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2 fined for treating wrong patient


By Carol Gentry

8/14/2009 © Health News Florida

Patients in the hospital may want to start wearing prominent name tags; apparently those little ID bracelets aren’t enough, judging from two cases that came before the Florida Board of Medicine this morning.

In remarkably similar cases, nephrologist Ankush Gulati of Fort Myers and surgeon James Westervelt of St. Petersburg were charged with treating the wrong patient after they mistakenly went into the wrong hospital room. Both cases were reported to the state by the hospitals, as required by law.

The board accepted settlement agreements for each physician, worked out by Florida Department of Health prosecutors and attorneys for the doctors, calling for a “Letter of Concern,” a fine, and community service. In accepting the agreements, the doctors neither accepted nor denied the accusations. They were not present at the board’s meeting in Jacksonville.

The Gulati case occurred at Palms West Hospital in Loxahatchee in July 2006, when another physician asked him to consult on a case of a woman he suspected had multiple myeloma. She was in room 216.

By mistake, Gulati went into room 217. The patient he ended up examining actually had viral meningitis.

Gulati had been asked to determine whether the patient needed to have a Quinton catheter installed and a procedure called plasmapheresis, in which blood cells are separated from plasma. The red blood cells are infused back in the patient; the plasma is treated and then returned.

Gulati decided the patient he examined did need those things. After a surgeon installed the catheter – it’s unclear from the records where it was placed – a nurse discovered the mistake. Gulati removed the catheter and canceled the order for plasmapheresis before it was carried out.

An expert for the health department said that while the patient suffered no permanent harm from the mistake, it was a violation of the standard of care to provide unnecessary treatment. 

In the other case, surgeon Westervelt was asked to place a central venous catheter on a patient who was on the sixth floor at Bayfront Medical Center. He went into a room on the south wing instead of the north wing.

There, he examined the 85-year-old woman patient and talked with her and her family about the need for the central line, and they agreed to let him place it.

As in the other case, a nurse caught the mistake. Westervelt contacted the woman’s primary-care physician, who decided she would be better off if he left the central line there. It wasn't clear in the records what happened to her.

Westervelt’s fine was $10,000. Gulati’s was $5,000. 

--Carol Gentry, editor of Health News Florida, can be reached at 727-410-3266 or by e-mail.