Search Cases

A 56-year-old female was referred by her primary care physician to a neurologist.  The patient’s primary care physician noted neck pain and numbness of the upper extremities, left greater than right, present for 1 year.  Her medications were lisinopril 5 mg daily, Lyrica 50 mg 3 times daily, Flexeril 10 mg 3 times daily, Mobic 15 mg daily, and Nexium 40 mg daily.  Her primary care physician noted that she had lumbar laminectomy for disk herniation in the past for low back pain and tingling of the left leg. He also noted that the MRI of her cervical spine was abnormal and requested a neurological evaluation.  It revealed an abnormal signal intensity C2-3 affecting posterior columns with the radiologist’s comment of “could account for arm numbness and tingling.” The x-ray of her cervical spine performed on 11/5/2012 ordered by her primary care physician showed moderate degenerative changes.  The x-ray of her lumbar spine performed on 2/23/2012 showed similar findings.

The neurologist first saw the patient on 12/10/2012 for the abnormal cervical spine MRI.  The patient’s complaints were “neck pain; left neck and arm numb; right arm and right knee; losing urine; and generalized weakness on the left.”  The patient also complained that she “also feels ‘dead’ hips down, [d]izzy spells several times, no energy, difficult to concentrate.” The neurologist noted the “neuro exam essentially normal.”  The neurologist’s diagnoses were demyelinating disease; paresthesias of face and her extremities, vertigo, and memory loss. The neurologist ordered the following tests: EMG/NCV lower extremities, though later she also did upper extremities; MRI of the brain; neuromuscular junction tests with EMG; BAER with vestibular testing; VEP; EEG, overnight; and EEG awake and sleep with digital analysis 95957.

The upper extremity EMG/NCV study was performed on 1/3/2013.  She tested 4 motor nerves, 5 sensory nerves, and F waves. The neurologist tested every muscle, which was present in the upper extremities.  The results of the study were normal.

The electrodiagnostic study of the lower extremities were performed on 1/10/2013.  The neurologist tested 4 motor nerves, 6 sensory nerves, 2 H reflexes, bilateral F waves of the motor nerves.  She did a needle EMG of all muscles in the lower extremities and paraspinal muscles. The results of the study were normal.

There was a report of a video-monitored EEG utilizing a 32-channel digital EEG system manufactured by Cadwell.  This test was performed on 12/26/2012. The report stated that the technician performed hyperventilation, but the patient reported she did not, and that the patient was videotaped, though the patient reported she was not.  It was read as normal.

The ambulatory EEG was performed on 2/5/2013 to 2/6/2013.  In the report, it was termed a 2-day ambulatory EEG despite lasting only 1 day.  The neurologist prepared the report. The report contained a printout of 1 page. It was timed 6:21 a.m., and it contained widespread artifacts lasting 10 seconds.  This was the exact time that the patient reported she stood in front of her microwaves. The neurologist read this as “Isolated sharp waves were noted in the frontal left hemispheric area. The isolated sharp waves may be epileptogenic in nature.”  The visual and brainstem auditory evoked potentials were normal.

On 2/26/2013, the neurologist saw the patient for a follow-up visit.  The test results were available to the neurologist at the visit. The neurologist noted that the EEG for the patient was normal for both awake and drowsy.  The neurologist also noted that the 2-day EEG, which lasted only 1 day and the MRI of the brain showed a corpus callosum lesion. Her assessment and plan contained the same diagnoses as the first visit of 12/10/2012, and she failed to consider new information that should have changed her initial diagnoses.

The neurologist did not diagnose seizures in the assessment and plan, but she prescribed Depakote.  The neurologist discussed with the patient that she met criteria for relapsing and remitting Multiple Sclerosis with an acute exacerbation.  The neurologist also noted that the patient had pain with neck movement, which was sharp and went to the toes. She believed that the symptom was consistent with the finding of the ambulatory EEG and thus started the patient on Depakote 500 mg b.i.d.  The neurologist failed to recognize Lhermitte’s sign, consistent with the myelopathy. The neurologist ordered laboratory studies for Lyme disease, lupus, and lumbar puncture. She ordered monitoring labs for Depakote, CBC, and liver function tests to be done before the next visit.

The MRI of the brain the neurologist referred to in the 2/26/2013 follow-up visit was performed at the neurologist’s request on 12/28/2012.  The report indicated 20 FLAIR hyperintensities and a possible tiny corpus callosum lesion. The neurologist concluded it was consistent with multiple sclerosis.  The 12/28/2012 report contained a comparison to a previous MRI of the brain performed on 7/1/2007. The radiologist thought the new MRI showed abnormalities “probably very slightly more numerous” than the 2007 MRI.  He further considered the appearance to be nonspecific, and the tiny lesion in the corpus callosum was considered possible.

The 2007 MRI was requested by another physician.  It was read as showing “a few nonspecific scattered punctate of unlikely clinical significance.”  Multiple sclerosis was not raised as a possible cause. Referring diagnosis was “recent vertigo and left-sided dizziness.”  The neurologist failed to question the patient on symptoms that occurred in 2007.

On 3/12/2013, the patient was seen in the emergency room for nausea and vomiting.  She was diagnosed with Depakote toxicity with a level of 108. She was told to stop the medication.  She was scheduled for the lumbar puncture the following day and was told to keep that appointment. The day following the lumbar puncture, she developed symptoms consistent with a postspinal headache.  She was seen by the neurologist in her office on the same day and diagnosed with Depakote toxicity. At this point, the neurologist erroneously believed that the patient had “definite” multiple sclerosis.  She also erroneously believed that “the patient wrongfully assumed” Depakote caused her symptoms and believed that they were from the lumbar puncture.

The neurologist next saw the patient on 3/26/2013 for an office visit.  The neurologist noted that the patient had a postspinal headache. She noted that the spinal fluid was negative for oligoclonal bands, but incorrectly thought the IgG synthesis was abnormal.  She incorrectly diagnosed “primary stabbing headache” despite her earlier entry of postspinal headache.

In a subsequent interview with a Medical Board investigator, the neurologist was questioned as to why she did not take a history of previous symptoms, such as optic neuritis, that help to establish a diagnosis of multiple sclerosis.  She was questioned if the examination was normal and why she did not check the “saddle” area for sensory loss, and she reported, “Why should I check the saddle area?” There were no “incontinence of stools.” When asked if she would have documented Lhermitte’s symptom or sign if present, she answered yes.  She obtained a history of symptoms consistent with Lhermitte’s, but did not recognize it as such. Memory loss was given as a diagnosis, but when asked how it was based, she could not recall. When asked to explain the reasons that each test was ordered, she responded that the EMG was based on symptoms, the neuromuscular test was based on the possibility of myasthenia gravis causing general weakness, the BAER and VEP as part of the multiple sclerosis work-up, and the EEG to rule out seizures as the cause of numbness and weakness.  She stated video monitoring on EEG was standard practice. Hearing loss was her reason for performing the BAER, but no hearing loss or visual disturbance was documented. She stated that the 2007 MRI showed infratentorial and supratentorial lesions whereas there was no mention of an infratentorial lesion in the radiology report. She ordered the EMG of the upper extremities to “rule out any other diseases” and stated “EMG is part of differential diagnosis,” and the indication she believed was numbness and tingling in the hands. When asked why she did 24 upper extremity and 6 cervical paraspinal muscles on EMG, she stated she wanted to make sure there was “no polyradiculopathy,” but she admitted there were no findings to suggest that diagnosis.  Further, she believed that numbness and tingling and incontinence would indicate polyradiculopathy. When questioned regarding indications for EMG of the lower extremities, she stated back problems, numbness right arm and right knee, and feeling the hips on down were “dead.” In the lower extremities, she tested 12 different muscles and 6 paraspinal muscles. She was then questioned about what were the indications for the EEG, and she believed they were generalized weakness, dizzy spells, no energy to work, and difficulty focusing. She was questioned as to why the first EEG was not sufficient. She stated that on 2/26/2013 visit, she had findings of generalized seizure disorder, but this was not the wording in the EEG report nor was it in her letter to the Board.  She was not aware that a microwave can cause artifacts. Regarding indication for Depakote, her answer was because of the EEG and numbness and tingling. She thought it would be trial and error to see if it would help. She thought that the patient’s symptom of “neck killing her” would be consistent with a multiple sclerosis plaque. When asked why she ordered Lyme disease and lupus blood tests, she stated that they were “on my mind.”

The Medical Board of California judged that the neurologist’s conduct departed from the standard of care because she failed to recognize symptoms and findings on the MRI of a partial transverse cervical myelopathy, ordered an EMG for the upper and lower extremities, video EEG, and ambulatory EEG without medical indication, conducted an excessive number of nerve tests for any diagnosis, misdiagnosed epilepsy, lacked knowledge in reading EEGs, and had no knowledge and/or did not consider the important interaction between Depakote and the patient’s other medications.  The neurologist also lacked knowledge in several fundamental areas.  She failed to recognize symptoms of a partial transverse cervical myelopathy and Lhermitte’s symptoms even though it was described to her by the patient.  She did not recognize or, if she did, did not reflect in her records that almost all of the patient’s symptoms were caused by the cervical myelopathy. The neurologist erroneously believed that a multiple sclerosis plaque could cause severe neck pain and that IgG synthesis could indicate active or inactive multiple sclerosis.  She diagnosed multiple sclerosis on the basis of the McDonald criteria, and she included the original report, but she gave no information in her records how those criteria fit the patient. She failed to question the patient for previous symptoms, which might establish an initial exacerbation of multiple sclerosis. The neurologist was aware that the patient had an MRI in 2007 and did not question the patient regarding her symptoms at that time.  She ordered laboratory studies for possible Lyme disease or “lupus” and a monophasic cervical myelopathy despite the fact that it was exceedingly unlikely to be caused by any of those disorders. She failed to consider alternative causes for the patient’s presentation, specifically B12 deficiency or adrenomyeloneuropathy.

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: Head/Neck Pain, Dizziness, Headache, Nausea Or Vomiting, Numbness, Urinary Problems, Weakness/Fatigue

Diagnosis: Spinal Injury Or Disorder, Drug Overdose, Side Effects, or Withdrawal

Medical Error: Diagnostic error, Failure to examine or evaluate patient properly, Unnecessary or excessive diagnostic tests, Improper medication management

Significant Outcome: N/A

Case Rating: 4

Link to Original Case File: Download PDF

From 2009 until 2014, an internist served as the patient’s primary care physician.

In 2009, the internist referred the patient to Cardiologist A for a cardiology evaluation.  The results of the 2009 cardiology evaluation revealed that the patient’s electrocardiogram and stress test were both abnormal.

At this time, Cardiologist A recommended that the internist increase the patient’s medication as needed in order to get the patient’s cholesterol to below seventy.

The patient was evaluated by Cardiologist A again in June 2010.

The June 2010 cardiac evaluation revealed that the patient had shortness of breath on exertion at times, possibly related to hypertension and subclinical congestive heart failure.

On 7/17/2013, the patient underwent lab work, the results which showed that his glomerular filtration rate (GFR) was thirty-four.  The internist staged the patient’s chronic kidney disease (CKD) at a stage III/IV.

The patient’s next set of lab work was conducted on 11/18/2013, the results of which showed that his GFR was twenty-two.  The internist wrote in a progress note that the patient’s CKD was a stage III/IV.

On 1/13/2014, the patient had lab work done again, the results which showed that his GFR was twenty-six.  In his progress note he wrote that the patient’s CKD was now a stage IV.

Despite a dramatic decline in the patient’s GFR levels indicative of worsening CKD, the internist did not refer the patient to a nephrologist.

On 1/13/2014, the patient presented to the internist complaining of left arm pain, numbness radiating to both hands, and shortness of breath.  The internist ordered an EKG, chest x-ray, and lab work.  His assessment of the patient at this time was dyspnea on exertion, questionable coronary artery disease, questionable pulmonary disease, and questionable anxiety.

On 1/14/2014, the patient returned to the office for an echocardiogram.  After the echocardiogram, the internist referred the patient to Cardiologist B for a consult.  The patient could not obtain an appointment with Cardiologist B until 2/3/2014.

The internist ordered that a stress test be conducted prior to the patient’s visit with Cardiologist B, and advised that the patient bring the results of the stress test to his appointment with Cardiologist B.

On 1/23/2014, the stress test was performed and the results were abnormal.

The Medical Board of Florida judged that the internist failed to adequately evaluate the patient’s symptoms and recognize the patient’s worsening coronary artery disease, development of congestive heart failure, and worsening chronic kidney disease.  He failed to refer the patient to a nephrologist for further evaluation upon seeing a dramatic decline in the patient’s GFR levels.  He also failed to send the patient to the emergency department for treatment when the patient presented to him with exhibiting cardiac symptoms and had a known history of heart disease.

The Medical Board of Florida issued a letter of concern against the internist’s license.  The Medical Board of Florida ordered that the internist pay a fine of $2,500 against his license and pay reimbursement costs for the case at a minimum of $5,756.36 and not to exceed $7,756.36.  The Medical Board of Florida also ordered that the internist complete five hours of continuing medical education in the treatment of patients with chronic kidney disease and chronic heart disease.

State: Florida

Date: December 2017

Specialty: Internal Medicine

Symptom: Extremity Pain, Numbness, Shortness of Breath

Diagnosis: Heart Failure, Cardiovascular Disease, Renal Disease

Medical Error: 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

From 2009 until 2014, an internist served as a patient’s primary care physician.

In 2009, the internist referred the patient to Cardiologist A for a cardiology evaluation.  The results of the 2009 cardiology evaluation revealed that the patient’s electrocardiogram and stress test were both abnormal.  At this time Cardiologist A recommended that the internist increase the patient’s medication as needed in order to get the patient’s LDL cholesterol below seventy.

The patient was evaluated by Cardiologist A again in June 2010.  The June 2010 cardiac evaluation revealed that the patient had shortness of breath on exertion at times, possibly related to hypertension and subclinical congestive heart failure.

On 7/17/2013, the patient underwent lab work, the results which showed that his glomerular filtration rate (“GFR”) was thirty-four.  The internist stated the patient’s chronic kidney disease (“CKD”) as stage III/IV.

The patient’s next set of lab work was conducted on 11/18/2013, the results of which showed that his GFR was twenty-two.  The internist wrote in a progress note that the patient’s CKD was stage III/IV.

The patient had lab work done again on 1/13/2014, the results of which showed that his GFR was twenty-six.  In a progress noted created on 1/13/2014, the internist wrote that the patient’s CKD was now at stage IV.

Despite the dramatic decline in the patient’s GFR levels indicative of worsening CKD, the internist did not refer the patient to a nephrologist.

On 1/13/2014, the patient presented to the internist complaining of left arm pain, numbness radiating to both hands, and shortness of breath.  The internist ordered an EKG, chest x-ray, and lab work.  The internist’s assessment of the patient at this time was dyspnea on exertion, questionable coronary artery disease, questionable pulmonary issue, and questionable anxiety.

The internist had the patient return to the office on 1/14/2014 for an echocardiogram.  After the echocardiogram, the internist referred the patient to Cardiologist B for a consult.

The patient could not obtain an appointment with Cardiologist B until 2/3/2014.

The internist ordered that a stress test be conducted prior to the patient’s visit to Cardiologist B, and advised that the patient bring the results of the stress test to his appointment with Cardiologist B.  The stress test was performed on 1/23/2014, and the results were abnormal.

The Board judged the internist’s conduct to be below the minimum standard of competence given that the internist failed to adequately evaluate the patient’s symptoms and recognize the patient’s worsening coronary artery disease, development of congestive heart failure, and worsening of chronic kidney disease.  The internist should have referred the patient to a nephrologist for further evaluation upon seeing a dramatic decline in the patient’s GFR levels. When the patient, with a known history of cardiac disease, presented with cardiac symptoms, the internist should have should have sent the patient to an emergency department for treatment.

The Board ordered that the internist pay a fine of $2,000 imposed against his license.  The Board also ordered that the internist pay reimbursement costs of a minimum of $5,756.36 and not to exceed $7,756.36.  The internist was ordered to complete five hours of continuing medical education in the treatment of patients with chronic kidney disease and five hours of continuing medical education in the treatment of patients with chronic heart disease.

State: Florida

Date: December 2017

Specialty: Internal Medicine

Symptom: Extremity Pain, Numbness, Shortness of Breath

Diagnosis: Renal Disease, Cardiovascular Disease

Medical Error: Referral failure to hospital or specialist

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

On 4/6/2016, a 69-year-old female with a prior history significant for pulmonary tuberculosis, essential hypertension, paroxysmal supraventricular tachycardia, osteoporosis, menopause, hypothyroidism, arthritis, chronic asthmatic bronchitis, and a former smoker, presented to a medical clinic.

An anesthesiologist initially diagnosed the patient with cervicalgia and cervical radiculopathy due to degenerative chronic cervical spondylosis.  The patient was also hearing and speech impaired and used an interpreter and tablet for communication during all preoperative meetings.

The patient presented to the anesthesiologist in the surgery room for a signed consent of cervical transforaminal epidural steroid injection at right C4 and C5.  The anesthesiologist instead performed a cervical epidural steroid injection (“CESI”) above C6-C7 without obtaining consent from the patient.

The anesthesiologist failed to have an interpreter in the surgery room during the patient’s evaluation and treatment so that he could effectively communicate with her.

The patient was positioned in the prone position on the table and the anesthesiologist administered Versed 2 mg IV and Fentanyl 100 mcg for IV conscious sedation.

The anesthesiologist failed to administer local anesthesia to numb the patient’s skin, while she was awake and alert, prior to injecting the first epidural steroid injection at C5-C6.  The patient, unaware that she was receiving an injection and unable to clearly communicate her discomfort, responded to the initial puncture to her skin by a sudden jumping movement.

The anesthesiologist withdrew the needle and targeted lower interspace, C7-T1, using fluoroscopy.  He used a seventeen gauge Tuohy needle under intermittent fluoroscopic guidance for entry into the epidural space at C7-T1 for the second attempt to perform the CESI.  The anesthesiologist then injected the medication between C4 and C5 neural foramen.

The anesthesiologist documented one or more times prior to the 4/6/2016 procedure that he was performing a TFESI on the right at C4 and C5;  however, he instead performed a cervical interlaminar epidural steroid injection (“ILESI”) at C5-C6, and additionally at C7-T1, without obtaining consent from the patient.  He inappropriately elected to perform a CESI above C6-C7.  The anesthesiologist did not create or maintain fluoroscopic images of his initial attempt to inject at C5-C6.

After the procedure, the patient was taken to the recovery room, where an interpreter and tablet was present for communication.  The patient was no longer able to move her arm to communicate using the tablet and she experienced right upper extremity weakness and some right sided facial numbness.

The patient was transferred out of the medical center as a “Stroke alert” to a hospital, where she received a CAT or MRI scan, and again transferred to another hospital which did not have a neurosurgeon on staff.

After the CESI, the patient was diagnosed with iatrogenic cervical nerve root injury.

It was requested that the Board order one or more of the following penalties for the anesthesiologist: permanent revocation or suspension of his license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Board deemed appropriate.

State: Florida

Date: August 2017

Specialty: Anesthesiology

Symptom: Weakness/Fatigue, Numbness

Diagnosis: Spinal Injury Or Disorder, Post-operative/Operative Complication

Medical Error: Wrong site procedure, Ethics violation, Failure of communication with patient or patient relations, Procedural error

Significant Outcome: Permanent Loss Of Functional Status Or Organ

Case Rating: 3

Link to Original Case File: Download PDF

On 1/15/2010, a 61-year-old female underwent an epidural injection.  Following the procedure, she complained of sharp pain in the lower extremities, followed by sensory and motor function loss below the T10 and T11 level.  The patient was transferred by ambulance to the emergency department.

A thoracic and lumbar MRI was performed and interpreted by a radiologist.  The final report for the lumbar spine states “Mild desiccation and degenerative changes of the disc but no disc bulge or herniation is noted.”  His final report of the thoracic spine demonstrates “normal MRI of the thoracic spine…A repeat study of the thoracolumbar spine is recommended without contrast infusion in both projections to better evaluate this area as this is on the edge of the study on the current images both lumbar and thoracic is not well delineated.”  Although the images were suboptimal, the epidural hematoma of the lower thoracic spine was evident in the axial images.

On 1/19/2010, a repeat MRI was performed.  The radiologist interpreted the MRI stating there is “abnormal signal focus demonstrated in the spinal canal from approximately the T10-T11 disc space inferiorly through the T12-L1 disc space located mostly in the posterior and posterolateral aspect of the spinal canal displacing the cords slightly anteriorly and causing a slight mass effect on the cord and subarachnoid sac.  This is consistent with a subdural or epidural hematoma.”

The Board judged the radiologist’s conduct as having fallen below the standard of care given failure to observe and document all pertinent findings on diagnostic imaging studies, failure to discuss findings requiring urgent treatment with the referring physician, failure to diagnose the abnormality found on MRI, and failure to document his discussion with the referring physician regarding the abnormality on MRI.

A public reprimand was issued against the radiologist.

State: California

Date: June 2017

Specialty: Radiology, Emergency Medicine

Symptom: Extremity Pain, Numbness, Weakness/Fatigue

Diagnosis: Spinal Injury Or Disorder

Medical Error: False negative, Failure of communication with other providers, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 3

Link to Original Case File: Download PDF

Between February 2006 and September 2012, a patient presented to a pain specialist with complaints of chronic low back pain.

On one or more occasions between February 2006 and September 2012, the pain specialist assessed the patient with, among other things, low back pain, lumbago, osteoarthritis, lumbar failed back surgery syndrome, lumbar radiculopathy, and lumbar muscle spasms.

On 9/28/2012, the patient presented to the pain specialist in order for him to perform a lumbar transforaminal epidural steroid injection with catheter and fluoroscopy.  Epidural administration is a medical route of administration in which a drug or contrast agent is injected into the epidural space of the spinal cord.

During the procedure, the pain specialist inserted the tip of the catheter through the patient’s epidural space and into the patient’s intrathecal space.  Intrathecal administration is a medical route of administration in which a drug or contrast agent is injected into the spinal canal, or into the subarachnoid space so that it reaches the cerebrospinal fluid.

During the procedure, the pain specialist injected contrast and injectate into the patient’s intrathecal space instead of the patient’s epidural space.

The pain specialist did not obtain an intra-injection lateral view epidurogram to confirm the location of the catheter tip and/or the dispersal pattern of the contrast and injectate.

The pain specialist did not obtain a post-injection lateral view epidurogram to confirm the location of the catheter tip and/or the dispersal pattern of the contrast and injectate.

The pain specialist did not recognize that he had performed an intrathecal injection instead of an epidural injection.

After the procedure, the patient complained of bilateral hip and leg pain, numbness, and paralysis.

The patient was transferred to a hospital where she was ultimately diagnosed with conus medullaris syndrome.

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

Specialty: Pain Management, Anesthesiology

Symptom: Back Pain, Numbness, Extremity Pain, Pelvic/Groin Pain, Weakness/Fatigue

Diagnosis: Post-operative/Operative Complication, Spinal Injury Or Disorder

Medical Error: Wrong site procedure, Lack of proper documentation, Procedural error

Significant Outcome: Permanent Loss Of Functional Status Or Organ

Case Rating: 3

Link to Original Case File: Download PDF

On 6/1/2015, a 65-year-old male with a history of hypertension, atrial fibrillation, hyperlipidemia, depression, and anxiety, visited his primary care physician (PCP) complaining of spontaneous movement and loss of sensation in his left arm.  On physical examination of this patient, his PCP identified a loss of coordination and sensation in the upper left extremities.  Three years prior, this patient had undergone a surgical C4 partial corpectomy and fusion of cervical level C4 and C5 for cervical cord compression with impaired gait.  On 6/1/2015, his PCP diagnosed intermittent left limb ataxia and transferred the patient to the emergency department of the Veterans Administration Medical Center.

In the emergency department, ED physician A diagnosed upper extremity neuropraxia after obtaining a CT scan of the cervical spine.  ED physician A also ordered an MRI for 6/4/2015 before discharging the patient.

On 6/2/2015, the patient returned to the emergency department.  The patient described to a triage nurse and a direct care nurse symptoms of worsening left arm numbness, light flashes, a change in depth perception, imbalance and overall feeling “a lot worse.”  Thereafter, ED physician B, who was the on-duty emergency physician, saw the patient.  ED physician B documented that the patient had recurrent loss of left upper extremity control and paresthesias and that the patient expressed fear that he was having a stroke and might die.  ED physician B’s medical note further stated that the patient had no vision changes and that his sense and strength were grossly intact.  ED physician B informed the patient that he would have to wait for his cervical MRI until 6/4/2015, and ED Physician B did not appear to complete a brain MRI for the patient.  ED physician B found the patient’s primary diagnosis to be anxiety.

After the patient’s discharge from the emergency department, he continued to have persistence of his symptoms.  The patient was ultimately referred to a neurologist who ordered a brain MRI on 7/27/2015, which showed right cerebral sub-acute watershed infarcts and an occluded right internal carotid artery.  The patient was transferred to a specialty stroke center for additional evaluation and treatment.

According to the Board, when ED Physician B undertook the care and treatment of the patient, a worried patient with substantial risk factors who returned to the emergency department less than 24 hours for progressing complex neurological symptoms, and failed to obtain an accurate history and review of systems.

In addition, the Board judged ED Physician B’s conduct of the patient to be below the minimal standard of care given his failure to perform an effective neurological examination of the patient, failure to perform indicated imaging studies, and failure to obtain a neurology consult.  The Board deemed ED physician B’s failures to collectively constitute an extreme departure from the standard of care.

The Board issued a public reprimand with stipulations to complete a continuing medical education course on the topic of patient communication and a course on medical record keeping.

State: California

Date: May 2017

Specialty: Emergency Medicine

Symptom: Numbness, Vision Problems, Weakness/Fatigue

Diagnosis: Ischemic Stroke

Medical Error: Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Lack of proper documentation

Significant Outcome: Hospital Bounce Back

Case Rating: 3

Link to Original Case File: Download PDF

On 7/24/2012, a patient saw an orthopedic surgeon for a preoperative appointment concerning the decision for unilateral decompression surgery at L4-5 secondary to chronic lower back pain radiating to the right lower extremity with numbness and tingling.  The orthopedic surgeon failed to document in his preoperative report his intention to use the iO-flex (minimally invasive micro-blade shaver), a newly-marketed surgical device, during the patient’s upcoming surgery.  The orthopedic surgeon did not disclose to the patient that he had never used this device before.  Specifically, the orthopedic surgeon did not obtain the patient’s informed consent to use the iO-flex.

On 8/9/2012, the patient returned to the orthopedic surgeon’s clinic presenting with a sudden onset of back pain radiating to the left lower extremity.  Magnetic resonance imaging (MRI) revealed a new large disc herniation at L4-5.  This newly discovered injury caused the original surgical plan to change, which the orthopedic surgeon failed to document in his preoperative report and failed to tell the patient.

On 8/15/2015, the orthopedic surgeon began the patient’s decompression with the iO-flex and the progress was being observed by a remote neuromonitoring physician and an on-site neuromonitoring technician.  The neuromonitoring technician informed the orthopedic surgeon that there was a decrease in some of the patient’s sensory nerve signals.  In response, the orthopedic surgeon removed all of the iO-Flex tools and waited for improvement.

While waiting for improvement, there was a lack of clear communication between the orthopedic surgeon, the neuromonitoring physician, and the neuromonitoring technician about a drop in neuromonitoring function.  The orthopedic surgeon had a duty to make sure the information received from the neuromonitoring physician and the neuromonitoring technician was correct.  The changes in function should have been noted in the orthopedic surgeon’s operative report, but were not included.  Due to this omission, the orthopedic surgeon’s report incorrectly implied there were no complications.  When the orthopedic surgeon inserted the iO-flex micro-blade shaver into the patient’s spine and performed about sixty reciprocations for decompression, the orthopedic surgeon unknowingly damaged the patient’s cauda equina (bundle of spinal nerves and spinal nerve roots).

On 8/16/2012, the orthopedic surgeon examined the patient in the recovery room.  The patient had weakness and numbness in both feet.  On 8/17/2012, based on the patient’s presentation of weakness in both feet and a newly experienced loss of bladder control, an MRI was ordered and the orthopedic surgeon recommended exploratory surgery.

On 8/18/2012, the orthopedic surgeon performed the exploratory surgery.  The exploratory surgery revealed cauda equina damage and a tear in the patient’s dura (a watertight sac of tissue that covers the spinal cord and spinal nerves).  Given the seriousness of the neurological complications (weakness, numbness, bladder dysfunction), the exploratory operation should have been completed when those symptoms were first noted, not two days later.

The orthopedic surgeon treated the patient’s dural tear with a sealant. The orthopedic surgeon failed to document fluid leaking in the patient’s spine in his post-operative report and there was no documentation of an appearance of fluid collection in the patient’s exploratory MRI report.  The orthopedic surgeon should have documented these complications.

The Commission stipulated the orthopedic surgeon reimburse costs to the Commission, complete a continuing education course on ethics, complete a continuing education course on medical record keeping, and write and submit a paper of at least 1000 words on what he learned from the courses and how information he learned applies to this case.

State: Washington

Date: January 2017

Specialty: Orthopedic Surgery, Neurosurgery

Symptom: Back Pain, Numbness, Extremity Pain

Diagnosis: Post-operative/Operative Complication, Spinal Injury Or Disorder

Medical Error: Procedural error, Delay in proper treatment, Ethics violation, Failure of communication with other providers, Failure of communication with patient or patient relations, Lack of proper documentation

Significant Outcome: Permanent Loss Of Functional Status Or Organ

Case Rating: 1

Link to Original Case File: Download PDF

The Board was notified of a professional liability payment made on 03/25/2016 on behalf of an orthopedic surgeon.

A patient presented to an orthopedic surgeon with right hand numbness and tingling in the thumb, index and middle fingers. The orthopedic surgeon performed a carpal tunnel release. During this procedure, the patient suffered an injury to her right median nerve resulting in right median neuropathy.

The Board raised concern that the orthopedic surgeon recommended surgery after a cursory examination and failed to recommend or first try recognized alternative treatment modalities, such as non-steroidal anti-inflammatory drugs, injection, or splinting before proceeding to surgery.

In addition, the Board noted that the orthopedic surgeon’s operative report does not provide details on how the carpal tunnel was released, and the orthopedic surgeon’s documentation of the patient’s post-operative evaluation was sparse and contradictory.

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: Orthopedic Surgery

Symptom: Extremity Pain, Numbness

Diagnosis: Musculoskeletal Disease

Medical Error: Improper treatment, Lack of proper documentation, Procedural error

Significant Outcome: Permanent Loss Of Functional Status Or Organ

Case Rating: 2

Link to Original Case File: Download PDF

The Board was notified of a professional liability payment paid on 04/29/2015.

In January 2011, a patient underwent a minimally invasive decompression lower back surgery with placement of an interbody cage for treatment of symptomatic spondylolisthesis with extensive work around the L5 nerve roots.  The first post-operative note following surgery indicated the patient complained of numb feet but had normal strength.  On post-operative day two, the patient had developed left foot drop and urinary retention, but was otherwise intact neurologically.  A post-operative MRI or CT scan was not performed because the neurosurgeon attributed these symptoms to nerve root edema, which the neurosurgeon treated with steroids, and because the neurosurgeon believed the risk involved in re-operating was likely greater than the potential benefit.  However, the neurosurgeon obtained a urology consult and was advised that the patient had good rectal tone and that the urinary retention was likely a result of the patient’s age, immobility, and the effects of general anesthesia.  The neurosurgeon obtained a CT scan on 01/25/2011, which showed no block of the spinal canal and confirmed that the hardware the neurosurgeon installed during the first surgery was appropriately positioned.  Although the patient’s overall condition improved during that hospitalization and subsequently, he was left with no improvement of the foot drop.

In March 2011, the patient contacted the neurosurgeon’s office and complained of worsening symptoms.  The neurosurgeon immediately ordered a CT myelogram, which showed a complete block of the spinal canal at the L4 level.  The neurosurgeon performed emergent surgery and performed an open decompression, which the patient tolerated well.  The neurosurgeon believed the cause of the persistent foot drop was the complete block of the spinal canal addressed during the second surgery.

The Board obtained the patient’s records and sent them to a qualified independent medical expert for review.  The independent medical expert judged the neurosurgeon’s conduct to be below the minimum standard of competence given failure to order a MRI or CT myelogram on post-operative day two to evaluate the patient’s new post-operative neurologic symptoms.

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: October 2016

Specialty: Neurosurgery

Symptom: Weakness/Fatigue, Numbness, Urinary Problems

Diagnosis: Post-operative/Operative Complication, Spinal Injury Or Disorder

Medical Error: Underestimation of likelihood or severity

Significant Outcome: N/A

Case Rating: 4

Link to Original Case File: Download PDF