Found 88 Results Sorted by Case Date
Page 9 of 9

Wisconsin – Emergency Medicine – 35-Year-Old With Shortness Of Breath, Left Arm Pain, And Recent History Of Heart Palpitations



On 12/27/2004, an emergency department physician treated a 35-year-old man who reported to the nurse that he had difficulty breathing “feels like I’m breathing in fiberglass,” pain running down his left arm “like pinched nerve,” and had a history of recent “heart palpitations.”  The ED physician listened to the patient’s heart and breath sounds with his stethoscope and ordered a chest x-ray, which was negative; the patient did not repeat his complaint of left arm pain to the ED physician.

The ED physician then diagnosed shortness of breath – resolved, and recommended that the patient stop smoking, use a humidifier, and apply bacitracin to his nose 3-4 times per day.  There is no charted indication that the ED physician considered heart conditions in his differential diagnosis or asked about a family history of heart problems; if he had done so he would have been informed that the patient’s father, mother, three paternal uncles, and one paternal aunt, all had major heart problems.

The patient was discharged home and suffered a fatal heart attack (thrombotic occlusion in the left circumflex coronary artery) sometime in the following nine hours.

The Board ordered that the ED physician pay the costs of the proceeding, be reprimanded, and complete 16 hours of continuing education in cardiovascular emergencies.

State: Wisconsin


Date: October 2005


Specialty: Emergency Medicine


Symptom: Extremity Pain, Shortness of Breath


Diagnosis: Acute Myocardial Infarction


Medical Error: Diagnostic error


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Wisconsin – Internal Medicine – Sickle Cell Anemia Patient With Post-Operative Shortness Of Breath And Chest Pain



A 32-year-old male had a history of sickle cell anemia, which was treated by an internist from 1996 through 1999.  Primary treatment consisted of control of pain, which varied throughout the patient’s body, but was generally located in his chest and lower back.

During the course of this treatment, the patient had periodically presented to the internist with chest pain, shortness of breath, splinting, and an accelerated pulse rate, which the internist attributed to a sickle cell pain crisis.

On 5/17/1999, the patient had surgery to remove an anterior mediastinal mass in his chest.  The surgeon noted that there was no evidence of malignancy but the patient did have some pulmonary issues, difficulty mobilizing his secretions, and a right side pleural effusion which needed to be drained.  The patient was treated prophylactically for pneumonia.

On 5/26/1999, the patient contacted the internist’s clinic with complaints of chest pain and shortness of breath.  An appointment was made with the internist for the following morning for a chest x-ray and evaluation of his complaints.

On 5/27/1999, the patient failed to appear for the morning appointment and arrived at the office at 1 p.m., when the internist had already departed to conduct a resident clinic.  The medical assistant who attended the patient at the clinic contacted the internist and advised him the patient had arrived and was complaining of pain around the surgical site.  The internist was unable to return to examine the patient due to the resident clinic and advised the medical assistant to have a chest x-ray taken and obtain the patient’s pulse rate and pulse oximetry.  The internist did not ask the medical assistant to take a blood pressure.  The medical assistant placed a second call to the internist and relayed her clinical findings of a pulse oximetry of 98% and a pulse rate of 144.   The internist advised the medical assistant that he would contact the surgeon to advise him of the pain at the surgical site and instructed her to advise the patient to seek additional medical care if the patient’s condition did not improve or worsened.  The internist ordered no further follow-up.

A lowered blood pressure can be an indication of fluid accumulation and combined with an elevated pulse rate may be symptomatic of pericarditis.  A narrow pulse pressure combined with the presence of fluid can be suggestive of pericarditis.

The internist attributed the patient’s shortness of breath and elevated pulse rate to his ongoing postsurgical chest pain or possibly another sickle cell crisis and believed that if the patient’s condition worsened he would go to the emergency department as he had in the past.

The patient left the clinic without further medical evaluation.  The patient died on 5/28/1999, of complications of fibrinous pericarditis.

The Board judged the internist’s conduct to be below the minimum standard of competence given failure to properly evaluate a patient with complaints of chest pain and an elevated pulse rate by not obtaining a blood pressure, which would have contributed to a diagnosis of the patient’s condition and may have indicated the need for further medical evaluation.

The Board ordered that the internist pay the costs of the proceeding and complete 6 hours of continuing education in the evaluation and treatment of sickle cell anemia and 6 hours in the diagnosis of pericardial conditions.

State: Wisconsin


Date: March 2005


Specialty: Internal Medicine


Symptom: Shortness of Breath, Back Pain, Chest Pain


Diagnosis: Post-operative/Operative Complication, Cardiovascular Disease


Medical Error: Failure to examine or evaluate patient properly, Improper supervision


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Wisconsin – General Surgery – Post-Operative Adult Respiratory Distress Syndrome After Gastrointestinal Bypass, Incidental Splenectomy, And Cholecystectomy



On 1/22/2002, a general surgeon performed a gastrointestinal bypass, incidental splenectomy, and cholecystectomy on a 41-year-old female.  The patient had a BMI of 44 and a history of asthma, obesity, gastroesophageal reflux disease, glucose intolerance, hypertension, migraines, and non-cardiac chest pain.

During the course of the surgery, a splenectomy had to be performed due to a capsular tear of the spleen.  Total blood loss for the surgery was estimated at 1400 ml.  The patient did well on the evening of 1/22/2002, but began to experience mild respiratory distress beginning in the afternoon on 1/23/2002.

A chest x-ray was obtained on 1/23/2002.  The general surgeon thought the distress to be due to atelectasis secondary to surgery and splinting from pain.  Incentive spirometry was reinforced and the patient remained on nasal cannula oxygen.

On 1/24/2002, the patient’s oxygen saturations dropped to the upper 80’s, although nasal cannula oxygen was given and a high flow mask was now being used.  A spiral CT scan of the chest occurred at 3:14 a.m. on 1/24/2002.  No embolus was seen, but there was patchy alveolar based infiltrate bilaterally.  The CT scan was ordered by a colleague of the general surgeon to investigate the possibility of pulmonary embolism.  The colleague reviewed the film with a radiologist at approximately 1:30 p.m. on 1/24/2002.  The colleague noted fluid in the splenic bed, but attributed it to the removal of the spleen.  The radiologist noted that the fluid could be due to post-operative hemorrhage or to an abscess.

A chest x-ray was taken later in the morning on 1/24/2002, and progression with bilateral fluffy infiltrates were noted.  The patient’s condition worsened throughout the day on 1/24/2002.  In the afternoon, she was intubated and placed on spontaneous mode ventilation.  On the morning of 1/25/2002, the patient was hypoventilated with a pH of 7.26, a pCO2 of 63, a PAO2 of 80, and a bicarb of 29.  The ventilation was increased and the blood gases normalized.  A central line was placed and the patient was started on TPN.

A subsequent chest x-ray on 1/25/2002 showed an increase in fluffy infiltrates bilaterally. The general surgeon believed that the patient was showing a pattern of adult respiratory distress syndrome, which the general surgeon believed to be secondary to surgery, possible fat embolism, or hypotension related to blood loss during the splenectomy.  The patient experienced fever beginning on 1/23/2002 and continuing.  The fevers were up to 102 degrees.

On 1/26/2002, the patient was transferred to another hospital and a CT scan showed a large amount of free fluid in the left upper abdomen.  A physician performed an exploratory surgery on 1/26/2002 at approximately 8:00 pm and located a 1 cm hole in the distal stomach at the proximal end of the greater curve and fluid coming out of the hole.  A total of 2700 ml of green, foul-smelling fluid was aspirated primarily from the left upper quadrant.

The patient died on 1/30/2002.  The cause of death was not directly attributable to the surgery performed by the general surgeon.

The Board judged the general surgeon’s conduct to be below the minimum standard of competence given his failure to recognize an anastomotic leak as one of the possible causes of the patient’s respiratory deterioration and adult respiratory distress.  The patient had a gastric bypass, for which an accepted complication is an anastomotic leak, and had an emergency splenectomy.  Each increased the possibility of an intraabdominal infection.

The minimally competence physician would have investigated or sought another cause of the adult respiratory distress syndrome, specifically an anastomotic leak as a cause, by doing a CT scan with contrast of the abdomen and pelvis at least by 1/25/2002 or an x-ray with contrast of the abdomen and pelvis.

The Board ordered that the general surgeon pay the costs of the proceeding and complete 12 hours of continuing education in the area of post-operative care of patients.

State: Wisconsin


Date: December 2004


Specialty: General Surgery


Symptom: Shortness of Breath, Fever


Diagnosis: Post-operative/Operative Complication


Medical Error: Diagnostic error


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



California – Cardiology – Ventricular Ectopy Found Incidentally During Cataract Surgery Diagnosed As Tachycardia-Bradycardia Syndrome



On 10/25/2001, a cardiologist first saw a patient for cardiac consultation because of ventricular ectopy found during cataract surgery earlier in the day.

The patient underwent Holter monitoring on 10/29/2001 and 10/30/2001.  The Holter monitor recording revealed frequent premature ventricular beats with compensatory pauses and variable significant ST depression.  The patient reported shortness of breath and chest pain during the monitoring period.

There were no sustained periods of bradycardia reflected on the Holter monitor recording.  The significant pauses noted by the cardiologist were all under 2 seconds and were compensatory pauses following ventricular ectopy.

The cardiologist failed to recognize that these Holter monitoring results were suggestive of ischemic heart disease and diagnosed the patient with tachycardia-bradycardia syndrome.

Based on his diagnosis of symptomatic tachycardia-bradycardia syndrome, the cardiologist decided to implant a pacemaker in the patient.  After implantation, he planned for the patient to undergo an IV Persantine Thallium stress test and an echocardiogram.

On 11/13/2001, the cardiologist implanted a dual-chamber pacemaker in the patient.

On 11/21/2001, the patient’s sutures were removed at the patient’s office.  He was scheduled to return for a follow-up visit in six weeks.

In late November, the patient had an echocardiogram done at the cardiologist’s office.  The cardiologist interpreted the echocardiogram to show a relatively well-preserved left ventricular function.  In actuality, per the board, the echocardiogram actually showed clear evidence of ischemic left ventricular dysfunction.  He did not take any action in response to these test results.

On 12/5/2001, the patient presented to the emergency department at a hospital complaining of shortness of breath for one month that was worse with walking.  The emergency department physician diagnosed the patient with atypical congestive heart failure.  The physician discussed the management plan with the cardiologist.

On 12/6/2001, the cardiologist sent a request to Hospital A for an IV Persantine Thallium stress test for chest pain.

On 12/14/2001, the patient underwent an IV Persantine stress test.  The physician reading the stress test results reported the following: “1. Severe dilated cardiomyopathy with ischemia of the lateral wall.  There is some degree of infarct involving the anterior, inferior and septal wall.  2.  Ejection fraction is 16%.”

During the test, the patient had a resting heart rate of 86, which increased to a maximum of 120 during Persantine infusion.  He had a chest pain of 4 to 6 on a scale of 1 to 10 with 10 being the most severe.  The patient’s next scheduled appointment with the cardiologist was 1/8/2002.

On 12/29/2001, the patient was admitted to Hospital B with complaints of increasing shortness of breath.  He underwent cardiac catheterization.  The left anterior descending coronary artery and right coronary artery were found to be occluded.  On 1/2/2002, the patient underwent three-vessel coronary artery bypass surgery with vein grafts to the diagonal branch and the posterolateral branch of the right coronary artery as well as left internal mammary bypass graft to the left anterior descending coronary artery.  On 1/15/2002, he was discharged from the hospital.

On 3/2/2002, the patient was readmitted to Hospital B complaining of weakness.  He was hypotensive with a pulse of 120.  He was admitted to the Intensive Care Unit for respiratory distress, wide complex tachycardia, renal insufficiency, atrial fibrillation, and progressive hypotension.

On 3/3/2002, the patient died of heart failure.

The Medical Board of California judged the cardiologist’s conduct as having fallen below the standard of care given failure to timely diagnose myocardial ischemia, committing a diagnostic error in misinterpreting the Holter monitor tracings, failure to hospitalize a patient despite evidence of heart failure, and failure to act in a timely fashion to address abnormal stress test results.

The cardiologist was placed on probation for three years with stipulations to complete a clinical training program such as the Physician Assessment and Clinical Education Program at the University of California, San Diego School of Medicine, complete 20 hours of continuing medical education annually for each year of probation in any areas of deficiency, and undergo clinical practice monitoring.

State: California


Date: July 2004


Specialty: Cardiology


Symptom: Chest Pain, Shortness of Breath, Weakness/Fatigue


Diagnosis: Heart Failure, Cardiac Arrhythmia


Medical Error: Diagnostic error, Delay in proper treatment, False negative


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



Wisconsin – Family Practice – Hospitalization Of Obese Patient With Shortness Of Breath, Chest Pain, And Elevated CPK



On 11/14/2001, a 64-year-old man presented to clinic.  His past medical history included diabetes mellitus type II, hyperlipidemia, hypertension, congestive heart failure, chronic obstructive pulmonary disease, arthritis, coronary artery disease, obesity, and 35 years of smoking.  His medication list included hydrochlorothiazide/lisinopril, potassium chloride, furosemide, atorvastatin, multivitamins, metformin, garlic, insulin NPH, regular insulin, nebulizer, albuterol, oxycodone/acetaminophen, hydrocodone/acetaminophen, ferrous gluconate, and oxygen.  The patient had a father, two brothers, and one sister who had died of heart disease.  None had lived as long as he had.  He was prescribed atorvastatin 20 mg a day.

On 01/30/2002, the patient underwent right knee arthroplasty.  In the weeks after his discharge from the hospital following his knee surgery, the patient experienced shortness of breath, weight gain, and peripheral edema.  He denied chest pain or fevers.  For two weeks after his knee surgery, he continued to have improvement in his mobility, but after two weeks, he developed inability to ambulate and became more sedentary.

At approximately 3:44 a.m. on 03/06/2002, the patient was admitted to the emergency department with shortness of breath, diaphoresis, and chest pain.  He said he awoke at 3:00 a.m. with chest pain, which had resolved at the time of presenting to the emergency department.  His blood pressure was 215/106, pulse was 130, respiratory rate 32, and oxygen saturation level 89%.  The ED physician found 2+ edema on exam.  Chest x-ray showed chronic changes, but no acute findings.  The EKG showed sinus tachycardia with no acute S-T changes, but with evidence of anterior and inferior infarcts of undetermined ages.

At 4:05 a.m., creatine phosphokinase was 4,253, CKMB 24.3, and %CKMB 0.6.  Troponin was 0.3.  Myoglobin was 1,357.2.  BUN was 32.  Creatinine was 0.8, sodium was 136, and potassium was 4.8.

The ED physician admitted the patient to rule out myocardial infarction.  Admitting diagnoses included dyspnea, COPD, chest pain, and possible rhabdomyolysis.  The patient weighed 292 pounds at time of admission.  The ED physician ordered a follow-up EKG, cardiac monitoring, routine vital signs, but did not order continuation of the atorvastatin presumably due to concerns for rhabdomyolysis.

Physician A assumed responsibility for the management of the patient after admission to the hospital.  CT scan of the chest was performed and was negative for pulmonary embolism.  Serial cardiac enzymes were obtained.  The CPK level remained significantly elevated.  The CKMB and %CKMB remained in the normal range.

On 03/07/2002, Physician A assumed the patient had not had a myocardial infarction and that the CKMB and troponin were not suggestive of it.  Vitals revealed no fever, a heart rate of 65, a respiratory rate of 32, a blood pressure of 133/72, and a weight of 294.4 pounds.  Physical exam revealed a regular rate and rhythm of the heart, clear lung fields, and no edema of the extremities.  Physician A presumed the patient would be ready for discharge on 03/08/2002.

On 03/08/2002, an exam revealed labored breathing and a weight that had increased to 298 pounds.  Blood pressure ranged from 154/86 to 172/83.  Heart exam revealed sinus tachycardia without murmurs and a pulse ranging from 99 to 120.  His lungs were clear to auscultation with some tachypnea and his extremities revealed trace pretibial edema.  Physician A believed the dyspnea was likely secondary to COPD and mild heart failure.  Medication list included aspirin, nitroglycerin patch, and furosemide.  IV fluids were also continued, presumably for rhabdomyolysis, even though the patient was also on furosemide for presumptive mild heart failure.

On 03/08/2002, Physician A resumed atorvastatin 10 mg daily.

At 10:40 p.m. on 03/08/2002, a specimen obtained from the patient revealed an elevated CPK of 2,957.

At 6:35 a.m. on March 9, 2002, CPK level increased to 3,375.  Later that day, Physician A examined the patient.  The patient reported right sciatica, but without numbness in his legs.  He reported that his muscles felt generally weak.  He was dyspneic with ambulation.  His lungs were clear to auscultation and a chest x-ray taken on 03/08/2002 was stable with no pulmonary infiltrates.  His weight was 296.6 pounds.  Physician A concluded that the patient had COPD, controlled congestive heart failure, hyponatremia, obesity, hyperlipidemia, rhabdomyolysis, right sciatica, borderline control of diabetes mellitus, and arteriosclerotic heart disease.  Given increase of the CPK from 2,987 to 3,375, Physician A assumed the increase was due to atorvastatin leading to rhabdomyolysis.  Atorvastatin was discontinued.  Furosemide was decreased to 40 mg in the morning.  1500 ml fluid restriction per 24 hour period was ordered.

On 03/10/2002, the patient continued to complain of sciatica and aches in his neck and perithoracic muscles.  His extremities showed trace pretibial edema.  His weight increased to 298 pounds.  His lungs remained clear to auscultation.  Physician A believed that he needed to keep the patient well hydrated to treat the rhabdomyolysis while managing fluid balance given a history of heart failure.

On 03/11/2002, Physician A noted that the patient’s systolic blood pressure had dropped to 70, but had returned to the 90’s by the time of his visit.  His lungs remained clear.  His extremities showed trace pretibial edema.  His weight had increased to 301.1 pounds.  His CPK level remained elevated at 3,922.  Lasix was discontinued.

On 03/12/2002, lungs remained clear, but his weight had increased to 301.7 pounds.  His CPK level was elevated at 4,440.  He also had a BUN of 62, creatinine of 1, sodium of 122, and a potassium of 5.7.  Fluid restriction was discontinued.  IV fluids (normal saline) were ordered at 55 ml/hour.

On 03/13/2002, the patient had intermittent dyspnea and his weight increased to 302 pounds.  He had a CPK of 3,817, a BUN of 57, a creatinine of 0.9, a sodium of 125, and a potassium of 5.3.  Physician A continued the normal saline at 50 ml/hour.

On 03/14/2002, lungs remained clear, but weight had increased to 304.8 pounds.  His CPK level was 4,062, his BUN was 48, creatinine was 0.8, sodium was 125, and potassium was 55.  Physician A ordered continuation of the IVF.

On 03/15/2002, the patient became progressively more dyspneic and his weight had increased to 311.3 pounds.  His lungs showed a few basilar rales, but no wheezes or rhonchi.  The chest x-ray showed prominence of the pulmonary vasculature, but no overt evidence for heart failure.  CPK was 6,086, BUN was 39, creatinine was 0.8, sodium was 123, and potassium was 5.6.  Physician A suspected the patient had borderline heart failure with hyponatremia and hyperkalemia.  2,000 ml/24 hours fluid restriction and a decrease in the IV fluid rate were ordered.  Furosemide 40 mg IV was administered.

On 03/16/2002, the patient reported aching in his right leg after having fallen twice while ambulating the prior evening.  His lungs had few basilar rales, but his shortness of breath had improved after furosemide.  He had edema in his lower abdominal wall and 1+ to 2+ pitting pretibial edema.  His CPK level was 6,854, BUN was 34, creatinine was 0.8, sodium was 121, and potassium was 5.5.  Physician A renewed his order for 2000 ml/24 hours fluid restriction and ordered furosemide 40 mg IV to be administered once and then every morning.

On 03/17/2002, Physician A left for vacation, and Physician B took over management.  CPK level was 13,690, creatinine was 0.8, sodium was 123, and potassium was 4.7.  Blood pressure was 115/90, his pulse rate was 130, and his respiratory rate was 32.  Physician B suspected heart failure.  He ordered furosemide 40 mg IV at noon and again at 6:00 p.m.  He also ordered 21 ml/hour of 5% hypertonic saline for 24 hours and 1,000 ml/24 hours fluid restriction.

When Physician B saw the patient for a second time on 03/17/2002, the patient became increasingly short of breath and was tachypneic.  Lung exam revealed inspiratory rales.  Oxygen saturation had dropped into the 80’s on 3 liters of oxygen.  Heart rate was 110.

Physician B saw the patient for a third time on 03/17/2002.  The patient was becoming increasingly short of breath and anxious.  The patient had 3+ pitting edema of the arms and legs and weighed 311 pounds.  Physician B ordered alprazolam and furosemide 40 mg IV.

Thereafter, the nursing notes for 03/17/2002 indicated that the patient was alert and oriented.  His urine output had increased to 2150 ml.  The patient was conversant with family members and was not experiencing any shortness of breath.  He was observed to be sleeping peacefully.

At 5:10 a.m. on 03/18/2002, the patient’s daughter found him to be pulseless and not breathing.  He was unable to be resuscitated.  No autopsy was conducted.

Physician B was alleged to have fallen below the standard of care by administering five percent hypertonic saline.

The Board invited testimony from four experts, one who was critical of Physician B’s conduct, and three who believed the physician’s conduct was within the standard of care.

The Board judged Physician B’s conduct to be within the standard of care and the order was dismissed.

State: Wisconsin


Date: June 2004


Specialty: Family Medicine, Internal Medicine


Symptom: Chest Pain, Shortness of Breath


Diagnosis: Heart Failure


Medical Error: No error found


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Virginia – Internal Medicine – Intubated With Central Venous Catheter Placed Leading To Complication



On 3/9/1998, a 76-year-old female with a history of chronic obstructive pulmonary disease was admitted with complaints of weakness, dizziness, and progressive shortness of breath with a diagnosis of possible gastrointestinal bleeding.

On 3/13/1998, the patient underwent partial gastrectomy with Billroth II anastomosis, during which she was intubated and a central venous catheter was placed.

On 3/14/1998, a CXR was ordered for the following morning.  On 3/15/1998, the progress note failed to mention the chest x-ray.  However, the x-ray indicated a large pneumothorax.

After a careful review of the records of his care regarding multiple patients and other information provided, and following a discussion with the nephrologist, the Committee found that he had no violations.  The physician provided evidence that in July 1999 after a six-month review of his medical records found no deficiencies, he was granted full staff privileges at a hospital.  Based on the foregoing, the Committee voted unanimously to dismiss this matter with no action.

State: Virginia


Date: June 1999


Specialty: Internal Medicine


Symptom: Shortness of Breath, Dizziness, Weakness/Fatigue


Diagnosis: Pneumothorax


Medical Error: No error found


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Virginia – Internal Medicine – Cardiac Arrest Shortly After Beginning Endoscopy



On 10/20/1997, a nephrologist admitted a 56-year-old male with a history of insulin dependent diabetes mellitus and chronic renal failure with complaints of shortness of breath, abdominal pain, and bloated abdomen.  On the date of admission, a chest x-ray showed bilateral pleural effusions suggesting pulmonary edema, and an electrocardiogram was abnormal, showing ST and T wave abnormality; however, the patient was taken for endoscopy on 10/21/1997, where cardiac arrest occurred shortly after initiation of the procedure.

After a careful review of the records of his care regarding multiple patients and other information provided, and following a discussion with the nephrologist, the Committee found that he had no violations.  The physician provided evidence that in July 1999, after a six-month review of his medical records found no deficiencies, he was granted full staff privileges at a hospital.  Based on the foregoing, the Committee voted unanimously to dismiss this matter with no action.

State: Virginia


Date: June 1999


Specialty: Internal Medicine, Nephrology


Symptom: Shortness of Breath, Abdominal Pain


Diagnosis: Cardiovascular Disease


Medical Error: No error found


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Virginia – Internal Medicine – Post-Operative Acute Hypercapnic Respiratory Distress



On 3/10/1998, a 61-year-old female with a history of coronary artery disease status post angioplasty and chronic obstructive lung disease was admitted for colon resection.  On 3/12/1998, the patient underwent surgery.

On 3/16/1998 at 6:30 a.m., the patient had an acute episode of respiratory distress.  At 7:30 a.m., the nephrologist reported the episode in a note.

The patient continued to have increasing PCO2 and low PO2, which was documented in a note at noon.

On 3/17/1992 at 11:00 a.m., the nephrologist reported in his note that the patient had had a very difficult night complicated by hypoxia.  She was confused at times.

On 3/17/1992 from 3:52 p.m. until 6:00 p.m., the nursing staff made approximately eight attempts to reach the nephrologist concerning the patient’s respiratory distress.  Because the nephrologist could not be reached, the patient’s family requested that her care be transferred to another physician.  The patient was intubated and placed on ventilation.

After a careful review of the records of his care regarding multiple patients and other information provided, and following a discussion with the nephrologist, the Committee found that he had no violations.  The physician provided evidence that in July 1999 after a six-month review of his medical records found no deficiencies, he was granted full staff privileges at a hospital.  Based on the foregoing, the Committee voted unanimously to dismiss this matter with no action.

State: Virginia


Date: June 1999


Specialty: Internal Medicine


Symptom: Shortness of Breath


Diagnosis: Post-operative/Operative Complication


Medical Error: No error found


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



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