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

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

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

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

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

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

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

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

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

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

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

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

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

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

For this case and others, the Medical Board of California placed the neurologist on probation and ordered the neurologist to complete a medical record keeping course, a professionalism program (ethics course), an education course (at least 40 hours per year for each year of probation), and a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.  The neurologist was assigned a practice monitor and was prohibited from supervising physician assistants and advanced practice nurses.

State: California

Date: January 2018

Specialty: Neurology

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

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

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

Significant Outcome: N/A

Case Rating: 4

Link to Original Case File: Download PDF

On 12/7/2016, a 30-year-old female was admitted to University Behavioral Center (“UBC”) while suffering from acute psychotic symptoms and was placed under a psychiatrist’s care.  The patient remained under the psychiatrist’s care at UBC for approximately eleven days.

On the day of the patient’s admission, the psychiatrist began treating the patient with lithium.  The psychiatrist continued treating the patient with lithium until 12/17/2016.

The patient had previously been prescribed lisinopril (an ACE inhibitor) and hydrochlorothiazide (a thiazide diuretic) for hypertension.  The psychiatrist continued treating the patient with hydrochlorothiazide until 12/16/2016.  The psychiatrist continued treating the patient with lisinopril for the duration of her stay at UBC.

During the course of the patient’s confinement at UBC, her condition worsened, and she experienced incontinence and increasing levels of confusion.  After falling in the shower on 12/18/2016, the patient was transferred to a hospital for medical treatment, where it was determined that the patient was experiencing lithium toxicity.  As a result of the lithium toxicity, the patient suffered kidney failure, which required dialysis.

The Board judged the psychiatrist’s conduct to be below the minimum standard of competence given that she should have been aware of the potential drug interactions with lithium and to prescribe alternative antipsychotic drug to a patient taking both a thiazide diuretic and an ACE inhibitor, as each of these drugs has a known interaction with lithium which presents risk of lithium toxicity.  The psychiatrist also failed to monitor the patient for signs of lithium toxicity, and she failed to immediately discontinue treatment with lithium when the patient began experiencing symptoms of lithium toxicity.

It was requested that the Board order one or more of the following penalties for the psychiatrist: permanent revocation or suspension of her 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: December 2017

Specialty: Psychiatry

Symptom: Psychiatric Symptoms, Confusion, Urinary Problems

Diagnosis: Drug Overdose, Side Effects, or Withdrawal

Medical Error: Improper medication management, Failure to properly monitor patient

Significant Outcome: N/A

Case Rating: 3

Link to Original Case File: Download PDF

From 4/25/2012 to 1/29/2014, a 66-year-old female was treated by a urologist for incomplete bladder emptying and renal cysts.

On 4/25/2012 and 1/15/2014, the patient underwent urinalysis tests which returned negative for blood in the urine.

On 1/15/2014, the patient underwent fluorescence in situ hybridization (FISH) ordered by the urologist, which returned negative.

At all times material to this complaint, the patient displayed no indications to receive FISH testing.

The Board judged the urologist’s conduct to be below the minimal standard of competence given that he failed to document his plan to order FISH testing in the patient’s medical records and that the urologist’s ordering of FISH testing for the patient was medically unnecessary.

It was requested that the Board order one or more of the following penalties for the urologist: 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: July 2017

Specialty: Urology

Symptom: Urinary Problems

Diagnosis: Urological Disease

Medical Error: Unnecessary or excessive diagnostic tests, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 1

Link to Original Case File: Download PDF

On 5/16/2014, a 47-year-old female presented to a gynecologist for a routine gynecological exam.  The patient had a significant history of heart disease, including a quadruple bypass surgery in 2009.

The patient had complaints of hot flashes, inability to lose weight, insomnia, night sweats, irritability, and mild bladder leakage.  The gynecologist diagnosed the patient as menopausal.  The gynecologist recommended hormone replacement therapy.  He ordered hormone and thyroid level lab work.  He did not order tests for cholesterol levels or basic metabolic status, despite the patient’s metabolic lab result, dated 2/6/2012, indicating an abnormally high glucose level.

On 6/11/2014, the patient presented to the gynecologist for follow-up.  The gynecologist prescribed compounded creams containing the hormones estrogen, progesterone, and testosterone.  He also prescribed Armour Thyroid, a thyroid hormone replacement drug containing the hormones T3 and T4.

At all times material to this complaint, the prevailing standard of care dictated that a physician prescribing hormone replacement therapy to a patient with a significant history of heart disease obtain appropriate medical clearance prior to prescribing such therapies.

The gynecologist did not obtain medical clearance prior to prescribing hormone replacement therapy to the patient, despite a significant history of heart disease.

The prevailing standard of care dictated that a physician prescribing hormone replacement therapy to a patient with a prior abnormal glucose value order or obtain sufficient blood work prior to prescribing hormone replacement therapy.

The gynecologist did not obtain sufficient blood work prior to prescribing hormone replacement therapy to the patient, despite the patient’s prior abnormal glucose value.

At all times material to this complaint, the prevailing standard of care dictated that a physician discuss the full risks and benefits of hormone replacement therapy with the patient prior to initiating the treatment.  The gynecologist failed to discuss, or did not create or maintain adequate, legible documentation of discussing the full risks and benefits of hormone replacement therapy with the patient.

The Board issued a letter of concern against the gynecologist’s license.  The Board ordered that the gynecologist pay a fine of $5,000 against his license and pay reimbursement costs for the case for a minimum of $7,244.87 and not to exceed $9,244.87.  Also, the Board ordered that gynecologist complete ten hours of continuing medical education in “hormone replacement therapy” and five hours of continuing medical education in “risk management.”

State: Florida

Date: July 2017

Specialty: Gynecology

Symptom: Urinary Problems

Diagnosis: N/A

Medical Error: Failure to order appropriate diagnostic test, Failure of communication with patient or patient relations, Improper medication management

Significant Outcome: N/A

Case Rating: 1

Link to Original Case File: Download PDF

A urologist treated a patient from 2/3/2011 to 3/4/2011.

On 2/3/2011, the patient first presented to the urologist with micro hematuria and stone disease.

On 2/9/2011, the urologist ordered pre-operative blood work and chest x-rays for the patient.

The radiology report of the chest x-ray dated 2/9/2011 revealed a “newly developed 2.5 cm irregular contoured nodule located in the right lower lobe” that was “suspicious for potential malignancy and chest CT correlation [was] recommended…”

The urologist did not review the 2/9/2011 chest x-ray or radiology report and subsequently did not notify the patient and the patient’s primary care physician of the radiology findings.

On July 2012, the patient’s primary care physician ordered a chest x-ray, which demonstrated a 5 cm mass with metastasis.

A medical malpractice lawsuit was filed against the urologist.

The Board judged the urologist conduct to be below the minimal standard of competence given that he failed to review the chest x-ray and radiology report that were ordered by his staff and inform the patient and the patient’s primary care physician of the findings of the chest x-ray.

It was requested that the Board order one or more of the following penalties for the urologist: 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: July 2017

Specialty: Urology

Symptom: Urinary Problems

Diagnosis: Urological Disease, Cancer, Renal Disease

Medical Error: Failure to follow up

Significant Outcome: N/A

Case Rating: 4

Link to Original Case File: Download PDF

A patient was referred to a general surgeon specialized in colorectal surgery by his primary care doctor.  The patient presented to the general surgeon on 4/10/2012 as a 35 year-old-man with anal pain since age 16.

The patient’s medical history included a 12/30/2003 colonoscopy with biopsies by a gastroenterologist, who made a postoperative diagnosis of anal fissure, rectal polyp, and two small sigmoid polyps.  The biopsies revealed benign hyperplastic polyps.  In 2009, the patient had a lumbar discectomy at L4-L5.  In October 2011, the patient was referred to, and seen by, a cardiologist.  The cardiologist found “no evidence of any fixed coronary arterial disease in the left dominant system…elevated resting left ventricular end-diastolic pressure suggests left ventricular diastolic non-compliance likely due to history of hypertension and obesity.”  In sum, the patient presented to the general surgeon with morbid obesity, hypertension, dyslipidemia, post-two back surgeries, with a resulting DVT, cardiac complaints, and a list of prescription medications; and a social history including a one pack per day smoking habit, cannabis use, and occasional alcohol use.

The patient appeared with his wife for his appointment with the general surgeon.  The patient was given a two-page medical questionnaire to complete.  The patient filled in page one of the questionnaire and the patient signed page two, leaving blank the box on page two asking the patient to circle symptoms applicable to their current condition (e.g., headaches, shortness of breath, chest pains, blood in stool, etc.).  The patient was called out of the lobby by a medical assistant, who took his vital signs and questioned him about the information listed on the questionnaire.  The medical assistant learned that the patient was allergic to penicillin, which the patient had not listed on the questionnaire.  The medical assistant reported that the patient’s vital signs to the general surgeon on a yellow sticky note was as follows: “Temp-98.2 F, Weight-341 lbs., Height-72 in., BP [Blood Pressure]-139/77, Pulse-84, RR[Respiratory Rate]-21, BMI [Body Mass Index]-46.3.”

The medical assistant then escorted the patient to an examination room. The general surgeon entered and spoke to the patient. The general surgeon took notes by hand, indicating the following:

“hemorrhoids three times after laminectomy[1l in January; symptoms greatly increased over the last six months; Bowel Habits-small stools, tenesmus [urge to defecate, but cannot], and mucus discharge; hiatal hernia; colonoscopy negative; History of polyps; no sigmoidoscopy.”

The general surgeon and the medical assistant created the chart note for the patient’s visit, which reports out the following:

CC [Current Complaint]: Hemorrhoids

HPI [History of Present Illness]: The patient is a pleasant 35- year-old referred here by [his primary care physician]. He is here because of a 3-year history of hemorrhoids with progressive painful BM’s [bowel movements], tenesmus, BRBPR [bright red blood per rectum], and small stools last 6 months. Known history of fissure. Last colonoscopy negative.

ROS [Review of Systems]: General-denies fever, night sweats, weight loss; Neurological-denies loc [loss of consciousness], ha [headaches], diplopia [double vision], tinnitus [ringing in the ears], vertigo [dizziness], numbness, tingling, incoordination; Respiratory-denies sob [shortness of breath], wheezing, coughing, hemoptysis [coughing up blood]; CV [cardiovascular system ]-denies angina, palpitation, leg cramps, pedal edema, pnd [ difficulty breathing], nocturia [ excessive urination at night], orthopmea [shortness of breath while lying down], claudication [cramping leg pain caused by exercise]; GI [gastrointestinal system]-denies nausea, vomiting, hematochezia [fresh blood in stool], hematemesis [vomiting blood], jaundice, diarrhea, incontinence, heartburn, indigestion, dysphagia [difficulty swallowing], poor appetite, constipation; GU [genitourinary]-denies dysuria [painful urination], hematuria [blood in urine], incontinence, impotence, pneumaturia [passage of gas with urine], fecuria [fecal matter in the urine]; MS [musculoskeletal]-denies stiffness, arthralgia joint pain], weakness, atrophy, bone pain, Raynaud’s [severe blood flow reaction to blood vessels in the cold in fingers and toes]; Endocrine-denies heat intolerance, cold intolerance, dry skin, dry hair, hoarseness, polydipsia [abnormally large thirst], polyuria [production of abnormally large levels of diluted urine]; Hematologic-denies bleeding, bruising, ecchymosis [discoloration of the skin resulting from bleeding underneath], pk [Pyruvate kinase deficiency, one of the most common enzymatic defects of the erythrocyte].

PMH [Past medical history]: Medical-hypertension, dyslipidemia [high cholesterol]; Surgical-lumbar laminectomy, micro-discectomy.

SH [Social history]: Patient denies recreational drug use; Smokes 1 pack/day for 15 years; Occasional alcohol consumption.

FH [Family history]: Mother- 69 alive with hypertension [high blood pressure]; Father-DEC [deceased] at 65 heart attack; Siblings- 1 brother alive at 41 with CVD [cardiovascular disease], 2 sisters alive, 1 with diabetes another with CVD.

Allergies: Penicillin.

Meds:

acetaminophen-hydrocodone 325 mg.-7.5 mg. [Norco] oral tablet, folic acid 1 mg oral tablet, Xanax XR 0.5 mg oral tablet, extended release, zolpidem [ Ambien] 10 mg oral tablet.

Vitals: T [temperature]-98.2 F, Wt [weight]-341 lbs., Ht [height]-72 in., BP [Blood Pressure]-139/77, P [pulse]-84, RR [Respiratory Rate]-21, BMI [Body Mass Index]-46.3.

PE [Physical examination]: General-WD/WN [well­-developed/well-nourished] in NAD [no abnormality detected]; HEENT[head, eyes, ears, nose, throat]-PERRLA [Pupils equal, round & reactive to light & accommodation], EOMl, [extraocular movements intact], ENT [ear, nose, throat] wnl [within normal limits]; Neck-not thyromegally [enlargement of the thyroid gland] or masses, no ND [jugular venous distension] or bruits [a systolic murmur heard in the neck]; Chest-clear to auscultation and percussion; Cardiac-no murmur or gallop; Abdomen-no masses or organomegaly [enlargement of the viscera], non-tender; Extremities-no clubbing, cyanosis or edema, full range of motion; Neuro-grossly intact; Anorectal­: inspection showed posterior fissure, with spasm, no further exam. Large skin tag RPQ [right posterior quadrant]. Cannot rule out hemorrhoids.

A/P [assessment/plan]:

#ANAL fissure (565.0);

#HYPERLIPIDEMIA OT/UNSPEC (272.4);

#HYPERTENSION UNSPEC (401.9).

Fissurectomy, lateral sphincterotomy, possible hemorrhoidectomy. The risks, benefits, and alternatives, including the slight chance of incontinence, are discussed.

Following the examination, the patient signed two information and consent forms: Hemorrhoids-Surgical Hemorrhoidectomy and Anal Fissure-Fissurectomy and Sphincterotomy.

No surgery was scheduled, and the patient left the general surgeon’s office. The general surgeon did not request the patient’s medical file from the primary care doctor.

On 4/23/2014, at approximately 9:00 a.m., the patient called the general surgeon’s office, complaining of terrible pain and pleading for relief. At the time, the general surgeon was in surgery at a surgery center. The general surgeon was contacted in the operating room (OR) by his office on behalf of the patient. Although the general surgeon was scheduled for a full day of surgeries, he offered to operate on the patient at the end of his surgical schedule that day. The patient accepted. The general surgeon’s office transmitted a Pre-Admission form, with Physician’s Orders, to the surgery center at approximately 10:00 a.m., requesting the patient have the following tests prior to surgery: “EKG [electrocardiogram]; CBC [complete blood count], without Differential (includes Platelets); UA[urine analysis]/Culture if indicated.”

At 3:44 p.m., the patient was admitted to the surgery center for his surgical procedures. The Admission’s Nurse completed the Admission Profile with the patient and the wife, noting, among other things: “Previous hospitalizations/surgeries-microdiscectomy 2010, lumbar laminectomy 2009, with DVT after laminectomy; Comprehensive Pain Assessment­ pain scale 10, rectum, onset at 16 years old, burning; Cardiovascular-high blood pressure, weird heartbeat about 8 months ago at cardiologist; Hema/Hepatic/GI-hemorrhoids, fissure; Psychiatric-Anxiety; Social Habits-smoker 1 PPD [pack per day], alcohol 2-4 times per month.”

The general surgeon completed a Short Form history and physical for the patient, noting: “Chief Complaint-Anal pain; History of Present Illness-severe pain secondary to anal fissure. Past Medical/Surgical History: HTN [hypertension]; Current Medications and Allergies: See-home medication list; Physical Exam-Head/Neck-normal,-Airway normal,-Neuro normal, Chest/Lungs normal, Heart normal, GI normal, GU normal, Extremities normal; Significant findings-anal fissure with right posterior skin tag; Diagnosis-Anal fissure; Plan-fissurectomy, sphincterotomy, and hemorrhoidectomy; Pre-Sedation Assessment For Procedure Without an Anesthesiologist-ASA2 II – mild systemic disease.”

At 4:12 p.m., a patient provided a urine sample and blood was taken for labs. At 4:53 p.m., labs revealed normal sodium, potassium, hemoglobin, and hematocrit. At 5:11 p.m., a pre-anesthetic evaluation was completed on the patient by an anesthesiologist. At 5:29 p.m., the patient was placed under general anesthesia. At 5:46 p.m., the general surgeon performed a hemorrhoidectomy, fissurectomy, and a right lateral sphincterotomy on the patient. The surgery was completed at 6:42 p.m., and the patient was in the recovery room at 7:00 p.m. The general surgeon prescribed the patient “Norco 10/325 mg., one tablet every four hours, as needed for pain; Valium 2 mg., one every six hours, as needed for pain; and Toredal (sic) 10 mg., one every six hours.” At 8:15 p.m., The patient was discharged.

The general surgeon drafted an Operative Report, noting, among other things:

“Preoperative Diagnosis-anal fissure; Postoperative Diagnosis-anal fissure and hemorrhoids; Procedures Performed-hemorrhoidectomy, fissurectomy, right lateral internal sphincterotomy; Anesthesia-general; Findings-anal stenosis with deep posterior anal fissure with large 3-quadrent (sic) hemorrhoids in the usual distribution, in the right anterior quadrant hemorrhoidal group there with chronic strangulation and gangrenous changes.”

On 4/24/2014, Post-Surgical Day 1 (PSDl), the patient’s wife called the general surgeon’s office four times: at 9:46 a.m., 10:32 a.m., 3:10 p.m., and 4:38 p.m. At 9:46 a.m., the patient’s wife reported that the patient had blood in his urine; the patient’s wife was told that the patient had a urinary catheter during surgery and blood in the urine was normal on PSDI. At 10:32 a.m., the patient’s wife reported the patient was vomiting and had diarrhea; the patient’s wife was told this was normal for PSDl. At 3:10 p.m., the patient’s wife reported the patient was still vomiting; a prescription for Reglan (anti-nausea) was called in. The patient’s wife collected the prescription, but the patient could not keep the Reglan down.

At 4:38 p.m., the patient’s wife reported the patient was still vomiting, with diarrhea, and feels hot, although his temperature is normal; the patient’s wife was told that the symptoms are normal for PSDl, and get fluids into the patient. The general surgeon did not return the calls from the patient’s wife on 4/24/2014.

On 4/25/2014, Post-Surgical Day 2 {PSD2); at 5:58 p.m., the patient’s wife called the surgery center and reported the patient was still vomiting, with diarrhea, and feels hot; the patient’s wife was told the symptoms were normal for PSD2, but to call the general surgeon’s office. The patient’s wife called the general surgeon’s office, spoke to the answering service, and requested a callback.

At 6:40 p.m., the general surgeon telephoned the patient’s wife. The patient’s wife reported pus at the surgical site and that the stitches looked ripped open and yellow; the general surgeon said they were breakaway stitches and the appearance was normal for PSD2. They did not discuss the patient’ s symptoms from PSD 1.

On 4/26/2014, the patient began speaking nonsensically. He complained about pain in his legs. The patient’s wife called the general surgeon’s office at 12:36 p.m. and 12:40 p.m., but the office was closed for lunch and the patient’s wife did not leave a message with the exchange.

The patient’s wife then telephoned the surgery center at 12:46 p.m. and 12:47 p.m. The patient’s wife reported the patient was speaking nonsensically, with purple, blotchy legs, purple lips, and slurred speech; the patient’s wife was told to bring the patient into the hospital. At 12:58 p.in., 911 was called. Paramedics appeared and transported the patient to the surgery center.

The patient arrived at the surgery center at 1:35 p.m. In the ambulance, the patient was intubated and described by EMS as “acutely cyanotic and mottled.” Upon arrival, the patient was treated by an ED physician in the ED for two hours.

The ED physician drafted an ED Report, indicating, among other things: “This is a 36-year-old white male who comes to the emergency room by ambulance in extremis [at the point of death]. He was intubated in the field by the paramedics.”

“On arrival in the department he was purple mottled, unresponsive with a heart rate in the 60s which later proceeded to become bradycardic into the 20s.” ” … [A] temperature of 41 Centigrade [105.8 Fahrenheit] was noted.”

“Examination of the rectum revealed maceration and postoperative changes. It does appear consistent with an infection in the area.”

“Labs later returned showing renal failure with a creatinine of 9. Potassium was elevated.”

“Diagnosis-septic shock, renal failure, perineal infection, status post hemorrhoidectomy. His prognosis seems exceedingly poor.”

“Total critical care time 120 minutes.”

At 2:50 p.m., the ED physician contacted the general surgeon regarding the patient, reporting sepsis, renal failure, hyperlipidemia, recent hemorrhoidectomy with local infection. The general surgeon telephoned the surgery center to reserve an OR for the patient, scheduling the first available OR at 5 p.m.

At approximately 3:30 p.m., the patient was admitted to the surgery center and his care was transferred to an internist. After 5:00 p.m., the patient was taken to interventional radiology (IR) for placement of an IVC [inferior vena cava] filter (5:35 p.m.) and a temporary dialysis catheter (5:43 p.m.).

At 5:50 p.m., the patient was moved from IR into the OR, where the general surgeon waited. On arrival to the OR, the transport staff reported a change in heart rhythm. A Code Blue was called at 6:05 p.m. Resuscitative measures commenced but were unsuccessful, and time of death was called at 6:41 p.m.

The internist charted a Discharge Summary, noting: “Discharge Diagnosis-(1) patient died, (2) severe septic shock, (3) most likely perirectal phlegmon [inflammatory process with pus] versus fasciitis [inflammation of connective tissue]. History of Hospital Stay-This was a 36-year-old gentleman admitted at [the hospital] with septic shock. He was hypotensive, unresponsive, intubated in the field. While in the emergency room, the patient had episodes of bradycardia [abnormally slow heart action]. He was found to have multi-organ system failure with acute kidney insufficiency. He was taken to the OR for an emergent exploratory laparotomy [a surgical incision into the abdominal cavity, for diagnosis or in preparation for surgery]. Unfortunately, he coded on the OR table.”

The general surgeon wrote a Death Note in the chart, indicating: “Patient came in with septic shock. Code blue called in route to OR. CPR commenced in the OR per ACLS [advanced cardiac life support] protocol. Planned perineal debridement and colostomy never took place. Code was called after 22 min of resuscitative effort then resumed after seemingly having spontaneous cardiac electrical activity and pulse, but this was transient, and soon patient became pulseless without meaningful cardiac activity. Patient after hemorrhoidectomy and has perineal gangrene.”

An autopsy was performed on April 28, 2012, at the Fresno County Coroner’s Office. A blood culture was taken, revealing gram-negative rods isolated [bacterial infection]. The cause of death is listed as probable cardiac arrhythmia due to idiopathic hypertrophic cardiomyopathy.

The general surgeon was placed on probation for three years with stipulations of completing an education course and undergoing monitoring by another physician.

State: California

Date: May 2017

Specialty: General Surgery, Internal Medicine

Symptom: GI Symptoms (GERD, Abdominal Distention, Dysphagia), Fever, Nausea Or Vomiting, Pain, Urinary Problems

Diagnosis: Sepsis

Medical Error: Delay in proper treatment, Failure of communication with patient or patient relations, Improper treatment

Significant Outcome: Death

Case Rating: 4

Link to Original Case File: Download PDF

On 11/19/2015, a patient presented to a physician assistant at a family care clinic with chief complaints of headache, vomiting, and incontinence since 11/17/2015.  The patient’s father reported, in addition to the severe headache, the patient was experiencing involuntary arm jerking.  Furthermore, the night prior, the patient experienced hearing voices.

The patient had a history of respiratory problems, was noted to have “poor” functional status, and was noted to be in preschool.

The physician assistant did not complete a neurological examination; however, he diagnosed the patient with pediatric migraine and ordered thirty 10 mg tablets of amitriptyline with instructions for the patient to take one tablet three times daily and the patient was to have one refill.  The physician assistant did not perform a thorough workup to include additional studies or tests prior to prescribing amitriptyline.

On 2/3/2016, the Board received a response from the physician assistant wherein he indicated, “I recall little about the episode, except possibly after reviewing his chart and the nurses [sic] report, in investigating his headache and cyclic vomiting and physical exam in UpToDate that the treatment I initiated would have been per the UpToDate recommendations.”

UpToDate is an online website claiming to be an evidence-based, physician-authored clinical decision support resource.

The physician assistant inappropriately prescribed amitriptyline due to the excessive dose and age of the patient.

The Board judged the physician assistant’s conduct to be below the minimum standard of competence given his inappropriate prescribing of amitriptyline.

For this allegation and others, the Board ordered the physician assistant to contact The Center for Personalized Education for Physicians, (“CPEP”) for a competence assessment, follow all recommendations of the CPEP assessment, and complete a medical record keeping seminar.

State: Kansas

Date: April 2017

Specialty: Physician Assistant, Family Medicine, Pediatrics

Symptom: Headache, Nausea Or Vomiting, Psychiatric Symptoms, Urinary Problems

Diagnosis: Neurological Disease

Medical Error: Improper medication management, Accidental Medication Error, Failure to examine or evaluate patient properly

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

Sometime in September 2009, an 86-year-old was evaluated by a gastroenterologist for complaints of abdominal pain, nausea, vomiting, and borderline anemia.  On 9/28/2009, the patient underwent a gastroscopy and was diagnosed with mild esophagitis and angiodysplasias of the lower stomach. The angiodysplasias were cauterized, and the patient was treated with acid-reducing agents and iron replacement.

Sometime in February 2010, the patient was admitted to the hospital on several occasions with urinary tract infection, suspected sepsis, deep vein thrombosis, and complaints of abdominal pain.  The patient underwent a series of endoscopic studies, including gastroscopies on 2/5/2010 and 2/26/2010 and a colonoscopy on 2/26/2010. Abdominal/pelvic CT scans showed an area of segmental small bowel narrowing.

On 3/11/2010, following a barium study, the patient was diagnosed with terminal ileal disease.  On 3/22/2010, the patient underwent a gastroscopy, which the gastroenterologist documented as being a small bowel enteroscopy.  On 4/19/2010, the patient underwent a “colonoscopy with ileoscopy.” The gastroenterologist billed for this examination using CPT billing code 45378.  On 6/16/2010 and 7/3/2010, the patient underwent a gastroscopy with the gastroenterologist. On 7/6/2010, the patient underwent a “colonoscopy with ileoscopy.”  The gastroenterologist billed for this examination using CPT billing codes 45380 and 44380, indicating that he performed both a colonoscopy and an ileoscopy separately instead of billing code 45378, indicating that he performed a colonoscopy with ileoscopy.

The Medical Board of California judged that the gastroenterologist’s conduct departed from the standard of care because he performed an excessive number of endoscopic procedures on the patient, had inadequate and illegible documentation, and submitted inaccurate billing.

For this case and others, the Medical Board of California issued a public reprimand and ordered the gastroenterologist to complete an education course (at least 40 hours) 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: February 2017

Specialty: Gastroenterology

Symptom: Abdominal Pain, Nausea Or Vomiting, Urinary Problems

Diagnosis: Gastrointestinal Disease

Medical Error: Unnecessary or excessive diagnostic tests, Lack of proper documentation

Significant Outcome: Hospital Bounce Back

Case Rating: 2

Link to Original Case File: Download PDF

Sometime around 2000, a 77-year-old male presented to a urologist for treatment of hematuria and benign prostatic hyperplasia.  Between 2000 and 2008, the patient continued to receive treatment from the urologist for various medical problems, which included but was not limited to, a right radical nephrectomy for cancer in 2001, a history of bladder cancer recurrence requiring transurethral resection and instillation of BCG (immune therapy) into the bladder, approximately twenty-five cystoscopies, and high grade prostate cancer treated with radiation and androgen deprivation in 2008.

On 12/18/2009, the then 86-year-old patient presented to the urologist with complaints of gross hematuria with clots for one week.  At that time, the urologist ordered a CT scan of the patient’s abdomen and pelvis.

On 12/22/2009, the urologist underwent a CT scan, which revealed a 5.7 cm mass in the upper pole cortex consistent with renal cell carcinoma.

On 12/29/2009, the urologist saw the patient for a follow-up visit.  Having reviewed the CT scan results, the urologist considered various options for treatment, including watchful waiting versus nephrectomy versus nephrectomy/cystectomy.  The urologist did not consider a partial nephrectomy.

On 1/6/2010, the urologist performed an uneventful total left nephrectomy, total cystoprostatectomy, and urinary diversion.  The pathology report showed a 6 cm clear cell cancer of the left kidney, nuclear grade 4/4, and the renal vein and renal sinus were not involved.  The bladder showed papillary transitional cell high-grade multifocal carcinoma in situ.  No tumor invasion was present in the bladder wall.

On 1/9/2010, the patient had developed some hypertension and was noted to have some greenish discharge from his surgical wound.  The patient was returned to surgery for an emergent laparotomy performed by the urologist and a co-surgeon.  During the laparotomy, it was discovered that the patient had small bowel perforations secondary to extensive bowel ischemia.  During the surgery, a bowel resection, jejunostomy, and double barrel colostomy were performed.  At the conclusion of the procedure, the patient had a cardiac arrest and died.

The Board expressed concern that the urologist practiced at a level below the standard of care by not considering less aggressive options such as a partial nephrectomy in a very elderly man with comorbidities.

The Board issued a reprimand and ordered continuing medical education of 40 hours.  It was also recommended that the urologist enrolls in the Physician Assessment and Clinical Education Program offered at the University of California – San Diego School of Medicine.

State: California

Date: February 2017

Specialty: Urology

Symptom: Mass (Breast Mass, Lump, etc.), Urinary Problems

Diagnosis: Post-operative/Operative Complication, Cancer

Medical Error: Improper treatment

Significant Outcome: Death

Case Rating: 3

Link to Original Case File: Download PDF

On 12/23/2013, a 63-year-old male presented to a medical center with complaints of fever, insomnia, urinary retention, and hematuria, lasting the past six days.

Upon admission to the medical center, the patient was examined by an internist, and the internist diagnosed the patient with a urinary tract infection and urinary retention.

Based on this diagnosis, the internist ordered the administration of ceftriaxone, the placement of a Foley catheter, a urinalysis work-up, and a consultation with a urologist.

The patient’s urinalysis came back negative, and the Foley catheter enabled the patient’s bladder to void.

While a consultation with a urologist was ordered, it was never actually completed.

There was no documentation in the patient’s medical records that indicated the underlying causes of the patient’s urinary retention, hematuria, fever, and pain.

The internist failed to perform and failed to document performing an examination of the patient’s abdomen, lower back, kidneys, and genitourinary system that was sufficiently detailed enough to confirm or rule out the possible underlying causes of the patient’s urinary retention, hematuria, fever, and pain.

The internist failed to order and failed to document ordering additional laboratory and imaging testing of the patient’s abdomen, lower back, kidneys, and genitourinary system, after the patient’s urinalysis came back negative.

The internist failed to follow up on and failed to document following up on the urology consultation and the urology consultation results ordered for the patient.

The internist stated in his discharge summary that the patient “was seen by urology and workup was negative.”

On 12/25/2013, the patient was discharged from the hospital with instructions to follow up with his primary care physician and an outpatient urology practice.

On 12/28/2013, the patient’s condition deteriorated and he expired in his home as a result of undiagnosed peritonitis.

The Medical Board of Florida judged the internist’s conduct to be below the minimal standard of competence given that he failed to perform an examination of the patient’s abdomen, lower back, kidneys, and genitourinary system that was sufficiently detailed enough to confirm or rule out the possible underlying causes of the patient’s urinary retention, hematuria, fever, and pain.  The internist also failed to follow up on additional laboratory and imaging testing of the patient’s abdomen, lower back, kidneys, and genitourinary system until the underlying causes of the patient’s urinary retention, hematuria, fever, and pain was determined.  The internist failed to follow up on the urology consultation and/or results of the urology consultation that was ordered for the patient.  Also, the internist failed to reevaluate and reassess the patient’s condition prior to his discharge from the hospital.

The Medical Board of Florida issued a letter of concern against the internist’s license. Also, the Medical Board of Florida ordered that the internist pay a fine of $8,000 against his license and pay reimbursement costs for the case at a minimum of 3,462.89 and not to exceed $5,462.89.  The Medical Board of Florida ordered that the internist complete five hours of continuing medical education in the “diagnosis and treatment of urinary retention and hyponatremia” and complete five hours of continuing medical education in “risk management.”

State: Florida

Date: November 2016

Specialty: Internal Medicine, Urology

Symptom: Fever, Bleeding, Pain, Urinary Problems

Diagnosis: Infectious Disease, Urological Disease

Medical Error: Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Failure of communication with other providers, Failure to follow up, Lack of proper documentation

Significant Outcome: Death

Case Rating: 3

Link to Original Case File: Download PDF