Found 88 Results Sorted by Case Date
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Arizona – Emergency Medicine – Right Leg Pain, Shortness Of Breath, And History Of A Deep Vein Thrombosis



The Board received a complaint regarding the care and treatment of a 71-year-old woman.

On 12/03/2015, a patient presented to the hospital complaining of right leg pain and shortness of breath.  She disclosed having a history of deep vein thrombosis.  The ED physician ordered labs, an ultrasound of the right leg, a chest x-ray, an ECG, and a CT angiogram.

The CT angiogram noted central, segmental, and subsegmental pulmonary emboli bilaterally and ground glass opacity at the right lung apex.  The ED physician reviewed the CT angiogram but failed to diagnose the patient with multiple pulmonary emboli.  Prior to the patient’s discharge, the ED physician re-examined her and told her to follow up with a cardiologist and pulmonologist.

On 12/5/2015, the patient presented to a different hospital with worsening complaints of shortness of breath.  The CT angiogram from the first hospital was reviewed.  A repeat CT angiogram was performed revealing the same findings of multiple bilateral pulmonary emboli.  The patient underwent ultrasounds on both legs which revealed deep vein thrombosis of the left leg and superficial vein thrombosis of the right leg.  An ECG did not show signs of right heart strain.  The patient was discharged on enoxaparin and coumadin.

State: Arizona


Date: October 2016


Specialty: Emergency Medicine


Symptom: Shortness of Breath, Extremity Pain


Diagnosis: Pulmonary Embolism, Deep Vein Thrombosis/Intracardiac Thrombus


Medical Error: Diagnostic error


Significant Outcome: Hospital Bounce Back


Case Rating: 2


Link to Original Case File: Download PDF



Washington – Hospitalist – CT Scan Results Reveal A 3.3 cm Right Renal Mass Mentioned On Page Two Of The Report



On 8/2/2014, a patient presented to the hospital for shortness of breath.  A hospitalist assumed care of the patient and admitted him for inpatient treatment.  Based on the patient’s presentation, the hospitalist ordered multiple labs and radiology studies, including a chest computed tomography scan (CT) with contrast, to rule out serious lung conditions, such as pulmonary embolism.  The 8/2/2014 chest CT report was negative for pulmonary embolism, but did show a 3.3 cm right renal mass highly suggestive of malignancy.  No mention of the renal mass was noted in the hospitalist’s chart notes.  The hospitalist reviewed page one of the CT report which was negative for pulmonary embolism, eliminating the problem from the hospitalist’s differential diagnosis.  The right renal mass suggestive of malignancy was reported on page two of the report; however, the hospitalist was not aware there was a page two.

The hospitalist indicated in her statement to the Commission that she did review the CT report and focused on the findings that addressed the current lung complaints.  She indicated that because the patient did not have complaints suggestive of a renal or bladder issue, she did not order the CT to evaluate renal issues.

The hospitalist continued to follow the patient throughout the hospital admission and prepared the discharge summary.  On 8/6/2014, she discharged the patient.  The discharge diagnoses included bilateral pneumonia, sepsis, and exacerbation of chronic obstructive pulmonary disease (COPD).  The discharge summary recommended that the patient follow up with his primary care provider in one week.  No recommendations were documented regarding the renal mass.

On 8/25/2014, the patient followed up with his primary care provider.  Notes do not indicate that the primary care provider was notified of the renal mass.  The patient continued to follow up with multiple providers for various medical conditions between August 2014 and March 2015.  The patient indicated that on follow-up for psoriasis with a different provider, the renal mass was brought to his attention.  On 3/31/2015, the patient underwent a follow-up CT, which showed that the renal mass had increased in size.  Subsequently, the patient was confirmed to have renal carcinoma and underwent successful treatment.

The Commission stipulated the hospitalist reimburse costs to the Commission, develop and follow a written protocol for the clinic to ensure outside lab and other tests results are promptly reviewed, and write and submit a paper of at least 1000 words, plus bibliography, addressing the standard of care applicable to the ordering provider when reviewing lab/radiology reports and the ordering provider’s responsibility for arranging follow-up of abnormal results.

State: Washington


Date: September 2016


Specialty: Hospitalist, Emergency Medicine, Family Medicine, Internal Medicine, Oncology


Symptom: Shortness of Breath


Diagnosis: Cancer, Pneumonia, Sepsis


Medical Error: Failure to follow up, Diagnostic error


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



Nevada – Emergency Medicine – Right Pleural Effusion, Ascites, And Transaminitis In A Pediatric Patient



On 10/16/2014, the Nevada Board of Medical Examiners (Nevada Board) filed a complaint against an ED physician.

On 3/25/2012, a 12-year-old female presented to the emergency department of a hospital in Nevada.  The radiologist’s interpretations of both an abdominal ultrasound and a computerized tomography scan of the patient indicated a “right pleural effusion” and a “small amount of ascites.”

Blood testing revealed a total bilirubin of 2, aspartate aminotransferase of 205, an alanine aminotransferase of 337, and an alkaline phosphatase of 66.  Her white blood cell count was 13.1 with a normal differential and an elevated hemoglobin of 15.4.  The patient had a decreased carbon dioxide level of 16 and a mildly elevated creatinine level of 1.13.

On 3/26/2012, the patient returned to the emergency department the next day where she was treated by an ED physician.  She presented with new onset of peripheral edema, a mildly diminished pulse oximetry, persistent tachycardia, and a cough that had lasted for three weeks.

According to the complaint, given the known presence of pleural effusion, ascites, and transaminitis, coupled with laboratory evidence of renal insufficiency, the ED physician should have considered congestive heart failure as the possible etiology of the patient’s symptoms.

The patient’s medical chart lacks any evidence demonstrating that the ED physician carried out the standard diagnostic evaluation for possible congestive heart failure by ordering a chest x-ray and an electrocardiogram.

Accordingly, the complaint alleges that the ED physician failed to use the reasonable care, skill, or knowledge ordinarily used under similar circumstances when she failed to order this diagnostic testing.  The complaint also alleges that the ED physician failed to maintain accurate and/or complete medical records relating to the diagnosis, treatment, and care of the patient.

On 9/9/2016, the Nevada Board entered a settlement agreement with the ED physician, in which the ED physician admitted to the medical records violation alleged in the complaint.  As part of the Nevada Settlement Agreement, the ED physician consented to the following discipline:

1) Reimbursement of the costs of investigation and prosecution

2) Completion of five hours of continuing medical education related to medical records, emergency-related practices, and preventing malpractice

3) Reporting of the agreement as discipline to the National Practitioner Data Bank

State: Nevada


Date: August 2016


Specialty: Emergency Medicine, Pediatrics


Symptom: Swelling, Cough, Shortness of Breath


Diagnosis: Heart Failure


Medical Error: Failure to order appropriate diagnostic test


Significant Outcome: Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



Wisconsin – Pediatrics – Post-Operative Tachycardia And Low Blood Pressure In Pediatric Patient With Multiple Serious Conditions



A fourteen-year old-boy with multiple serious medical conditions including cerebral palsy, type I diabetes mellitus, and dysarthria was scheduled to undergo a laparoscopic lysis of adhesions, a laparoscopic jejunostomy placement, and a laparoscopic-assisted abdominoperineal resection.  He had previously undergone a total colectomy with ileostomy placement and J-tube placement and replacement by interventional radiology.

On 1/13/2011, the patient presented for surgery.  A pediatrician and a surgeon agreed that if the surgical procedures went well, the patient would not be placed in the pediatric intensive care unit, but would be cared for postoperatively on an inpatient pediatric unit, which was also being staffed by the pediatrician.

At approximately 4 p.m. the patient was transferred from recovery to a room in inpatient pediatrics on unit 4 West with no noted complications.  The pediatrician saw the patient on unit 4 West at approximately 5:15 p.m. and 7:20 p.m.

The pediatrician’s note of the 5:15 p.m. visit indicates that the patient seemed to be doing well.  The pediatrician’s note from the 7:20 p.m. visit indicates that the patient’s vital signs were stable.  The patient’s records indicate that around 7:20 p.m., he had a small amount of bloody drainage from the rectum suture line and that he was running a low-grade fever.  The pediatrician left the hospital shortly thereafter.

Between approximately 9:30 p.m. on 1/13/2011, and 3:00 a.m. on 1/14/2011, the pediatrician was provided updates on the patient’s condition by telephone and notified that the patient was experiencing tachycardia and decreased blood pressure.  The pediatrician entered several orders but failed to take urgent action to address the patient’s declining condition.

At approximately 3:30 a.m. the patient began experiencing respiratory distress.  The pediatrician was contacted and he ordered chest x-rays and lab tests.  A blood transfusion had also been ordered and administered, but the patient’s condition became critical and he died at approximately 4:45 a.m. on 1/14/20114.

The Board judged the pediatrician’s conduct to be below the minimum standard of competence given his failure to provide appropriate urgent action to address the patient’s declining condition.

The Board ordered the pediatrician be reprimanded and pay a fine.

State: Wisconsin


Date: July 2016


Specialty: Pediatrics


Symptom: Shortness of Breath, Bleeding, Fever, Shortness of Breath


Diagnosis: Post-operative/Operative Complication, Sepsis


Medical Error: Improper treatment, Delay in proper treatment


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



Arizona – Emergency Medicine – Gastroenteritis Diagnosed For A Patient With Shortness Of Breath, Palpitations, Chest Pain, Nausea And Vomiting, And Numbness Of The Arms Or Legs



The Board received notice of a malpractice settlement.

On 12/03/2012, a 63-year-old female presented to urgent care.  The patient’s boyfriend completed her health history document and provided the urgent care physician (UC physician) with information on the patient’s current medications and her history of a motor vehicle accident a year prior to the appointment.  She was noted to have a history of frequent and severe headaches.

The patient’s current symptoms included shortness of breath, “palpitations or pounding heart…chest pain or pressure,” “nausea and vomiting,” and “numbness of the arms or legs.”  The patient reportedly had neck or back pain with “numbness of the arms or legs.”

The medical assistant (MA) completed the Urgent Care “Abdomen/Groin GI/GU” encounter form.  On the form, the MA noted the patient’s blood pressure to be 106/68 with respirations of 18, “O2 99%,” and a temperature of 95.5.  The UC physician wrote on the same encounter form that the patient had been experiencing symptoms, which included four hours of vomiting and myalgia.  The UC physician noted that the patient felt like she had impending diarrhea.

The encounter documentation stated that she had a history of a cholecystectomy and an appendectomy.  The UC physician checked off current patient symptoms of nausea, vomiting, and chills.  He checked boxes indicating a “no” to constipation, fever, black stools, diarrhea, flank pain, heartburn, jaundice, dysuria, hematemesis, hematuria, dyspepsia, fatty food intolerance, and post-prandial pain.

In his objective notations, the UC physician noted only a single finding of abdominal tenderness by checking “yes.”  He checked “no” to 18 other exam findings which included the cardiac, pulmonary, skin, neurologic, gastrointestinal, and genitourinary systems along with mental status.

The UC physician’s diagnosis was listed as gastroenteritis and “viral syndrome” was checked as “no.”  The UC physician concluded the written record by indicating “medications” and giving prescriptions for prochlorperazine 25 mg, OTC Imodium, and Pepcid AC.  He also noted that he had counseled the patient on her diet.

At 10:00 a.m. on 12/04/2015, there was a final entry in the patient’s record, a handwritten note, that the Scottsdale Police had contacted the UC physician informing him that the patient was found unresponsive on that morning and that the paramedics could not revive her.

An autopsy on the patient revealed a 95% atherosclerotic occlusion of the major coronary arteries, ventricular hypertrophy, acute coronary artery thrombosis, pericarditis, chronic pulmonary and renal disease, and an adrenal mass.  The cause of death was acute myocardial infarction.

The Board judged the UC physician’s conduct to be below the minimum standard of competence given failure to diagnose acute myocardial infarction.

The Board ordered the UC physician to be reprimanded.

State: Arizona


Date: June 2016


Specialty: Emergency Medicine, Internal Medicine


Symptom: Chest Pain, Constipation, Nausea Or Vomiting, Numbness, Back Pain, Head/Neck Pain, Palpitations, Shortness of Breath


Diagnosis: Acute Myocardial Infarction


Medical Error: Diagnostic error


Significant Outcome: Death


Case Rating: 2


Link to Original Case File: Download PDF



California – Anesthesiology – Attempted Intubation On Patient With Abscess At The Right Mandibular Angle



On 3/1/2014, a patient arrived at the hospital by air ambulance.  The patient presented with intermittent respiratory difficulties, and his throat was constricted.  The patient could only open his mouth 1 cm. CT scans of the patient’s neck showed a 6.8 x 4.8 cm abscess at the right mandibular angle.  The CT scans indicated that there were severe edema and tracheal narrowing. The patient complained of respiratory difficulty when lying down.  The patient was prepped for the surgical drainage of the neck abscess. The anesthesiologist assigned to the procedure noted that he performed an assessment at 4:15 p.m.  The patient entered the operating room at 4:23 p.m.

The anesthesiologist documented a compromised airway and noted a CT scan that showed a left shift of pharyngeal tissues.  The anesthesiologist noted the need to perform awake intubation if the airway was compromised. The anesthesiologist administered IV sedation, providing 1 mg x 2 of midazolam and 100 mcg of fentanyl, to the patient.  The anesthesiologist had the patient lay down in a supine position. At 4:30 p.m., the anesthesiologist administered general anesthesia consisting of oxygen and sevoflurane. He then provided the patient with a dose of 80 mg of succinylcholine.

The anesthesiologist attempted to obtain endotracheal intubation while the patient was sedated.  The anesthesiologist repeatedly used a trachlight, also known as a light wand, in an attempt to transilluminate the soft tissues of the patient’s neck for placement of the endotracheal tube.  The anesthesiologist attempted to use different pieces of equipment as he repeatedly tried to intubate the patient. Additional airway equipment was not immediately available and had to be brought to the operating room.  The anesthesiologist did not attempt to wake the patient to try an awake intubation. The anesthesiologist’s multiple attempts at intubation were unsuccessful, and surgical intervention was required. At 5:10 p.m., a surgeon performed a tracheostomy.  The patient’s preoperative note was written at 5:42 p.m., and he signed the note at 5:53 p.m.

The Medical Board of California judged that the anesthesiologist’s conduct departed from the standard of care because he failed to appreciate the degree of airway difficulty in preparation for the administration of general anesthesia despite documenting swelling, a restricted mouth opening, a CT scan showing severe edema and tracheal narrowing, and a complaint of respiratory difficulty when lying down.  The anesthesiologist also failed to prepare for and manage a known difficult airway by inadequately documenting the case before attempts at intubation began, failing to use proper equipment, and failing to have the necessary intubation equipment available in case initial intubation attempts were unsuccessful.

The Medical Board of California placed the anesthesiologist on probation for 4 years and ordered him to complete a medical record-keeping course, education course for at least 20 hours for the first year of probation, and clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California


Date: May 2016


Specialty: Anesthesiology


Symptom: Shortness of Breath, Swelling


Diagnosis: Ear, Nose, or Throat Disease


Medical Error: Procedural error, Underestimation of likelihood or severity, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Virginia – Anesthesiology – Multiple Attempts At Intubation Fail With Resulting Complications



On 11/24/2005, a patient presented to a Virginia hospital for an elective hysterectomy.  Anesthesiologist A was scheduled to work the patient’s case but could not provide services due to an unrelated emergency.  As a result, Anesthesiologist B took over.  His pre-operative evaluation included reviewing the patient’s medical history, inquiring about her prior surgery and anesthesia experience, and reviewing her symptoms.

Anesthesiologist B examined the patient’s oropharynx and airway and deemed her suitable for anesthesia.  Anesthesiologist B later testified that this was his routine for all pre-operative patients.  The patient reported that she was taking over-the-counter medications and an intermittent low-dose of prednisone.

In the operating suite, once the patient was paralyzed, Anesthesiologist B made three attempts to intubate using different-sized equipment each time.  In between attempts, Anesthesiologist B was able to ventilate the patient using a bag valve mask, which kept her oxygen saturations above 95%.

When his initial attempts to intubate were unsuccessful, he called for assistance from Anesthesiologist C.  Anesthesiologist C arrived with an intubation cart and attempted to intubate the patient using a laryngeal mask airway.  These attempts were unsuccessful.  The patient was then ventilated using a bag valve mask.

Subsequently, anesthesiologist B used a bronchoscope to visualize the vocal cords.  At this time, Anesthesiologist D entered the operating room and offered assistance.  Anesthesiologist D was also unsuccessful in intubating the patient.

After a discussion with the surgeon, the decision was made to cancel the surgery and reverse the patient’s anesthesia.  After the reversal, the patient began moving her extremities and breathing spontaneously.  As preparations were made to move the patient to a recovery room, she experienced a sudden decrease in her oxygen level, which was presumed to be due to laryngospasm.

Anesthesiologist B attempted to medically reverse the laryngospasm.  Once he realized that the reversal was unsuccessful, he immediately called for surgical intervention.  The surgeon was able to perform the emergency tracheostomy within minutes.  Despite having a patent airway, the patient was unable to be ventilated due to pulmonary edema.

The patient’s autopsy concluded that she died from anoxic encephalopathy, had pulmonary edema, and had an abnormally small larynx (2.5 cm versus a normal of 4.1 cm).  The autopsy found a lack of edema of the vocal cords, demonstrating that there was no evidence of trauma from the repeated intubation attempts.

Allegations were raised, that Anesthesiologist B failed to case his attempts at intubation when it became clear that intubation was not possible, and he delayed his request for a tracheostomy when the patient experienced difficulty breathing.  Further allegations were raised that he did not fully review the patient’s history and physical medical records preoperatively and failed to perform and document a thorough pre-operative exam on the patient.  The Board noted that Anesthesiologist B operated within the guidelines of the American Society of Anesthesia and dismissed the above issue.

State: Virginia


Date: March 2016


Specialty: Anesthesiology


Symptom: Shortness of Breath


Diagnosis: Post-operative/Operative Complication


Medical Error: No error found


Significant Outcome: Death


Case Rating: 5


Link to Original Case File: Download PDF



Washington – Internal Medicine – Abnormal ECG, Elevated CPK, And Tachycardia Following A Fall



On 12/10/2014, a patient, a resident of an inpatient psychiatric facility, fell on his face during a fire drill.  Per ward staff, it appeared the patient had experienced a seizure.  An on-the-scene physician ordered labs for the next morning, checked the patient’s vital signs, performed a dental consult, and provided a dose of antibiotic and some Gatorade.

On 12/11/2014, the same physician examined the patient and noted his pulse to be 90-100, after an initial measurement of 113, and his blood pressure stable.  Soon after, a second physician performed an examination on the patient and noted that he was “feeling generally unwell, had a low grade temperature and some muscle pain.”  It appeared to the physician the patient had an upper respiratory infection.  Albuterol and a complete blood count were ordered.

On the afternoon of 12/11/2014, a third physician examined the patient.  The physician’s records showed the patient presented with a probable upper respiratory virus with asthmatic bronchitis.  The patient’s heart rate was 120.  The physician documented that the patient’s tachycardia was probably due to mild dehydration and medications.  The treatment plan for the patient included a chest x-ray and evaluation of creatine phosphokinase (CPK) levels.  It was reported that the patient’s chest x-ray “seemed negative.”  The patient denied having any chest pain.  The physician opined that the increased CPK level may have been caused by medications or a possible recent seizure.  The physician’s treatment plan included an electrocardiogram (ECG), rechecking labs, and oral hydration.

On 12/12/2014, an internist entered the patient’s medical room.  She ordered fluid monitoring every shift, continuation with vital signs every four hours, and repeat lab testing in the morning.  The ECG reported “probably abnormal ECG.”  The internist was notified of this reporting and informed an assisting physician.

The internist failed to review the patient’s previous medical records, which included chest x-rays and perpetuated the diagnosis of dehydration despite adequate hydration.  The internist failed to respond to abnormal vital signs and properly diagnose and treat the patient’s medical condition.  The internist also failed to transfer the patient to a higher level of care for additional work-up.

On 12/13/2014,  the patient’s treating psychiatrist received a call from the nursing staff informing her the patient was suffering from an elevated heart rate, and had an elevated, though declining, CPK level.  The patient continued to receive treatment from various physicians who noted the patient’s decline, which included symptoms of tachycardia and weakness.

On 12/14/2014, the patient was transported to a hospital by ambulance where diagnostic tests revealed “extensive bilateral pulmonary emboli and probably thrombus in the right atrium.” The patient was transported to a second hospital.  While in interventional radiology, the patient became pulseless and was later pronounced dead.

The Commission stipulated the internist reimburse costs to the Commission and write and submit a paper of at least 1000 words on how to appropriately evaluate patients with shortness of breath and tachycardia.  The paper should also discuss the proper review of ECG findings consistent with pulmonary embolisms.

State: Washington


Date: March 2016


Specialty: Internal Medicine


Symptom: Palpitations, Shortness of Breath, Weakness/Fatigue


Diagnosis: Pulmonary Embolism


Medical Error: Diagnostic error


Significant Outcome: Death


Case Rating: 5


Link to Original Case File: Download PDF



Washington – Emergency Medicine – End Stage Renal Disease Started On Levofloxacin 500 mg Oral Daily For 7 Days



On 1/21/2015, a man in his mid-50s came to the emergency department (ED) presenting with coughing, shortness of breath, and sounds in his lungs.  The ED physician evaluated the patient and diagnosed him with asthmatic bronchitis with probably underlying viral influenza-like illness.

The patient’s ED records for the visit documented that the patient had end stage renal disease (ESRD).  In spite of the patient’s ESRD, the ED physician chose to prescribe 500 mg of levofloxacin per day for seven days.

The patient’s creatinine clearance at the time of his visit was documented as 12 ml/min.  The ED physician prescribed a standard dose of levofloxacin, not a renally adjusted dose based on the patient’s renal insufficiency.

The patient began to experience symptoms of severe bilateral Achilles tendinopathy, diagnosed subsequently by another physician as being due to the patient’s treatment with levofloxacin.

The Commission stipulated the ED physician reimburse costs to the Commission, complete 5 hours of continuing education covering the subject of appropriate medication choices and doses for patients with renal insufficiency, write and submit a paper of at least 1000 words, with references, regarding appropriate medication choices and doses for patients with renal insufficiency to the Commission and to all members of his former practice group.

State: Washington


Date: February 2016


Specialty: Emergency Medicine


Symptom: Cough, Shortness of Breath


Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Infectious Disease, Renal Disease


Medical Error: Improper medication management


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



North Carolina – Radiology – Evaluation Of A Chest X-Ray In A Patient With Shortness Of Breath And COPD



The Board was notified of a professional liability payment on 06/20/2014.

A 79-year-old female received general medical care at a Washington state clinic for many years.

in January 2011, the patient presented to that clinic with complaints of cough shortness of breath, and wheezing.  The patient’s chest x-ray was read by a radiologist.  A diagnoses of chronic obstructive pulmonary disease (COPD) was made, along with “blunting of both posterior costophrenic angles.”  In December 2012, the patient was found to have lung cancer.

The Board obtained the patient’s records and sent them to a qualified independent medical expert for review.  The reviewing expert noted that the x-ray the radiologist read revealed a spiculated mass adjacent to the right hilum that was suspicious for lung cancer.  The expert further opined that this mass clearly showed asymmetric density and should have been identified as suspicious for cancer.  The Board noted that the radiologist had some concerns that the x-ray the Board reviewed was not the same as the original x-ray the radiologist reviewed for the patient.

The Board expressed concern that the radiologist’s conduct was below the minimum standard of competence given failure to appreciate the mass on the chest x-ray.

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: January 2016


Specialty: Radiology


Symptom: Shortness of Breath


Diagnosis: Lung Cancer


Medical Error: Diagnostic error


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



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