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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

On 12/7/2011, an 8-year-old male presented to a medical emergency department with a deep laceration to his right knee.  The laceration was a full thickness cut with visualization of the capsule.  An x-ray revealed air in the knee joint.

A pediatrician examined the patient’s knee and performed debridement, cleaning by irrigation, and suturing of the laceration.  Bacitracin and dressing were applied to the patient’s knee.

On 12/10/2011, the patient returned to the emergency department with complaints of right knee swelling, redness, and pain.  The patient was admitted to the pediatric floor.

Further examination revealed septic arthritis in the patient’s right knee, which required two operations and the introduction of a PICC line for long-term antibiotic therapy.  The patient sustained cartilage damage as a result of the septic arthritis and suffered from significant knee pain.

The Board judged the pediatrician’s conduct to be below the minimal standard of competence given that he failed to refer the patient to an orthopedic surgeon and to fully wash out the patient’s joint by performing an open debridement under anesthesia.

The Board issued a letter of concern against the pediatrician’s license.  The Board ordered the pediatrician to pay a fine of $10,000 against his license and pay reimbursement costs at a minimum of $5,496.59 and not to exceed $7,496.59.  The Board also ordered that the pediatrician complete ten hours continuing medical education in pediatric orthopedic diagnosis and treatment and complete five hours of continuing medical education in “risk management.”

State: Florida

Date: June 2017

Specialty: Pediatrics, Orthopedic Surgery

Symptom: Joint Pain, Swelling

Diagnosis: Trauma Injury, Septic Arthritis

Medical Error: Improper treatment, Referral failure to hospital or specialist

Significant Outcome: Permanent Loss Of Functional Status Or Organ

Case Rating: 4

Link to Original Case File: Download PDF

On 2/28/2012, a 27-year-old male presented to a neurologist with chief complaints of neck, lower back, and headache following a motor vehicle accident that occurred approximately 3 weeks earlier.  The patient denied any loss of consciousness in the accident and gave no history of suffering a head trauma. The patient’s neurological examination was normal except for mild reflex asymmetry in the upper and lower extremities and a slow gait.  The neurologist noted moderate tenderness on palpation of the cervical paraspinal musculature with full range of motion, but no neck stiffness. The neurologist listed his diagnoses of the patient as: post-concussive headache/migraine syndrome; status post MVA and head injury; cervical spasm; lumbar spasm; and the neurologist wanted to rule out cervical and lumbar radiculopathy.

On this initial visit, the neurologist performed an in-office EEG for the patient’s headaches and “head injury,” but the patient never reported suffering a head injury in the accident, or any loss of consciousness or any seizure activity that would justify this study at this time.  The EEG was normal. The neurologist also performed an in-office EMG and NCV of both bilateral upper and lower extremities, testing 68 muscles, which the neurologist stated took approximately 1 hour. During the study, the neurologist obtained no response of bilateral tibial H-Reflexes.  The neurologist’s impression of the NCV was that the patient suffered from “right sided mild carpal tunnel syndrome” in the “bilateral upper extremities.” The test results, however, did not support the neurologist’s impression as the patient did not have the electrophysiological features for carpal tunnel syndrome.  The neurologist’s further impression was that the patient “possible S1 radiculopathy,” however, the test results did not establish a diagnosis of S1 radiculopathy.

The neurologist also ordered an MRI of the patient’s brain, cervical spine, and lumbar spine.  The neurologist also advised the patient to obtain physical therapy/occupational therapy or chiropractic treatment, but the neurologist failed to write a prescription for physical or occupational therapy and failed to refer the patient to a facility where he could obtain such treatments.

On this visit, the neurologist billed $550 for the office visit, $4,320 for the NCV, $380 for he H-Reflex amp study, $640 for the needle EMG, and $1,125 for the EEG, for a total single visit charge of $7,015.

On 3/6/2012, the patient returned for a follow-up visit complaining of increased neck, shoulder, and low back pain.  The neurologist’s list of diagnoses remained the same as the previous visit and appeared to be cut and pasted into the new chart note.  During this visit, the neurologist performed “Cervical and Lumbar trigger points” injections, but there was no report documenting this procedure in the certified chart, and the neurologist’s billing summary did not reflect a charge for this procedure on this date.

On 4/19/2012, the patient underwent an MRI of his brain and lumbar spine at an outside facility, which were interpreted as normal.  The cervical MRI, however, revealed a 3 to 4 mm left paramedian disc protrusion at C7-T1, degenerative changes at C2 to C6, and a 13 mm x 6 mm lesion in the left lobe of the thyroid gland consistent with thyroid adenoma or colloid cyst.

On 4/30/2012, the patient returned for a follow-up visit complaining of neck and shoulder pain.  The neurologist noted moderate tenderness on palpation of the cervical paraspinal musculature at C6 to C7, but the patient’s range of movement was within normal limits.  The neurologist’s diagnoses were post-concussive headache syndrome, status post MVA, and cervical and lumbar spasm.

The neurologist performed “Cervical Trigger point” injections at 6 different points, but there was no report documenting this procedure in the certified chart.  The neurologist also had the patient undergo an in-office carotid artery duplex scan even though the patient had no carotid bruits on examination, had no clinical evidence or history of vascular pathology involving the anterior circulation, nor any evidence or history of transient ischemic attack or other similar medical conditions, which would justify the scan.  The scan was completely normals. The neurologist charted that he asked the patient to go to “intense physical therapy” and told the patient that his symptoms were mostly due to spasm due to “cervical acute disc herniation.” The patient, however, did not have a herniated cervical disc.

On this visit, the neurologist billed $1,350 for the in-office carotid artery duplex scan, $950 for the trigger point injections with ultrasound guidance (for which there was no procedure report), $415 for interpreting the outside MRI of the spinal canal, and $415 for interpreting the MRI of the brain, which had been reported by the outside facility to be normal.

On 5/2/2012, the patient returned for another follow-up visit complaining of pain with spasm in his neck and shoulder area.  The neurologist charted that the patient stated the injections from 2 days earlier and the new medication helped relieve his pain, but it returned last night.  The neurologist noted neck pain and spasm in the midscapular area with “back pain/spasm but less.” The neurologist, however, did not explain how the patient’s back pain was less since on the prior visit, 2 days earlier, the patient had no back complaints.  The neurologist’s list of diagnoses were identical to those listed on the patient’s initial visit on 2/28/2012, including the status post “head injury” and ruling out “cervical and lumbar Radiculopathy,” which appeared to be copied and pasted from the February note.

On 5/18/2012, the patient returned for another follow-up visit complaining of severe neck pain.  The neurologist noted moderate tenderness in the cervical paraspinal muscles at C4 to C7, and moderate tenderness in the paraspinal muscles at L2 to S1, but the patient had no back complaints on this visit.  The neurologist’s list of “current” diagnoses were identical to those listed on the patient’s initial visit on 2/28/2012, including the status post “head injury,” “lumbar spasm,” and ruling out of “lumbar Radiculopathy,” which appeared to be cut and pasted from the initial visit in February.  In his unsigned cervical injection procedure report, the neurologist listed the patient’s diagnoses as cervical radiculopathy, cervical spinal stenosis, intractable migraine, post concussion headache, and cervical muscle spasm, but here was no evidence in the certified chart that the patient suffered from all these conditions.

On 5/30/2012, the patient returned for a further follow-up visit complaining of neck pain radiating into his left shoulder.  The neurologist’s review of systems was identical to that of the previous visit, including the misspelling, and appeared to have been copied and pasted from the prior note.  The neurologist noted back pain and spasms even though the patient had no back complaints on this visit and no tenderness was found upon examination.

The neurologist performed another NCV/EMG of the patient’s bilateral upper extremities, but there had been no significant change in the patient’s condition to justify repeating this test.  The neurologist’s impression was that the patient had bilateral cervical radiculopathy at C5-C7, inter alia, but the test results did not support the neurologist’s impression for radiculopathy.

For all the previous appointments, the neurologist’s plan was to order physical therapy for the patient, but there as no prescription or order found in the certified chart indicating that the neurologist ordered or prescribed physical therapy on this visit.

On 6/13/2012, the patient returned for another follow-up visit complaining of increased neck pain radiating into his left shoulder.  The neurologist’s review of systems was identical to the previous visit, including the misspelling, and noted back pain and spasms even though the patient had no back complaints on this visit.  In his unsigned procedure note, the neurologist performed a cervical thoracic facet steroid injection, under ultrasound guidance, but the corresponding ultrasound images listed a date of 6/14/2012.  The consent for the procedure was not signed by the patient, and there was no explanation in the certified chart indicating why someone else signed the consent for the patient, who was alert and talking with the neurologist during the visit.  On this visit, the neurologist wrote a prescription for the patient to receive physical or occupational therapy.

On 6/27/2012, the patient returned for another follow-up visit with improved neck pain, but now complained of back pain and spasm.  The neurologist’s review of systems was identical to the previous visit, including the misspelling, and it appeared to have been copied and pasted from the prior note.  The neurologist noted moderate tenderness in the paraspinal musculature at L2-S1, but the patient’s range of motion was normal. The neurologist also recorded ankle jerks upon examination.  The neurologist performed another NCV/EMG of the patient’s bilateral extremities, which the neurologist interpreted as showing bilateral radiculopathy at L5 and S1, but the test results did not support a diagnosis of radiculopathy.  The neurologist again obtained no responses of the bilateral tibial II-Reflexes, demonstrating improper placement of the electrodes or that these areas were not tested.

Throughout these appointments, the neurologist failed to order additional tests or studies concerning the thyroid lesion identified on the cervical MRI, and failed to refer the patient to an endocrinologist or other appropriate specialist for further evaluation and treatment of the thyroid lesion.

The patient ordered a repeat MRI of the patient’s lumbar spine and continued physical therapy, but there was no documentation in the certified chart that the patient was actually receiving physical therapy at this time.  This appeared to be the last time the patient saw the neurologist, but there was a LabCorp lab request form in the certified chart indicating that labs were collected on 6/13/2014 at 3:48 p.m., but there was no corresponding chart notes reflecting a patient visit on this date

The Medical Board of California judged that the neurologist’s conduct departed from the standard of care because he failed to accurately analyze and interpret the repeat in-office EMG/NCV studies performed, appropriately evaluate the large lesion identified on the cervical MRI and/or refer the patient to an endocrinologist or other appropriate professional for its evaluation and treatment, fully evaluate and initially treat the patient’s neck and back pain and headaches with conservative care and non-interventional treatment, initially order physical therapy for the patient while repeatedly performing invasive treatments, and overall fully, properly, and appropriately evaluate and treat the patient’s complaints.

For this case and others, the Medical Board of California revoked the neurologist’s license.

State: California

Date: June 2017

Specialty: Neurology

Symptom: Head/Neck Pain, Headache, Back Pain, Joint Pain

Diagnosis: Spinal Injury Or Disorder

Medical Error: Unnecessary or excessive diagnostic tests, Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, False positive, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

From 10/15/1998 to 3/7/2008, Physician A treated a 38-year-old female who presented with complaints of severe fatigue, disturbed sleep, irritability, joint pains, frequent sore throats, nausea, and diarrhea.  At her initial visit, the patient reported that 9 years earlier she had been told she had a borderline Lyme test and was treated with antibiotics.  In the past 5 years, she had frequent bouts of fatigue and was diagnosed with Chronic Fatigue Syndrome.

In December 1998, the patient was seen by a neurologist who, based on an abnormal MRI, recommended a lumbar puncture but one was not done.  In June 1999, the patient had an abnormal brain SPECT.  In January 2002, the patient had her first and only physical examination at Physician A’s practice.  In January 2008, ten years after the initial MRI, the patient had a second MRI, which was again abnormal.  A neurologist performed a lumbar puncture.

The results of the lumbar puncture were negative for Lyme disease but revealed positive oligoclonal band proteins which are consistent with the diagnosis of multiple sclerosis.

The Board judged Physician A’s conduct to have fallen below the standard of care given failure to take an adequate history of present illness, failure to obtain prior medical records, failure to perform a physical examination, failure to construct a differential diagnosis, failure of prescribing medications without appropriate medical conditions, failure to perform a lumbar puncture, and failure to timely diagnose the patient’s multiple sclerosis.

The Board charged Physician A with professional incompetence and gross negligence.

State: New York

Date: April 2017

Specialty: Internal Medicine, Family Medicine, Neurology

Symptom: Weakness/Fatigue, Nausea Or Vomiting, Joint Pain

Diagnosis: Neurological Disease, Autoimmune Disease

Medical Error: Diagnostic error

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

On 9/15/2011, a 57-year-old male presented to a pain management specialist with complaints of knee pain in his prosthetic knees.

On 10/13/2011, the pain management specialist established a treatment plan to obtain x-rays of the patient’s knees and refer him to an orthopedic surgeon for evaluation of his prosthetic knees.

The pain management specialist failed to review, or document reviewing, x-rays of the patient’s prosthetic knees.  He also failed to refer the patient to an orthopedic surgeon for evaluation of his knee pain, per his treatment plan.

On 2/2/2012, the pain management specialist injected Zeel and Traumeel (both homeopathic products) with bupivacaine into the patient’s prosthetic left knee.

The pain management specialist did not create or maintain records documenting an examination of the patient’s left knee for the 2/2/2012 appointment.

On 2/8/2012, the pain management specialist performed a second injection of Zeel and Traumeel with bupivacaine into the patient’s prosthetic left knee.  He did not create or maintain records documenting an examination of the patient’s left knee for the 2/8/2012 appointment.

Shortly after the second injection, the patient’s left knee began to swell, and on 2/21/2012, he presented to an orthopedic institute with complaints of pain, swelling, and redness.

An orthopedic surgeon admitted the patient to a hospital for further evaluation.  At the hospital, the patient was diagnosed with acutely infected left total knee arthroplasty and, on 2/25/2012, underwent surgery to remove part of the left knee prosthesis, insert an antibiotic disc and PICC line, and begin IV antibiotics.

The Medical Board of Florida judged the pain management specialists conduct to be below the minimal standard of competence given that he should not have injected homeopathic substances into the patient’s prosthetic left knee and he did not refer the patient to an orthopedic surgeon for evaluation of his left knee pain.

It was requested that the Medical Board of Florida order one or more of the following penalties for the pain management specialist: 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: April 2017

Specialty: Pain Management, Anesthesiology, Orthopedic Surgery

Symptom: Joint Pain, Swelling

Diagnosis: Procedural Site Infection

Medical Error: Unnecessary or excessive treatment or surgery, Failure to examine or evaluate patient properly, Referral failure to hospital or specialist, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

A 31-year-old man was a history of anxiety and chronic left shoulder pain from a left labral tear documented by a shoulder Magnetic Resonance Imaging (MRI) in July 2009.  The patient was 77 inches tall and weighed 325 pounds.

On 6/11/2007, the patient first saw an internist.  He was diagnosed with a “sprain of the scapula.”  The only positive finding noted was tenderness of his left scapula wing, and he was prescribed hydrocodone/acetaminophen 10 mg/325 mg and alprazolam.

On 6/18/2007, the patient returned complaining of insomnia.  The internist prescribed zolpidem and carisoprodol.

On 7/6/2007, the patient came back complaining of abdominal pain that was attributed to ibuprofen.  He was given esomeprazole and hydrocodone/acetaminophen was discontinued.  He was given a dietary supplement called “Sleep Tight” for his sleep disorder, which he preferred to zolpidem.

On 8/21/2007, the patient returned.  His gastritis had resolved, and he was given alprazolam for anxiety and tramadol for pain.

On 11/9/2007, the patient was given alprazolam 2 mg every 6 hours.

On 12/7/2007, the patient was seen for anxiety.  The internist prescribed buspirone daily and continued alprazolam 2 mg every 6 hours.  The patient was then not seen by the internist for a year and a half.

On 5/6/2009, the patient presented with complaints of anxiety and insomnia.  Blood pressure was noted to be 185/98.  The internist advised the patient to start on a 2 gm per day sodium-restricted diet.  The internist continued the patient on alprazolam.  The Board noted that the internist neither took an adequate history nor performed an adequate physical examination.  The internist neither recommended a weight loss program and nor medications to address the patient’s elevated blood pressure.

On 6/19/2009, the patient came in for a dislocation of his shoulder.  The patient’s blood pressure was better.  The internist prescribed oxycodone/acetaminophen.  The internist tapered his alprazolam and again noted the patient’s problems with anxiety and insomnia.  The internist prescribed the patient tramadol and hydromorphone.

On 7/1/2009, the patient returned for a clinic visit and stated that he had obtained an MRI.  He was found to have had a torn labrum and had been seen by an orthopedic surgeon with plans to perform a left shoulder arthroscopy.  The patient had been prescribed hydromorphone.

On 7/22/2009, the internist prescribed a fentanyl patch for baseline pain control and hydromorphone for breakthrough pain.  There was no documentation that the internist had communicated with the orthopedic surgeon.

On 8/10/2009, the patient visited the internist and said that he had undergone arthroscopic surgery, which went well.

On 08/31/2009, the patient returned and stated that his shoulder pain had resolved.  He complained of low back pain.  The internist then prescribed a fentanyl patch at a dose of 125 mcg (100 mcg plus 25 mcg).  Hydromorphone was discontinued.  The patient’s blood pressure was 180/100 and was not addressed.

On 9/25/2009, the patient had lost a substantial amount of weight.  Blood pressure decreased down to 150/92.  The internist continued to prescribe fentanyl.

On 11/20/2009, the internist refilled the fentanyl patch prescription for both the 100 mcg and 25 mcg patches.

On 1/15/2010, the patient’s weight had gone up to 244 pounds.  He was using hydrocodone/acetaminophen.  The internist prescribed citalopram 60 mg (which the Board noted was a high starting dose that may increase the risk of cardiotoxicity).

On 4/26/2010, the patient presented for a clinic visit.  The internist had switched from a sparsely documented written record to an electronic typed record.  It was noted that the patient was on hydrocodone/acetaminophen 7.5 mg/325 mg and alprazolam 2 mg three times a day.  His blood pressure was 156/88, and his weight had increased to 283 pounds.  The hydrocodone/acetaminophen was stopped and hydrocodone/acetaminophen 10 mg/325 mg was prescribed.  Per the Board, this note had much better documentation, but still no analysis of the patient’s clinical problem.  The Board noted that the patient had Kaiser Insurance and noted that the internist did not document why the patient was getting pain medications outside of Kaiser’s clinics.  The internist did not address the patient’s weight gain or hypertension.

On 9/30/2010, the internist’s assessment was a sprain of the shoulder, and he again prescribed hydrocodone/acetaminophen 10 mg/325 mg.  He suggested heat, ice, and physical therapy.

The patient’s last visit with the internist occurred on 10/26/2010.  The patient explained that he had hurt his back.  He had been taking hydrocodone/acetaminophen, which reduced the pain from a 10 to a 7.  His blood pressure was 178/106.  His weight had increased to 308 pounds.  The internist did not address the patient’s weight gain or hypertension.  The only diagnosis was sprain/strain at the unspecified site of the upper arm.  Hydrocodone/acetaminophen 10 mg/325 mg was prescribed with 8 mg hydromorphone for breakthrough pain.  The patient was later seen by a different doctor who prescribed methadone.

On 11/11/2010, the patient was found unconsciousness and brought to an emergency department where he was pronounced dead.

The Board judged the internist’s conduct to have fallen below the standard of care given failure to coordinate with other physicians regarding pain control, failure of documentation, failure to address the patient’s hypertension, failure to monitor the efficacy of the narcotic medications, failure to appropriately prescribe narcotic medications, and failure to administer citalopram at a reasonable starting dose.

The internist was placed on probation for 35 months with the stipulations that he complete 20 hours of continuing medical education per year for each year of probation, complete a prescribing practices course, complete a medical record keeping course, and undergo monitoring by a designated clinical monitor.

State: California

Date: March 2017

Specialty: Internal Medicine

Symptom: Pain, Back Pain, Extremity Pain, Joint Pain, Psychiatric Symptoms

Diagnosis: Drug Overdose, Side Effects, or Withdrawal

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

Significant Outcome: Death

Case Rating: 2

Link to Original Case File: Download PDF

On 6/11/2014, a 20-year-old male at that time presented to an emergency department with left knee pain and swelling of the left leg.  On 6/15/2014, Orthopedic Surgeon A provided an orthopedic consultation, which was requested by the admitting physician to rule out infection in the knee.  In his exam, Orthopedic Surgeon A noted swelling around the left leg area, satisfactory circulation of the left lower extremity, a mildly tender left leg, and definite tenderness over the tibia.  Diffuse tenderness over the left knee and no obvious swelling were noted.  The range of movement for the left knee was painful from full extension to beyond 90 degrees; otherwise, the knee was stable.

Orthopedic Surgeon A reviewed an x-ray of the left knee finding no obvious swelling and an essentially normal exam.  No complaint of an acute infection was found on the tibia or knee by the orthopedic surgeon. Orthopedic Surgeon A’s impression was a healed fracture of the left tibia with tibial nailing with positive blood culture for infection. Orthopedic Surgeon A’s aspiration of the left knee did not show any pus and very little serosanguinous fluid was aspirated, the fluid was sent for culture and sensitivity. Orthopedic Surgeon A did not feel the patient needed aggressive orthopedic treatment, and his plan was for the patient to be treated for infection as per the infectious disease specialist’s recommendations.

On 6/17/2014, an internal medicine physician noted that the patient had severe sepsis due to methicillin-resistant Staphylococcus aureus bacteremia.  The patient was receiving IV vancomycin; however, he continued to have persistent bacteremia, which was suspected to be secondary to the knee.  The internal medicine physician attempted to have Orthopedic Surgeon A evaluate the patient on that day; however, Orthopedic Surgeon A felt there was no needed to see the patient on 6/17/2014.  The internal medicine physician then requested a second opinion from Orthopedic Surgeon B.

On 6/17/2014, the patient was examined by Orthopedic Surgeon B.  Upon his exam, Orthopedic Surgeon B noted a circumferential anterior cellulitis type of finding on the anterior left knee and that the skin appeared to be indurated in this region.  Orthopedic Surgeon B’s impression was left knee infection, possible prepatellar bursitis.  Orthopedic Surgeon B was not convinced that the aspiration performed by Orthopedic Surgeon A was in the knee joint as he saw the location of the aspiration was directly through the red prepatellar bursa region.  Orthopedic Surgeon B found that the patient would likely need surgery for treatment of infection.  However, the treatment would depend on whether the patient had prepatellar bursitis or septic knee.  Orthopedic Surgeon B noted that he called Orthopedic Surgeon A on 6/17/2014 in an attempt to discuss his findings.  However, Orthopedic Surgeon A did not feel the need to follow up with the patient that day.

On 6/18/2014, Orthopedic Surgeon A examined the patient for the second time.  Orthopedic Surgeon A noted redness over the anterior surface of the knee.  He did not find any evidence of prepatellar bursitis except for redness and noted that there was diffuse tenderness around the left knee.  Orthopedic Surgeon A reviewed an MRI of the knee, finding synovitis with effusion.  Orthopedic Surgeon A aspirated the knee again, obtaining 2 ml of bloody fluid and finding no evidence of pus.  Based on the MRI and his evaluation, Orthopedic Surgeon A’s impression was that the patient had hypertrophic synovitis with effusion of the left knee per MRI.  Orthopedic Surgeon A’s plan was for the patient to be treated with IV antibiotics as recommended by the infectious disease specialist until the infection was under control.  Orthopedic Surgeon A did not recommend surgery of the left knee.

Orthopedic Surgeon B also reviewed the MRI of the left knee and found a large effusion with evidence of soft tissue edema.  Orthopedic Surgeon B noticed a clear abscess in subcutaneous tissue and loculated fluid in the knee joint.  Orthopedic Surgeon B’s impression was severe sepsis due to probable left septic knee and possible secondary cellulitis over the left knee.  Accordingly, on 6/18/2014, the patient underwent a left knee arthroscopy, incision and drainage with lavage of the left knee joint; left knee arthroscopy; synovectomy; left knee arthroscopy and synovial biopsy; left knee prepatellar bursa incision and drainage; and left knee proximal tibia hardware removal of one single locking bolt of tibia intramedullary nail.

Orthopedic Surgeon B’s findings included positive gross pus in the prepatellar bursa consistent with prepatellar bursa and abscess of 150 ml of gross pus; positive gross pus and left knee joint synovitis; and medial proximal locking bolt of tibia intramedullary nail exposed in the prepatellar bursa region.

The Board reprimanded Orthopedic Surgeon A and ordered him to complete 20 hours of a continuing medical education course in reading and interpreting MRI’s.

State: California

Date: January 2017

Specialty: Orthopedic Surgery, Internal Medicine

Symptom: Joint Pain, Swelling

Diagnosis: Septic Arthritis, MRSA, Sepsis

Medical Error: Diagnostic error

Significant Outcome: N/A

Case Rating: 4

Link to Original Case File: Download PDF

On 9/22/2010, a woman in her forties fell at work, striking her forehead and injuring her left hip.  She was transported to a hospital and evaluated by a family practitioner working in occupational medicine.  The patient denied any headache, but complained of left hip pain and fatigue.  The family practitioner’s examination did not note any acute findings.  The family practitioner obtained a left hip x-ray and interpreted the films as showing “no acute process.”  The family practitioner diagnosed the patient with left hip strain and superficial abrasion.  The family practitioner noted her prior history of ankylosing spondylitis, sciatica, and multiple extremity arthroplasties, including a prior hip replacement.  The family practitioner prescribed physical therapy as well as two days off duty then return to work.

On 9/23/2010, the patient’s hip x-rays were interpreted by a radiologist to show a possible fracture in the inferior pubic ramus inferior to the acetabulum.  The radiology report stated, “an acute fracture is not excluded.”  The report was transmitted to the family practitioner via facsimile.

On 10/19/201, the patient presented to the family practitioner for follow-up.  The family practitioner documented left hip complaints but failed to document any review of the radiology report.  The family practitioner ordered more physical therapy and return to work.

On 11/22/2010, the patient presented again to the family practitioner.  She continued to have left hip complaints, and the family practitioner documented decreased range of motion of the left hip.

The family practitioner made an orthopedic referral but did not refer the patient for any further radiological study, and the family practitioner continued to fail to document any review of the prior left hip x-ray report.  The family practitioner’s orthopedic referral was made on a routine (not emergent or stat) basis, and the orthopedic appointment was scheduled for 1/11/2011.

On 12/20/2010, the patient presented again to the family practitioner, now complaining of a “pop” with increased hip pain and shortening of the left leg.  The family practitioner ordered new left hip x-rays, which he interpreted as showing “no acute findings.”

On 12/21/2010, this second set of x-rays were interpreted by a radiologist to show “more deformity” in the left hip than prior films, and “healing fractures.”  The family practitioner documented review of these findings on 12/22/2010.  However, the family practitioner failed to order stat orthopedic referral, failed to inform the patient of the findings, and failed to order any additional diagnostic studies.

On 1/11/2011, the patient was seen by an orthopedic surgeon who reviewed the x-ray films previously obtained by the family practitioner.  The orthopedic surgeon diagnosed femoral neck fracture, ordered additional tests, took the patient off duty from work, and recommended no weight bearing until surgery.  Ultimately, the patient underwent reconstructive hip surgery.

The Board judged the family practitioner’s care of the patient to be below the minimum level of competence given failure to review the radiologist’s hip x-ray findings when they were sent to him on 9/23/2010; failure to review these findings when the patient presented for follow-up on 10/19/2010, 11/22/2010, and 12/20/2010; and failure to refer the patient for treatment in a timely fashion either to an orthopedic surgeon or to the emergency department.

Based on this case and others, the Board revoked the family practitioner’s license.  The family practitioner was placed on probation for three years with stipulations to complete 40 hours annually in the areas of deficient practice, complete an education program equivalent to the Physician Assessment and Clinical Education Program, and undergo clinical monitoring.

State: California

Date: October 2016

Specialty: Family Medicine, Orthopedic Surgery

Symptom: Joint Pain

Diagnosis: Fracture(s)

Medical Error: False negative, Failure to order appropriate diagnostic test, Referral failure to hospital or specialist, Failure to follow up

Significant Outcome: N/A

Case Rating: 3

Link to Original Case File: Download PDF

On 9/10/2012 at 5:00 p.m., a 64-year-old male was brought into the emergency department by ambulance on a backboard with cervical spine precautions taken after he fell 8 feet off of a ladder onto a concrete surface.  The patient complained of pain in the chest, right elbow, and back. Medical history was significant for a mechanical heart valve requiring anti-coagulation with warfarin. Vital signs included a normal temperature, pulse rate 57 bpm, respiratory rate 22, and pulse oximetry 96% on room air.  Pain level was listed as 10/10. Tenderness was noted on the right chest and right elbow. A right laceration was noted on one finger. The right elbow had limited range-of-motion (ROM). The ED physician noted a palpable fracture on the right chest and ecchymosis. Breath sounds were marked as questionable/decreased.  Blood work was ordered. CBC and chemistry were unremarkable, and PT/INR indicated anti-coagulation. The ED physician noted no fractures on examining a series of rib x-rays ordered on the patient. The CT scan of the head was negative for bleeding. Lumbosacral (LS) spine x-rays were also read by the ED physician as negative.

The ED physician ordered an intramuscular (IM) injection of 10 mg of morphine given at 5:15 p.m., and he ordered a second dose of 10 mg morphine given at 5:36 p.m.  The ED physician’s last note was entered at 7:09 p.m. indicating that the patient was improved and that a posterior splint was applied. At 7:20 p.m., the patient could not walk due to pain in his tailbone.  At 8:40 p.m., the patient was discharged home with a supply of Norco, and vital signs before discharge included normal temperature, pulse rate 66 bpm, respiratory rate 18, blood pressure 112/73, and pulse oximetry down to 94%.

The following morning, the radiologist noted in the x-rays a 30% pneumothorax and a sixth-rib fracture and informed the ED physician.  The ED physician called the patient back to the hospital, and he was admitted and treated with a chest tube.

The Medical Board of California judged that the ED physician’s conduct departed from the standard of care because he failed to detect a large pneumothorax apparent on x-rays ordered and read by the ED physician on the patient’s initial emergency department visit. Traumatic rib fractures present a known risk of life-threatening pneumothorax.  The patient had experienced a significant mechanism of injury with an 8-foot fall onto concrete, clinical evidence of rib fracture, and falling pulse oximetry readings.

The ED physician ordered and had administered 2 large doses of IM morphine approximately 21 minutes apart.  The onset of IM narcotic medication is between 10-30 minutes with analgesia peaking between 30-60 minutes and of 4-5 hours duration.  The administration of 2 doses of IM morphine 10 mg, so close together before the first dose had a chance to take effect was virtually the same as giving one dose of 20 mg morphine, an excessive amount.  The ED physician documented no reason for the patient needing the back-to-back administration and noted no results for either injection. Furthermore, despite an aggressive initial approach to pain management, no additional pain medications were given to the patient 2 hours later when the patient was unable to walk due to tailbone pain.  The ED physician did not appreciate the onset, peak, and duration of the narcotic medications given to the patient.

For this case and others, the Medical Board of California placed the ED physician on probation for 5 years and ordered the ED physician to complete a medical record keeping course, an education course (at least 40 hours per 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 ED physician was assigned a practice monitor and prohibited from supervising physician assistants.

State: California

Date: September 2016

Specialty: Emergency Medicine

Symptom: Chest Pain, Back Pain, Joint Pain

Diagnosis: Pneumothorax, Trauma Injury, Fracture(s)

Medical Error: False negative, Improper medication management

Significant Outcome: Hospital Bounce Back

Case Rating: 3

Link to Original Case File: Download PDF

On 4/25/2011, a 54-year-old male presented to a family practitioner.  The patient reported that he had not seen a physician in several years.

During the initial office visit, the family practitioner performed a physical examination of the patient.  During the physical examination, the family practitioner should have performed a digital rectal exam on the patient but failed to do so.

On 4/25/2011, the family practitioner ordered labs for the patient, which subsequently were collected on 4/29/2011.  The lab results revealed that the patient had an elevated PSA of 9.9

In May 2011, the family practitioner’s office received the patient’s lab results via facsimile; however, those results were never discussed with the patient.

The family practitioner should have referred the patient to a urologist for further evaluation of the elevated PSA level but failed to do so.

On 3/29/2012, the patient returned to the family practitioner’s office with complaints of right shoulder pain.  At that time, the family practitioner failed to discuss the elevated PSA level from the labs taken on 4/29/2011.

On 4/24/2013, the patient presented to the family practitioner for an established patient annual exam.  At that time, the family practitioner failed to discuss the elevated PSA level from the labs taken on the 4/29/2011 appointment; however, the family practitioner did diagnose the patient with benign prostatic hypertrophy and referred him to a urologist for further evaluation.

On 5/9/2013, lab results for the patient revealed a PSA level of 14.8.  The patient was subsequently seen by a urologist who diagnosed the patient with prostate cancer.

The Medical Board of Florida judged the family practitioner’s conduct to be below the minimal standard of competence given that she failed to perform a digital rectal exam on the patient during the initial examination on 4/11/2011.  She also failed to refer the patient to a urologist for further evaluation of the elevated PSA which was collected on 4/29/2011.

The Medical Board of Florida issued a letter of concern against the family practitioner’s license.  The Medical Board of Florida ordered that the family practitioner pay a fine of $4,000 against his license and pay reimbursement costs for the case at a minimum of $3,391.79 and not to exceed $5,391.79.  The Medical Board of Florida ordered that the family practitioner complete an FMA laws and rules course, complete five hours of continuing medical education in urological conditions, and complete five hours of continuing medical education in risk management.

State: Florida

Date: August 2016

Specialty: Family Medicine, Internal Medicine, Urology

Symptom: Joint Pain

Diagnosis: Prostate Cancer

Medical Error: Failure to follow up, Failure to examine or evaluate patient properly, Referral failure to hospital or specialist

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF