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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 11/6/2016, a 61-year-old female presented to the emergency department, suffering from confusion and weakness after a fall.  A CT scan revealed that the patient had a large, left-sided subdural hematoma.

That same day, a neurosurgeon was asked to evaluate the patient.  The neurosurgeon correctly documented that the patient was suffering from a left-sided subdural hematoma.  The neurosurgeon further documented his intention to remove a blood clot from the left side of the patient’s subdural space.

Shortly thereafter, the patient was brought to the operating room and preparations were begun for a left-sided craniotomy.  However, at some point during the preparation process, the patient’s head was turned and the neurosurgeon began to operate on the right side.

After the neurosurgeon made an incision through the skin, he removed a bone flap and punctured the dura mater on the right side of the patient’s brain.  The neurosurgeon realized that he was operating on the incorrect side.  The neurosurgeon closed the operating site and proceeded to perform the correct procedure.

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

Specialty: Neurosurgery

Symptom: Confusion, Weakness/Fatigue

Diagnosis: Intracranial Hemorrhage, Trauma Injury

Medical Error: Wrong site procedure

Significant Outcome: N/A

Case Rating: 3

Link to Original Case File: Download PDF

On 2/24/2014, a 36-year-old female presented to an obstetrician for fatigue, breast tenderness, and absence of menstruation.  At the aforementioned visit, the obstetrician diagnosed the patient with amenorrhea and sent her to have blood work.

On 2/25/2014, the patient was notified of her positive pregnancy test.

On 3/20/2014, 3/17/2014, 3/24/2014, 4/24/2014, 8/7/2014, and 9/25/2015, the obstetrician ordered obstetrical ultrasounds and/or sonograms on the patient.

On 4/23/2014 and 8/20/2014, the patient presented to the obstetrician with thick vaginal fluid and bloody discharge and/or morning sickness, nausea, chills, fever, and back pain.

On 5/23/2014, 6/20/2014, 7/16/2014, 8/15/2014, 9/12/2014, 10/13/2014, 10/20/2014, and 10/27/2014, the patient presented to the obstetrician for follow-up visits.

On 11/2/2014, the patient gave birth to her son.  The child was born with a neural tube defect called spina bifida/myelomeningocele.

The obstetrician failed to observe on imaging studies, and follow-up on, known indicators that the patient’s child may have had a neural tube defect, or alternatively, did not create, keep, or maintain adequate legible documentation of observing on imaging studies, and following up on known indicators that the patient’s child may have had a neural tube defect.

The obstetrician failed to order maternal serum alpha-fetoprotein (MSAFP) test, or alternatively, did not create, keep, or maintain adequate legible documentation of ordering a MSAFP test.

The obstetrician failed to order an anatomical survey sonogram, or alternatively, did not create, keep, or maintain adequate legible documentation of ordering an anatomical survey sonogram.

It was requested that the Board order one or more of the following penalties for the obstetrician: 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: Obstetrics

Symptom: Weakness/Fatigue, Bleeding, Abnormal Vaginal Discharge, Back Pain

Diagnosis: Neurological Disease

Medical Error: Failure to order appropriate diagnostic test, Failure to follow up, Lack of proper documentation

Significant Outcome: Permanent Loss Of Functional Status Or Organ

Case Rating: 1

Link to Original Case File: Download PDF

On 4/6/2016, a 69-year-old female with a prior history significant for pulmonary tuberculosis, essential hypertension, paroxysmal supraventricular tachycardia, osteoporosis, menopause, hypothyroidism, arthritis, chronic asthmatic bronchitis, and a former smoker, presented to a medical clinic.

An anesthesiologist initially diagnosed the patient with cervicalgia and cervical radiculopathy due to degenerative chronic cervical spondylosis.  The patient was also hearing and speech impaired and used an interpreter and tablet for communication during all preoperative meetings.

The patient presented to the anesthesiologist in the surgery room for a signed consent of cervical transforaminal epidural steroid injection at right C4 and C5.  The anesthesiologist instead performed a cervical epidural steroid injection (“CESI”) above C6-C7 without obtaining consent from the patient.

The anesthesiologist failed to have an interpreter in the surgery room during the patient’s evaluation and treatment so that he could effectively communicate with her.

The patient was positioned in the prone position on the table and the anesthesiologist administered Versed 2 mg IV and Fentanyl 100 mcg for IV conscious sedation.

The anesthesiologist failed to administer local anesthesia to numb the patient’s skin, while she was awake and alert, prior to injecting the first epidural steroid injection at C5-C6.  The patient, unaware that she was receiving an injection and unable to clearly communicate her discomfort, responded to the initial puncture to her skin by a sudden jumping movement.

The anesthesiologist withdrew the needle and targeted lower interspace, C7-T1, using fluoroscopy.  He used a seventeen gauge Tuohy needle under intermittent fluoroscopic guidance for entry into the epidural space at C7-T1 for the second attempt to perform the CESI.  The anesthesiologist then injected the medication between C4 and C5 neural foramen.

The anesthesiologist documented one or more times prior to the 4/6/2016 procedure that he was performing a TFESI on the right at C4 and C5;  however, he instead performed a cervical interlaminar epidural steroid injection (“ILESI”) at C5-C6, and additionally at C7-T1, without obtaining consent from the patient.  He inappropriately elected to perform a CESI above C6-C7.  The anesthesiologist did not create or maintain fluoroscopic images of his initial attempt to inject at C5-C6.

After the procedure, the patient was taken to the recovery room, where an interpreter and tablet was present for communication.  The patient was no longer able to move her arm to communicate using the tablet and she experienced right upper extremity weakness and some right sided facial numbness.

The patient was transferred out of the medical center as a “Stroke alert” to a hospital, where she received a CAT or MRI scan, and again transferred to another hospital which did not have a neurosurgeon on staff.

After the CESI, the patient was diagnosed with iatrogenic cervical nerve root injury.

It was requested that the Board order one or more of the following penalties for the anesthesiologist: 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: Anesthesiology

Symptom: Weakness/Fatigue, Numbness

Diagnosis: Spinal Injury Or Disorder, Post-operative/Operative Complication

Medical Error: Wrong site procedure, Ethics violation, Failure of communication with patient or patient relations, Procedural error

Significant Outcome: Permanent Loss Of Functional Status Or Organ

Case Rating: 3

Link to Original Case File: Download PDF

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

Sometime prior to 2011, a gynecologist began treating a patient with a history of a prior myomectomy in 2011, pre-diabetes, and fibromyalgia.

On 3/8/2011, the patient presented to the gynecologist with complaints of irregular vaginal bleeding with some pain in her right lower quadrant that worsened when she was on her period.  The patient informed the gynecologist that she was “ready for a hysterectomy.”  Medical records for this visit do not document the extent of the bleeding, whether or not the bleeding contributed to any other symptoms, the patient’s level of pain, or whether or not the pain interfered with the patient’s lifestyle.  At the conclusion of this visit, the gynecologist referred the patient for a pelvic ultrasound with plans to follow up after the ultrasound.

On 4/5/2011, the patient had a pelvic ultrasound which showed the uterus was oriented anteverted and located midline.  A fibroid was visualized in the right lateral aspect of the uterus that measured 5.3 by 4.2 by 5.3 centimeters.  The endometrial stripe measured 12 millimeters.  No other fibroids were seen.  The left and right ovary were normal.  There was no fluid in the cul-de-sac.  The fibroid had increased in size compared to a prior ultrasound in 2010.

On 4/11/2011, the patient presented to the gynecologist for a follow-up.  The gynecologist went over the results from the ultrasound and discussed possible treatment options.  The gynecologist did not recommend or perform an endometrial biopsy to determine the reason for endometrial thickening or repeat the ultrasound to watch this condition.  The gynecologist did not consider or document that the irregular bleeding could be caused by endometrial thickening, endometrial hyperplasia, or endometrial polyp.  She did not recommend a dilation and curettage.  At the conclusion of this visit, a decision was made for the patient to undergo a hysterectomy, which was scheduled to occur on 6/27/2011.  The patient indicated that she wanted a bilateral salpingo-oophorectomy, but the gynecologist advised her to leave in the ovaries.

On 6/24/2011, the patient presented to the gynecologist for a preoperative evaluation.  The gynecologist offered the patient medical and surgical options and the patient chose a hysterectomy.  The gynecologist explained various surgical options, including risk factors and complications.  During the physical examination of the patient, the gynecologist noted the patient’s uterus was bulky and that it did not descend well.  The gynecologist did not document any observable vaginal bleeding or any pelvic pain with palpation of the pelvic organs.  At the conclusion of this visit, the gynecologist had formed a surgical plan to include a total vaginal hysterectomy and depending on whether the uterus was mobile in the operation room, possible laparoscopic assisted vaginal hysterectomy, possible exploratory laparotomy, and possible cystoscopy.

On 6/27/2011, the gynecologist performed a laparoscopic assisted vaginal hysterectomy, bilateral salpingo-oophorectomy, cystoscopy, and lysis of adhesions on the patient.  The medical records do not document a specific clinical reason for this choice in surgical technique versus a laparotomy approach.

During the surgery, the gynecologist encountered a web of filmy adhesions that were abundant along the back of both ovaries and continued along the back of the uterus.  The adhesions connected the bowel to the uterus and ovaries.

There were also adhesions from the ovaries to the side walls.  The gynecologist considered converting to an open procedure but opted to continue with laparoscopic dissection.  After dissection of all of the adhesions, the gynecologist obtained a general surgery consultation as a precaution to review the small bowel, which had been adherent, especially near the right ovary.  After observation through the monitor only, neither the surgeon nor the gynecologist noted any bowel injuries.

The gynecologist then proceeded with the vaginal hysterectomy portion of the surgery, which progressed “a bit more difficult than average but not remarkably so.”

Upon completion of the vaginal portion of the surgery, the gynecologist returned to the abdominal cavity.  Upon doing so, she noted a slight oozing from the round ligament on the left, which she cauterized.  The gynecologist then irrigated the pelvis and looked for any bleeding or injury but found none.

Prior to closing, the gynecologist requested a urology consultation.  After cystoscopy and examination revealed no injury to the bladder or ureter, the gynecologist completed the procedure.  The gynecologist’s detailed operative report does not specifically document the difficulties or complexities she encountered during the over eight-hour operation.

During the first three post-operative days, the patient experienced complications from the surgery that began to worsen.  The patient’s symptoms included abdominal pain, distention, lack of appetite, bowel dysfunction, fever, tachycardia, weakness, emesis, and anemia.

After attempting to treat the patient with antibiotics and observation, on 7/5/2011, the patient was taken in for an exploratory laparotomy.

During the surgery, several liters of feces were found in the patient’s abdomen, which were suctioned out.  Then, the abdomen was irrigated.  Further into the surgery, a 1-centimeter tear in the distal sigmoid and another 3-centimeter tear in the proximal rectum were identified, repaired, and treated with a colostomy.

From 7/5/2011 to 8/1/2011, the patient remained hospitalized and experienced complications including but not limited to nausea, vomiting, fatigue, fever, tachycardia, wound infection, anemia, and significant leukocytosis.  During this time period, the patient had to undergo radiological drainage of intraabdominal collections and was on several courses of antibiotics.  The patient was discharged from the hospital on 8/1/2011, approximately thirty-five days after her total hysterectomy.

Per the Board, the gynecologist committed gross negligence in her care and treatment of the patient by continuing with a long and complicated abdominal and pelvic surgery through laparoscopy without converting to laparotomy to prevent multiple intraoperative injuries.

In addition, the Board judged the gynecologist’s conduct to be below the minimum level of competence given the performance of a total abdominal hysterectomy and bilateral salpingo-oophorectomy without definitive clinical indication and without consideration of alternative treatments, prior to consideration of a major surgery, and given failure to maintain adequate and accurate records relating to her care and treatment of the patient.

The Board issued a public reprimand with stipulations to complete a medical record keeping course.

State: California

Date: July 2017

Specialty: Gynecology, General Surgery

Symptom: Abdominal Pain, Fever, Gynecological Symptoms, Nausea Or Vomiting, Weakness/Fatigue

Diagnosis: Post-operative/Operative Complication, Gynecological Disease

Medical Error: Procedural error, Unnecessary or excessive treatment or surgery, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 3

Link to Original Case File: Download PDF

On 1/15/2010, a 61-year-old female underwent an epidural injection.  Following the procedure, she complained of sharp pain in the lower extremities, followed by sensory and motor function loss below the T10 and T11 level.  The patient was transferred by ambulance to the emergency department.

A thoracic and lumbar MRI was performed and interpreted by a radiologist.  The final report for the lumbar spine states “Mild desiccation and degenerative changes of the disc but no disc bulge or herniation is noted.”  His final report of the thoracic spine demonstrates “normal MRI of the thoracic spine…A repeat study of the thoracolumbar spine is recommended without contrast infusion in both projections to better evaluate this area as this is on the edge of the study on the current images both lumbar and thoracic is not well delineated.”  Although the images were suboptimal, the epidural hematoma of the lower thoracic spine was evident in the axial images.

On 1/19/2010, a repeat MRI was performed.  The radiologist interpreted the MRI stating there is “abnormal signal focus demonstrated in the spinal canal from approximately the T10-T11 disc space inferiorly through the T12-L1 disc space located mostly in the posterior and posterolateral aspect of the spinal canal displacing the cords slightly anteriorly and causing a slight mass effect on the cord and subarachnoid sac.  This is consistent with a subdural or epidural hematoma.”

The Board judged the radiologist’s conduct as having fallen below the standard of care given failure to observe and document all pertinent findings on diagnostic imaging studies, failure to discuss findings requiring urgent treatment with the referring physician, failure to diagnose the abnormality found on MRI, and failure to document his discussion with the referring physician regarding the abnormality on MRI.

A public reprimand was issued against the radiologist.

State: California

Date: June 2017

Specialty: Radiology, Emergency Medicine

Symptom: Extremity Pain, Numbness, Weakness/Fatigue

Diagnosis: Spinal Injury Or Disorder

Medical Error: False negative, Failure of communication with other providers, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 3

Link to Original Case File: Download PDF

On 5/8/2014, a 74-year-old female presented to an internist for the purpose of establishing care.  The patient had multiple medical problems, including diabetes, end-stage renal disease, and recurrent C. difficile infections.

At all times pertinent to this complaint, the patient was undergoing chronic hemodialysis treatment.

On 6/10/2014, the patient presented to the internist for a follow-up visit.  The internist prescribed 600 mg tablets of gabapentin to the patient to treat her diabetic neuropathy.  The patient’s prescription directed her to take the 600 mg of gabapentin twice daily, totalling 1200 mg of gabapentin per day.

On 6/14/2014, after taking her prescribed dosage of gabapentin, the patient lost control of her leg muscles and fell, resulting in a fracture of the T12 vertebrae in her back.

The prevailing professional standard of care required the internist to prescribe the patient a dosage of gabapentin not to exceed 150 mg per day, due to her end-stage renal disease.  The internist prescribed the patient an inappropriate and/or excessive dosage of gabapentin.

According to the internist, he verbally instructed the patient and/or her family members to modify the gabapentin prescription.

The internist failed to document and/or accurately document the alleged verbal instruction to the patient and/or her family members to modify the patient’s gabapentin prescription.

The Board issued a letter of concern against the internist’s license.  The Board ordered that the internist pay a fine of $5,000 against his license and pay reimbursement costs for the case at a minimum of $30,433.57 and not to exceed $32,433.57.  The Board also ordered that the internist complete a medical records course and complete five hours of continuing medical education in clinical pharmacology and drug dosing.

State: Florida

Date: June 2017

Specialty: Internal Medicine, Nephrology

Symptom: Weakness/Fatigue

Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Diabetes, Neurological Disease, Spinal Injury Or Disorder, Renal Disease, Fracture(s)

Medical Error: Improper medication management, Accidental Medication Error, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 3

Link to Original Case File: Download PDF

On 10/11/2015, Patient A, an 89-year-old male presented to the emergency department with complaints of chest congestion, weakness, and chest pressure.

Lab results revealed that Patient A had elevated troponin levels, and he was admitted and referred for a cardiology consultation.

On 10/11/2015, the patient saw a cardiologist for the cardiology consultation.  The cardiologist documented that the patient had an upper respiratory infection and recommended that the patient continue antibiotics, gentle diuresis, and outpatient medical therapy.

At around the same time, on the same date, the cardiologist saw Patient B for a cardiology consultation.  Sometime after the cardiac consultations of Patient A and Patient B, the cardiologist contacted a physician assistant and instructed him to order a cardiac catheterization for Patient B.

The physician assistant placed an entry in Patient A’s medical chart instead of Patient B’s chart, ordering the cardiac catheterization.  The physician assistant failed to review Patient A’s available medical records, including labs, notes, and imaging studies, before placing the cardiac catheterization order in his chart.

The following morning, cardiac catheterization was unnecessarily performed on Patient A.

The Board judged the physician assistant’s conduct to be below the minimal standard of competence given that he failed to review the patient’s available medical records, including labs, notes, and images studies, before placing the cardiac catheterization order in his chart.

The Board issued a letter of concern against the physician assistant’s license.  The Board ordered that the physician assistant pay a fine of $2,000 against his license and pay reimbursement costs for the case at a minimum of $2,611.86 and not to exceed $3,111.86.  The Board also ordered that the physician assistant complete five hours of continuing medical education in “risk management.”

State: Florida

Date: June 2017

Specialty: Physician Assistant, Cardiology

Symptom: Weakness/Fatigue

Diagnosis: Infectious Disease

Medical Error: Accidental error, Unnecessary or excessive treatment or surgery

Significant Outcome: N/A

Case Rating: 3

Link to Original Case File: Download PDF

Between February 2006 and September 2012, a patient presented to a pain specialist with complaints of chronic low back pain.

On one or more occasions between February 2006 and September 2012, the pain specialist assessed the patient with, among other things, low back pain, lumbago, osteoarthritis, lumbar failed back surgery syndrome, lumbar radiculopathy, and lumbar muscle spasms.

On 9/28/2012, the patient presented to the pain specialist in order for him to perform a lumbar transforaminal epidural steroid injection with catheter and fluoroscopy.  Epidural administration is a medical route of administration in which a drug or contrast agent is injected into the epidural space of the spinal cord.

During the procedure, the pain specialist inserted the tip of the catheter through the patient’s epidural space and into the patient’s intrathecal space.  Intrathecal administration is a medical route of administration in which a drug or contrast agent is injected into the spinal canal, or into the subarachnoid space so that it reaches the cerebrospinal fluid.

During the procedure, the pain specialist injected contrast and injectate into the patient’s intrathecal space instead of the patient’s epidural space.

The pain specialist did not obtain an intra-injection lateral view epidurogram to confirm the location of the catheter tip and/or the dispersal pattern of the contrast and injectate.

The pain specialist did not obtain a post-injection lateral view epidurogram to confirm the location of the catheter tip and/or the dispersal pattern of the contrast and injectate.

The pain specialist did not recognize that he had performed an intrathecal injection instead of an epidural injection.

After the procedure, the patient complained of bilateral hip and leg pain, numbness, and paralysis.

The patient was transferred to a hospital where she was ultimately diagnosed with conus medullaris syndrome.

It was requested that the Medical Board of Florida order one or more of the following penalties for the pain specialist: 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 Medical Board of Florida deemed appropriate.

State: Florida

Date: June 2017

Specialty: Pain Management, Anesthesiology

Symptom: Back Pain, Numbness, Extremity Pain, Pelvic/Groin Pain, Weakness/Fatigue

Diagnosis: Post-operative/Operative Complication, Spinal Injury Or Disorder

Medical Error: Wrong site procedure, Lack of proper documentation, Procedural error

Significant Outcome: Permanent Loss Of Functional Status Or Organ

Case Rating: 3

Link to Original Case File: Download PDF