Found 22 Results Sorted by Case Date
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Florida – Ophthalmology – Lack Of Diagnostic And Preoperative Testing To Assess An Epiretinal Membrane



From 8/12/2015 to 4/1/2016, (“treatment period”) a 69-year-old male presented to an ophthalmologist with complaints of blurred vision in his eyes.

During the treatment period, the ophthalmologist diagnosed the patient with a mature cataract in his right eye, and complicated cataract, proliferative diabetic retinopathy, and epiretinal membrane (“ERM”) in his left eye.

During the treatment period, the ophthalmologist did not perform or document performing the appropriate objective preoperative diagnostic testing, such as an Optical Coherence Tomography (“OCT”), of the retina to adequately assess the ERM in the patient’s left eye.

During the treatment period, the ophthalmologist did not thoroughly examine or document a thorough examination of the patient’s eyes by performing objective preoperative testing and imaging, such as fundus photos documenting the ERM, an Amsier grid showing distortion of the patient’s vision, an Amsier grid on either eye, or showing the patient’s retina and irregularities in the retina to support the epiretinal membrane peel in the patient’s left eye.

During the treatment period, the medical records maintained by the ophthalmologist did not clearly document any indication of the ERM on the patient’s left eye preoperatively.

During the treatment period, the ophthalmologist did not perform or document performing, objective preoperative testing and imaging studies, such as an OCT of the retina, an Amsier grid showing distortion or metamorphopsia, taking fundus photos, or a fluorescein angiogram to justify his course of treatment in the patient’s left eye.

During the treatment period, the ophthalmologist did not thoroughly discuss with the patient or document thoroughly discussing with the patient the option of cataract surgery alone versus cataract surgery with the ERM.

On 8/27/2015, the ophthalmologist performed a cataract removal and intraocular lens implantation on the patient’s right eye.

On 10/8/2015, the ophthalmologist performed a cataract removal and epiretinal membrane peel on the patient’s left eye.

During the treatment period, the ophthalmologist did not maintain medical records that justified an appropriate plan or treatment for the patient’s condition.

The Board judged the ophthalmologist’s conduct to be below the minimal standard of competence given that he failed to perform and document appropriate diagnostic and preoperative testing.  The ophthalmologist also failed to discuss with the patient the option of cataract surgery alone versus cataract surgery with the ERM.

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

State: Florida


Date: October 2017


Specialty: Ophthalmology


Symptom: Vision Problems


Diagnosis: Ocular Disease


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


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Ophthalmology – Failure To Utilize Optical Coherence Tomography To Evaluate A Patient For Macular Conditions



An ophthalmologist treated a 90-year-old female from 1/26/2012 to 3/12/2014.  The patient presented to the ophthalmologist on 1/26/2012 with complaints of decreased vision and a prior history of Avastin injections.

The ophthalmologist diagnosed the patient with wet macular degeneration, vitreous membranes, posterior vitreous detachments, dry eyes, and previous cataract surgery with intraocular lenses.

The ophthalmologist performed fluorescein and indocyanine angiographies and ultrasonography.  The ophthalmologist performed a Lucentis injection in the right eye.

Over the course of his treatment of the patient, the ophthalmologist performed focal laser treatments in the patient’s left eye six times and in his right eye seven times;  intravitreal Lucentis injections in the patient’s left eye twenty-one times and the patient’s right eye twenty-two times;  intravitreal Avastin injections in both of the patient’s eyes four times;  fundus photos, fluorescein angiography and indocyanine green angiography over forty times, and ultrasounds on both of the patient’s eyes eight times.

The ophthalmologist failed to utilize, or did not create, keep, or maintain adequate, legible documentation of utilizing optical coherence tomography to evaluate the patient.

At all times material to this complaint, the prevailing standard of care dictates that a physician:  perform testing and/or treatment that are medically justified; provide medical justification for the testing and treatment provided to the patient;  utilize optical coherence tomography to evaluate a patient for macular conditions;  and record the lot number and/or other identifying information from used vials of Lucentis.

The ophthalmologist performed focal laser treatment on both of the patient’s eyes excessively and/or without medical justification on one or more occasions.  He also performed fluorescein and indocyanine angiography on the patient’s eyes excessively and/or without medical justification on one or more occasions.  The ophthalmologist performed ultrasounds on both of the patient’s eyes without medical justification on one or more occasions.  He did not document, or did not create, keep, or maintain adequate, legible documentation of the lot number of any other identifying information from any of the vials of Lucentis used during the course of treatment in the patient.  The ophthalmologist did not document, or did not create, keep, or maintain adequate, legible documentation of the patient’s conditions, any changes in the patient’s conditions, and/or medical indications for the testing and treatment.

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

State: Florida


Date: August 2017


Specialty: Ophthalmology


Symptom: Vision Problems


Diagnosis: Ocular Disease


Medical Error: Unnecessary or excessive treatment or surgery, Failure to order appropriate diagnostic test, Unnecessary or excessive diagnostic tests, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Washington – Physician Assistant – History Of Diabetes And Hypertension With Chest Pain, Left-Sided Weakness, Headache, And Loss Of Vision



On 11/7/2011, a patient presented as a “medical emergency” and was seen by a physician assistant at a correctional facility.  The patient was a 62-year-old man whose medical record included a history of arthritis, diabetes, and hypertension for which he was treated with blood pressure medication.

The patient told the physician assistant he thought he had a stroke three days earlier and described symptoms of chest pain, left-sided tingling, left-sided weakness, headache, and loss of vision in the bottom visual field of his left eye.  The patient’s presenting blood pressure was 180/94 with a repeat at the end of the visit of 127/82.  The physician assistant noted normal pupil, funduscopic, heart and lung exams.  Cranial nerves II-XII were intact.  The patient’s strength was equal bilaterally.  An EKG was done and interpreted as having a normal sinus rhythm.  The physician assistant’s diagnosis was “No evidence of stroke.”  The patient was given a GI cocktail and released to his unit.

The physician assistant did not verify the patient’s complaint by conducting a visual field exam.  The physician assistant did not consider temporal arteritis as a possible cause of the patient’s vision loss.  Also, he did not at that time discuss his care of the patient with a supervising physician.  The physician assistant failed to recognize the emergent nature of the complaint of sudden vision loss by a patient.

The patient again presented to the physician assistant a week later on 11/14/2011.  He reported continued loss of vision in the bottom visual field of his left eye. The physician assistant completed a form recommending the patient be referred to an ophthalmologist.

The patient was seen two weeks later on 11/29/2011 by a local ophthalmologist who ordered a sed rate to help rule out temporal arteritis and placed the patient on clopidogrel.  The ophthalmologist diagnosed “[a]cute anterior ischemic optic neuropathy OS.”  He stated that at the visit the patient was “already showing signs of superior optic atrophy and inferior visual field loss from superior involvement approximately three weeks previous.”

The Commission stipulated the physician assistant reimburse costs to the Commission and write and submit a paper, with bibliography, on the evaluation of a patient with non-traumatic sudden vision loss.

State: Washington


Date: August 2017


Specialty: Physician Assistant, Family Medicine, Internal Medicine


Symptom: Vision Problems, Headache, Chest Pain, Weakness/Fatigue


Diagnosis: Ocular Disease


Medical Error: Diagnostic error


Significant Outcome: N/A


Case Rating: 5


Link to Original Case File: Download PDF



California – Emergency Medicine – Spontaneous Movement And Loss Of Sensation Of The Left Arm



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

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

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

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

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

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

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

State: California


Date: May 2017


Specialty: Emergency Medicine


Symptom: Numbness, Vision Problems, Weakness/Fatigue


Diagnosis: Ischemic Stroke


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


Significant Outcome: Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



Washington, D.C. – Ophthalmology – Floaters And Decreased Vision Following Cataract Surgery



On 8/12/2011, an ophthalmologist performed cataract surgery on a patient’s left eye, which resulted in serious complications immediately following the surgery.  During the procedure, a rent occurred in the capsule.  On the following day, the patient met with the ophthalmologist during a post-operative appointment, and the patient allegedly informed the ophthalmologist that he suffered pain and discomfort in the left eye.  The ophthalmologist allegedly told the patient that his eye “looked okay” as there were no floaters, cells, or flair in vitreous, and scheduled a follow-up appointment for the following week.

At the follow-up appointment, the patient complained of floaters and decreased vision in the left eye and the ophthalmologist referred the patient to a retina specialist, who determined that there was a tear of the capsule in the left eye and that there was still some cortex within the eye.  The retina specialist performed corrective surgery and the patient received treatment and medical care from the retina specialist thereafter.  After the corrective surgery, the patient allegedly continued to suffer pain and decreased vision in the left eye.

At the time of the procedure performed by the ophthalmologist, the patient’s pre-surgical best corrected vision was allegedly 20/40-20/100; after the cataract surgery performed by the ophthalmologist and subsequent retina surgery performed by the retina surgeon, the patient’s vision was reduced to 20/70-20/100.  The patient was sent back to the ophthalmologist for glasses but was upset when the ophthalmologist recommended “temporary readers” until his vision became stable.  The patient never returned for a follow-up examination.

The Board obtained the patient’s medical records so that those records could be reviewed by an independent peer reviewer.  The peer reviewer concluded that the “overall patient management did not meet the standard of care.”  Specifically, the peer reviewer found that the ophthalmologist failed to provide a comprehensive evaluation of the patient prior to cataract surgery.  The patient’s medical records did not reflect a complete eye examination with visual acuity, refraction for best correct vision, pupil evaluation, slit lamp evaluation for rubeosis iridis, or posterior segment evaluation.  In view of the patient’s pre-surgical vision of 20/100, the peer reviewer noted the ophthalmologist’s inadequate discussion of the surgery, the reasons for the surgery, possible complications, and alternative management.

For this allegation and others, the Board judged the ophthalmologist’s conduct to be below the minimum standard of competence given his significant complications post-cataract surgery in several cases, his consistent use of-of the incorrect intraocular lens type when a posterior capsule tear occurred, and his inadequate record documentation.

For this allegation and others, the Board ordered the ophthalmologist not to perform any procedures, make any appropriate and/or necessary referrals for his patients, and undergo an assessment and audit of his practice every 3 months until this requirement is terminated by the Board.

State: Washington D.C.


Date: February 2017


Specialty: Ophthalmology


Symptom: Vision Problems


Diagnosis: Post-operative/Operative Complication, Ocular Disease


Medical Error: Procedural error, Failure to examine or evaluate patient properly, Failure of communication with patient or patient relations, Lack of proper documentation


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 2


Link to Original Case File: Download PDF



North Carolina – Ophthalmology – Loss Of Vision Secondary To Glaucoma



In July 2015, the Board received a complaint.

In March 2005, a patient presented with blurry vision.  The patient was seen frequently by an ophthalmologist over the subsequent nine years.  The patient had cataract surgery on her right eye in March 2007.  In 2013, the patient developed elevated intraocular pressure and was treated for glaucoma, but had progressive loss of vision in both of her eyes, including severe loss of vision in her right eye.

As a result of the complaint, the Board opened an investigation.  The Board obtained the patient’s records and sent them to a qualified independent medical expert for review.  The independent medical expert judged the ophthalmologist’s conduct to be below the minimum standard of competence given failure to treat the patient’s high intraocular pressure level within a reasonable amount of time and that the ophthalmologist’s medical records were incomplete.

The Board ordered the ophthalmologist to be reprimanded.  The incident was reported to the Federation of State Medical Boards and to the National Practitioner Data Bank.

State: North Carolina


Date: April 2016


Specialty: Ophthalmology


Symptom: Vision Problems


Diagnosis: Ocular Disease


Medical Error: Improper treatment, Lack of proper documentation


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 1


Link to Original Case File: Download PDF



Kansas – Obstetrics – History Of Hypertension And Presentation With Vaginal Bleeding And Cramping



On 2/25/2013, a 26-year-old pregnant female with a history of four prior pregnancies, resulting in four prior premature births, presented to the emergency department with complaints of vaginal bleeding and cramping.  The patient was documented to have a history of hypertension and an ultrasound confirmed an intrauterine pregnancy.

The patient was scheduled to see an obstetrician for follow-up care the following morning but failed to keep the appointment.

On 5/30/2013, the obstetrician saw the patient for an appointment.  He designated the appointment as the patient’s first prenatal visit. At the time of the appointment, the patient’s blood pressure was documented as 198/154.

That same day, the obstetrician sent the patient for a sonogram and lab tests with a follow-up appointment to be scheduled in two weeks.  Lab results showed that the patient had a urinalysis protein of 100, but there was no documentation showing the obstetrician reviewed the results or that the patient was contacted with the results.

On 6/4/2013, the patient returned to the obstetrician’s office.  The patient’s blood pressure was documented as 202/136.

The patient was subsequently admitted to a clinic that same day at approximately 5:00 p.m. with hypertension and severe headache.  The obstetrician’s admission diagnosis was documented as severe chronic hypertension, single intrauterine pregnancy at twenty-nine weeks.

The nursing notes for the patient’s admission to the clinic document that the patient arrived from the obstetrician’s office for a non-stress test and labs.  The nursing staff further documented that the patient was experiencing a severe headache with the right side of her head feeling numb.  Her blood pressure was documented at 208/129.

The obstetrician initially ordered pregnancy-induced hypertension lab testing but canceled the ordered labs.  The patient was given labetalol 400 mg by mouth twice daily with the first dose administered at approximately 5:37 p.m.  Two non-stress tests were also completed.

After the administration of Labetalol, the patient’s blood pressure slowly dropped with systolic measurements in the 160’s and diastolic measurements in the 90-100’s.

At 7:20 p.m., the clinic staff informed the obstetrician of the patient’s high blood pressure and requested medication and parameters.  The obstetrician instructed the staff that the patient was to be left alone and do nothing different.

At 8:00 p.m., orders were obtained by the staff to administer Tylenol for the patient’s continued headache.  However, the Tylenol was not effective as the patient continued to complain of a severe headache.

No new orders were issued for the remainder of 6/4/2013, but staff continued to document the patient’s blood pressure and fetal heart tones. The patient’s systolic measurements remained between 170-220’s and diastolic measurements remained in the 100’s.

At 4:47 a.m. on 6/5/2013,  the patient’s fetal heart tones were documented to have decreased to 125 for approximately 140 seconds, and then returned to baseline.  At 5:38 a.m., the patient was given labetalol 400 mg by mouth.

At 8:55 .m., the patient was documented as resting and denied having a headache or pain.

At 10:13 a.m., the obstetrician saw the patient and ordered a twenty-four hour urine protein.

At 3:25 p.m., the patient again complained of a constant, dull headache.  The patient was given Tylenol 1000 mg orally and later complained that she was feeling “shaky all over.”

At or around 4:03 p.m., the staff notified the obstetrician of the patient’s status, including the fact that the patient had an elevated blood pressure in spite of labetalol.  They asked whether the patient should be on bed rest.  The notified the obstetrician of the patient’s complaint of headache, shakiness, and limited voiding.  They asked if these issues could be related to preeclampsia.  The obstetrician gave no new order or diagnosis and stated that he would be on the OB floor in approximately an hour.

At 4:59 p.m., the patient was documented with a continued complaint of a headache when she moved her eyes.

At 5:20 p.m., the obstetrician was in to see the patient and again wrote orders reiterating the patient’s diagnosis of severe chronic hypertension, and ordered an EKG, echocardiogram, ophthalmology consult, continued twenty-four hour urine protein, and labetalol 20 mg IV bolus with a repeat dose of 40 mg IV if the patient’s blood pressure were to be greater than 160/110 after ten minutes, and to continue Labetalol 400 mg by mouth twice daily.

At 5:40 p.m., the obstetrician dictated the patient’s history and physical for her admission.  The obstetrician documented the patient had severe hypertension; had 100 mg/dl of proteinuria; had no headaches, and had “[n]o sign of preeclampsia at this time.”

The patient received an additional 80 mg of labetalol IV at 8:57 p.m. and her blood pressure remained in the severe level above 160/110, only dropping briefly to 185/115 before returning to the 200’s systolic and 120’s to 130’s diastolic.

On or about 6/6/2013, the patient’s blood pressure remained elevated despite receiving labetalol 40 mg IV at 12:57 a.m., 20 mg IV at 2:00 a.m., and 40 mg IV at 4:12 a.m.

The obstetrician was updated on the patient’s blood pressure status, but was not in to see the patient until 10:35 a.m.  At that time, the obstetrician ordered labetalol 400 mg by mouth every eight hours.

The patient’s previously ordered twenty-four urine protein results was 1953 mg/dl.  The obstetrician was notified by staff of the patient’s results and was documented as saying the patient’s protein was good.

The patient’s blood pressure continued to run in the 210-220’s systolic and 120’s-130’s diastolic

At 6:37 p.m., the obstetrician dictated a progress note for the patient documenting the patient as having severe chronic hypertension.  The obstetrician also noted the patient was on labetalol 400 mg three times daily and that the patient’s blood pressure remained high.  The obstetrician planned to continue the patient’s labetalol.

The patient’s blood pressure remained elevated and at 9:58 p.m. the obstetrician was notified of the situation and the patient’s complaint of a headache.  No new orders were given.

At 10:22 p.m., the obstetrician called to check on the patient’s condition.  The patient continued to complain of a headache and had a documented blood pressure of 221/129.

At 10:25 p.m., the obstetrician ordered “hydralazine 10 mg SIVP over 2 min x 1 Now” for the patient’s symptoms.

At 1:08 a.m. on 6/7/2013, the staff again contacted the obstetrician with the patient’s high blood pressure and headache.  The obstetrician gave orders for repeat a hydralazine 10 mg SIVP and for the patient to be started on magnesium sulfate.  Twenty minutes later the obstetrician ordered the magnesium sulfate to be held.

The patient continued to have a headache and at 1:42 a.m. was documented to complain of blurry vision.  The staff notified the obstetrician of the patient’s symptoms and continued headache.

At 5:34 p.m., the fetal heart rate dropped to sixty for two and a half minutes with recovery to the 120’s.

The patient continued to complain of a headache and at 5:49 p.m. the staff documented the patient as stating, “I feel like there is something wrong with me…I just don’t feel myself…headache is not going away and I feel weird.”

At 6:10 p.m., the obstetrician was in to see the patient who was complaining of upper abdominal pain, increasing headache pain and decreased urine output.  The obstetrician ordered the staff to give the patient hydralazine 10 mg SIVP, and magnesium sulfate 4 gm bolus followed by magnesium sulfate 2 gm/hr and betamethasaone intramuscularly.

The obstetrician also decided to transfer the patient to a different medical center for further care.

At 7:58 p.m., the patient was discharged to EMS care for transfer to a medical center.

In the obstetrician’s discharge summary for the patient, he documented that the patient was admitted with a diagnosis of “severe chronic hypertension with superimposed preeclampsia.”  In addition, he noted that he had given the patient three doses of labetalol, but failed to mention the three previous doses given during the early morning hours on 6/6/2013.

The board judged that the obstetrician failed to adhere to applicable stand of care to a degree constituting ordinary and/or gross negligence due to the following omission: the obstetrician delayed involving other specialists to assist the patient’s care and treatment, failed to acknowledge the patient’s proteinuria and high blood pressure, failed to diagnose and treat the patient’s severe preeclampsia, placed the patient at an increased risk for placental abruption, seizures, and renal damage, and stroke, and the obstetrician delayed to transfer the patient to a facility that could care for the patient and her premature infant.

The Board revoked the obstetrician’s license.

State: Kansas


Date: March 2016


Specialty: Obstetrics


Symptom: Bleeding, Headache, Numbness, Abdominal Pain, Vision Problems


Diagnosis: Preeclampsia


Medical Error: Underestimation of likelihood or severity, Delay in proper treatment, Failure to follow up, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Virginia – Obstetrics – 29 Weeks Pregnant With Persistent Hypertension And Proteinuria



On 2/25/2013, a 26-year-old pregnant female with a history of four prior pregnancies resulting in four prior premature births presented to the emergency department with complaints of vaginal bleeding and cramping.  The patient had a history of hypertension and a prior ultrasound confirming intrauterine pregnancy.

The patient was referred and scheduled to see an obstetrician for follow-up care the following morning but failed to keep the appointment.

On 5/30/2013, the obstetrician saw the patient for an appointment.  The obstetrician designated the appointment as the patient’s first prenatal visit.  At the time of the appointment, the patient’s blood pressure was documented at 198/154.

The same day, the obstetrician sent the patient for a sonogram and lab tests with a follow-up appointment to be scheduled in two weeks.  The urinalysis revealed a protein of 100 but there was no documentation showing that the obstetrician reviewed the results.

On 6/4/2013, the patient returned to the office with a blood pressure of 202/136.

On the same day, the patient was admitted with hypertension and a severe headache.  She was diagnosed with severe chronic hypertension and single intrauterine pregnancy at twenty-nine weeks.

Nursing notes for the patient’s admission documented that the patient arrived from the obstetrician’s office for a non-stress test and labs.  The nursing staff further documented that the patient was experiencing a severe headache with the right side of her head feeling numb and her blood pressure was documented at 208/129.

The obstetrician initially ordered pregnancy-induced hypertension lab testing but canceled the ordered labs.  The patient was given “400 mg po bid” of labetalol with the first dose administered at approximately 5:37 p.m.  Two non-stress tests were also completed.

After the administration of labetalol, the patient’s blood pressure slowly dropped with systolic blood pressure in the 160’s and diastolic blood pressure in the 90-100’s.

At 7:20 p.m., the hospital staff informed the obstetrician of the patient’s high blood pressure and requested medications and parameters.  The obstetrician staff had no further recommendations.

At 8:00 p.m., the orders were obtained by staff to administer acetaminophen for the patient’s continued headache.  However, the acetaminophen was not effective as the patient continued to complain of a severe headache.

For the rest of the night, the obstetrician wrote no further orders.  The staff continued to document the patient’s blood pressure and fetal heart tones.  The patient’s systolic blood pressures remained between 170-220’s and diastolic measurements remained in the 100’s.

On 6/5/2013 at 4:47 a.m., the patient’s fetal heart tones decreased to 125 for 140 seconds and then returned to baseline.  At 5:38 a.m., the patient was given 400 mg p.o. of labetalol.

At 8:55 a.m., it was documented that the patient was resting and she denied having a headache or pain.

At 10:13 a.m., the obstetrician saw the patient and ordered a twenty-four hour urine protein.

At 3:25 p.m., the patient again complained of a constant, dull headache.  The patient was given 1000 mg of acetaminophen orally and later complained that she was feeling “shaky all over.”

At 4:05 p.m., the staff notified the obstetrician of the patient’s status including the fact that the patient had an elevated blood pressure in spite of labetalol.  Staff also asked whether the patient should be on bed rest.  The patient complained of having a headache and shakiness.  Her urine output was decreased.  Staff was concerned whether these issues could be due to preeclampsia.  The obstetrician gave no new orders or diagnoses and stated that he would be on the floor in an hour.

At 4:59 p.m., the patient was documented with the complaint of a headache when she moved her eyes.

At 5:20 p.m., the obstetrician was in to see the patient and reiterated the patient’s diagnosis of severe chronic hypertension.  He wrote for an EKG, an echocardiogram, an ophthalmology consult, a 20 mg labetalol IV bolus, and a repeat dose of 40 mg labetalol IV if the patient’s blood pressure was greater than 160/110 after ten minutes.  He wrote for a continuation of 400 mg labetalol orally twice a day.

At 5:40 p.m., the obstetrician dictated the patient’s history and physical for her admission.  The obstetrician documented that the patient had severe hypertension, had 100 mg/dl of protein in her urine, had no headaches, and had “[n]o sign of preeclampsia at this time.”

The patient received an additional 80 mg of labetalol IV at 8:57 p.m. and her blood pressure remained in the severe level above 160/110, only dropping briefly to 185/115 before returning to the 200’s systolic and 120’s to 130’s diastolic.

On 6/6/2013, the patient’s blood pressure remained elevated despite receiving labetalol 40 mg IV at 12:57 a.m., 20 mg IV at 2 a.m., and 40 mg IV at 4:12 a.m.

The obstetrician was updated on the patient’s blood pressure status but was not in to see the patient until 10:35 a.m.  At that time, the obstetrician ordered labetalol 400 mg by mouth every eight hours.

The patient’s previously ordered twenty-four urine protein result was 1953 mg/dl.  The obstetrician was notified by staff of the patient’s result and is documented as saying the patient’s urine protein was “good.”

The patient’s systolic blood pressure continued to run in the 210’s-220’s and diastolic blood pressure in the 120’s-130’s.

At 6:37 p.m., the obstetrician dictated a progress note for the patient documenting that the patient as having severe chronic hypertension.  The obstetrician also noted that the patient was on labetalol 400 mg three times a day and that the patient’s blood pressure remained high.  The obstetrician planned to continue the patient’s labetalol.

The patient’s blood pressure remained elevated and at 9:58 p.m., the obstetrician was notified of the blood pressure and the patient’s complaint of a headache.  No new orders were given.

At 10:22 p.m., the obstetrician called to check on the patient’s condition.  The patient continued to complain of a headache and had a documented blood pressure of 221/129.

At 10:25 p.m., the obstetrician ordered “Hydralazine 10 mg SIVP over 2min x 1 Now” for the patient’s symptoms.

On 6/7/2013 at 1:08 a.m., the staff again contacted the obstetrician with the patient’s hypertension and headache.  The obstetrician gave orders for repeat hydralazine 10 mg SIVP (“slow IV push”) and for the patient to be started on magnesium sulfate.  Twenty minutes later the obstetrician ordered the magnesium sulfate to be held.

The patient continued to have a headache and at 1:42 a.m. was documented to complain of blurry vision.  Staff notified the obstetrician of the patient’s symptoms and continued headache.

At 5:34 p.m., the fetal heart rate dropped to sixty for two and a half minutes with recovery to the 120’s.

The patient continued to complain of a headache.  At 5:49 p.m., the staff documented the patient as stating, “I feel like there is something wrong with me…I just don’t feel myself…headache is not going away and I feel weird.”

At 6:10 p.m., the obstetrician was in to see the patient, who was complaining of upper abdominal pain, worsening headache, and decreased urine output.  The obstetrician ordered staff to give the patient hydralazine 10 mg SIVP and magnesium sulfate 4 gm bolus followed by magnesium sulfate 2 gm/hr and betamethasone intramuscularly.

The obstetrician also decided to transfer the patient to a different medical center for further care.

At 7:58 p.m., the patient was taken by ambulance to a different medical center.

In the obstetrician’s discharge summary, he documented the patient was admitted with a diagnosis of “severe chronic hypertension with superimposed preeclampsia.”  In addition, he noted that he had given the patient three doses of labetalol but failed to mention the three prior doses given during the early morning hours on 6/6/2013.

On 6/4/2014, the obstetrician’s clinical privileges at the hospital were revoked.

The Board raised concern that the obstetrician failed to achieve the standard of care in the following ways:

  1. The obstetrician delayed in consulting other specialists.
  2. The obstetrician failed to promptly address the patient’s proteinuria and hypertension.
  3. The obstetrician failed to diagnose and treat the patient’s severe preeclampsia.
  4. The obstetrician placed patient at an increased risk for placental abruption, seizures, renal failure, and stroke.
  5. The obstetrician delayed in transferring the patient to a facility capable of caring for her.

The obstetrician’s license was revoked by the State of Kansas and suspended by the Board of Virginia.

State: Virginia


Date: July 2015


Specialty: Obstetrics


Symptom: Headache, Bleeding, Gynecological Symptoms, Numbness, Abdominal Pain, Vision Problems


Diagnosis: Preeclampsia


Medical Error: Underestimation of likelihood or severity, Delay in proper treatment, Failure to follow up, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Anesthesiology – Loss Of Vision And Eye Pain During Left Supraorbital Nerve Block



On 12/29/2008, a patient went to the hospital for a procedure to treat her migraines.  Specifically, she was to undergo a left greater occipital nerve block and a left supraorbital nerve block.  An anesthesiologist was the treating physician. A supraorbital nerve block is a rare procedure with few indications.  It involves blocking a small nerve that innervates a portion of the patient’s brow. Specifically, supraorbital nerve blocks are performed where the supraorbital nerve exits the supraorbital foramen, which lies approximately 2-3 cm lateral to the midline of the face at the inferior ridge of the supraorbital ridge.  The injection is usually performed with a 25-gauge needle and usually contains lidocaine or bupivacaine. The use of steroids in this type of injection is controversial.

The patient had a previous supraorbital nerve block performed by the anesthesiologist’s associate on 12/11/2008.  There was no indication that this block provided any significant improvement of her migraine headaches that would indicate that the second block was necessary for treatment.

Nonetheless, on 12/29/2008, the patient underwent an occipital nerve block at 2:10 p.m.  She underwent the supraorbital nerve block shortly thereafter. The anesthesiologist used a 27-gauge needle for the injection, which was extremely thin and flexible, and it also provides no feedback from the needle tip as to its position.  As previously noted, a 25-gauge needle was indicated for this type of procedure.

During the supraorbital nerve block, the patient immediately reported an unusual sharp pain and said that she couldn’t see when she opened her eye.  The patient reported that the immediate sharp pain in her eye was different from the previous injections that had been done. Immediately after the injection, the patient had lost nearly all sight in her left eye.

The anesthesiologist had admitted that the patient reported an immediate loss of vision after the injection.  Following the injection, there was an obvious presence of the anesthetic solution within the patient’s eye. The anesthesiologist’s records noted there was evidence of anesthetic solution within the conjunctiva while still in the procedure room.  In addition to the solution being visible in the patient’s eye, it was clear that there was swelling of the conjunctiva or pressure within her eye. The anesthesiologist stated during his deposition that he was concerned about the possibility that the intraocular injection was causing pressure within the patient’s eye.  After the procedure, the patient also had elevated blood pressure.

At this point in time, it was or should have been apparent to the anesthesiologist that the needle penetrated the patient’s globe and injected particulate corticosteroid, yet the anesthesiologist didn’t take the appropriate steps to treat this post-injection complication sustained by the patient.  He didn’t give the patient a proper eye examination and he didn’t refer her elsewhere for appropriate medical treatment to mitigate the damage caused by the injection. The anesthesiologist admitted that he didn’t have the proper equipment available or the expertise necessary to do a complete examination of the patient’s eye to determine what damage occurred or was occurring by the injection that he had done.  Following the procedure, the patient wasn’t taken to the emergency department, which was about 100 yards away from where the anesthesiologist performed the procedure. Instead, the patient was taken to the office’s recovery area with her first post-procedure vital signs noted at 2:40 p.m. The patient was discharged at 3:15 p.m., and she was told to call her primary care doctor if her vision remained impaired.

The patient called her primary care physician the next day and was seen by the physician’s associate.  The patient was noted to have a loss of vision in the left eye and was sent to a local ophthalmologist, who noted evidence of loss of vision with cloudiness of the vitreous.  The ophthalmologist was not able to see the fundus and immediately referred the patient to a retinal specialist. The patient saw the retinal specialist the next day on 12/31/2008.  He performed an urgent vitrectomy and attempted to remove the particles of the injected corticosteroid. The patient had a second operation on 3/18/2009 performed by the ophthalmologist.  Her vision had not returned to normal and she still had significant vision loss. The ophthalmologist found that it was evident that the patient’s left eye had been injected with a steroid, which resulted in a decrease in her vision.  The ophthalmologist found that the injected corticosteroid caused opacity of the vitreous as well as retinal damage.

The anesthesiologist’s operative report stated that the patient had a left-sided greater occipital nerve block with 2 ml of 0.25% bupivacaine and 40 mg Depo-Medrol and a left-sided supraorbital nerve block with 0.5 ml of normal saline with 20 mg of Kenalog.  However, in his deposition and interview with the Medical Board of California, the anesthesiologist stated that he injected the patient with local anesthetic and Kenalog. Also, the nurse’s notes indicated that only Depo-Medrol was provided at 60 mg with no indication that Kenalog was used during the procedure.  Moreover, the anesthesiologist wrote in his operative report, “The patient did have some of this injection track down to the conjunctiva, but it did not affect her extraocular eye muscles or orbital nerves. At this point, it has not affected her vision.” This statement was directly contradicted by both the patient’s and the anesthesiologist’s testimony during deposition, wherein both stated that the patient immediately reported that she could not see after the injection.

The Medical Board of California placed the anesthesiologist on probation for 3 years and ordered the anesthesiologist to complete a medical record-keeping course, education course (at least 40 hours for 3 years) and professionalism program (ethics course) offered at the University of California San Diego School of Medicine.

State: California


Date: April 2015


Specialty: Anesthesiology, Ophthalmology


Symptom: Vision Problems, Headache, Head/Neck Pain


Diagnosis: Post-operative/Operative Complication, Neurological Disease, Ocular Disease


Medical Error: Unnecessary or excessive treatment or surgery, Referral failure to hospital or specialist, Lack of proper documentation, Procedural error


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 5


Link to Original Case File: Download PDF



Virginia – Emergency Medicine – Presentation Of Suicidal Thoughts With Missed Incidental Findings



On 1/10/2012, a teenage male presented to the emergency department after being referred for a psychiatric referral by his high school for making a “suicide pact” with his girlfriend.  The patient’s mother accompanied him to the emergency department.  His admitting diagnoses were suicidal thoughts and depression.

An ED nurse conducted a “suicide screening.”  The nurse elicited and documented a history from the patient regarding the suicide pact that he made in September 2011 with his girlfriend who lived in Kansas.  The patient told his friends about the suicide pact, and his friends reported the information to school officials.

The nurse evaluated and documented the patient’s vital signs, including his blood pressure, which was elevated at 182/114 mmHg.

There was no documentation in the patient’s medical record that his blood pressure was repeated.

The nurse started an intravenous line and obtained a urinalysis, drug abuse screen, comprehensive metabolic panel, complete blood count, thyroid stimulating hormone level, and an alcohol level.  The patient’s BUN level was elevated at 33.  His urine creatinine level was elevated at 3.5.  His urine had red blood cells and protein present.  A second nurse documented on a computer-generated form that she had conducted a physical assessment of the patient.

A social worker conducted a 27-minute mental health evaluation and determined that the patient could be discharged from the emergency department.  She notified the ED physician.

The ED physician circled “major depression” on a pre-printed physical examination form and checked off the box stating “cleared medically for psychiatric referral” and discharged the patient home.  The ED physician failed to document any history, physical examination, medical decision-making or any plan for the patient or that he had ordered and/or reviewed any laboratory tests or procedures.

The patient had a history of juvenile rheumatoid arthritis.  He had been treated with methotrexate from 2000 to 2006.  The ED physician failed to document this history.

On 1/4/2013, the patient was evaluated at a clinic for decreasing vision and headaches.  His blood pressure was 200/130.  The staff repeated the reading three times.  He was diagnosed with hypertensive urgency/emergency.  Later that day, he went to an emergency department where he was then transported by helicopter to another hospital, admitted to the intensive care unit, and diagnosed with end-stage renal disease and severe hypertension.

On 2/7/2013, the Board received a complaint from the mother of a patient.  She alleged that the ED physician failed to address her son’s high blood pressure reading and abnormal laboratory results.

In May 2013, the patient received a kidney transplant.

The Board judged the ED physician’s conduct to be below the standard of care given failure to address the abnormal labs and hypertension of the patient.

The Board reprimanded the ED Physician, ordered him to pay a fine, ordered him to complete a course in medical recordkeeping, ordered him to complete a course in pediatric/adolescent emergency medicine, and stipulated that agents may conduct a chart review or peer review of ED physician A’s practice.

State: Virginia


Date: June 2014


Specialty: Emergency Medicine


Symptom: Psychiatric Symptoms, Headache, Vision Problems


Diagnosis: Renal Disease, Hypertensive Emergency, Psychiatric Disorder


Medical Error: Failure to follow up


Significant Outcome: Hospital Bounce Back


Case Rating: 2


Link to Original Case File: Download PDF



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