. It was assumed that the patient’s disease had progressed to esophageal scleroderma and that a percutaneous endoscopic gastrostomy (“PEG”) would be necessary to bypass his esophagus and would allow him to take in adequate nutrition without swallowing. The patient was referred to the gastroenterology clinic for evaluation and a PEG.
On 6/25/2012, the gastroenterologist ordered a PEG, and she scheduled an esophagogastroduodenoscopy (“EGD” or upper endoscopy) and esophageal manometry for the afternoon of 6/25/2012, both elective, non-emergent diagnostic procedures, scheduled to be done on an outpatient basis. On 6/23/2012 or 6/24/2012, the patient had been discharged from the hospital on antibiotics with home oxygen administration after treatment for aspiration pneumonia.
The gastroenterologist performed a pre-endoscopy history and physical examination in the early afternoon of 6/25/2012 and noted that the patient had active diffuse scleroderma complicated by renal crisis, diffuse systemic sclerosis, interstitial lung disease, GAVE with multiple cauterizations, and end stage kidney disease. In past medical history, she listed “scleroderma renal crisis, “Started dialysis December 30, 2011,” and “Pneumonia. Admitted to er 6/24/12.” She noted that the patient had had multiple upper endoscopies for gastrointestinal bleeding prior to this EGD. Her physical examination listed “Lungs: Clear Auscultation. Clear percussion and Normal Symmetry and Expansion.” She noted that she, not an anesthesiologist, was ordering sedation.
Sedation was to be administered by a registered nurse. The gastroenterologist listed Airway as Class 2 and ASA Level (American Society of Anesthesiologists physical status classification system) as 3 (severe systemic disease).
On 6/25/2012 at 2:48 p.m. and ending at approximately 3:15 p.m., the gastroenterologist performed an upper endoscopy on the patient and took biopsies. Nursing records indicate that sedation consisted of midazolam, 7 mg, administered over the 22 minutes; fentanyl, 175 mcg administered over the 22 minutes, and Cetacaine spray applied to the throat prior to the procedure.
The patient was transferred from the endoscopy procedure room to the recovery area under the care of a registered nurse. The nurse noted that the patient was unresponsive to verbal and painful stimuli, with blood pressure 108/70, heart rate 86, and O2 saturation 89% on 2 liters delivered by nasal cannula. A face mask was applied at 10 liters O2 and oxygen saturation went up to 97%. When the gastroenterologist was notified, she ordered reversal medications: flumazenil 0.25 mg IVP over 15 seconds and Narcan 0.4 mg IVP at 3:40 p.m., and the patient was still unresponsive. A second dose of flumazenil 0.25 mg IVP was given at 3:43 p.m., and the patient became responsive at 3:44 p.m. Once the patient was responsive, the gastroenterologist performed the esophageal manometry procedure. No time is entered in the medical record for this procedure although the gastroenterologist acknowledges that it was done and the results are recorded.
The gastroenterologist was later notified by nursing staff of concerns with the patient’s breath sounds, and the gastroenterologist noted stridor at 4:26 p.m. She was notified at 5:19 p.m. that the patient’s oxygen saturation was 89% on 5 liters oxygen delivered by nasal cannula. At 5:20 p.m., the gastroenterologist ordered a chest x-ray due to the inability to wean the patient off oxygen after the endoscopy. A face mask was applied at 10 liters oxygen at 5:21 p.m., and oxygen saturation went up to 93%. The chest x-ray indicated “a dense retrocardiac opacity and a left pleural effusion” and a “volume loss in the left lung with mild shift of the mediastinum towards the left.”
After the manometry procedure in the recovery room, the patient’s oxygen saturation was monitored, and when the oxygen saturation remained above 90% for 30 minutes on room air, the patient met endoscopy discharge criteria. The patient was discharged home with instructions concerning any complications that might arise.
The gastroenterologist states that she arranged to admit the patient to the hospital, but the patient left against medical advice (AMA). Neither notation of this nor a signed AMA release was found in the record. Pathology results revealed gastritis and the manometry procedure revealed a condition consistent with esophageal scleroderma.
On 6/27/2012, the patient presented to the emergency department with shortness of breath and cough. Chest x-ray showed new right lung patchy opacities, and the patient was cachectic. He was admitted to the intensive care unit for treatment of pneumonia. The admission diagnosis was “most likely persistent pneumonia, likely aspiration due to esophageal dysmotility.” The patient failed to improve despite intensive hospital care. Although the gastroenterologist had scheduled a PEG for 7/2/2012, it was decided that the patient would not go through with the procedure. Instead, it was decided that the medical team would provide palliative care for the patient.
On 7/4/2012, the patient died with the cause of death listed as aspiration pneumonia due to esophageal dysmotility and end-stage scleroderma with severe malnutrition as a contributing factor.
The Board deemed the gastroenterologist’s conduct as falling below the standard of care for the following reasons:
1) The gastroenterologist failed to provide an accurate analysis of the patient’s suitability for the endoscopic and manometry procedures.
2) She classified the patient as an ASA Level 3, which denotes an individual with stable multiple system disease that limits daily activity without immediate danger of death.
3) At the time of the EGD and manometry done by the gastroenterologist, the patient had just been released from another hospital, where he had been treated for aspiration pneumonia and discharged on antibiotics and home oxygen.
4) By reason of the patient’s recent aspiration pneumonia and the necessity for home oxygen administration, his ongoing scleroderma renal crisis which necessitated hemodialysis, his persistent interstitial lung disease, and his frequent bleeding and cauterizations for GAVE, his condition was not stable, and elective procedures at this time were contraindicated. The patient’s classification was clearly ASA level 4, which denotes an individual with severe, incapacitating disease, poorly controlled or end-stage, at risk for death due to organ failure.
5) The gastroenterologist failed to provide for an anesthesiology consultation, given the patient’s unstable and life-threatening condition, and instead elected to provide conscious sedation directed by the gastroenterologist and administered by a registered nurse. The level of sedation administered to the patient during the upper endoscopy procedure was relatively large for an individual with so many co-morbid conditions, and an anesthesiologist or nurse anesthetist should have been in attendance.
6) Since both procedures were elective, the gastroenterologist failed to reschedule the procedures for a time when the patient was stable and able to tolerate conscious sedation directed by the gastroenterologist and administered by a nurse.
7) The patient had a very unstable post-procedure course in the recovery room. He was unresponsive to verbal and painful stimuli and oxygen saturation was below 90%. Reversal medications had to be administered before the patient became responsive. When the patient became responsive, the gastroenterologist performed the esophageal manometry in the recovery room. This procedure was unnecessary to determine the need for a PEG and further endangered the health of the patient.
8) The respondent approved sending the patient home with instructions after his oxygen saturation was above 93% for 30 minutes. The patient was a very high-risk patient for elective procedures and had had a very unstable post-procedure course in the recovery room, including the development or exacerbation of pneumonia. Under these circumstances, in conjunction with his numerous co-morbidities, it was unsafe to send the patient home. There was no record found of the patient leaving the clinic AMA.
The Board issued a public reprimand against the gastroenterologist. Stipulations included continuing medical education in the topics of pre-operative patient evaluation, informed consent, sedation, and medical record keeping.
State: California
Date: May 2017
Specialty: Gastroenterology, Hospitalist, Internal Medicine
Symptom: GI Symptoms (GERD, Abdominal Distention, Dysphagia), Cough, Shortness of Breath, Weight Loss
Diagnosis: Gastrointestinal Disease, Pneumonia, Pulmonary Disease
Medical Error: Unnecessary or excessive treatment or surgery, Failure of communication with other providers, Lack of proper documentation
Significant Outcome: Death, Hospital Bounce Back
Case Rating: 5
Link to Original Case File: Download PDF
California – Pediatrics – Long Term Regimen Of Compounded Dexamethasone Cough Syrup For Pneumonia And Asthma
On 1/13/2015, a pediatrician saw a child just short of her second birthday. She had been diagnosed with asthma and was maintained on corticosteroid and albuterol inhalers. The patient presented with fever, coughing, and loss of appetite. Although she had taken an antibiotic prior to this visit, it is not noted in the pediatrician’s chart notes. The pediatrician diagnosed pneumonia, laryngotracheobronchitis (croup), and asthma and prescribed a different antibiotic for her.
The pediatrician stated that she followed up with the patient by telephone on 1/14/2015 and 1/15/2015. Based on these follow-up calls, the pediatrician prescribed compounded cough syrup at a daily dose containing 0.55 mg dexamethasone, a corticosteroid. She prescribed a sufficient amount of the medication to last a month and when the patient’s mother said that she was afraid that the patient would begin to cough again because her entire family had caught the cold, the pediatrician called in a partial refill for the medication. None of this information was included in the pediatrician’s chart notes for the patient.
The pediatrician’s chart notes for the patient’s follow-up visits on 1/20/2015 and 2/20/2015 did not make reference to the compounded cough medication, instructions on how to take the medication, or to the advice she gave the patient’s mother concerning weaning the patient off the medication. Although the pediatrician stated that she was concerned about the patient’s reduced “immunity” and recommended an over the counter immune pediatric supplement for the patient on 2/20/2015, this concern was not documented in the patient’s chart notes.
The Board judged the pediatrician’s conduct to have fallen below the standard of care given failure to appropriately prescribe dexamethasone to the patient and given failure to document the follow-up telephone calls, the fact that she had prescribed the compounded cough medication to the patient, instructions for the patient to wean off the dexamethasone, concern for the patient’s reduced “immunity,” and the fact that the patient had taken antibiotics prior to her first visit with the patient.
A public reprimand was issued against the patient with stipulations to take a medical record keeping course.
State: California
Date: May 2017
Specialty: Pediatrics
Medical Error: Improper medication management, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
Florida – Emergency Medicine – Mass Shown On Chest X-Ray Of Patient Discharged After Upper Respiratory Infection Treatment
On 12/20/2013, a 71-year-old female presented to the emergency department with a complaint of coughing.
An ED physician, as the patient’s attending physician, ordered a chest x-ray. The chest x-ray revealed a 4-centimeter mass-like density.
The ED physician discharged the patient with a diagnosis of upper respiratory infection, bronchitis, and viral syndrome.
The patient was not given any follow-up instructions regarding the 4-centimeter mass-like density, which resulted in a delay of diagnosis and treatment.
The Medical Board of Florida judged the ED physicians conduct to be below the minimal standard of competence given that he failed to inform the patient of the 4-centimeter mass on the chest x-ray and refer her for a follow-up with a pulmonologist or alternatively a primary care physician for further testing.
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: May 2017
Specialty: Emergency Medicine
Symptom: Mass (Breast Mass, Lump, etc.), Cough
Diagnosis: Cancer
Medical Error: Failure to follow up, Referral failure to hospital or specialist, Failure of communication with patient or patient relations
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
North Carolina – Physician Assistant – 10-Year-Old With Cough, Fever, High Blood Pressure, and Sore Throat Diagnosed With Strep Throat
The Board was notified of a professional liability payment made on 1/28/2016.
A 10-year-old presented to a physician assistant with a chief complaint of cough, headache, sore throat, and fever. The patient’s blood pressure was elevated, 140/190, and she had a fever of 103.2 degrees F. According to the history, the patient denied nausea, vomiting, or diarrhea. In the physical examination, it was documented a normal respiratory assessment. The patient was diagnosed with strep throat, prescribed amoxicillin, and the patient was discharged home.
The patient died two days later from pneumonia secondary to influenza infection, which was not listed in the differential diagnosis.
The Board expressed concern that the physician assistant did not consider influenza in the differential diagnosis, prescribed an antibiotic without identifying the pathogen responsible for the infection, and did not perform a blood pressure recheck for the patient’s hypertension. The Board noted a failure to document providing adequate follow up instructions to the patient’s family enumerating red flag signs and symptoms which would prompt the family to return the child to a health care facility.
The Board issued a public letter of concern, which was reported to the Federation of State Medical Boards. It was not reported to the National Practitioner Data Bank.
State: North Carolina
Date: April 2017
Specialty: Physician Assistant, Emergency Medicine, Pediatrics
Symptom: Fever, Cough, Headache
Diagnosis: Pneumonia
Medical Error: Diagnostic error, Lack of proper documentation
Significant Outcome: Death
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Emergency Medicine – Fever, Cough, Sore Throat, And Shortness Of Breath With An Oxygen Saturation Of 91%
On 1/30/2013, a 33-year-old female presented to an ED physician with complaints of fever, cough, and sore throat, which began three days prior. The patient also complained of shortness of breath.
The ED physician obtained the patient’s vital signs and performed a physical exam.
The ED physician noted the patient’s pulse oximetry was 91%. He interpreted the patient’s pulse oximetry as “mild desaturation.”
The ED physician noted the patient’s heart rate was 129. On cardiac exam, he found the patient to be tachycardic.
The ED physician ordered lab work. The patient’s white blood cell count was found to be elevated at 20.4. The patient was also found to have bandemia.
The ED physician ordered a chest x-ray. He interpreted the chest x-ray as showing no infiltrate and no acute disease. However, the radiologist later reported the chest x-ray as showing right middle lobe infiltrate worrisome for pneumonia.
The patient was administered ketorolac, acetaminophen, and intravenous fluids.
On re-evaluation, the ED physician noted that the patient had diffuse wheezing.
The ED physician discharged the patient home with a diagnosis of viral syndrome, cough, febrile illness, leukocytosis, and tobacco abuse.
The patient’s presentation was consistent with possible septicemia.
On 2/2/2013, the patient returned to the emergency department with complaints of high fever, cough with sputum, and shortness of breath.
The patient was subsequently diagnosed with bilateral pneumonia, septic shock, acute kidney injury, acute respiratory failure, bilateral pleural effusions, and pneumothorax, requiring admission to the hospital, and later transfer to the ICU, for approximately twenty days.
The Medical Board of Florida judged the ED physician’s conduct to be below the minimal standard of competence given that he failed to evaluate, or failed to document evaluating the patient’s septicemia. He also failed to check, or failed to document checking the patient’s lactate level. He failed to obtain, or failed to document obtaining blood cultures for the patient. He failed to treat, or failed to document treating the patient for septicemia. The ED physician failed to administer, or failed to document administering, IV antibiotics for the patient. He also failed to recheck, or failed to document rechecking the patient’s vital signs prior to discharging her home. He failed to admit, or failed to document admitting the patient to the hospital.
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 of $5,500 against his license and pay reimbursement costs for the case at a minimum of $2,004.13 but not to exceed $4,004.13. The Medical Board of Florida also ordered that the ED physician complete five hours of continuing medical education in diagnosis of septicemia and five hours of continuing medical education in “risk management.”
State: Florida
Date: February 2017
Specialty: Emergency Medicine
Symptom: Fever, Cough, Head/Neck Pain, Shortness of Breath
Diagnosis: Pneumonia, Sepsis, Pulmonary Disease, Pneumothorax
Medical Error: Diagnostic error, Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Referral failure to hospital or specialist, Lack of proper documentation
Significant Outcome: Hospital Bounce Back
Case Rating: 4
Link to Original Case File: Download PDF
North Carolina – Nephrology – Deciding To Initiate Vancomycin For Patient With Prior History Of Tachycardia And Dyspnea After Receiving Vancomycin
The Board was notified of a professional liability payment made on 6/5/15.
A 31-year-old male with end-stage renal disease presented to the emergency department with cough, fever, and acute pain. The initial diagnosis was sepsis. He was given cefazolin and gentamicin. The patient’s allergy history was noted to include penicillin and vancomycin.
The patient subsequently underwent two transfers of care. During these transfers, it was indicated by various physicians that the patient would require intravenous vancomycin to treat sepsis. Given the patient’s ambiguous allergy history, the evening hospitalist made the decision to defer to a nephrologist the decision regarding the treatment of the patient with vancomycin as the nephrologist had treated the patient in the past. As the patient’s nephrologist, he was aware that the patient had received vancomycin in the past both intravenously and intraperitoneally. The patient had previously developed tachycardia and dyspnea after receiving vancomycin. The nephrologist had concluded that the patient’s reaction to the most recent exposure to vancomycin was not a true allergic reaction, but rather “red man syndrome” and that the patient now required vancomycin to successfully treat the sepsis. Within minutes of the start of the vancomycin infusion, the patient developed tachycardia, dyspnea, and ultimately cardiac arrest from which he could not be revived.
The Board expressed concern that the nephrologist’s care of the patient fell below the standard of care.
The Board issued a public letter of concern, which was reported to the Federation of State Medical Boards. It was not reported to the National Practitioner Data Bank.
State: North Carolina
Date: February 2017
Specialty: Nephrology
Diagnosis: Sepsis
Medical Error: Improper medication management, Underestimation of likelihood or severity
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF
Wisconsin – Physician Assistant – 25-Year-Old Man With Cough, Fever, Chills, And Night Sweats
On 12/15/2003, a 25-year-old non-smoking man presented to a clinic with 10 days of cough, fever, chills, and night sweats. He was noted to have a heart rate of 142 and a respiratory rate of 24. He was on amoxicillin, doxycycline, and prescription cough medication.
Physician Assistant A switched him to a different cough medication. He reported that he had re-checked the heart rate, but there was no documentation of the re-check. He recommended that the patient continue with amoxicillin and doxycycline. A TB skin test was ordered. Physician A was supervising Physician Assistant A. She reviewed and signed the note sometime after 2/13/2004.
On 12/18/2003, the patient returned to the clinic to have his TB test read. At that time, he was doing worse. He saw Physician Assistant B, who was also being supervised by Physician A. Physician Assistant B reviewed Physician Assistant A’s notes and documented that “his cough seems to be worse” and that the antibiotics “do not seem to be helping.” His temperature was noted to be 101.3, respiratory rate 32, and on physical exam, it was noted that he was coughing, the coughing intensified when he was reclined, he had a headache with coughing, he had bilateral lower pleuritic pain, and he had “decreased breath sounds to the right base.” The TB test was negative. He was diagnosed with “probable pneumonia.”
She recommended a chest x-ray and a CBC, but the patient declined due to cost. Antibiotics were changed to gatifloxacin 400 mg daily. It was recommended that he increase fluid intake. On 12/19/2003, Physician Assistant B dictated the note for the patient visit from the prior day. The note contained her signature, but not the date. The medical records reflected that Physician A reviewed and signed the note, but did not reflect when she reviewed or signed it. On review of the chart, oxygen saturation was not documented. Physician A did not contact the patient or direct Physician Assistant B to contact the patient, in order to obtain an updated oxygen saturation.
On 12/23/2003, the patient was admitted to the ICU. Oxygen saturation was at 71%. On 12/26/2003, he was placed on a mechanical ventilator. On 1/1/2004, the patient suffered cardiac arrest and could not be resuscitated.
The cause of death was noted to be acute respiratory distress syndrome secondary to pneumonia due to blastomycosis. On 10/2/2009, a jury concluded that Physician A was negligent in her supervision of Physician Assistant A and B. The jury attributed 35% of the total causal negligence to Physician A.
The Board addressed the issue of whether Physician A should have sought to obtain an oxygen saturation level. The Board ultimately decided that Physician A was within the standard of care.
Physician Assistant B’s conduct in her treatment of the patient was below the minimum standards for the profession in the following respects: she failed to document in the patient’s chart that the chest x-ray and CBC were not done “against medical advice”; failed to recommend admission for the patient; failed to consult with her supervising physician; and failed to request a pulmonary consult.
The Board ordered Physician Assistant B be reprimanded, complete 4 hours of continuing medical education in the areas of evaluation and treatment of pneumonia and respiratory distress, and pay the costs of the proceeding.
State: Wisconsin
Date: January 2017
Specialty: Physician Assistant, Internal Medicine
Symptom: Cough, Fever, Headache, Chest Pain, Shortness of Breath
Diagnosis: Pneumonia
Medical Error: Improper treatment, Failure to order appropriate diagnostic test, Failure of communication with other providers, Referral failure to hospital or specialist, Improper supervision, Lack of proper documentation
Significant Outcome: Death, Hospital Bounce Back
Case Rating: 5
Link to Original Case File: Download PDF
North Carolina – Family Practice – Evaluation Of A Patient With Persistent Symptoms of Pneumonia
In May 2015, a patient with a remote history of smoking presented to a family practitioner with symptoms of worsening cough of two months duration.
The patient was diagnosed with seasonal allergies and offered empiric treatment for chronic cough. Per the Board, the initial treatment complied with the applicable standard of care.
In early August 2015, the patient returned to the office complaining of diarrhea and a cough that had started one month earlier.
The family practitioner ordered a chest x-ray, diagnosed the patient with pneumonia, and treated her accordingly.
By September 2015, the patient developed additional symptoms such as dyspnea on exertion, low-grade fevers, and weight loss. On examination, the family practitioner noted decreased breath sounds and ordered a repeat chest x-ray that showed interval worsening with consolidation.
The family practitioner also ordered a CT scan that revealed enlarged mediastinal and hilar lymph nodes or mass with effusion. These findings were consistent with an infectious etiology, but also raised significant concern for an underlying neoplasm.
The Board noted that the standard of care for a patient with the patient’s presentation – worsening symptoms, radiologic findings, and past history of smoking – would have been to further evaluate the patient for possible lung cancer through referral to a pulmonologist; instead, the family practitioner continued to treat pneumonia.
Though the patient returned to your office in early October 2015 reporting significant improvement in her symptoms, by late October, the patient demonstrated recurrent symptoms of pneumonia and presented with a tongue mass.
At that point, the family practitioner referred the patient to a pulmonologist for a second opinion. The patient underwent another CT scan on 11/09/2015 and saw a pulmonologist on 11/11/2015.
The patient was diagnosed with Stage IV lung cancer and ultimately died in April 2016.
The Board issued a public letter of concern, which was reported to the Federation of State Medical Boards. It was not reported to the National Practitioner Data Bank.
State: North Carolina
Date: December 2016
Specialty: Family Medicine, Internal Medicine
Symptom: Shortness of Breath, Cough, Diarrhea, Fever
Diagnosis: Lung Cancer, Pneumonia
Medical Error: Diagnostic error
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF