Found 10 Results Sorted by Case Date
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California – Cardiothoracic Surgery – Triple Coronary Bypass Operation For Less Than 50% Stenosis



On 8/24/2001, a 58-year-old non-insulin dependent diabetic patient with hypercholesterolemia and systemic hypertension was transferred to a medical center.  The patient complained of chest pains. ECG was negative for acute abnormalities and was essentially normal. At the medical center the patient was referred to Cardiologist A, who thereafter conducted cardiac catheterization and coronary arteriography on the same day as admission to the medical center, having concluded that the patient was “high-risk,” without first conducting further non-invasive testing, exploring the fact that the patient’s symptoms responded to oxygen, or otherwise obtaining additional coronary “markers” prior to instituting invasive testing.  Cardiologist A also failed to assess the patient’s anticoagulation status prior to proceeding with the intravenous ultrasound study and failed to continue antiplatelet therapy or initiate beta blockers for the patient, despite diagnosing the patient as having acute coronary syndrome and there being no contraindications for continuation of the medication. Cardiologist A spent 3 minutes on the recorded angiography, with 3 angiograms obtained.

Based on the referenced catheterization and arteriography, including angiography and intravenous ultrasound studies, Cardiologist A recorded diagnoses for the patient indicating that the right coronary artery had “definite ulceration with combination of dissection immediately after its origin.  Angiographically it is 80%, but as usual, the angiogram is underestimating the lesion and character of the plaque… The left coronary system shows moderate narrowing estimated to be 50%.” Cardiologist A also recorded “moderate left main artery disease,” “high grade stenosis,” and “diffuse disease with multiple ulceration,” and a “lumen compromise of probably higher than 80%.” In addition, Cardiologist A recorded an overall diagnosis of “acute coronary syndrome secondary to multiple unstable plaque through the system.”  Cardiologist A failed to record whether his angiographic diagnoses were based on angiography or ultrasound, but recommended the patient “… for triple vessel coronary disease as soon as possible.” referring the patient to Cardiothoracic Surgeon A for multivessel coronary bypass surgery or a “triple bypass.”

Review of the patient’s coronary angiogram revealed that, notwithstanding Cardiologist A’s recorded diagnoses to the contrary, the patient had no ulcerations, no dissections and no significant coronary stenosis such that bypass surgery would be indicated.  Review of the patient’s intravascular ultrasound study revealed no ulceration or dissection. The patient’s record, including angiography and IVUS, provided evidence of calcification and mild to moderate plaques in some areas, but no significant stenosis. The smallest lumen measured 8 mm, which does not indicate significant narrowing of the lumen, and the maximum area of stenosis found was 50%, or less than the hemodynamically significant standard of a 70% narrowing.  The patient record revealed no signs of ischemia or infarction, and only non-obstructive coronary atherosclerosis, which Cardiologist A misinterpreted as critical coronary artery disease requiring immediate surgery.

Based on Cardiologist A’s erroneous diagnostic examination and conclusions and his recommendation for coronary artery bypass surgery, the patient was referred to Cardiothoracic Surgeon A for surgical consultation prior to a proposed coronary artery bypass graft procedure. Cardiothoracic Surgeon A relied on Cardiologist A’s angiography and diagnosis and concluded that the patient was an appropriate candidate for triple bypass. In doing so, Cardiothoracic Surgeon A failed to first obtain a thallium study to determine whether the patient’s myocardium was actually ischemic, as Cardiologist A had indicated. Cardiothoracic Surgeon A further failed to conduct an independent review of the patient’s angiography to determine the extent of cardiac disease equal to or greater than 70% narrowing of the arteries proposed for bypass.  Thereafter, on 8/27/2001, Cardiothoracic Surgeon A performed a triple bypass coronary artery graft procedure on the patient. The patient recovered from this unnecessary procedure without incident.

Cardiothoracic Surgeon A’s reliance on Cardiologist A’s erroneous angiographic testing and diagnosis, his failure to conduct appropriate Thallium testing to confirm the diagnosis in the face of inadequate angiography as provided by Cardiologist A, and his proceeding with a triple coronary artery bypass operation on the patient when the diagnostic indications were such that surgery was not indicated and other less invasive forms of intervention were available or appropriate constituted gross negligence.

For this allegation and others the Medical Board of California, Cardiologist B was placed on probation for three years as well as ordered to attend an education course, an ethics course, a PACE program, and be assigned a practice monitor.

State: California


Date: September 2009


Specialty: Cardiothoracic Surgery, Cardiology


Symptom: Chest Pain


Diagnosis: Cardiovascular Disease


Medical Error: Unnecessary or excessive treatment or surgery, Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Improper medication management


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Cardiothoracic Surgery – Coronary Artery Bypass Surgery Performed For Minor Coronary Artery Disease



In March 2002, a 52-year-old female presented to her primary care physician with complaints of exertional chest pain and shortness of breath.  Her primary care physician referred her to Cardiologist A for evaluation and stress testing. A persantine nuclear study was performed at the medical center on 3/19/2002, which demonstrated a small focal defect that was partially reversible, at the junction of the anterior and septal walls approaching the apex of the patient’s heart.  The patient’s ECG was normal. A wall motion study showed concentric contraction with normal thickening during systole.

On 4/2/2002, Cardiologist A diagnosed the patient as having acute coronary syndrome, admitted her to the medical center, and performed a diagnostic cardiac catheterization and coronary angiography, including intravenous ultrasound.  Cardiologist A interpreted the angiography as showing unstable angina due to multiple complex vulnerable plaques burdening 75% of the lower anterior descending artery, with a dissection at the distal ⅓ of the LAD and circumflex. He referred the patient for coronary bypass surgery.  Cardiologist A urged the patient and her family members to approve the proposed surgery, describing the plaques he claimed he saw in the angiogram as “hanging down like hamburger.” Cardiologist A suggested that the patient’s grandchildren might find her dead if she did not undergo the proposed coronary bypass procedure.  A subsequent review of Cardiologist A’s angiography, however, revealed that the patient only had borderline single vessel disease with no significant luminal irregularities, fissuring or dissections present. Neither of the patient’s 2 suspect coronary vessels demonstrated significant stenosis, unstable vulnerable plaque, or dissection.  Her circumflex had no significant stenosis and the left anterior descending artery showed no significant narrowing beyond significant stenosis in the luminal area. Despite the misinterpretation of the patient’s angiography by Cardiologist A, the patient was referred to Cardiologist B for coronary artery bypass graft surgery of both the undiseased circumflex and the LAD.

On 4/7/2002,  based on the referral from Cardiologist A, Cardiothoracic Surgeon A examined the patient for possible coronary artery bypass graft surgery of her circumflex and LAD arteries.  In his history and physical examination of the patient, Cardiothoracic Surgeon A simply restated Cardiologist A’s findings on heart catheterization and obtained the patient’s consent to surgery. Cardiothoracic Surgeon A recorded as indications for surgery that “coronary angiography demonstrates she has severe coronary artery disease with high-grade stenosis of the left anterior descending and circumflex, confirmed by intravascular ultrasound.” Thereafter, on 4/9/2002, Cardiothoracic Surgeon A performed the proposed surgery, using only vein conduits rather than the preferred LIMA for bypass material. Cardiothoracic Surgeon A failed to record any reason for failing to utilize the LIMA for the bypass, use of which would provide the patient with a greater likelihood of patent success and durability of the graft.

Cardiothoracic Surgeon A’s decision to proceed with coronary artery bypass graft surgery on the patient’s circumflex and LAD arteries based on Cardiothoracic Surgeon A’s erroneous interpretation of the patient’s angiogram and IUS studies and his findings of stenosis and disease constituting a narrowing of greater than 70% when in fact the patient had only minor, if any, coronary artery disease, constituted gross negligence. Cardiothoracic Surgeon A’s failure to thoroughly review the patient’s angiographic studies independently of Cardiologist A, as well as his failure to consider a pulmonary workup for other possible causes of the patient’s shortness of breath prior to performing surgery further constituted gross negligence.

For this allegation and others the Medical Board of California, Cardiothoracic Surgeon A was placed on probation for three years as well as ordered to attend an education course, an ethics course, a PACE program, and be assigned a practice monitor.

State: California


Date: September 2009


Specialty: Cardiothoracic Surgery, Cardiology


Symptom: Chest Pain, Shortness of Breath


Diagnosis: Cardiovascular Disease


Medical Error: Unnecessary or excessive treatment or surgery, Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Procedural error


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Cardiothoracic Surgery – Quadruple Coronary Artery Bypass Surgery Performed On Patient With 40-50% Stenosis



On 7/15/2002, a 76-year-old diabetic, hypertensive, and hypercholesterolemic woman presented to Cardiologist A at a medical center with complaints of progressive intermittent substernal chest pain for approximately 1 week.  The patient had a prior history of coronary artery disease and had undergone balloon angioplasty of the left anterior descending artery in 1994. She had been under Cardiologist A’s care since that time. When the patient presented, she was given an echocardiogram, which Cardiologist A failed to read before ordering her to present to the emergency room where he performed catheterization with an intravenous ultrasound.  Despite the fact that the ECG was normal, Cardiologist A did not perform any other noninvasive tests before ordering invasive catheterization. Without any data or medical indication, therefore, Cardiologist A diagnosed the patient as having “suspicion for Acute Coronary Syndrome.” Cardiologist A recorded the patient as having high-grade stenosis of the lateral anterior descending artery and the first diagonal branch artery with multiple unstable, vulnerable plaques, high-grade stenosis of the acute marginal branch of a nondominant right coronary artery and moderate stenosis of the left circumflex artery “with haziness suggesting unstable plaque.” Cardiologist A referred the patient to Cardiothoracic Surgeon A with his recommendation that she undergo multi-vessel coronary artery bypass graft surgery.

Subsequent review of the patient’s records revealed that, notwithstanding Cardiologist A’s interpretation of the results of the patient’s angiogram, the patient actually had only moderately diffuse disease in the middle segment of a relatively small lower anterior descending artery, with no focal stenosis, and only moderate disease of the proximal segment of a non dominant right coronary artery.  The LCA was large and dominant with a 40-50% focal stenosis distally, but with no evidence of haziness or a filling effect indicative of unstable plaque. There were no high grade or critical lesions. Cardiologist A’s recommendation that the patient undergo multivessel CABG based on the data and information available to him was unwarranted.

On 7/19/2002, Cardiothoracic Surgeon A examined the patient and obtained her consent to surgery, apparently based on Cardiologist A’s erroneous interpretation of the patient’s angiographic results.  The patient underwent 4 vessel bypass surgery on 7/19/2002 with Cardiothoracic Surgeon A. Thereafter, on 7/21/2001, as a result of this unnecessary surgery, the patient suffered a major embolic stroke which she had yet to fully recover.

Cardiothoracic Surgeon A’s decision to perform quadruple coronary artery bypass graft surgery on the patient when her angiographic test results revealed only 30-50% stenosis and without first obtaining more objective tests such as Cardiolite or thallium tests, or a stress echo test to determine whether the patient had CAD with appropriate indications for surgery, constituted gross negligence.

For this allegation and others the Medical Board of California, Cardiothoracic Surgeon A was placed on probation for three years as well as ordered to attend an education course, an ethics course, a PACE program, and the assignment of a practice monitor.

State: California


Date: September 2009


Specialty: Cardiothoracic Surgery, Cardiology


Symptom: Chest Pain


Diagnosis: Cardiovascular Disease


Medical Error: Unnecessary or excessive treatment or surgery, Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 3


Link to Original Case File: Download PDF



Wisconsin – Vascular Surgery – Perioperative Bleeding During Left Carotid Endarterectomy



On 07/10/2006, the vascular surgeon performed a left carotid endarterectomy with an AcuSeal graft on a 73-year-old woman.  At the end of the surgical procedure, protamine was administered to the patient to reverse the heparin.  Attempts to stop the oozing from the suture line continued for 80 minutes.  No clots were observed, and three ampules of thrombin were sprayed over the suture line.  Platelets were also administered, but oozing continued from the suture line.  There was no arterial bleeding.  The vascular surgeon made the decision to keep the patient intubated after the operation, and a critical care specialist was consulted.  Following the endarterectomy, the patient was admitted to the surgical intensive care unit.

In the morning of 07/11/2006, the vascular surgeon assessed the patient, including an assessment of the neck and mouth, on two occasions.  The vascular surgeon determined that in his professional opinion there was no surgical contraindication to extubate the patient.  There was a dispute between the parties as to whether the vascular surgeon issued an order to extubate the patient or whether he advised the nurse that the patient could be extubated after consultation with the intensivist.

The intensive care nurse contacted the respiratory therapist who extubated the patient.  The nurse noted in the chart that the vascular surgeon had given a verbal order that it was “okay to extubate the patient.”  When asked to complete his charts, the vascular surgeon became aware of the nurse’s entry and after consultation with the Chief of Quality Assurance, made a correction to reflect that the order had actually been that it was “okay to extubate if okay with [vascular surgeon] et. al.”  The vascular surgeon then signed both entries.

A formal complaint had been filed alleging that the vascular surgeon placed the patient at risk for harm by failing to properly evaluate the patient’s airway or to seek consultation with an intensivist prior to ordering extubation of the patient.

It is unclear from the Public Records if the patient failed extubation or if the patient developed complications from a failed extubation.

The Board understood the ongoing dispute between parties and made no determination regarding this allegation.  The Order did not constitute disciplinary action against the vascular surgeon.

The Board ordered that the vascular surgeon complete The Sterling Healthcare “The Difficult Airway Course: Anesthesia;” the “Case Western Reserve: Intensive Course in Medical Record Keeping;” and the National Center of Continuing Education’s Strategies for Developing Communication Between Nurses and Physicians.”

State: Wisconsin


Date: September 2009


Specialty: Vascular Surgery, Critical Care Medicine


Symptom: Bleeding


Diagnosis: Post-operative/Operative Complication


Medical Error: Failure of communication with other providers, Procedural error


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Alaska – Dermatology – Fluconazole Prescribed For A 10.5 Month Old With A Skin Rash



An Ob/Gyn physician advertised specializing in cosmetic dermatology despite not holding a certification in dermatology.

On 06/14/2005, the Ob/Gyn physician saw a 10.5 month old given skin rash of the feet that was spreading to involve the body.  It was documented that the patient had erythematous dry patches involving the thigh, trunk, scrotum, and chest.  The physician diagnosed systemic mycosis and placed the patient on fluconazole for 14 days.

On a later date, the mother took the patient to a dermatologist for a second opinion.  The patient was diagnosed with seborrheic dermatitis with distribution involving the scalp, trunk, and extremities.  The dermatologist treated the patient’s condition with Nizoral shampoo, topical corticosteroids, and antipruritic topical creams.

The Board judged the Ob/Gyn’s conduct to be below the standard of care given that he provided improper treatment for seborrheic dermatitis and failed to refer the patient to a dermatologist.  The Board noted that the medical records lacked any record of a complete dermatological examination.

The Board ordered that the Ob/Gyn physician cease the practice of dermatology and cease advertising of dermatological services.  He was placed on probation for 5 years and ordered to complete 12 hours of medical education.  He was reprimanded and fined.

State: Alaska


Date: September 2009


Specialty: Dermatology


Symptom: Dermatological Abnormality


Diagnosis: Dermatological Issues


Medical Error: Improper treatment, Ethics violation, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Alaska – Dermatology – Use Of IPL For Rosacea Leads To Complications



An Ob/Gyn physician advertised specializing in cosmetic dermatology despite not holding a certification in dermatology.

On 08/18/2005, the Ob/Gyn physician saw a patient who presented with redness, bumps, and swelling on her face.  The physician diagnosed her condition as rosacea and recommended noritate cream.

On 09/19/2005, the patient returned to the Ob/Gyn physician, who treated the patient’s facial erythema with Intermittent Pulse Light.  The patient had excessive pain for 14 days after the procedure.  Her facial erythema did not resolve with treatment.

The patient also had a rash on her hands.  The Ob/Gyn physician diagnosed the rash as eczema, and recommended use of a light box.

The patient saw a second opinion from a dermatologist, who took a biopsy of the rash, which revealed granuloma annulare.

According to the Board, the medical records did not adequately document the history, symptoms, and physical exam findings.  There was no formal operative report for the IPL treatment.

The Board ordered that the Ob/Gyn physician cease the practice of dermatology and cease advertising of dermatological services.  He was placed on probation for 5 years and ordered to complete 12 hours of medical education.  He was reprimanded and fined.

State: Alaska


Date: September 2009


Specialty: Dermatology


Symptom: Dermatological Abnormality


Diagnosis: Dermatological Issues


Medical Error: Improper treatment, Ethics violation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Alaska – Internal Medicine – Improper Treatment For Osteoporosis



On 08/06/2004, a patient with a history of an esophageal B-ring (a Schatzki ring) and GERD complicated by esophagitis presented to an Ob/Gyn physician with a “hormonal complaint.”  The Board noted that the Ob/Gyn physician performed an inadequate physical examination and then completed a Certificate of Medical Necessity for Hyperbaric Oxygen Therapy.  He wrote in the Narrative Description on the form “Aseptic Necrosis Hip” and “osteoporosis.”  The patient had severe osteoporosis and a prior vertebral fracture.

There was no documentation noted to support the diagnosis of aseptic necrosis of the hip.  For the patient’s osteoporosis, the Ob/Gyn physician prescribed risedronate for osteoporosis.

The patient completed 17 days of hyperbaric oxygen therapy.  The patient’s insurance company declined coverage for the hyperbaric oxygen therapy with the following reason: “I am unaware of any significant data to support the use of HBOT for osteoporosis…”

The Board judged the Ob/Gyn’s conduct to be below the minimum standard of care given failure to avoid risedronate in a patient with a Schatzki ring.  He ordered hyperbaric oxygen therapy for osteoporosis, for which there is no significant data.

Given multiple other acts of gross negligence or professional incompetence, the Division placed the Ob/Gyn physician on probation for 5 years and ordered him to complete 12 hours of medical education.  He was reprimanded and fined.

State: Alaska


Date: September 2009


Specialty: Internal Medicine, Family Medicine


Symptom: N/A


Diagnosis: Musculoskeletal Disease


Medical Error: Improper treatment


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Alaska – Internal Medicine – Supplements For Hypertension



On 12/03/2008, the patient presented to an Ob/Gyn Physician with severe menstrual cramping.  The Ob/Gyn physician took her blood pressure and told her she was obese, had hypertension, and had a thyroid problem without performing a physical exam, pelvic exam, or obtaining laboratory confirmation.  He recommend that the patient purchase supplements directly from him for $200 a month to lower her blood pressure.

The Board judged the Ob/Gyn’s conduct to be below the minimum standard of care given that he suggested the prescription of supplements alone would treat the patient’s hypertension, which is not supposed by mainstream medical literature and represents deceit, fraud, and intentional misrepresentation.

Given multiple other acts of gross negligence or professional incompetence, the Board placed the Ob/Gyn physician on probation for 5 years and ordered him to complete 12 hours of medical education.  He was reprimanded and fined.

State: Alaska


Date: September 2009


Specialty: Internal Medicine, Family Medicine


Symptom: Gynecological Symptoms


Diagnosis: Cardiovascular Disease


Medical Error: Improper treatment, Ethics violation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Alaska – Dermatology – Use of Intermittent Pulse Light Leads To Scarring



An Ob/Gyn physician advertised specializing in cosmetic dermatology despite not holding a certification in dermatology.

On 05/01/2006, the Ob/Gyn physician saw a patient with redness of her cheeks and chin.  The Ob/Gyn physician diagnosed her with rosacea and used Intermittent Pulse Light (IPL) on her cheeks, nose, and chin.  The patient developed swelling, bruising, and a 1.5 cm blister involving her left cheek.

In 3 weeks, the Ob/Gyn physician told the patient that her skin issues would respond to an Obagi chemical peel program.  The patient developed scarring involving her cheeks, which she described as white blotches within red areas involving her cheek.

The medical records lacked any record of a complete dermatological exam, and there was no documentation to support the diagnosis of rosacea.  The operative report lacked detail in how IPL was administered.

The Board ordered that the Ob/Gyn physician cease the practice of dermatology and cease advertising of dermatological services.  He was placed on probation for 5 years and ordered to complete 12 hours of medical education.  He was reprimanded and fined.

State: Alaska


Date: September 2009


Specialty: Dermatology


Symptom: Dermatological Abnormality


Diagnosis: Dermatological Issues


Medical Error: Improper treatment, Ethics violation, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Alaska – Dermatology – Use Of Intermittent Pulse Light Leads To Left Eye Swelling And Scarring



An Ob/Gyn physician advertised specializing in cosmetic dermatology despite not holding a certification in dermatology.

On 06/19/2006, a patient presented to the Ob/Gyn physician with erythema of the cheeks and nose.  The patient was diagnosed with rosacea.  The Ob/Gyn physician treated the patient using Intermittent Pulse Light (IPL)  on her face and failed to provide eye protection.  The patient developed swelling and blistering on the skin of her cheeks when driving home from the physician’s office.  Her left eye was swollen shut for several days.

On 06/21/2006, the Ob/Gyn physician saw the patient on follow-up and diagnosed her with a first-degree burn.  The Ob/Gyn physician said that the swelling, bruising, and blistering would heal in 10 days.  The patient developed a permanent scar on her face.

On 08/11/2006, the patient presented to a dermatologist for a second opinion.  He noted erythematous plaques overlaying the right and left malar cheeks with induration of the skin and sclerosis at the inferior margin of the “scar” on the left malar cheek.  He diagnosed erythematous scarring induced by IPL for telangiectasias of the cheeks.

The Board judged the Ob/Gyn physician’s conduct to be gross negligence given failure to provide eye protection to the patient during the use of IPL.  The medical records lacked any record of a complete dermatological exam, and there was no documentation to support the diagnosis of rosacea.

The Board ordered that the Ob/Gyn physician cease the practice of dermatology and cease advertising of dermatological services.  He was placed on probation for 5 years and ordered to complete 12 hours of medical education.  He was reprimanded and fined.

State: Alaska


Date: September 2009


Specialty: Dermatology


Symptom: Dermatological Abnormality


Diagnosis: Dermatological Issues


Medical Error: Improper treatment, Ethics violation, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



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