Found 88 Results Sorted by Case Date
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Florida – Internal Medicine – Patient With Worsening Chronic Kidney Disease Presents With Arm Pain, Numbness, And Shortness Of Breath



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



Florida – Internal Medicine – Worsening Chronic Kidney Disease, Abnormal Stress Test, And Cardiac Symptoms



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



Florida – Internal Medicine – Inadequate Monitoring For Post-Operative Care After Thyroid Lobectomy



On 8/12/2011, a patient was admitted to a medical center for post-operative care after a right thyroid lobectomy.

The patient presented with multiple risk factors for coronary artery disease, including obesity and tobacco use.  She had a prolonged and difficult time with extubation after the surgery and complained of shortness of breath.

An internist was consulted for medical management.  The internist diagnosed the patient with questionable and mild pulmonary edema.  The internist’s plan of care for the patient was to admit her to the hospital, obtain ventilation/perfusion (V/Q) scan, perform cardiology and deep vein thrombosis evaluations, and perform peptic ulcer disease prophylaxis.  The internist did not order telemetry monitoring for the patient.

On 8/12/2011, the patient was found slumped over the left side of her hospital bed and unresponsive. Staff initiated resuscitative efforts but they were unsuccessful and the patient expired.

The Board judged the internists conduct to be below the minimum standard of competence given that he failed to order telemetry monitoring for her upon her admission to the medical center.

The Board ordered that the internist pay a fine of $5,000 against his license and pay reimbursement costs for the case for a minimum of $2,378.85 and not to exceed $4,378.85.  The Board also ordered that the internist complete five hours of continuing medical education in “Risk Management” and complete a one hour lecture/seminar on “Risk Management.”

State: Florida


Date: November 2017


Specialty: Internal Medicine


Symptom: Shortness of Breath


Diagnosis: Pulmonary Disease


Medical Error: Failure to properly monitor patient


Significant Outcome: Death


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Emergency Medicine – A Patient With Diabetes Presents With Hyperglycemia, Nausea, Vomiting, And A Bicarbonate Level



On 4/28/2015, a 69-year-old female presented to the emergency department with complaints of nausea and vomiting, which had persisted for two to three days.

The patient reported that members of her family had recently experienced similar symptoms.

The patient presented with a history of diabetes and high blood pressure.

An ED physician ordered a general chemistry lab.  The patient’s lab work revealed a high blood glucose level of 383 with a reference range of 65-99.  The patient’s lab work also showed that her bicarbonate level was low at 15 with a reference range of 21-32.  The low bicarbonate level indicated possible acidosis.

The ED physician treated the patient with insulin and antinausea medications and discharged her.  The ED physician did not further investigate the patient’s low bicarbonate level.  The ED physician did not assess the patient for diabetic ketoacidosis.

On 4/29/2015, the patient returned to the emergency department with recurrent nausea, vomiting, and worsening shortness of breath.

The patient was diagnosed with diabetic ketoacidosis and severe sepsis.

The patient’s condition deteriorated and she expired in the hospital on 5/4/2015.

The Board judged the ED physician’s conduct to be below the minimal standard of competence given that he failed to further investigate a low bicarbonate level by ordering additional laboratory studies such as a serum ketone, serum beta-hydroxybutyrate, or serum pH.

It was requested that the Board 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 Board deemed appropriate.

State: Florida


Date: October 2017


Specialty: Emergency Medicine


Symptom: Nausea Or Vomiting, Shortness of Breath


Diagnosis: Diabetes, Sepsis


Medical Error: Failure to order appropriate diagnostic test


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Vermont – Emergency Medicine – Suspected Ventricular Tachycardia Not Addressed In A Patient With Respiratory Distress, Fever, And An Elevated Heart Rate



On 2/6/2013 a patient’s father contacted EMS (emergency medical services) because his son had respiratory distress, fever, and an elevated heart rate.

EMS documented a heart rate of 278 and performed a pre-hospital EKG because ventricular tachycardia (VTach) was a concern.  EMS contacted the hospital to report vital signs and their impression of VTach.

The patient presented to the emergency department at 11:29 p.m.  The patient was triaged at 11:42 p.m. and a pulse of 245, blood pressure of 53/39, and a temperature of 101.02 were recorded.  An EKG was performed at 11:43 p.m.  The results were shown to the ED physician at 11:47 p.m.

The ED physician’s notes state that at 12:13 a.m. the patient was examined.  It was documented that the ED physician suspected the patient was in VTach, but no therapy was administered.

The ED physician then contacted the on-call cardiologist, who advised the ED physician to treat the patient for probable sepsis with fluids and Tylenol.  The ED physician then ordered IV antibiotics and spoke to a critical care physician about transfer of the patient.

At 12:29 a.m. the patient had a ventricular fibrillation cardiac arrest.  He was treated with various medications but no shock was given.  At 12:45 a.m. the patient was pronounced dead.

The Board concluded that the ED physician be reprimanded, complete 15 hours of continuing education on Advanced Cardiac Life Support, and pay a fine of $1000.

State: Vermont


Date: September 2017


Specialty: Emergency Medicine, Cardiology


Symptom: Shortness of Breath, Fever, Palpitations


Diagnosis: Cardiac Arrhythmia


Medical Error: Improper treatment, Delay in proper treatment


Significant Outcome: Death


Case Rating: 3


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 – Fourteen-Year-Old Male With A Hemoglobin Of 8.2



On 7/30/2013, a 14-year-old male was seen by a pediatrician for a well-child assessment.  The pediatrician reviewed the patient’s height, weight, temperature, and blood pressure and administered hearing and vision tests.  She reviewed the patient’s development, including body image, home situation, education, school progress, risk-taking behaviors, sexuality, and mental health.  A complete physical examination was performed.

On 7/30/2013, the patient received a routine HPV immunization.  Routine diagnostic laboratory tests were ordered, including urinalysis.  A hemoglobin test by finger stick was performed.  The patient’s urinalysis test result was normal, but his hemoglobin result of 8.2 was significantly lower than normal.  The pediatrician repeated the hemoglobin test by finger stick but did not order a complete blood count by venipuncture.  The patient’s hemoglobin result was again 8.2.  The pediatrician started the patient on iron supplement therapy and instructed him to follow up in three months.  No additional diagnostic tests were done during this visit.

On 8/18/2013, the clinic received a report that the patient was experiencing shortness of breath and chest pain.  The patient was instructed to go to an emergency room.

At the emergency room, the patient experienced a full cardiac arrest.  His complete blood count revealed severe anemia, with a hemoglobin result of 7.5, a hematocrit of 21, 99 atypical lymphocytes, and a critically low platelet count of 39,000.  The patient’s cause of death was acute lymphoblastic leukemia/lymphoma.

The Board deemed the pediatrician’s level of conduct to be below the standard of care given failure to order a complete blood count by venipuncture for the follow-up blood test, failure to schedule a visit and lab check at an earlier date, and failure to consider other diagnoses in addition to iron deficiency anemia.

The Board issued a public reprimand against the pediatrician.  Stipulations included performing sixty hours of free services to a community or a non-profit organization, conducting 40 hours of continuing medical education, enrolling in a professionalism program, and undergoing a clinical competency assessment program.

State: California


Date: May 2017


Specialty: Pediatrics, Hematology


Symptom: Shortness of Breath, Chest Pain


Diagnosis: Cancer, Hematological Disease


Medical Error: Failure to order appropriate diagnostic test, Delay in proper treatment


Significant Outcome: Death


Case Rating: 5


Link to Original Case File: Download PDF



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



Florida – Family Medicine – Discontinuation Of Aspirin And Propafenone For A Patient With Arrhythmia After Repair For A Tibial Fracture



On 9/1/2012, a patient suffered a tibial fracture in her left leg after falling during a seizure.  In the aftermath of the fracture, the patient underwent left comminuted tibial open reduction internal fixation (“ORIF”) surgery.

During the patient’s discharge, she was prescribed aspirin and propafenone (Rythmol).  The aspirin was intended to help prevent post-surgical pulmonary embolism.  The propafenone was intended to control the patient’s atrial fibrillation.

On 9/14/2012, the patient was transferred to a rehabilitation facility for post-surgical rehabilitation.

Throughout her post-surgical rehabilitation, the patient was at an increased risk of pulmonary embolism.

Initially, the patient was continued on aspirin and propafenone at the rehabilitation center.

On 9/28/2012, the physician’s orders for October 2012 included a stop order on the administration of the patient’s aspirin and propafenone, effective 10/13/2012 and 10/14/2012.

In late September and early October 2012, a family practitioner electronically signed, approved, and executed the aforementioned physician’s orders.

On 10/18/2012, the patient suffered shortness of breath and decreased oxygen saturation.  Although the family practitioner transferred the patient for treatment at an emergency room, the patient passed away several hours later.

According to the medical examiner, the cause of the patient’s death was pulmonary embolism.

The Medical Board of Florida judged the family practitioners conduct to be below the minimal standard of competence given that he should have facilitated the long-term continuation of aspirin and/or propafenone to the patient.  Also, the family practitioner should not have signed, approved, and/or otherwise have executed physician’s orders that were in conflict with the physician’s intended course of prescribing/treatment for the patient.

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 $7,500 against his license and pay reimbursement costs for the case at a minimum of $1,708.35 and not to exceed $3,798.35.  The Medical Board of Florida also ordered that the family practitioner complete five hours of continuing medical education in “risk management.”

State: Florida


Date: February 2017


Specialty: Family Medicine, Internal Medicine


Symptom: Shortness of Breath


Diagnosis: Cardiac Arrhythmia, Pulmonary Embolism


Medical Error: Accidental Medication Error


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



California – Hospitalist – Post-Operative Complications Of Tachycardia, Abdominal Swelling, And Respiratory Distress After Knee Replacement Surgery



On 12/5/2011, a patient underwent knee replacement surgery.  In the course of his post-operative recovery in the hospital, the patient developed a rapid heartbeat.

On 12/6/2011, he was seen by Hospitalist A in the morning.  Hospitalist A attributed the patient’s rapid heart rate to his pre-existing atrial fibrillation and ordered an oral beta-blocker.  The patient’s heart rate was soon restored to a more moderate level.  The patient was transferred to the telemetry unit for closer monitoring at about 11:00 a.m.  Hospitalist A saw the patient again the following morning, noting that the patient was on nasally-administered supplemental oxygen, that his cardiac rhythm was irregular, that he was anemic, and that he had diminished bilateral breath sounds.  The hospitalist ordered chest x-rays and a blood transfusion.  The hospitalist’s order for a chest x-ray read “?chf” under “Indications.”

On 12/8/2017 at 8:40 a.m., nursing notes stated that the patient was receiving 2 liters of oxygen per minute via nasal cannula and his oxygen saturation level was 94%.  Hospitalist A’s chart entries made at about 10:40 a.m. indicate the patient was anemic, displayed some mental confusion, and had abdominal distention.  Hospitalist A opined that the distention “(m)ay be ileus due to oral morphine SR plus PRNs But r/o bleeding.”

Hospitalist A ordered x-rays of the patient’s abdomen, which confirmed the presence of an intestinal ileus.  Hospitalist A did not obtain a CT scan of the patient’s abdomen.  At about 3:50 p.m., Hospitalist A directed a nasogastric tube be placed to decompress the ileus.  Nursing notes from that evening indicate that the patient’s abdomen was “very distended, rounded” with hypoactive bowel sounds.

On 12/9/2017 at 2:30 a.m., a chart entry by Hospitalist B noted that the patient was “extremely uncomfortable with increased abdominal distention.”  She ordered a Harris flush procedure to reduce the patient’s intestinal pressure.

On 12/9/2017 at 3:58 p.m., the patient’s oxygen monitor alarm was sounding.  His oxygen saturation was 74% despite 2 liters per minute of supplemental oxygen.  Nurses repositioned the patient in bed and increased the oxygen flow rate to 5 liters per minute.  The indicated oxygen saturation increased to 88%.  The nasal cannula was moved to the patient’s mouth and the indicated oxygen saturation increased to 91-93%.  Hospitalist A was notified of the patient’s condition.

At 4:30 p.m., the attending nurse again called Hospitalist A to report that the patient was extremely short of breath with “labored” respirations and an indicated oxygen saturation “in the low to mid 80s.”  Hospitalist A directed that the patient be repositioned higher in bed; the nurse informed Hospitalist A that the patient was in the highest possible position.  Hospitalist A gave no new orders regarding the patient’s care.

The attending nurse’s chart entry for 5:10 p.m. states the following:

“(p)t’s condition continues to worsen.  Pt unable to hold O2 sats about low to mid 80’s on 5 liters NC.  Respiratory called to put on non-rebreather mask.  Pt’s LOC is decreased.  Pt repositioned up in bed.  NG tube flushed.  Pt requiring one-to-one nursing care.  Follow-up call to break and relief nurse’s call to [Hospitalist A] to ask that he come to the floor to see pt, d/t pt’s deteriorating respiratory status.  [Hospitalist A] still not answering the phone.”

The attending nurse placed a “Rapid Response” call to summon a physician to assess the patient at 5:20 p.m.  Hospitalist A came to the patient’s room, and his notes state that the patient’s oxygen saturation improved when he was repositioned in bed, “up to the 90s and stayed above 92” per measurement by the respiratory care provider.  Hospitalist A decided to continue with the current treatment on the medical floor rather than transferring the patient to the intensive care unit.

The medical record indicates that at 5:50 p.m., the patient’s oxygen saturation level is “in the 90’s but the O2 sat is variable with sat going down into the 80’s.”  The patient was still receiving supplemental oxygen via the 100% non-rebreathing mask.  The nursing notes for this time state that the patient’s daughter, a nurse, believed the patient should be monitored in the intensive care unit rather than on the medical floor and conveyed that desire for transfer to nursing staff, the nursing supervisor, and to Hospitalist A.

Nursing notes for 6:45 p.m. state the following:

“BP 92/63 HR 120’s.  Pt minimally responsive, respirations increasingly labored.  Telemetry and O2 sat monitors frequently alarming.  Pt requiring RN at bedside at all times.  pt hands cyanotic and remain cool to touch and forehead now appears slightly bluish in color.  [Hospitalist A] aware.  Family tearful, verbalizing anger w/staff regarding pt not being transferred to ICU.”

At 7:05 p.m., Hospitalist B ordered the patient to be transferred to the intensive care unit, apparently in deference to the fact that the “family, rn, supervisor want the pt moved to icu though it was discussed with all by the rounding hbs that there are not criteria for icu…”  The patient was taken to the intensive care unit at about 7:35 p.m.

The intensive care nurse’s notes state that the patient arrived at the ICU unresponsive with his oxygen saturation reading in the 70% range despite being on 15 liters of supplemental oxygen per minute via non-rebreather mask.  The patient’s fingers and toes were cyanotic and his body mottled.

On 12/10/2011 at 3:10 a.m., the patient died despite additional care.

The Board expressed concern that Hospitalist A practiced below the standard of care by failing to order an abdominal CT scan in a patient with an identified bowel obstruction that was not responding to care.  He failed to recognize clinical indicators of early septic shock and make a timely transfer of the patient to a higher level of care.  He failed to recognize and respond to the patient’s acute respiratory distress.

The Board issued a public reprimand.  He was ordered to take a course in early recognition of septic shock.

State: California


Date: January 2017


Specialty: Hospitalist, Internal Medicine


Symptom: Shortness of Breath, GI Symptoms (GERD, Abdominal Distention, Dysphagia)


Diagnosis: Sepsis, Acute Abdomen


Medical Error: Delay in proper treatment, Diagnostic error, Failure to order appropriate diagnostic test, Failure of communication with patient or patient relations, Failure to properly monitor patient


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



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