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Florida – Ophthalmology – Entropion Surgical Repair Performed On Patient’s Right Lower Eyelid Instead Of The Left Lower Eyelid
On 3/18/2015, a patient presented to an ophthalmologist for a left lower eyelid entropion surgical repair.
Prior to initiating the procedure, the ophthalmologist marked the patient’s left lower eyelid as the operative site, performed a timeout identifying the patient and procedure to be performed, and administered a local anesthetic to the patient’s left lower eyelid.
After performing the timeout but prior to beginning the procedure, the ophthalmologist briefly left the operating room.
After returning to the operating room, the ophthalmologist performed a second verbal timeout; however, he failed to create or maintain documentation of performing the second verbal timeout.
Despite the foregoing measures, the ophthalmologist mistakenly made his initial incision on the patient’s right lower eyelid (incorrect site) as opposed to the left lower eyelid (correct site). He recognized this error, closed the incision on the incorrect site, and then proceeded to perform the procedure on the correct site.
The Medical Board of Florida issued a letter of concern against the ophthalmologist’s license. The Medical Board of Florida ordered that he pay a fine of $4,000 against his license and pay reimbursement costs for the case at a minimum of $1,328.84 and not to exceed $3,328.84, The Medical Board of Florida also ordered that the ophthalmologist complete five hours of continuing medical education in “risk management” and complete a one hour lecture/seminar on wrong site surgeries.
State: Florida
Date: February 2017
Specialty: Ophthalmology
Symptom: N/A
Diagnosis: Ocular Disease
Medical Error: Wrong site procedure, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
North Carolina – Gynecology – Hypoxia During Hysteroscopic Resection
On 1/9/2015, a female presented to a gynecologist for a hysteroscopy to resect a large submucosal fibroid, which was in excess of 3 cm, after being treated in the office for several months. The Board noted that the gynecologist recommended a complete hysterectomy for the patient, but the patient refused. Regardless, the gynecologist chose to proceed with a hysteroscopic resection. Because the fibroid was large, the operative time was far in excess of what would be expected. During the operation, hysteroscopic fluid management indicated a significant excess in fluid intake. The excess fluid retention caused the patient to suffer oxygen desaturation as a result of significant pulmonary and laryngeal edema.
The Board expressed concern that the gynecologist failed to stage the operation to avoid prolonged operative time and fluid overload.
The Board issued a public letter of concern, which was reported to the Federation of State Medical Boards. It was not reported to the National Practitioner Data Bank.
State: North Carolina
Date: February 2017
Specialty: Gynecology
Symptom: Mass (Breast Mass, Lump, etc.)
Diagnosis: Post-operative/Operative Complication
Medical Error: Procedural error
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
California – Internal Medicine – Rectal Cancer With Metastatic Disease, Fall, And A Perineal Wound
In July 2013, a patient was diagnosed with rectal cancer with metastasis to the liver. He was treated with chemotherapy. His course was complicated by colovesical fistula and scrotal abscess.
On 2/4/2014, the patient underwent a laparoscopic diverting colostomy. He had further chemotherapy after this operation.
On 7/7/2014, the patient went to Internist A’s office. At that time, the patient’s medication regimen included a fentanyl patch, hydrocodone-acetaminophen, hydromorphone, valium, zolpidem, and oxycodone-acetaminophen. Adderall was not listed as a prescribed medication in the patient’s medical records.
On 7/22/2014, the patient was admitted to the medical center after a fall at home. The accompanying diagnosis included syncope, dehydration, volume depletion, generalized weakness, and perineal wound. During that hospital stay, the patient was found to have streptococcal bacteremia, for which he was treated with intravenous antibiotics. In the emergency department’s record from the medical center, Adderall was listed in his prior to admission medication list. It was continued in the inpatient setting and carried over with his discharge orders at the time of transfer to a skilled nursing facility. Internist A did not perform a medication reconciliation when the patient’s care was transitioned.
On 8/2/2014, the patient was discharged from the hospital. At that time, his medication regimen was as follows: Adderall 20 mg daily; zolpidem 10 mg at bedtime; fentanyl patch 25 mcg every 72 hours; oxycodone 10-20 mg every 4 hours as needed; and diazepam 5 mg daily as needed. Based on the patient’s wife’s concern, the physician covering for Internist A discontinued the Adderall and the fentanyl patch. However, the discharge summary makes no mention of discharge medications. The patient was transitioned to a skilled nursing facility for continuation of intravenous antibiotics. He received physical therapy/occupational therapy there and intravenous antibiotics. He subsequently developed a fever.
On 9/18/2014, the patient was transferred back to the emergency department for tachycardia and was admitted to the hospital.
On 9/25/2014, the patient was discharged home with his spouse under hospice care. On 10/1/2014, the patient expired at home.
While at the skilled nursing facility, the patient’s wife was concerned that the patient was on too many medications, that he was not required to ambulate, and that is dentures were lost, which impaired his oral intake. During this period of time, the patient’s wife made multiple phone calls to Internist A, attempting to express her concerns about the care provided to her husband, but was unable to speak to Internist A. Internist A failed to communicate with the wife regarding her husband’s condition.
The Board felt that Internist A had practiced below the standard of care given failure to perform medication reconciliation at transitions of care. He failed to fulfill his responsibility as a treating clinician to update the patient’s wife. He failed to maintain accurate and adequate medical records. The patient’s perineal wound was not mentioned in his admissions notes or in subsequent follow-up notes.
The Board issued a reprimand against Internist A. He was ordered to comply with attending a course in medical record keeping.
State: California
Date: February 2017
Specialty: Internal Medicine, Hospitalist
Symptom: Weakness/Fatigue, Fever
Diagnosis: Sepsis, Colon Cancer
Medical Error: Failure of communication with patient or patient relations, Improper medication management, Lack of proper documentation
Significant Outcome: Hospital Bounce Back
Case Rating: 1
Link to Original Case File: Download PDF
North Carolina – Nephrology – Deciding To Initiate Vancomycin For Patient With Prior History Of Tachycardia And Dyspnea After Receiving Vancomycin
The Board was notified of a professional liability payment made on 6/5/15.
A 31-year-old male with end-stage renal disease presented to the emergency department with cough, fever, and acute pain. The initial diagnosis was sepsis. He was given cefazolin and gentamicin. The patient’s allergy history was noted to include penicillin and vancomycin.
The patient subsequently underwent two transfers of care. During these transfers, it was indicated by various physicians that the patient would require intravenous vancomycin to treat sepsis. Given the patient’s ambiguous allergy history, the evening hospitalist made the decision to defer to a nephrologist the decision regarding the treatment of the patient with vancomycin as the nephrologist had treated the patient in the past. As the patient’s nephrologist, he was aware that the patient had received vancomycin in the past both intravenously and intraperitoneally. The patient had previously developed tachycardia and dyspnea after receiving vancomycin. The nephrologist had concluded that the patient’s reaction to the most recent exposure to vancomycin was not a true allergic reaction, but rather “red man syndrome” and that the patient now required vancomycin to successfully treat the sepsis. Within minutes of the start of the vancomycin infusion, the patient developed tachycardia, dyspnea, and ultimately cardiac arrest from which he could not be revived.
The Board expressed concern that the nephrologist’s care of the patient fell below the standard of care.
The Board issued a public letter of concern, which was reported to the Federation of State Medical Boards. It was not reported to the National Practitioner Data Bank.
State: North Carolina
Date: February 2017
Specialty: Nephrology
Diagnosis: Sepsis
Medical Error: Improper medication management, Underestimation of likelihood or severity
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF
California – Urology – Treatments Options For Renal Mass In An Elderly Man With History Of Bladder And Renal Cancer
Sometime around 2000, a 77-year-old male presented to a urologist for treatment of hematuria and benign prostatic hyperplasia. Between 2000 and 2008, the patient continued to receive treatment from the urologist for various medical problems, which included but was not limited to, a right radical nephrectomy for cancer in 2001, a history of bladder cancer recurrence requiring transurethral resection and instillation of BCG (immune therapy) into the bladder, approximately twenty-five cystoscopies, and high grade prostate cancer treated with radiation and androgen deprivation in 2008.
On 12/18/2009, the then 86-year-old patient presented to the urologist with complaints of gross hematuria with clots for one week. At that time, the urologist ordered a CT scan of the patient’s abdomen and pelvis.
On 12/22/2009, the urologist underwent a CT scan, which revealed a 5.7 cm mass in the upper pole cortex consistent with renal cell carcinoma.
On 12/29/2009, the urologist saw the patient for a follow-up visit. Having reviewed the CT scan results, the urologist considered various options for treatment, including watchful waiting versus nephrectomy versus nephrectomy/cystectomy. The urologist did not consider a partial nephrectomy.
On 1/6/2010, the urologist performed an uneventful total left nephrectomy, total cystoprostatectomy, and urinary diversion. The pathology report showed a 6 cm clear cell cancer of the left kidney, nuclear grade 4/4, and the renal vein and renal sinus were not involved. The bladder showed papillary transitional cell high-grade multifocal carcinoma in situ. No tumor invasion was present in the bladder wall.
On 1/9/2010, the patient had developed some hypertension and was noted to have some greenish discharge from his surgical wound. The patient was returned to surgery for an emergent laparotomy performed by the urologist and a co-surgeon. During the laparotomy, it was discovered that the patient had small bowel perforations secondary to extensive bowel ischemia. During the surgery, a bowel resection, jejunostomy, and double barrel colostomy were performed. At the conclusion of the procedure, the patient had a cardiac arrest and died.
The Board expressed concern that the urologist practiced at a level below the standard of care by not considering less aggressive options such as a partial nephrectomy in a very elderly man with comorbidities.
The Board issued a reprimand and ordered continuing medical education of 40 hours. It was also recommended that the urologist enrolls in the Physician Assessment and Clinical Education Program offered at the University of California – San Diego School of Medicine.
State: California
Date: February 2017
Specialty: Urology
Symptom: Mass (Breast Mass, Lump, etc.), Urinary Problems
Diagnosis: Post-operative/Operative Complication, Cancer
Medical Error: Improper treatment
Significant Outcome: Death
Case Rating: 3
Link to Original Case File: Download PDF
California – Gastroenterology – Second Colonoscopy Performed Within Days Of First Due To Concerns Of Suboptimal Bowel Preparation
On 1/6/2010, an 84-year-old patient was admitted to the hospital with complaints of dizziness, anemia, and possible GI bleeding. On 1/8/2010, a gastroenterologist provided a GI consultation for the patient. The gastroenterologist’s handwritten note on that date was cursory and lacking in detail without documenting a comprehensive history, comprehensive physical examination, and/or the gastroenterologist’s medical decision-making. The gastroenterologist submitted billing for the consultation using CPT billing code 99223, which was not supported by the gastroenterologist’s documentation of the visit.
On 1/9/2010, the patient underwent a gastroscopy. Small gastric natural ulcers and a bulbar duodenal ulcer, which was 2.5 cm in size, were identified and cauterized. Sometime later in January 2010, the patient was readmitted to the hospital with complaints of nausea, vomiting, diarrhea, weakness, and interval decline in hemoglobin. The patient underwent laboratory tests, which showed anemia with borderline iron deficiency.
On 1/27/2010, the patient underwent both a gastroscopy and a colonoscopy. Small oozing angiodysplasias were found in the duodenum and were cauterized. Small adenomatous polyps were excised from the distal colon. On 2/1/2010, the patient underwent a second colonoscopy due to concerns that pathology may have been missed due to suboptimal bowel preparation during the first examination.
The Medical Board of California judged that the gastroenterologist’s conduct departed from the standard of care because he performed a medically unnecessary second colonoscopy on 2/1/2010 within days of an initial colonoscopy, his documentation was cursory and some of the physician’s handwritten notes were illegible, and he submitted billing using the CPT billing code 99223, which was not supported by the physician’s documentation of his care and treatment of the patient.
For this case and others, the Medical Board of California issued a public reprimand and ordered the gastroenterologist to complete an education course (at least 40 hours) and clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.
State: California
Date: February 2017
Specialty: Gastroenterology
Symptom: Dizziness, Diarrhea, GI Symptoms (GERD, Abdominal Distention, Dysphagia), Nausea Or Vomiting, Weakness/Fatigue
Diagnosis: Gastrointestinal Disease
Medical Error: Unnecessary or excessive diagnostic tests, Lack of proper documentation
Significant Outcome: Hospital Bounce Back
Case Rating: 2
Link to Original Case File: Download PDF
California – Gastroenterology – Repeated Colonoscopies And Gastroscopies For Left-Sided Colitis And Improper Billing
Sometime in May 2009, a patient presented to a gastroenterologist with a history of sporadic rectal bleeding and chronic reflux-type complaints. An index colonoscopy conducted on 5/7/2009 demonstrated predominantly left-sided colitis. The patient was treated with oral and topical mesalamine preparations. Initially, the patient’s symptoms responded to the treatment, but then worsened several months later.
On 8/24/2009, the patient underwent a second colonoscopy. The patient was prescribed oral budesonide to treat what was believed to be an extension of the colitis. The patient continued to have ongoing symptoms. On 11/9/2009, the patient underwent a third colonoscopy, which showed reduced activity of disease. On 1/8/2010, the patient underwent a gastroscopy and a fourth colonoscopy in order to determine the course of future treatment. The colitis was believed to be inactive, and the patient was continued on oral mesalamine preparations. The patient’s increased bleeding was believed to be hemorrhoidal in origin, and internal hemorrhoids were cauterized. The biopsy from the distal esophagus demonstrated inflammatory changes without Barrett’s metaplasia.
The patient had difficulty swallowing (dysphagia) and abdominal pain. The patient underwent gastroscope on 2/15/2010, 3/25/2010, 5/20/2010, and 4/19/2011. In each instance, biopsies from the gastric antrum and distal esophagus/gastroesophageal junction were obtained, and mild chronic inflammatory changes were observed. In each instance, the gastroenterologist did not obtain biopsies from the esophageal body. Repeated esophageal dilutions were performed in order to alleviate dysphasia symptoms. The gastroenterologist did not document the presence or absence of constricting pathology.
The patient underwent additional colonoscopies on 8/24/2010, 4/11/2011, and 12/7/2012. The patient underwent additional gastroscopies on 12/30/2011, 4/3/2012, 9/21/2012, 1/11/2013, and 3/1/2013. In each instance, biopsies form the distal esophagus demonstrated inflammatory changes without Barrett’s metaplasia.
The gastroenterologist maintained handwritten notes of each visit. Some of the handwritten notes were not legible. The gastroenterologist consistently failed to note any assessment and/or plan based on the assessment. The gastroenterologist consistently billed using CPT billing code 99213, in the absence of documenting any expanded problem focused history or medical examination or medical decision-making.
The Medical Board of California judged that the gastroenterologist’s conduct departed from the standard of care because he performed repeated colonoscopies and gastroscopies of the patient without medical indication or necessity, failed to maintain adequate and accurate medical records of his care and treatment of the patient, and submitted billing for his care and treatment of the patient using the CPT billing code 99213, which was not supported by the physician documentation of his care and treatment of the patient.
For this case and others, the Medical Board of California issued a public reprimand and ordered the gastroenterologist to complete an education course (at least 40 hours) and clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.
State: California
Date: February 2017
Specialty: Gastroenterology
Symptom: Bleeding, GI Symptoms (GERD, Abdominal Distention, Dysphagia), Abdominal Pain
Diagnosis: Gastrointestinal Disease
Medical Error: Unnecessary or excessive diagnostic tests, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
California – Gastroenterology – Repeated Colonoscopies And Gastroscopies For Worsening Esophagitis And Billing For Complex Evaluation
On 4/21/2010, a 58-year-old was admitted to the hospital with chest and abdominal pain, nausea, vomiting, and leukocytosis. The patient was seen by a gastroenterologist for GI consultation.
On 4/29/2010, the patient underwent a gastroscopy, which revealed erosive esophagitis, Los Angeles grade B, and “small ulcers with overlying semi fresh blood” were cauterized.
On 5/21/2010, the patient was re-hospitalized with complaints of persistent abdominal pain. On 5/28/2010, a second gastroscopy was performed. The ulcers that were previously found had resolved. The gastroenterologist biopsied the gastric antrum. The reasons for doing so were not documented in the patient’s medical chart. The patient continued to experience pain, but the medical records did not characterize the pain complaints.
On 6/2/2010, the patient underwent a colonoscopy. It was unclear from the medical documentation whether the colonoscopy was performed on an urgent basis. During the study, the gastroenterologist removed small, benign polyps. The gastroenterologist recommended a repeat colonoscopy due to suboptimal bowel preparation.
On 6/15/2010, the patient was hospitalized with complaints of nausea and vomiting. On 6/19/2010, a third gastroscopy was performed and revealed mild esophagitis. Sometime in August 2010, the patient was hospitalized with complaints of abdominal pain, nausea, and vomiting. On 8/11/2010, a fourth gastroscopy was performed, which the gastroenterologist interpreted as showing “extensive ulcerative esophagitis with multi foci of blood.”
On 5/24/2011, the patient underwent a fifth gastroscopy, which the gastroenterologist interpreted as showing esophagitis and numerous erosions or superficial ulceration in the lower stomach. Also on this date, the patient underwent a second colonoscopy, and the gastroenterologist recommended a “follow-up colonoscopy after a more thorough prep.”
The Medical Board of California judged that the gastroenterologist’s conduct departed from the standard of care because he performed repeated gastroscopic examinations of the patient without medical indication or necessity, failed to maintain adequate or accurate records regarding his care and treatment of the patient, and submitted billing for each hospital visit with the patient using CPT billing code 99233, or a complex evaluation, which was not supported by the gastroenterologist’s documentation of the visits.
For this case and others, the Medical Board of California issued a public reprimand and ordered the gastroenterologist to complete an education course (at least 40 hours) and clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.
State: California
Date: February 2017
Specialty: Gastroenterology
Symptom: Chest Pain, Nausea Or Vomiting, Abdominal Pain
Diagnosis: Gastrointestinal Disease
Medical Error: Unnecessary or excessive diagnostic tests, Lack of proper documentation
Significant Outcome: Hospital Bounce Back
Case Rating: 2
Link to Original Case File: Download PDF
California – Gastroenterology – Hemorrhoids Cauterized During Multiple Colonoscopies
A 58-year-old had a history of diabetes and generalized atherosclerotic vascular disease. On 12/18/2009, the patient underwent an outpatient colonoscopy to assess complaints of diarrhea and abdominal pain. The study was interpreted to show mild colitis, but biopsies were normal.
On 2/10/2010, the patient complained of abdominal discomfort and reflux-type symptoms. The patient underwent a gastroscopy with finding of mild esophagitis and gastritis. Following placement of a stent and initiation of anticoagulation therapy, the patient presented with GI bleeding with bloody stools and hemoglobin decline necessitating multiple transfusions.
On 3/15/2010, the patient underwent a second gastroscopy, which the gastroenterologist interpreted to show multiple bleeding gastric ulcers. The gastroenterologist cauterized the bleeding gastric ulcers with a BICAP probe. The patient continued to have bloody stools.
On 3/18/2010, the patient underwent a second colonoscopy and a third gastroscopy. The gastroenterologist again interpreted the gastroscopy to show hemorrhagic erosions, which he again cauterized. The colonoscopy was technically inadequate due to retained blood and debris.
On 3/20/2010, the patient underwent a third colonoscopy. The gastroenterologist interpreted a finding of sigmoid diverticulosis. On 6/4/2010, the patient was re-hospitalized with complaints of nausea, vomiting, weakness, and dark stools. The patient was receiving antiplatelet therapy following a vascular intervention. On 6/4/2010 or 6/5/2010, the patient was seen by the gastroenterologist for GI consultation. The gastroenterologist’s dictated consultation note was cursory, making no mention of the patient’s complaints or contributory medications. The gastroenterologist billed for the consultation using CPT billing code 99254, indicating a Level 4 consultation, which was not documented in the gastroenterologist’s consultation note.
On 6/5/2010, the patient underwent a fourth gastroscopy. The gastroenterologist, again, cauterized “hemorrhagic erosion with evidence of slow bleed.” On 6/7/2010, the patient underwent a fourth colonoscopy due to concerns of a lower GI tract contribution to bleeding. The patient was found out have internal hemorrhoids, which the gastroenterologist cauterized.
The Medical Board of California judged that the gastroenterologist’s conduct departed from the standard of care because he performed repeated upper and lower endoscopic examinations of the patient in the absence of important pathology to justify the repeat studies, failed to maintain adequate and accurate medical records of his care and treatment to the patient, and submitted billing for his care and treatment of the patient using the CPT billing code 99254, which was not supported by the physician’s documentation.
For this case and others, the Medical Board of California issued a public reprimand and ordered the gastroenterologist to complete an education course (at least 40 hours) and clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.
State: California
Date: February 2017
Specialty: Gastroenterology
Symptom: Diarrhea, Blood in Stool, GI Symptoms (GERD, Abdominal Distention, Dysphagia), Nausea Or Vomiting, Abdominal Pain, Weakness/Fatigue
Diagnosis: Gastrointestinal Disease
Medical Error: Unnecessary or excessive diagnostic tests, Lack of proper documentation
Significant Outcome: Hospital Bounce Back
Case Rating: 2
Link to Original Case File: Download PDF
California – Gastroenterology – Multiple Endoscopic Studies For Ulcerative Esophagitis
A patient had been seen by a gastroenterologist, as an outpatient, since sometime in 2005 for chronic gastroesophageal reflux disease (GERD). The patient had received long-term treatment with acid-reducing medications and prokinetic agents. Between 2005 and 2009, the patient underwent 23 separate endoscopic studies. The gastroenterologist’s hand-written documentation of his care and treatment of the patient was scant, illegible, and failed to state the gastroenterologist’s thoughts regarding evaluating and/or modifying the patient’s clinical course.
Sometime in June 2010 and again in July 2010, the patient was admitted to the hospital with upper GI tract bleeding. On 7/13/210, the gastroenterologist dictated an admission summary, which failed to provide any meaningful historical details regarding the patient. The gastroenterologist used PT billing code 99223 indicating a “complex” level of assessment for the consultation.
From 6/16/2010 through 10/9/2010, the gastroenterologist performed a total of 7 endoscopic studies to evaluate the patient. The studies demonstrated that the patient had severe ulcerative esophagitis, secondary to reflux and/or vomiting. The gastroenterologist documented that he cauterized areas of hemorrhagic mucosa in the esophagus. However, the gastroenterologist’s dictated procedure reports failed to document any additional anatomy or physiology related to these studies and treatment.
The Medical Board of California judged that the gastroenterologist’s conduct departed from the standard of care because he failed to properly manage the patient’s reflux disease, performed an excessive number of endoscopic procedures that provided no relief to the patient’s symptoms or improvement in clinical outcome, failed to maintain adequate or accurate records of his care and treatment of the patient, and submitted billing using the CPT billing code 99223, which as not supported by the physician’s documentation of his care and treatment of the patient.
For this case and others, the Medical Board of California issued a public reprimand and ordered the gastroenterologist to complete an education course (at least 40 hours) and clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.
State: California
Date: February 2017
Specialty: Gastroenterology
Symptom: GI Symptoms (GERD, Abdominal Distention, Dysphagia), Bleeding, Nausea Or Vomiting
Diagnosis: Gastrointestinal Disease
Medical Error: Unnecessary or excessive diagnostic tests, Improper treatment, Lack of proper documentation
Significant Outcome: Hospital Bounce Back
Case Rating: 2
Link to Original Case File: Download PDF