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Florida – Internal Medicine – Patient With Worsening Chronic Kidney Disease Presents With Arm Pain, Numbness, And Shortness Of Breath
From 2009 until 2014, an internist served as the 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 cholesterol to 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 staged the patient’s chronic kidney disease (CKD) at a 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 a stage III/IV.
On 1/13/2014, the patient had lab work done again, the results which showed that his GFR was twenty-six. In his progress note he wrote that the patient’s CKD was now a stage IV.
Despite a 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. His assessment of the patient at this time was dyspnea on exertion, questionable coronary artery disease, questionable pulmonary disease, and questionable anxiety.
On 1/14/2014, the patient returned to the office 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 with Cardiologist B, and advised that the patient bring the results of the stress test to his appointment with Cardiologist B.
On 1/23/2014, the stress test was performed and the results were abnormal.
The Medical Board of Florida judged 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 chronic kidney disease. He failed to refer the patient to a nephrologist for further evaluation upon seeing a dramatic decline in the patient’s GFR levels. He also failed to send the patient to the emergency department for treatment when the patient presented to him with exhibiting cardiac symptoms and had a known history of heart disease.
The Medical Board of Florida issued a letter of concern against the internist’s license. The Medical Board of Florida ordered that the internist pay a fine of $2,500 against his license and pay reimbursement costs for the case at a minimum of $5,756.36 and not to exceed $7,756.36. The Medical Board of Florida also ordered that the internist complete five hours of continuing medical education in the treatment of patients with chronic kidney disease and chronic heart disease.
State: Florida
Date: December 2017
Specialty: Internal Medicine
Symptom: Extremity Pain, Numbness, Shortness of Breath
Diagnosis: Heart Failure, Cardiovascular Disease, Renal Disease
Medical Error: Failure to examine or evaluate patient properly, Referral failure to hospital or specialist
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
Florida – Gynecology – CBC Tests Show Neutropenia And Leukopenia At An Annual Gynecological Exam
On 8/15/2013, a 34-year-old female presented to a gynecologist for an annual gynecological exam. At the exam, the patient expressed concerns about infertility. The gynecologist and the patient discussed various tests that may be used to address infertility and the gynecologist began ordering tests.
On 2/23/2015, the patient gave blood for a complete blood count (“CBC”) test that was ordered by the gynecologist.
On 3/5/2015, the gynecologist received and signed for the results of the CBC test. The CBC test indicated the patient had an abnormal white blood cell count, marked leukopenia, and severe neutropenia.
The gynecologist failed to notify the patient of the abnormal results of the CBC test.
The gynecologist failed to ensure that the patient had otherwise established a plan of care to address the abnormal results of the CBC test.
On 5/28/2015, the patient presented to the gynecologist for an annual gynecological exam. At the exam, it was determined that the patient was pregnant, and the gynecologist ordered blood tests for the patient. The gynecologist failed to order a repeat CBC test.
On 7/17/2015, the gynecologist received and signed for the results of the repeat CBC test. The repeat CBC test indicated that the patient’s white blood cell count had decreased further, the neutropenia had worsened, and she now had pancytopenia with a drop in the red blood cell and platelet count.
On 7/30/2015, the gynecologist notified the patient of the results of her repeat CBC test and referred her to a hematologist.
On 8/8/2015, the patient experienced a massive intracranial hemorrhage with herniation, as well as severe pancytopenia.
On 8/12/2015, the patient expired in the hospital. The fetus was also lost at that point.
The Medical Board of Florida judged the gynecologists conduct to be below the minimal standard of competence given that she failed to ensure that the patient had been notified of the abnormal results of the CBC test. The gynecologist failed to ensure that the patient had otherwise established, a plan of care to address the abnormal results of the CBC test. The gynecologist failed to order a repeat CBC test at the patient’s May exam.
The Medical Board of Florida issued a letter of concern against the gynecologist’s license. The Medical Board of Florida ordered that the gynecologist pay a fine of $8,500 against her license and pay reimbursement costs for the case at a minimum of $3,126.31 and not to exceed $5,126.31. The Medical Board of Florida ordered that the gynecologist complete five hours of continuing medical education in “risk management.”
State: Florida
Date: December 2017
Specialty: Gynecology, Obstetrics
Symptom: N/A
Diagnosis: Hematological Disease, Intracranial Hemorrhage
Medical Error: Failure to follow up, Delay in proper treatment, Failure of communication with patient or patient relations
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF
Virginia – Neurosurgery – All-Terrain Vehicle Rollover Accident Causes L1 Compression Fracture
On 1/19/2008, a 32-year-old man suffered an L1 compression fracture following an all-terrain vehicle rollover accident. He saw a neurosurgeon who placed him in a rigid back brace and prescribed pain medications. The patient’s fracture appeared to be clinically stable and appeared to be improving. The Board deemed the long-term risk of developing a kyphotic deformity low in this patient.
On 3/7/2008, the neurosurgeon performed a kyphoplasty of the spine the patient. During the kyphoplasty, the vertebral body was too dense to accept the cement. As a consequence, the cement extruded out of the fracture plans into the epidural space.
The neurosurgeon addressed this complication by performing a posterior laminectomy and decompression of the thecal sac. The Board stated that the laminectomy procedure subjected the patient to a far greater risk for development of kyphosis than had existed prior to the kyphoplasty.
The Board considered the surgery unwarranted and issued a reprimand. The neurosurgeon was ordered to complete 10 hours of continuing medical education in the subject of patient selection for spinal surgery.
State: Virginia
Date: November 2017
Specialty: Neurosurgery
Symptom: Back Pain
Diagnosis: Spinal Injury Or Disorder, Fracture(s)
Medical Error: Unnecessary or excessive treatment or surgery, Procedural error
Significant Outcome: N/A
Case Rating: 5
Link to Original Case File: Download PDF
Florida – Family Medicine – Three Patients Seen At Once Without Proper Examination and Documentation
On 9/21/2012, Patient A, Patient B, and Patient C presented to a geriatric practitioner at the same time in his office. The geriatric practitioner saw the patients for less than nine minutes total. At no time were the patients separated for individual assessments. The patients were an undercover detective and two informants, using pseudonyms. The appointment was audiotaped and videotaped.
The geriatric practitioner failed to perform a physical examination on any of the three patients. The geriatric practitioner failed to create a treatment plan for any of the three patients. He also sent the three patients for x-rays without a physical examination. Per the geriatric practitioner’s instructions, all three patients presented for x-rays; however, only Patient A and Patient C actually had x-rays performed. The geriatric practitioner failed to create or maintain documentation of referring the three patients for x-rays.
On 10/30/2012, the three patients presented to the geriatric practitioner for a follow-up visit. At that time, the geriatric practitioner failed to review readily available medical records from the patients’ first visit, failed to inquire about x-ray results, failed to review physical therapy results, failed to perform physical examinations and/or failed to create treatment plans for all three patients.
The Board judged the geriatric practitioner’s actions to be below the minimum standard of competence given his failure to perform a physical examination, perform a complete individual physical examination for each patient prior to referral for x-rays, other diagnostic testing, or further treatment. Also, the geriatric practitioner failed to review any medical records or results at a follow-up visit, including x-rays, from prior visits, and/or procedures and review and analyze the physical therapy progress of the patients, and create treatments plans for each patient.
The Board ordered that the geriatric practitioner pay a fine of $12,000 against his license and pay reimbursement costs for the case for a minimum of $37,421.80 and not to exceed $39,421.80. The Board also ordered that the geriatric practitioner complete a medical records course and complete five hours of continuing medical education on “Risk Management.” The Board put the geriatric practitioner’s license on probation and required that he have indirect supervision to practice by a Board-approved physician.
State: Florida
Date: November 2017
Specialty: Family Medicine
Symptom: N/A
Diagnosis: N/A
Medical Error: Failure to examine or evaluate patient properly, Ethics violation, Failure to follow up, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
Florida – Family Medicine – Recurrent Chest Pain Diagnosed As Esophageal Spasm
On 8/27/2012 a 47-year-old female presented with complaints of hypertension, possible hyperlipidemia, and pain in her foot. A family practitioner assessed the patient and diagnosed her with poor control of her hypertension and reinforced medical advice for the patient to increase her lisinopril. Additionally, the family practitioner waited for the results of the previous laboratory work and recommended conservative management and stretching for the foot and ankle.
On 4/1/2013, the patient again presented to the family practitioner to address difficulties with concurrent chest pain. The patient stated the chest pains were very severe and “stopped her in her tracks at times.” The patient stated that she felt she was having a heart attack, although she reportedly realized that that was not the case. The family practitioner deemed the chest pain was likely an esophageal spasm, for which he prescribed the patient Librax (chlordiazepoxide/clidinium) and recommended that she see a gastroenterologist for an endoscopy if the medication failed to provide relief. The family practitioner also assessed the patient for hypertension and instructed the patient to stop taking hydrochlorothiazide. The family practitioner provided the patient with a trial of Dyrenium (triamterene).
On 4/12/2013, the patient complained of chest pain and suffered a cardiac arrest. Upon EMS arrival, the patient was unstable and unresponsive. The patient was transported to a hospital where she was later pronounced deceased.
The Board judged the family practitioners conduct to be below the minimal standard of competence given that he failed to conduct an adequate history, which included a risk factor assessment for a patient complaining of chest pain, to order or perform an EKG on a patient complaining of chest pain, and send a patient complaining of chest pain to an emergency room or an expedited outpatient facility for a chest pain evaluation.
The Board ordered that the family practitioner pay a fine of $5,000 against his license and pay reimbursement costs for a minimum of $2,122.00 and not to exceed $4,122.00. The Board also ordered that the family practitioner complete ten hours of continuing medical education in diagnosis in cardiology and five hours of continuing medical education in “Risk Management.”
State: Florida
Date: November 2017
Specialty: Family Medicine
Symptom: Chest Pain, Extremity Pain
Diagnosis: Cardiovascular Disease
Medical Error: Diagnostic error, Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Referral failure to hospital or specialist
Significant Outcome: Death
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Internal Medicine – Retained Guide Wire Found After Replacement Of Dialysis Catheter
On 3/19/2015, a patient presented to a hospital with complaints of chest pain, history of acute stent thrombosis, and renal failure.
On 3/21/2015, a physician referred the patient to an internist for replacement of temporary dialysis catheter to address her acute kidney failure. The internist placed a double-lumen dialysis catheter in the patient’s left subclavian vein.
Due to the catheter not functioning properly, another physician performed a catheter exchange procedure on the patient on 3/23/2015. After the procedure, the inspection of the catheter revealed that the guide wire remained in one of the lumens of the catheter.
Neither the internist nor his staff removed the guide wire from the catheter prior to the insertion of the catheter into the patient’s left subclavian vein.
The Board judged the internist’s conduct to be below the minimum standard of competence given that he left a foreign body in a patient.
The Board ordered that the internist pay a fine of $3,500 against his license and pay reimbursement costs for the case for a minimum of $3,419.35 and not to exceed $5,419.35. The Board also ordered that the internist complete five hours of continuing education in “Risk Management” and complete a lecture/seminar on retained foreign body objects to medical staff.
State: Florida
Date: November 2017
Specialty: Internal Medicine, Nephrology
Symptom: Chest Pain
Diagnosis: Renal Disease
Medical Error: Retained foreign body after surgery
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
Florida – Neurosurgery – Cervical Microdiscectomy At Levels C5/7 And C6/7 Instead Of Levels C4/5 And C5/6
On 11/17/2014, a patient presented to a neurosurgeon for an anterior cervical microdiscectomy for decompression with allograft fusion at cervical levels C4/5 and C5/6. During the procedure, it was discovered that the initial localization x-ray was misinterpreted and that the neurosurgeon performed the fusion at cervical levels C5/7 and C6/7 instead of cervical levels C4/5 and C5/6. After the neurosurgeon discovered the error, he proceeded to perform the fusion at the correct cervical levels, C4/5 and C5/6.
The Board judged the neurosurgeons conduct to be below the minimum standard of competence given that he performed the procedure on the wrong site.
The Board ordered that the neurosurgeon pay a fine of $5,000 against his license and pay reimbursement costs of a minimum of $1,859.22 but not to exceed $3,859.22. The Board also ordered that the neurosurgeon complete five hours of continuing medical education in “Risk Management” and complete a one hour lecture/seminar on wrong site surgeries.
State: Florida
Date: November 2017
Specialty: Neurosurgery
Symptom: N/A
Diagnosis: Spinal Injury Or Disorder
Medical Error: Wrong site procedure
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
Florida – Anesthesiology – Proceeding With A Colonoscopy With A Non-Functioning End Tidal CO2 Monitor
A 59-year-old female presented to an anesthesiologist during her colonoscopy. The anesthesiologist conducted a pre-operative anesthesia assessment of the patient. She was then transported to the procedure room where a certified registered nurse anesthetist (“CRNA”) was to provide total intravenous anesthesia to the patient.
The end-tidal CO2 monitor (“ETCO2 monitor”) located in the scheduled procedure room was non-functional on the day before the surgery and a functioning ETCO2 monitor had not been received on the day of the surgery.
The anesthesiologist instructed the CRNA to proceed with the anesthesia without the ETCO2 monitor. The anesthesiologist did not delay the procedure or postpone it for another date to allow time to obtain a functioning ETCO2 monitor. The anesthesiologist did not transfer the patient to another procedure room that had a functioning ETCO2 monitor. The anesthesiologist did not implement additional precautionary measures by closely monitoring the patient with his presence since he elected to proceed without an ETCO2 monitor as recommended by the ASA (American Society of Anesthesiologists). The anesthesiologist was not present in the procedure room during the procedure.
The CRNA experienced difficulties with the patient’s airway soon after the induction of anesthesia. The oral airway was inserted to assist the patient’s breathing, and the amount of oxygen flow was increased to help with the falling oxygen saturation. Despite the increase in the amount of oxygen flow, the CRNS reported transient desaturations and reported repositioning the pulse oximeter numerous times throughout the procedure.
The patient developed bradycardia, which culminated to intubation and cardiac arrest, and the anesthesiologist’s presence was requested in the procedure room. The anesthesiologist started chest compressions and resuscitated the patient.
The Board judged the anesthesiologist’s conduct to be below the minimum standard of competence given that he should have delayed the procedure, or postponed it for another date to allow time to obtain a functioning ETCO2 monitor. He should also have transferred the patient to another procedure room that had a functioning ETCO2 monitor and implemented additional precautionary measures by closely monitoring the patient with since he elected to proceed without an ETCO2 monitor.
The Board ordered that the anesthesiologist pay a fine of $5,000 against his license and pay reimbursement costs for the case for a minimum of $6,841.07 and not to exceed $8,841.07. The Board also ordered that the anesthesiologist complete five hours of continuing medical education in general anesthesia and complete five hours of continuing medical education in “Risk Management.”
State: Florida
Date: November 2017
Specialty: Anesthesiology
Symptom: N/A
Diagnosis: Post-operative/Operative Complication
Medical Error: Failure to properly monitor patient
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Obstetrics – Obstetrician Unavailable During Labor With Fetal Heart Decelerations
On 1/24/2014 a 21-year-old female presented to a hospital with spontaneous rupture of membranes and meconium-stained amniotic fluid at about thirty-nine weeks of pregnancy.
Upon admission, the patient was placed on a fetal monitor, which documented variable decelerations of the fetal heart rate. In response to the monitor tracings, an obstetrician ordered the administration of intravenous fluids. Shortly thereafter, the obstetrician ordered the performance of an amnioinfusion.
Over the next couple of hours, the fetal monitor began documenting recurrent late fetal heart rate decelerations and loss of fetal heart rate variability, indicative of probable insufficient fetal oxygenation. The obstetrician was notified of the recurrent late fetal heart rate decelerations and loss of fetal heart rate variability.
In response to the monitor tracings, the obstetrician ordered the rate of IV fluid administration increased. Despite the monitor tracings indicating probable fetal distress, the obstetrician did not diagnose, or did not document diagnosing, fetal intolerance to labor and allowed the trial of labor to continue.
At some point in time between 6:15 p.m. and 7:30 p.m., the obstetrician decided to manage the trial of labor from outside of the hospital. Based on the patient’s presentation, the obstetrician should have continued to manage the trial of labor, in person, at the hospital. The fetal monitor continued to document recurrent late fetal heart rate decelerations and a loss of fetal heart rate variability over the next several hours. The obstetrician was notified of the recurrent late fetal heart rate decelerations and loss of fetal heart rate variability on multiple occasions during that time span. Despite the monitor tracings indicating probably continued fetal distress, the obstetrician did not promptly return to the hospital to deliver the baby.
Shortly after midnight on 12/25/2014, the obstetrician was again notified of the recurrent late fetal heart rate decelerations and loss of fetal heart rate variability. At 1:28 a.m., the obstetrician returned to the hospital, presented to the delivery room, and shortly thereafter delivered the baby.
The baby was in full cardiac arrest at the time of delivery. Efforts to resuscitate the baby were abandoned after about 20 minutes. The final diagnosis was stillborn.
The obstetrician did not dictate or write any progress notes during the trial of labor.
The Board judged the obstetrician’s conduct to be below the minimum standard of competence given that she failed to diagnose fetal intolerance to labor, manage the trial of labor, in person, at the hospital, and promptly return to the hospital and deliver the baby upon receiving continued reports of probably fetal distress.
The Board ordered that the obstetrician pay a fine of $5,000 against her license and pay reimbursement costs for the case at a minimum of $3,949.77 and not to exceed $5,949.77. The Board also ordered that the obstetrician complete five hours continuing medical education in the area of obstetric medicine and five hours of continuing medical education in “Risk Management.”
State: Florida
Date: November 2017
Specialty: Obstetrics
Symptom: N/A
Diagnosis: Obstetrical Complication
Medical Error: Diagnostic error, Failure to properly monitor patient, Lack of proper documentation
Significant Outcome: Death
Case Rating: 2
Link to Original Case File: Download PDF
Florida – Ophthalmology – Persistent Pain And Inflammation In The Right Eye Following Cataract Surgery
On 12/4/2013, a 78-year-old female presented to an ophthalmologist for phacoemulsification with posterior chamber implant (“cataract surgery”) on her right eye.
During the cataract surgery, the patient experienced a posterior capsule tear, a known complication and an accepted risk associated with cataract surgeries.
On 2/3/2014, the patient presented to the ophthalmologist for an examination, and the ophthalmologist noted inflammation in the patient’s operative eye.
On 3/27/2014, the patient presented to the ophthalmologist for an examination, and the ophthalmologist noted inflammation in the patient’s operative eye.
On 4/8/2014, the patient presented to the ophthalmologist for an examination, and the ophthalmologist noted that the patient experienced post-operative chronic iritis in her operative eye.
On 5/6/2014, the patient presented to the ophthalmologist for a follow-up examination of her operative eye.
On 8/14/2014, the patient presented to the ophthalmologist for a follow-up examination of her operative eye.
On 9/18/2014, the patient presented to the ophthalmologist and reported throbbing pain in her operative eye.
Despite knowing that the patient experienced a complicated cataract surgery, followed by persistent inflammation in her operative eye, the ophthalmologist did not perform a dilated examination until 9/18/2014.
Despite knowing the patient experienced a complicated cataract surgery, followed by persistent inflammation in her operative eye, the ophthalmologist did not refer her to a retina specialist.
The Board judged the ophthalmologist’s conduct to be below the minimum standard of competence given his failure to perform a dilated examination on the patient’s operative eye to investigate the causes of persistent post-operative inflammation within a reasonable time after the cataract surgery. The ophthalmologist also failed to refer the patient to a retina specialist to investigate the causes of persistent post-operative inflammation within a reasonable time after cataract surgery.
The Board ordered that the ophthalmologist pay a fine of $2,500 against his license and that the ophthalmologist pay reimbursement costs for the case for a minimum of $4,634.56 but not to exceed $6.634.56. The Board also ordered that the ophthalmologist complete five hours of continuing medical education in post-operative care and complete one hour of continuing medical education in “Risk Management.”
State: Florida
Date: November 2017
Specialty: Ophthalmology
Symptom: Head/Neck Pain, Swelling
Diagnosis: Post-operative/Operative Complication, Ocular Disease
Medical Error: Failure to examine or evaluate patient properly, Referral failure to hospital or specialist
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF