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Florida – Family Medicine – Treatment Of Elevated Blood Pressure And Headaches From Illicit Testosterone Injections
On 2/17/2014, a male patient in his early twenties presented to a family practitioner for medical assessment and/or treatment.
On 2/17/2014, the patient disclosed to the family practitioner that he was obtaining injectable testosterone from a source unknown to the family practitioner. The patient indicated that he was utilizing the testosterone for bodybuilding purposes.
On 2/17/2014, the patient reported to the family practitioner that he was suffering from headaches and elevated blood pressure.
On 2/17/2014, the family practitioner surmised that the patient’s symptoms were likely the result of excess estrogen production secondary to the patient’s high-dose testosterone use.
On 2/17/2014, the family practitioner wrote the patient a prescription for Anastrozole, an estrogen-blocking substance.
On 2/20/2014, the patient presented to the family practitioner for medical assessment and/or treatment. The family practitioner continued the patient on Anastrozole.
In February 2014, the family practitioner did not obtain or review any medical records establishing that the patient was experiencing excess estrogen production. He also did not obtain bloodwork or perform other diagnostic testing to confirm whether the patient was experiencing excess estrogen production.
On 4/6/2014, the patient presented to the family practitioner for medical assessment and/or treatment. The patient reported to the family practitioner that he was continuing to use testosterone, and that he was continuing to experience headaches. The family practitioner surmised that the patient’s ongoing headaches were caused by elevated prolactin levels. The family practitioner wrote the patient a prescription for Cabergoline, a prolactin-blocking substance.
On 4/10/2014, the patient presented to the family practitioner for medical assessment and/or treatment. The family practitioner continued the patient on Cabergoline.
In April 2014, the family practitioner did not obtain or review any medical records establishing that the patient was experiencing elevated prolactin levels. He did not obtain bloodwork or perform other diagnostic testing to confirm whether the patient was experiencing elevated prolactin levels.
On one or more occasions between 6/27/2014, and 1/9/2015, the family practitioner prescribed the following substances to the patient: clindamycin, Bactroban ointment, doxycycline, Zithromax, oral prednisone, Neurontin, and diazepam. On one or more occasions in 2015, the family practitioner also prescribed the patient Anastrozole.
The family practitioner did not keep any contemporaneous medical records regarding the medical assessment and/or treatment that he provided to the patient between 2/17/2014 and 1/9/2015.
To the extent that the family practitioner had medical records regarding the medical assessment and/or treatment that he provided to the patient between 2/17/2014 to 1/9/2015, such records were all created in October 2015.
The Medical Board of Florida issued a letter of concern against the family practitioner’s license. The Medical Board of Florida ordered that the family practitioner pay a fine of $8,000 and pay reimbursement costs for the case at a minimum of $1,457.57 and not to exceed $3,457.57. The Medical Board of Florida ordered that the family practitioner complete a drug course, a medical records course, and five hours of continuing medical education in “risk management.”
State: Florida
Date: December 2017
Specialty: Family Medicine, Endocrinology, Internal Medicine
Symptom: Headache
Diagnosis: Drug Overdose, Side Effects, or Withdrawal
Medical Error: Failure to order appropriate diagnostic test, Improper medication management, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
Florida – Radiology – Gastrografin GI Series Performed to Ascertain GI Leak But No Leak Reported By Radiologist
On 6/23/2014, a 66-year-old male presented to the Physicians Regional Medical Center for gastric bypass surgery.
Following the gastric bypass procedure, on 6/24/2014, a radiologist performed a Gastrografin upper GI series on the patient to ascertain whether there was a leak or obstruction in the patient’s digestive tract. A leak of contrast material was visible on radiographic images obtained by the radiologist during the procedure; however, the radiologist failed to detect the leak in the patient’s digestive tract and reported a negative GI series. The patient was subsequently discharged from the hospital.
Approximately thirty hours after his discharge, the patient returned to the hospital suffering from abdominal pain and sepsis. It was discovered that the patient had a perforation in his digestive tract. During surgery to repair this perforation, the patient suffered cardiac arrest and anoxic brain injury. The patient ultimately expired as a result of these complications on 7/10/2014
The Board judged the radiologist’s conduct to be below the minimum standard of competence given his failure to detect a leak in the patient’s digestive tract during the performance of a Gastrografin upper GI series.
State: Florida
Date: December 2017
Specialty: Radiology
Symptom: N/A
Diagnosis: Acute Abdomen
Medical Error: False negative
Significant Outcome: Death, Hospital Bounce Back
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Gynecology – Unnecessary Biopsies Performed When Lumps Are Noted on A Patient’s Breasts
Between December 2010 and August 2013, a patient presented to her gynecologist.
On 5/19/2011, the gynecologist found small, smooth, mobile lumps in the patient’s left and right breasts.
On 6/17/2011, the gynecologist performed a right breast biopsy on the patient. The gynecologist noted that the right breast lump was likely a fibroadenoma. The biopsied right breast tissue was found to be benign.
On 7/5/2011, the gynecologist performed a left breast biopsy on the patient. The gynecologist noted that the left breast lump was likely a fibroadenoma. The biopsided left breast tissue was found to be benign.
At all times, the patient was at a low risk for having breast cancer.
The Board judged the gynecologist’s conduct to be below the minimum standard of practice given that the prevailing professional standard of care required that the gynecologist medically manage the patient’s left and right breast lumps with breast exams, breast sonographies, and/or mammograms. The obstetrician’s performance of left and right breast biopsies on the patient was medically unnecessary.
The Board ordered that the gynecologist pay a fine of $16,000 against his license. Also, the Board ordered that the case fine be set at $9,486.57. The Board ordered that the gynecologist complete five hours of continuing medical education in “Risk Management.”
State: Florida
Date: December 2017
Specialty: Gynecology, Gynecology
Symptom: Mass (Breast Mass, Lump, etc.)
Diagnosis: N/A
Medical Error: Failure to order appropriate diagnostic test, Unnecessary or excessive treatment or surgery
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
Florida – Emergency Medicine – Patient With Intussusception Involving Loop Of Small Bowel Discharged Home With Magnesium Citrate
At 1:45 a.m. on 7/26/2014, a 46-year-old female presented to the emergency department with complaints of severe abdominal pain. Upon arrival at the emergency department, the patient was evaluated by the ED physician.
The patient complained of severe abdominal pain and stated the pain was “10 out of 10.” The patient then underwent laboratory studies and a CT scan of the abdomen/pelvis with intravenous and oral contrast.
A radiologist reviewed the CT scan at some time before 4:16 a.m., when he read and signed the preliminary report. Upon review of the CT scan results the radiologist recorded in the preliminary report “intussusception involving loop of small bowel in the left lower quadrant with involved loops appearing edematous.” The radiologist relayed the results of the CT scan to the ED physician via teleradiology.
The ED physician recorded the results of the CT scan in the patient’s emergency provider report and noted “thickened loop of small bowel in the left lower quadrant, [m]ay be intussuception [sic].”
At 4:32 a.m. the ED physician discharged the patient to her home with a magnesium citrate prescription and no additional discharge instructions.
At 8:28 a.m. a physician signed the final radiology report and noted “[i]ntussesception involving loop of small bowel in the left lower quadrant” and “preliminary report related to referring physician teleradiology at the time of the exam by the radiologist.”
Later that day, the patient developed worsening pain, and presented to another emergency department, and underwent an emergency surgery for resection of necrotic bowel.
The Board judged the ED physician’s conduct to be below the minimum standard of competence given his failure obtain emergent surgical consultation for further evaluation and treatment and continue hospitalization for operative intervention or ongoing evaluation of abdominal pain.
The Board ordered the ED physician to pay an administrative fine in the amount of $8,000. Also, the Board ordered the ED physician to complete five hours of continuing medical education in the area of emergency medicine.
State: Florida
Date: December 2017
Specialty: Emergency Medicine
Symptom: Abdominal Pain
Diagnosis: Acute Abdomen
Medical Error: Improper treatment, Referral failure to hospital or specialist
Significant Outcome: Hospital Bounce Back
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Orthopedic Surgery – Documentation Error Of Laceration Of Flexor Pollicis Longus Leads To Wrong Site Surgery
On 5/16/2014, a patient presented to an orthopedic outpatient surgery center with a left-hand work-related injury. During the visit, an orthopedic surgeon properly diagnosed the patient with a flexor pollicis longus (FPL) tendon laceration of her left thumb.
The FPL tendon laceration was confirmed by the MRI scan performed on the patient on 7/3/2014.
On 8/7/2014, during the follow-up visit, the orthopedic surgeon wrongly documented the patient’s injury as an extensor pollicis longus (EPL) tendon laceration in the patient’s medical records
Consequently, on 9/10/2014, the patient presented to the orthopedic surgeon at the center, for an EPL tendon surgery (the wrong site, and/or medically unnecessary procedure) of her left thumb. During the EPL tendon surgery, the orthopedic surgeon realized that the FPL tendon laceration repair should have been performed on the patient instead. On 10/10/2014, the orthopedic surgeon performed the FPL tendon laceration repair on the patient’s left thumb.
The Board ordered the orthopedic surgeon pay a fine of $3,000 to the Board. Also, the Board ordered the orthopedic surgeon pay a reimbursement cost of $4,670.40. The Board ordered that the orthopedic surgeon complete five hours of continuing medical education in “Risk Management.” The Board ordered that the orthopedic surgeon complete one hour of lecture on wrong site procedure.
State: Florida
Date: December 2017
Specialty: Orthopedic Surgery
Symptom: N/A
Diagnosis: Musculoskeletal Disease, Trauma Injury
Medical Error: Wrong site procedure, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Anesthesiology – Wrong Site Procedure For A Transforaminal Epidural Steroid Injection
On 4/28/2015 an 80-year-old female, presented to an anesthesiologist for an initial consultation for possible epidural steroid injections. On 4/28/2015, the patient had a history of left sided lower back pain and left lower extremity pain.
On 4/28/2015, the anesthesiologist scheduled the patient for a left transforaminal epidural steroid injection (TFESI) to be performed on 4/29/2015.
On 4/29/2015, the patient presented to the anesthesiologist at outpatient surgery and laser center for the planned left TFESI. On 4/29/2015, the patient and anesthesiologist signed a consent form for a left TFESI. After the patient was prepped for the procedure, the anesthesiologist performed a TFESI on the patient’s right side (the wrong site). While the patient was still in the procedure room, the anesthesiologist was informed that he performed the TFESI on the incorrect side. The anesthesiologist then performed a TFESI on the patient’s left side (the correct site).
The anesthesiologist’s procedure report on 4/29/2015 procedures did not accurately document the anesthesiologist’s performance of TFESI procedures on two different sides of the patient.
The Board ordered the anesthesiologist to pay a fine of $5,000 against his license. Also, the Board ordered that the anesthesiologist pay reimbursement costs of $5,857.63. The Board ordered that the anesthesiologist complete a medical records course. The Board ordered that the anesthesiologist complete five hours of continuing medical education on “Risk Management.” Also, the Board ordered the anesthesiologist to complete a one hour lecture on wrong site surgeries to medical staff at an approved site.
State: Florida
Date: December 2017
Specialty: Anesthesiology, Neurology
Symptom: Pain
Diagnosis: Spinal Injury Or Disorder
Medical Error: Wrong site procedure, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
Florida – Neurosurgery – Wrong Site Procedure When Performing Surgery On A Subdural Hematoma
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
Florida – Psychiatry – Lithium Administration With Lisinopril And Hydrochlorothiazide
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
Florida – Obstetrics – Lack Of Maternal Serum Alpha-Fetoprotein Testing With Pregnancy Complications
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 3/10/2014, 3/17/2014, 3/24/2014. 4/24/2014, 8/7/2014, and 9/25/2015, the obstetrician ordered obstetrical ultrasounds and/or sonograms for the patient.
On 4/23/2014 and 8/20/2014, the patient presented to the obstetrician with thick vaginal fluid and blood discharge, 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, who was born with spina bifida/myelomeningocele.
The obstetrician failed to diagnose neural tube defect on imaging studies.
The obstetrician failed to order a maternal serum alpha-fetoprotein (MSAFP) test and did not maintain adequate legible documentation of ordering an MSAFP test.
The obstetrician failed to order an anatomical survey sonogram.
The Board ordered that the obstetrician pay a fine of $7000 against his license. The Board ordered that the obstetrician pay reimbursements costs of a minimum of $3,786.18 and not to exceed $5,786.18. The Board also ordered that the obstetrician complete a course on “Quality Medical Record Keeping for Health Care Professionals” and that he complete five hours of continuing medical education on “Risk Management.”
State: Florida
Date: December 2017
Specialty: Obstetrics
Symptom: Fever, Bleeding, Nausea Or Vomiting, Back Pain
Diagnosis: Obstetrical Complication, Spinal Injury Or Disorder
Medical Error: Failure to order appropriate diagnostic test, Failure to follow up, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Internal Medicine – Worsening Chronic Kidney Disease, Abnormal Stress Test, And Cardiac Symptoms
From 2009 until 2014, an internist served as a patient’s primary care physician.
In 2009, the internist referred the patient to Cardiologist A for a cardiology evaluation. The results of the 2009 cardiology evaluation revealed that the patient’s electrocardiogram and stress test were both abnormal. At this time Cardiologist A recommended that the internist increase the patient’s medication as needed in order to get the patient’s LDL cholesterol below seventy.
The patient was evaluated by Cardiologist A again in June 2010. The June 2010 cardiac evaluation revealed that the patient had shortness of breath on exertion at times, possibly related to hypertension and subclinical congestive heart failure.
On 7/17/2013, the patient underwent lab work, the results which showed that his glomerular filtration rate (“GFR”) was thirty-four. The internist stated the patient’s chronic kidney disease (“CKD”) as stage III/IV.
The patient’s next set of lab work was conducted on 11/18/2013, the results of which showed that his GFR was twenty-two. The internist wrote in a progress note that the patient’s CKD was stage III/IV.
The patient had lab work done again on 1/13/2014, the results of which showed that his GFR was twenty-six. In a progress noted created on 1/13/2014, the internist wrote that the patient’s CKD was now at stage IV.
Despite the dramatic decline in the patient’s GFR levels indicative of worsening CKD, the internist did not refer the patient to a nephrologist.
On 1/13/2014, the patient presented to the internist complaining of left arm pain, numbness radiating to both hands, and shortness of breath. The internist ordered an EKG, chest x-ray, and lab work. The internist’s assessment of the patient at this time was dyspnea on exertion, questionable coronary artery disease, questionable pulmonary issue, and questionable anxiety.
The internist had the patient return to the office on 1/14/2014 for an echocardiogram. After the echocardiogram, the internist referred the patient to Cardiologist B for a consult.
The patient could not obtain an appointment with Cardiologist B until 2/3/2014.
The internist ordered that a stress test be conducted prior to the patient’s visit to Cardiologist B, and advised that the patient bring the results of the stress test to his appointment with Cardiologist B. The stress test was performed on 1/23/2014, and the results were abnormal.
The Board judged the internist’s conduct to be below the minimum standard of competence given that the internist failed to adequately evaluate the patient’s symptoms and recognize the patient’s worsening coronary artery disease, development of congestive heart failure, and worsening of chronic kidney disease. The internist should have referred the patient to a nephrologist for further evaluation upon seeing a dramatic decline in the patient’s GFR levels. When the patient, with a known history of cardiac disease, presented with cardiac symptoms, the internist should have should have sent the patient to an emergency department for treatment.
The Board ordered that the internist pay a fine of $2,000 imposed against his license. The Board also ordered that the internist pay reimbursement costs of a minimum of $5,756.36 and not to exceed $7,756.36. The internist was ordered to complete five hours of continuing medical education in the treatment of patients with chronic kidney disease and five hours of continuing medical education in the treatment of patients with chronic heart disease.
State: Florida
Date: December 2017
Specialty: Internal Medicine
Symptom: Extremity Pain, Numbness, Shortness of Breath
Diagnosis: Renal Disease, Cardiovascular Disease
Medical Error: Referral failure to hospital or specialist
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF