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California – Hospitalist – Syncope After Cholecystectomy And Wedge Liver Biopsy
On 1/17/2011, a 40-year-old female with a history of hepatitis, gallstones, hypertension, diabetes, and obesity was admitted to a medical center for obstructive jaundice.
On 1/19/2011, a hospitalist performed a pre-operative evaluation of the patient. The hospitalist noted that the patient had a blood pressure at 91/56, a heart rate at 51 beats per minute, and a hemoglobin level of 11.3 gm/dl. The hospitalist diagnosed the patient with “Acute on Chronic Cholecystitis” and noted the patient would proceed with a cholecystectomy.
On 1/19/2011, a general surgeon performed a laparoscopic cholecystectomy with intraoperative cholangiogram and wedge liver biopsy on the patient.
At 2:50 a.m. on 1/20/2011, the patient’s hemoglobin level was noted at 11.3 gm/dl.
At 1:10 p.m., the patient fainted on the way out of the bathroom. Subsequent to this episode, the patient was awake, lethargic, and registered a blood pressure of 80/53 at 1:14 p.m. The patient was placed in the Trendelenburg position. The general surgeon was contacted and left orders for one liter of normal saline. The hospitalist, as the on-duty hospitalist, was also contacted. He ordered a hemoglobin and hematocrit, cardiac enzymes, and an EKG. He ordered 125 ml/hr of fluid to be started after the 1 liter bolus ordered by the general surgeon.
At 1:14 p.m., the patient’s hemoglobin was noted to be at 9.3 gm/dl. It is assumed that this hemoglobin level was obtained prior to 1:14 p.m., as the hemoglobin result obtained after the patient had fainted would have unlikely been available for review by 1:14 p.m.
At 4:25 p.m., the hospitalist saw the patient for persistent low blood pressure and altered mental status. The hospitalist noted that the previously ordered fluid boluses had not improved the patient’s blood pressure. The hospitalist documented a blood pressure of 77/50, heart rate of 118, and a hemoglobin of 9.3. The hospitalist additionally noted that the patient was pale and lethargic. The hospitalist diagnosed the patient with “shock, possibly hypovolemic.” The hospitalist made the following orders: transfer to the intensive care unit (ICU), start pressors, initiate a PICC line, start antibiotics, and control blood sugar. The hospitalist requested a complete blood count and a complete metabolic panel for the following morning.
At 4:50 p.m. on 1/20/2011, a rapid response was called, and the patient was transferred to the ICU. At approximately 6:32 p.m., the patient coded.
At 7:05 p.m., the hospitalist gave verbal orders for “crossmatch 2 units now; if not available transfuse 2 units uncrossed STAT.” The patient never received the transfusion and expired at approximately 7:23 p.m. The hospitalist claimed she contacted the general surgeon after the patient’s transfer to the intensive care unit. This call is not documented in the patient’s medical records.
On 1/22/2011, the hospitalist dictated a discharge summary that stated, “[w]e think the patient have had a DIC and sepsis.” The hospitalist does not document the possibility of hemorrhagic shock in her discharge summary.
The Board judged the hospitalist as having committed gross negligence given failure to promptly evaluate the patient in light of her syncope, severe hypotension, and altered mental state; failure to consider the possible causes of hypovolemic shock; and failure to consider hemorrhagic shock as a possibility given the patient’s recent surgery and declining hemoglobin.
The Board placed the hospitalist on probation for three years with stipulations to complete 40 hours annually of continuing medical education in the subjects of hemorrhagic shock and diagnostic medicine, complete a medical record keeping course, and undergo clinical practice monitoring while on probation.
State: California
Date: November 2016
Specialty: Hospitalist, General Surgery, Internal Medicine
Symptom: Syncope, Confusion, Weakness/Fatigue
Diagnosis: Post-operative/Operative Complication, Hemorrhage
Medical Error: Diagnostic error, Delay in proper treatment, Failure of communication with other providers, Improper treatment, Lack of proper documentation
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF
Arizona – Urology – Hepatic Artery, Portal Vein, and Common Bile Duct Transected During Partial Nephrectomy
The Board was notified of a malpractice settlement regarding the treatment of a 76-year-old woman.
On 02/14/2012, a woman was evaluated by a urology regarding a renal lesion that had been found on a CT scan. The urologist ordered a CT scan which was performed on 11/28/2012 and which revealed no no significant change in size of the 0.9 cm lesion located on the upper pole of the right kidney. The lesion had a slightly thickened and irregular enhancing wall. There was a small ventral wall hernia. The urologist documented the renal lesion as being complex and enhancing with no significant enlargement. It was around 1 cm in diameter and was not causing the patient any symptoms. The urologist recommended a biopsy.
On 01/24/2013, the patient underwent a right renal biopsy. Pathology revealed probable clear cell renal cell carcinoma Fuhrman grade 2.
On 01/30/2013, the urologist documented that he discussed the risks and benefits with the patient regarding surgery. The urologist offered a hand assisted approach to allow for repair of the patient’s hernia. The patient gave consent for the procedure.
On 04/17/2013, the patient was admitted for right nephrectomy via hand assisted laparoscopy. Per the anesthesia record, the anesthesia start time was 1:51 p.m. and surgery start time was 2:26 p.m. The surgery end time was 5:54 p.m. The urologist’s operative note documented adhesions and significant bleeding he initially thought was due to injury of the inferior vena cava. The patient received two packed red blood cell transfusions and the operation was converted to an open procedure.
At 3:00 p.m., the anesthesia record stated that the blood pressure was 60/30.
At 3:47 p.m., a general surgeon was consulted and arrived in the operating room. The surgeon noted that there was bleeding along the anterolateral edge of the patient’s duodenum and pancreas. The portal vein, common bile duct, and hepatic artery were transected. The urologist stated that he proceeded with a radical nephrectomy prior to liver vascular repair to avoid further liver vascular damage. Per the general surgeon’s note, hepatic warm ischemia time was one hour and fifteen minutes. After the nephrectomy was completed, the hepatic artery, portal vein, and common bile duct were repaired, including graft replacement.
At 5:30 a.m. on 04/18/2013, the urologist dictated his operative report.
On 04/18/2013, the patient was taken back to surgery after sanguineous fluid was found in the drain output. The general surgeon’s intraoperative findings included 1500 ml of intra-abdominal blood along with bleeding from a gonadal vessel and from the insertion of the renal vein on the vena cava. The family requested DNR status for the patient. The patient subsequently died.
The Board judged urologist’s conduct to be below the minimum standard of competence given failure to use proper surgical technique with correct tissue transection/ligation, failure to timely convert to an open procedure, and failure to consider hepatic artery and portal vein repair prior to proceeding with the performance of the nephrectomy.
The Board ordered the urologist to be reprimanded.
State: Arizona
Date: November 2016
Specialty: Urology, General Surgery, Nephrology, Oncology
Symptom: N/A
Diagnosis: Post-operative/Operative Complication, Cancer
Medical Error: Procedural error
Significant Outcome: Death
Case Rating: 3
Link to Original Case File: Download PDF
Wisconsin – Gynecology – Woman With History Of Breast Cancer, Rectal Cancer, Colorectal Resection, With Post-Menopausal Bleeding
In October 2013, a 62-year-old woman with a history of breast cancer, rectal cancer, colorectal resection, and ileostomy reversal presented to Gynecologist A for post-menopausal bleeding. Abdominal hysterectomy and bilateral salpingo-oophorectomy was recommended and a consent form was signed.
On 10/29/2013, Gynecologist A noted on the ultrasound the presence of a uterus and ovaries. Gynecologist A documented that the patient neither had a uterus nor ovaries.
On 11/25/2013, Gynecologist A performed an exploratory laparotomy with lysis of adhesions on the patient. As documented, Gynecologist A discussed with the patient and the family that she neither had a uterus nor ovaries.
On 3/10/2014, a gynecologist oncologist performed a total abdominal hysterectomy and bilateral salpingo-oophorectomy on the patient. It is not reported if the patient was eventually diagnosed with cancer.
The Board stated that Gynecologist A engaged in unprofessional conduct by increasing risk of harm to the patient. She was reprimanded with order for payment of costs.
State: Wisconsin
Date: November 2016
Specialty: Gynecology
Symptom: Gynecological Symptoms
Diagnosis: Gynecological Disease
Medical Error: Diagnostic error, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
Wisconsin – Radiology – Chest Wall Pain And Mass With Only Interstitial Lung Disease Reported On CT
In February 2009, a patient presented to his primary care physician with chronic chest pain. A CT scan was performed. On 3/9/2009, Radiologist A reviewed the CT scan of the chest and documented interstitial disease.
A high resolution CT scan was performed on 3/19/2009. Radiologist B reviewed the CT scan of the chest and affirmed findings of interstitial lung disease.
In August 2009, the patient followed up with his primary care physician and complained of a chest mass. A nurse noted that he had “a large mass in the middle of [his] chest.”
On 8/24/2009, Radiologist C remotely reviewed the patient’s CT scan of the chest. The 3/5/2009 and 3/9/2009 studies were made available to him. The clinical history stated “CT Chest Mass in Mid Chest.” The report stated, “Old granulomatous disease and chronic interstitial lung disease. Nodular pleural thickening right middle lobe. Stable findings compared to earlier examination.”
On January 2010, the patient presented to his physician with growing mass. A biopsy was performed revealing a solitary plasmacytoma of the sternum.
The patient died on 4/25/2010 after radiation treatment. Radiologist D reviewed all three CT scans and testified that the chest wall mass was present in all three.
Radiologist B and C were reprimanded for engaging in conduct that tends to constitute a danger to the health, welfare, and safety of a patient.
State: Wisconsin
Date: November 2016
Specialty: Radiology
Symptom: Mass (Breast Mass, Lump, etc.), Chest Pain
Diagnosis: Cancer
Medical Error: False negative
Significant Outcome: N/A
Case Rating: 4
Link to Original Case File: Download PDF
North Carolina – General Surgery – Alcohol Based Solution For Surgical Prep And Electrocautery Device Causes Complications During Lipoma Removal
The Board was notified of a professional liability payment made on 7/17/2015.
In preparation for the removal of a lipoma on a patient’s posterior neck, the surgery area and the hairline were treated with an alcohol based antibacterial solution called DuraPrep. Although the manufacturer’s recommended drying time is two to three minutes, the general surgeon allowed the DuraPrep to dry for approximately ten minutes. The general surgeon also blotted the patient’s neckline with a sponge. Seeing no visible residue on the blotting sponge, the patient’s head was covered with a drape. During the procedure, which was performed using open oxygen under monitored anesthesia care, strands of the patient’s hair covered with DuraPrep solution residue were ignited from the electrocautery. The oxygen, which had accumulated under the drapes, served as a fire accelerant. The patient was transferred by air with an endotracheal intubation to a burn center for flash burns to the midface, nose, mouth, eyelids, and right ear.
The Board believed the general surgeon responded appropriately to the intraoperative emergency and noted that the general surgeon sustained second degree burns to his hand trying to extinguish the flame. The Board also acknowledged the general surgeon and his operating team’s rapid response minimized harm to the patient.
The cause of the fire was multifactorial; however, the Board believed the surgeon was ultimately responsible for the patient’s safety during the operation. They recommended that in similar cases, the general surgeon should use a non-alcohol based skin prep, allow additional drying time, or use a non-sparking cautery, minimize the use of open oxygen, and use draping techniques that would allow adequate ventilation when open oxygen is used. The Board acknowledged that the general surgeon received additional training in surgical fire prevention and safety.
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: October 2016
Specialty: General Surgery
Symptom: Mass (Breast Mass, Lump, etc.)
Diagnosis: Post-operative/Operative Complication
Medical Error: Procedural error
Significant Outcome: N/A
Case Rating: 5
Link to Original Case File: Download PDF
California – Dermatology – Rosacea Treated With Intense Pulsed Light Treatment
On 5/5/2011, a patient presented to a cosmetic laser clinic. At this initial appointment, a nurse recommended that the patient receive Intense Pulsed Light treatment (“IPL”) utilizing the Lumenis One machine to treat rosacea, redness, and discoloration on his neck and chest. On 5/5/2011, a dermatologist approved the nurse’s treatment recommendations. The proposed IPL treatments were to be administered over three clinical visits. The patient was not informed of the potential risk of severe burn and significant scarring associated with IPL treatment.
On 5/16/2011, the patient underwent his first IPL treatment without any adverse outcome.
On 8/15/2011, the dermatologist performed the second IPL treatment on the patient’s neck and chest using the Lumenis One machine. At the time that respondent performed the second IPL on the patient, she had not previously reviewed the clinic’s written IPL protocol. The dermatologist did not adjust the settings on the Lumenis One machine and instead relied on the preset settings. The patient complained of extreme pain during this administration of the IPL treatment. The patient asked the dermatologist to stop the IPL treatment at least four times during the course of the treatment. The dermatologist did not stop the treatment, but only hesitated momentarily to wait for the patient to regain his composure.
The dermatologist continually made comments to coax the patient to proceed with the IPL treatment. The dermatologist did not adjust the settings on the Lumenis One machine during the course of the IPL treatment.
On 8/15/2011, following the IPL treatment, the patient observed two large purple spots with blistering on his chest.
On 8/19/2011, the patient returned to the clinic for an IPL follow-up appointment with the dermatologist. During this visit, the dermatologist diagnosed the patient with post-IPL second-degree burns to the neck and chest area.
On 6/7/2012, the patient returned to the clinic for an IPL follow-up appointment with the dermatologist. The dermatologist noted that the patient had hypopigmented rectangles on his chest.
The dermatologist failed to adequately inform the patient of the potential risks of IPL treatment including burns and scarring. The dermatologist failed to read the protocol governing the Lumenis One machine prior to treating the patient and failed to adjust the machine to a lower energy prior to treating the patient.
The Board issued a reprimand to the dermatologist and ordered the dermatologist to enroll in a clinical in-service training provided by the vendor of the IPL medical device.
State: California
Date: October 2016
Specialty: Dermatology
Symptom: Dermatological Abnormality
Diagnosis: Dermatological Issues
Medical Error: Procedural error
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
Kansas – Pediatrics – Unnecessary Use of Azithromycin In Viral Infection
On 2/27/2013, a 13-year-old female presented to a pediatrician for follow-up five days after a visit to the emergency department where she had complained of chest pain and had an abnormal D-dimer lab value. No patient education was documented related to the significance of the finding or the risk of a pulmonary embolism. The patient record appeared to have been signed with a stamp and not dated.
On 4/24/2013, the patient presented with complains of bilateral ear pain and sore throat. The patient’s past medical history stated “Significant for allergies.” However, at her previous appointment, it listed only left knee injury. There was no other information contained in her past medical history. The record was electronically signed by an advanced practice registered nurse (“APRN”) on 5/23/2013.
On 10/21/2013, the patient was seen by the APRN with complaints of vomiting, diarrhea, and abdominal cramping. At this appointment, the patient’s past medical history stated, “Noncontributory.” The APRN documented putting the patient on Phenergan 25 mg tablets #40 one by mouth every eight hours as needed, Bentyl 20 mg #40 one by mouth every eight hours as needed, and acidophilus tablets #20 one by mouth twice daily for ten days. The record was electronically signed by the APRN on 11/15/2013.
On 1/28/2014, the patient presented with cough, sore throat, hoarseness, body aches, and headache. Vitals were taken and documented within normal limits; however, no blood pressure or heart rate was documented. The patient was positive for cervical lymphadenopathy and flu A, rhonchi and wheezing were noted, and the pediatrician prescribed azithromycin. Azithromycin is not indicated for a viral infection and not otherwise justified in the absence of a non-current bacterial infection.
The patient record was signed electronically by the APRN on 3/19/2014.
The Board judged the pediatrician’s conduct to be below the minimum standard of competence given his failure to keep written medical records which accurately describe the services rendered to the patient, including patient histories, pertinent findings, examination results and test results. Also, the pediatrician prescribed, dispensed, and administered or distributed a prescription drug, in an improper or inappropriate manner.
The Board ordered that the pediatrician attend and successfully complete the Medical Record Keeping Seminar at the Center for Personalized Education for Physicians (“CPEP”). Also, the Board ordered that the pediatrician hire a medical scribe. Finally, the Board ordered that the pediatrician have another pediatrician monitor his work.
State: Kansas
Date: October 2016
Specialty: Pediatrics, Emergency Medicine
Symptom: Cough, Headache, Pain
Diagnosis: Infectious Disease
Medical Error: Improper medication management, Failure of communication with patient or patient relations, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
Kansas – Obstetrics – Administering Vaccines In A Pregnant Patient Without Consent
On 3/6/2013, a patient presented for a newborn screening. No pregnancy or labor and delivery history were documented. A family history was documented; however, no detail of family history was documented. The patient was not seen until eleven days after discharge.
On 7/3/2013, the patient presented to the obstetrician for her four month well exam. At that appointment, the patient was administered the following vaccines: Hib, PEDIARIX, PCV 13, and Rota. No consent form for the aforementioned vaccines was found in the record.
On 9/10/2013, the patient presented to the obstetrician for her six-month exam. The obstetrician electronically signed the record on 9/27/2013, approximately seventeen days later.
The Board judged the obstetrician’s conduct to be below the minimum standard of competence given his failure to describe the services rendered to the patient.
The Board ordered that the obstetrician attend and successfully complete the Medical Record Keeping Seminar at Center for Personalized Education for Physicians (“CPEP”). Also, the Board ordered that the obstetrician hire a medical scribe. Finally, the Board ordered that the obstetrician have another obstetrician monitor his work.
State: Kansas
Date: October 2016
Specialty: Obstetrics
Symptom: N/A
Diagnosis: N/A
Medical Error: Failure of communication with patient or patient relations, Ethics violation
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
Kansas – Pediatrics – Improper Documentation In A Patient With Cough, Wheezing, and Runny Nose
On 12/5/2012, a newborn patient presented for his two-week check. No family history, pregnancy, or labor and delivery history were documented. The patient was not seen until thirty-three days after discharge.
The patient was seen only a total of three times by six months of age. The medical record did not discuss why immunizations were late. The plan/treatment section of the record was word-for-word the same information as in other patient records.
On 8/26/2013 a pediatrician saw the patient. The pediatrician documented the patient had a cough, wheezing, and a runny nose. No other information regarding an exam was given outside of the patient’s vitals being taken. The pediatrician administered Microephrine 0.2 ml in the office. The record appears to have been stamped in the pediatrician’s signature, but there was no corresponding date.
On 9/3/2013, the patient presented to the pediatrician after being admitted to the hospital the week prior with croup, bronchiolitis, and respiratory distress. No information regarding the patient’s hospital stay was found in the pediatrician’s record.
The Board judged the pediatrician’s conduct to be below the minimum standard of competence given his failure to keep written medical records which accurately describe the services rendered to the patient, including patient histories, pertinent findings, examination results and test results.
The Board ordered that the pediatrician attend and successfully complete the Medical Record Keeping Seminar at Center for Personalized Education for Physicians (“CPEP”). Also, the Board ordered that the pediatrician hire a medical scribe. Finally, the Board ordered that the pediatrician have a pediatrician to monitor his work.
State: Kansas
Date: October 2016
Specialty: Pediatrics
Symptom: Cough
Diagnosis: N/A
Medical Error: Lack of proper documentation, Failure to examine or evaluate patient properly
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
Kansas – Pediatrics – Improper Documentation For Reactive Airway Disease And Improper Use of Bactrim
On 2/4/2013 a 7-year-old female presented to a pediatrician and saw the advanced practice registered nurse (“APRN”). The patient presented with chief complaints of allergies, congestion, and diarrhea. The patient was prescribed albuterol, Qvar 40 mcg, Bactrim, and triamcinolone. The Bactrim was prescribed inappropriately for diarrhea. The pediatrician agreed but thought that he had perhaps forgotten to document otitis media.
On 2/19/2013, the pediatrician saw the patient for a follow-up appointment. The pediatrician documented that the patient was there for a follow-up for her asthma, even though the patient previously presented with reactive airway disease. The pediatrician did not document his thought process in how reactive airway disease developed in asthma. The pediatrician did not electronically sign the record until 4/11/2013.
On 6/11/2013, the patient presented to the pediatrician for a school physical. The pediatrician failed to document the patient’s asthma. In the school health examination, the pediatrician stamped signature appears on the form with the date 6/11/2013. The pediatrician stamped the document “No” to the question, “Is this student subject to any condition which might cause a possible classroom emergency such as seizures, fainting, diarrhea, diabetes, asthma, allergies, etc.”
The Board judged the pediatrician’s conduct to be below the minimum standard of competence given his failure to keep written medical records, and inappropriately prescribing a medication.
The Board ordered that the pediatrician attend and successfully complete the Medical Record Keeping Seminar at Center for Personalized Education for Physicians (“CPEP”). Also, the Board ordered that the pediatrician hire a medical scribe. Finally, the Board ordered that the pediatrician have a pediatrician monitor his work.
State: Kansas
Date: October 2016
Specialty: Pediatrics
Symptom: Allergic Reaction Symptoms, Diarrhea
Diagnosis: Asthma
Medical Error: Lack of proper documentation, Improper medication management
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF