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



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