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On 7/25/2012, a patient presented to a plastic surgeon regarding having her breasts enlarged as well as making them more symmetrical.  The patient’s medical history was remarkable for arteriovenous malformations in her lungs, a heart murmur, bronchitis, asthma, sinusitis, arthritis, and kidney stones.  The patient also had a mildly obese abdomen with a hernia.  The plastic surgeon failed to document the patient’s hernia in the preoperative history and physical.  On 8/28/2012, the patient underwent a breast augmentation and a mini abdominoplasty.  No drains were placed.  The procedures were performed under local anesthesia with sedation using alprazolam (Xanax) and lidocaine for local anesthesia.  The breast augmentation was performed using a periareolar incision, and the implants were placed into a sub-pectoral pocket.  The patient had Allergan smooth, round, moderate profile implants placed.  On the left side, a 330 cc implant (presumably filled to 330 cc) was placed, and on the right side, a 420 cc implant was placed (presumably filled to 420 cc).  According to the operative report, a full abdominoplasty was also performed floating the umbilicus.  No drains were placed.

Postoperatively, the relationship between the patient and the plastic surgeon became “conflicted.”  The patient had severe pain in her left breast and in her lower abdomen, and the patient also had difficulty urinating.  No follow-up appointment was scheduled.  The patient was not given any contact information.  In order to reach the plastic surgeon, the patient had to rely on her friend who was a nurse in the plastic surgeon’s office at that time.  The plastic surgeon returned the patient’s call a day later but did not schedule a follow-up appointment for another 7 days.  The patient did not hear from the plastic surgeon until the day after surgery, and the plastic surgeon recommended that the patient come into his office on 9/5/12 (7 days after the surgery).

The patient followed up on 9/5/2012 at which time she voiced several complaints – namely, that her left breast was larger than the right, the right breast was very hard, the left breast implant could be felt moving in the pocket, and that the patient had significant pain in her left breast and stomach.  According to the plastic surgeon’s progress note for 9/5/2012, the patient was healing well, and there were no complications.  The patient continually had difficulty seeing the plastic surgeon postoperatively.  The visits were frequently canceled or rescheduled.  The plastic surgeon’s progress notes showed that the patient was seen on 9/13/2012, 9/19/2012, 10/3/2012, and 11/28/2012.  At the 11/28/2012 visit, the patient was found to have a mild keloid in the abdominal area.  The patient was given a topical corticosteroid cream and bleaching cream at that time and told to follow up in 2 months.  The patient’s last visit was on 1/23/2013, but the plastic surgeon did not document this visit.

On 2/6/2013, the patient asked for a letter from the plastic surgeon to state that everything was okay from his standpoint in regards to the procedures that were performed.  The plastic surgeon provided documentation on two prescription forms: on one, the plastic surgeon indicated that the breast implants were normal with no capsulitis, and on the other, the plastic surgeon indicated that the patient’s abdominoplasty did not have any pathology and was healing well without any complications.

The standard of care is that a surgeon is available for the post-operative care of his patients.  Itinerant surgery can be defined simply as surgery performed by a surgeon in a community where the surgeon is not available to provide post-operative care.  The plastic surgeon’s failure to make himself available or to provide timely post-operative care to the patient is an extreme departure from the standard of care.

The standard of care is that anesthesia should be provided in a manner to minimize discomfort for patients while optimizing their safety.  In this case, there was inadequate monitoring of the anesthesia administered to the patient, or the plastic surgeon failed to document the necessary monitoring.

The Medical Board of California judged that the plastic surgeon’s treatment of the patient was inadequate and an extreme departure from the standard of care because he failed to make himself available or to provide timely post-operative care to the patient, and there was inadequate monitoring of the anesthesia administered to the patient or he failed to document the necessary monitoring.

The Medical Board of California ordered that the plastic surgeon be placed on probation for 2 years and complete a medical record-keeping course and an education course (at least 25 hours per year for four years) equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California

Date: September 2015

Specialty: Plastic Surgery

Symptom: Chest Pain, Abdominal Pain, Urinary Problems

Diagnosis: Post-operative/Operative Complication

Medical Error: Failure of communication with patient or patient relations, Failure to properly monitor patient, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 1

Link to Original Case File: Download PDF

In 5/22/2012, a family practitioner saw a wheelchair-dependent female.  The family practitioner took an in-depth history with regards to the patient’s care with over 15 doctors, a hospitalization for severe pain, and a complete medical workup.  The patient told the family medicine physician that she had been bitten by a tick while working outside, after which she suffered from a target rash and joint pain typical of Lyme Disease.  The family practitioner had the patient sign a consent for treatment and another consent for treatment for IV antibiotics on 5/22/2012.  The records showed that the patient was advised that the use of the IV antibiotics had specific risks, such as sepsis related to a catheter infection, and that is why the family practitioner enforced monthly blood draws and monthly appointments while patients remained on intravenous therapy.  No physical examination was noted on the initial chart provided by the family practitioner regarding the patient’s functional capacity while confined to a wheelchair.  There was also no documentation of a supportive individual present with the patient, and she had stated that she had once been her boyfriend’s caretaker prior to falling ill herself.

The patient followed up with the family practitioner after the initial labs had been drawn on 6/29/2012.  The family practitioner charted in her notes that the patient was Lyme disease positive and prescribed IV antibiotics for the patient.  There were no vital signs charted on the preliminary notes provided or a physical exam charted.  The family practitioner informed the patient in the consent forms that Lyme Disease is a controversial disease and is largely a clinical diagnosis when the primary test, Western Blot, was negative.  The patient signed her consent understanding the risks were more severe with IV therapy than oral antibiotic therapy, and there was a greater need for accountability and follow up.

The patient’s records reflected notes for an 8/14/2012 “follow up.”  However, this appeared to be a “telephone appointment” during which the family practitioner notified the patient that her laboratory results came back positive for Lyme Disease.  The family practitioner asked her staff to email the test results and labs to the patient.  It appeared that prior to the telephone appointment, the patient had received three weeks of antibiotic therapy and had reported some improvement.  The patient was told to return in a month for her standard monthly laboratory tests and blood tests to be drawn prior to her appointment.

The patient returned on 8/18/2012 for her follow up appointment without any labs.  There were no vital signs or a physical exam of the wound site noted in the chart.  The patient told the family practitioner that she could not afford ertapenem, and she had several other concerns about how she could not get certain labs drawn or referrals due to cost.  As a result, the family medicine physician switched antibiotics, but first ordered an abdominal ultrasound to assess if the patient had a healthy gallbladder.

The family practitioner’s staff appeared to have asked the patient if she was working with a registered nurse to help her with weekly wound care and home assessments.  A registered home health nurse must provide chart notes to the attending physician who is supervising the patient’s care.  Thus, such an inquiry would be unnecessary if proper protocols were being followed.  The family practitioner’s records, or the lack thereof, indicated that she and/or her staff failed to communicate on a regular basis with nursing staff providing home health care monitoring to the patient, but the family practitioner’s re-written chart notes included new charted notes warning the patient of the consequences for non-compliance.  The specific entries were not present in the original provided notes produced and called into question when they were actually written.

In October 2012, the patient did not appear for her appointment.  She also went an additional month being non-compliant with labs, did not follow up with a neurologist, and did not enroll in physical therapy.  The family practitioner’s staff made several attempts to reach the patient to reschedule, but the family practitioner did not discontinue the IV antibiotics by calling the infusion center.  The patient was responsible for mixing and administering her own home IV antibiotics with no skilled nursing assistance.

In November 2012, the family practitioner’s staff reached out to the patient trying to reach her to come and make an appointment, but this call appeared to have occurred only because the infusion center notified the family practitioner’s clinic that they would no longer provide IV antibiotics to the patient due to non-payment.  The records for this month indicated that the family practitioner requested a referral for removal of the Hickman catheter and a request for the patient to come into the clinic to pick up that removal referral.  At no time did the family practitioner take responsibility and attempt to telephone the patient herself to warn her of the risk of sepsis if the Hickman catheter was not removed.  Although the patient listed her daughter as the emergency contact person, at no time did the family medicine physician’s office document that they tried to contact the daughter.

The family practitioner took a detailed history on the patient’s new patient intake but failed to assure that at least two other people would serve as contact points to ascertain that the patient was safe and capable of self-care.  In fact, the family medicine physician failed to determine the name or phone number of the patient’s boyfriend stated that she lived with as an emergency contact.

In December 2012, the patient’s sister, a registered nurse, found the patient at her home soiled in urine with adult diapers around the room.  When discovered, the patient was unable to even support herself to get in and out of her bed.  Also, the patient had fallen at some point in time and had fractured her hip and not sought medical care.  The patient’s sister eventually took the patient to the hospital, where the line sepsis was discovered and the Hickman catheter was removed.  The patient was hospitalized for three weeks on IV antibiotics as a result.

The Medical Board of California judged that the family practitioner committed gross negligence in her care and treatment of the patient given that she failed to take an appropriate intake history when she chose to allow the patient to do home IV therapy, failed to establish a point of contact and safety for the patient, allowed the patient to mix and administer her own IV antibiotics, and gave the patient a new ceftriaxone medication on 9/18/2012 even though the patient failed to obtain an abdominal ultrasound as ordered, which was necessary for the family practitioner to know if it was safe to administer ceftriaxone.  The family practitioner also failed to appropriately monitor and survey the safety of the patient’s home IV, cancel the home IV antibiotics in September 2012 when the patient failed to have her laboratory tests and blood draws done prior to her appointment or at all, and discontinue home IV antibiotics following the patient’s repeated failures to comply with the signed patient plan as well as failing to communicate on a regular basis with nursing staff providing home health care monitoring to the patient and/or the patient herself as to her status.

The Medical Board of California issued a public reprimand and ordered that the family practitioner complete a prescribing practices course, medical record-keeping course, and education course for at least 20 hours equivalent to the courses offered at the University of California San Diego School of Medicine (Program).

State: California

Date: September 2015

Specialty: Family Medicine, Infectious Disease, Internal Medicine

Symptom: Weakness/Fatigue

Diagnosis: Sepsis, Fracture(s)

Medical Error: Failure to examine or evaluate patient properly, Failure of communication with other providers, Failure of communication with patient or patient relations, Failure to follow up, Improper medication management, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 3

Link to Original Case File: Download PDF

On 2/25/2005, a plastic surgeon performed breast augmentation on a patient.  The plastic surgeon saw the patient for follow-up care in March, August, and October 2005, and he next saw the patient in October 2006 at which time he observed that she was healing well and did not have any complications.  The patient next presented to the plastic surgeon on 3/19/2009.  The patient was now 31-years-old.  She complained to the plastic surgeon of a mass in her left breast that she discovered after performing a regular breast self-examination.  After examining the patient, the plastic surgeon advised her that she was merely feeling the implant valve and reassured her.  The plastic surgeon did not follow up with timely diagnostic studies or reassessment.  Instead, the plastic surgeon advised her to return to see him if the mass changed.  The standard of care when dealing with a new breast mass discovered by a patient was to obtain a thorough history, perform a thorough physical examination, and follow up with timely diagnostic studies or reassessment.

On 10/21/2009, over 7 months later, the patient presented again to the plastic surgeon.  The patient was concerned that the mass was growing.  The plastic surgeon examined her.  The mass was painful on palpation and had grown.  The plastic surgeon referred her for a mammogram and ultrasound.  The patient had a mammogram, ultrasound, and breast MRI showing a malignant-appearing mass of the left breast.  On 11/13/2009, a breast biopsy confirmed a diagnosis of infiltrating high-grade ductal carcinoma.  The patient underwent chemotherapy and radiation treatment, but expired.

The Medical Board of California judged that the plastic surgeon’s treatment of the patient was inadequate and an extreme departure from the standard of care because he failed to order timely diagnostic examinations, have the patient return to see him within a specific time period to re-evaluate the mass, and document a complete breast examination after the March 2009 visit.

The Medical Board of California ordered that the plastic surgeon be placed on probation for 2 years and complete a medical record-keeping course and an education course (at least 25 hours per year for four years) equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California

Date: September 2015

Specialty: Plastic Surgery

Symptom: Mass (Breast Mass, Lump, etc.)

Diagnosis: Breast Cancer

Medical Error: Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Underestimation of likelihood or severity, Lack of proper documentation

Significant Outcome: Death

Case Rating: 4

Link to Original Case File: Download PDF

A 92-year-old female was an internist’s patient for many years.  On 5/25/2005, the internist first noted that the patient was “forgetting names more frequently.”  The internist did not note a mental status exam or treatment plan. On 12/5/2005, the internist noted that the patient was having nightmares and “memory was blanking at times.”  The internist did not note a mental status exam or treatment plan.

On 8/5/2006, the patient’s chart contained a mini-mental status exam (MMSE), graded 29/30, with no date or physician signature noted.  On 6/9/2008, the internist noted that the patient was disoriented and was experiencing “noises in the head.” The internist ordered a CT scan of her brain and a carotid ultrasound.  The CT scan showed age-related changes and an old frontal infarct. The carotid ultrasound showed minimal plaque.

On 9/18/2008, the internist again noted that the patient was experiencing memory problems, particularly with names.  Memory loss was noted repeatedly in progress notes through 2009 and 2010. On 1/4/2011, the internist noted memory dysfunction on Namenda.  No mental status exam or treatment plan was noted.

On 9/13/2012, the internist prescribed Targretin to the patient, 75 mg twice daily.  Targretin is a drug that has been approved by the FDA for the treatment of cutaneous T cell lymphoma.  In 2012, a study was published that showed that Targretin was effective in clearing certain neuritic plaques in mouse models of Alzheimer’s disease.  To date, no studies have been published with human Alzheimer’s subjects.

On 9/26/2012, the patient’s pharmacy sent a fax to the internist concerning a prescription for Targretin, indicating that it was not covered.  The internist then sent a prior authorization request to the pharmacy asking for Targretin to be approved for Alzheimer’s disease.

On 11/5/2012, the internist noted “trial Targretin, no benefit.”  The internist did not order any laboratory studies for the patient from 10/29/2010 until 12/5/2012.  During an interview with a Board investigator on 1/31/2014, the internist stated that he monitored the patient during her treatment with Targretin through telephone calls to the patient and her family.

On 12/6/2012, the patient noted “memory loss progressive.”  On 12/12/2012, the patient’s son sent a letter to the internist indicating that the patient’s husband should not be dispensing any medication to the patient and that another physician was now her primary care provider.

The standard of care in California is to perform an appropriate workup to support a diagnosis of dementia.  Their workup should include mental status testing, laboratory studies, brain imaging, or neurological specialist consultation.  Underlying causes of dementia include vascular dementia, Parkinson’s disease, drug intoxication, toxic disorders, psychiatric disorders, and degenerative disorders such as Alzheimer’s disease.  The standard of care in California is also to obtain written informed consent prior to treating a patient with a non-FDA approved medication. The standard of care is to monitor therapy with medication by performing appropriate blood tests that are recommended by the Physician’s Desk Reference or other publications.  Targretin is associated with lipid abnormalities and laboratory testing should be performed weekly while a patient is taking the drug. Liver function tests should be obtained prior to the start of the medication and at 1, 2, and 4 weeks thereafter, and, if stable, every 8 weeks. Thyroid blood tests and WBC counts should be obtained at baseline and periodically thereafter.

The Medical Board of California judged that the internist’s conduct departed from the standard of care because he failed to order an appropriate workup for a patient with documented progressive dementia and memory loss, did not pursue further studies prior to beginning treatment for Alzheimer’s, failed to obtain written informed consent from either the patient or her family prior to beginning treatment with Targretin, failed to monitor the patient through appropriate blood tests during the time that he treated her with Targretin, relied upon telephone calls to the patient and her family to monitor the patient’s functioning, and failed to maintain legible medical records.

The Medical Board of California issued a public reprimand and ordered the internist to complete a prescribing practice course and a medical record keeping course.

State: California

Date: September 2015

Specialty: Internal Medicine

Symptom: Psychiatric Symptoms

Diagnosis: Neurological Disease

Medical Error: Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Failure of communication with patient or patient relations, Failure to properly monitor patient, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

On 11/17/2006, a plastic surgeon performed ear surgery as part of a larger operation on a patient.  The plastic surgeon failed to describe the actual procedure performed on the patient in her medical records.  On 1/9/2007, the plastic surgeon injected the patient’s scars with Kenalog, a corticosteroid, for treatment of scar thickness.  The plastic surgeon failed to identify the location of the scars or the relative success of the injection in the patient’s medical records.  On 1/22/2007, 2/26/2008, and 4/5/2009, the plastic surgeon transferred fat from an unknown location on the patient to her submental area.  The plastic surgeon failed to document why these procedures were performed or the results in the patient’s medical records.

On 9/13/2007, 10/4/2007, and 10/25/2007, the plastic surgeon performed mesotherapy for which there were multiple solutions and solution concentrations available for mesotherapy.  The plastic surgeon failed to document what solution or solution concentrations he used on the patient in her medical records.  The plastic surgeon also failed to document the results of these procedures.  On 10/30/2007, the plastic surgeon used a needle to try to release scars around the patient’s chin.  The plastic surgeon failed to document the results in the patient’s medical records.  On 12/11/2007, the plastic surgeon performed a minor post-auricular scar revision on the patient but failed to describe the actual procedure performed on the patient in her medical records.

On 5/27/2008, the plastic surgeon documented that the patient was planning on having a chin implant and had requested eyelid skin removal.  The plastic surgeon failed to document why the chin implant was going to be placed or the goals of the implant.  On 6/4/2008, the patient consented to a chin implant, fat injection, and eye lift.  That same day, the plastic surgeon only performed a chin implant, but there was no documentation in the patient’s medical records indicating that the fat injection and eye lift were either performed or canceled.  There was also no documentation indicating that the plastic surgeon and the patient decided to only perform a chin implant or the reasons why only a chin implant was performed.  Also, the sticker from the chin implant that contains identification data for the prosthesis was placed in the chart next to a note dated 6/16/2008.  The sticker should have been placed in the chart next to the date on which the implant was used.

On 6/10/2008, the plastic surgeon prescribed a “refill” of Augmentin, an antibiotic, to the patient.  However, the initial antibiotic that the plastic surgeon ordered on 6/4/2008 was Penicillin, not Augmentin.  The plastic surgeon failed to indicate the reason why he prescribed additional and different antibiotics only six days after the chin implant that he performed on the patient.  The plastic surgeon also failed to document any assessment of the surgical incision or chin implant status in the patient’s medical records.  On 6/16/2008, the plastic surgeon removed the chin implant due to the patient’s insistence.  The chart entries indicated that the plastic surgeon could not convince the patient to wait until the swelling was resolved.  The plastic surgeon failed to document why the patient wanted the implant removed, what the physical examination showed, what his assessment of the surgical results was, or whether pre-operative goals were reached.

The Medical Board of California judged that the plastic surgeon failed to cease performing new procedures on a non-compliant patient.  The patient continued to smoke cigarettes despite the plastic surgeon’s instructions to stop, showed up to his medical office smelling of alcohol, and asked him for Vicodin to sell on the black market.  The patient had a poorly healing wound, which the plastic surgeon attributed to ongoing smoking.  There were also contentious interactions between them, such as telephone calls by the patient to the plastic surgeon’s home at odd hours in the middle of the night, sometimes while drunk.  In spite of the foregoing, the plastic surgeon continued to schedule and perform new elective procedures on the patient, including placement and later removal of the chin implant.

The Medical Board of California ordered that the plastic surgeon be placed on probation for 2 years and complete a medical record-keeping course and an education course (at least 25 hours per year for four years) equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California

Date: September 2015

Specialty: Plastic Surgery

Symptom: N/A

Diagnosis: N/A

Medical Error: Physician concern overridden, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 1

Link to Original Case File: Download PDF

A 34-year-old pregnant female, who had five previous vaginal deliveries, presented to Obstetrician A for prenatal care on 1/5/2012 at 16-weeks gestation.  The patient had a total of 7 visits with Obstetrician A. During her previous, most recent 2 pregnancies, the patient received treatment for gestational diabetes.  The delivery of her most recent baby, with a birth weight of 11 lbs 14 oz, was complicated by shoulder dystocia. The patient was again diagnosed with diabetes during her current pregnancy.

On 6/4/2012, the patient called the Obstetrician A’s office to report decreased fetal movement.  The patient was advised to go to labor and delivery for further evaluation. She did not go, but waited for her already scheduled appointment with Obstetrician A the following day.  At the patient’s appointment with Obstetrician A on 6/5/2012, Obstetrician A could not document fetal heart tones. An office ultrasound confirmed fetal demise, and the patient was referred to the hospital for admission and induction of labor.

At the hospital at around 3:00 p.m. on 6/5/2012, a repeat ultrasound was performed, which confirmed fetal demise.  The ultrasound indicated that the fetus had an estimated weight of 14 lbs 9 oz with the fetus in the vertex presentation, a markedly enlarged abdominal circumference, and a ratio of head circumference to abdominal circumference of 0.72.  Obstetrician A’s plan for the patient included having her admitted and inducing labor with misoprostol.

Misoprostol was first administered at 4:28 p.m.  Obstetrician A ordered Pitocin augmentation at 9:00 p.m.  By 9:40 p.m., the patient was having painful regular contractions, and she received a combined spinal epidural for anesthesia.  At 12:47 a.m., the following morning, the nurse contacted Obstetrician A to relay patient’s progress. The nurse expressed concern that the patient had experienced shoulder dystocia with her last delivery of a baby that was 11 lbs 14 oz and asked Obstetrician A whether she had considered Cesarean section for delivery.  Obstetrician A informed the nurse that she had no plans for Cesarean section due to the fetal demise and the fact that the patient had successfully delivered large babies in the past. The nurse continued the Pitocin augmentation as ordered.

At 6:16 a.m. on 6/6/2012, the nurse contacted Obstetrician A and asked her to come to the bedside for delivery.  Obstetrician A informed the nurse that she was on her way to the hospital and that the patient should begin pushing.  Obstetrician A subsequently arrived in the room at 7:15 a.m. At 7:30 a.m., the patient delivered the fetal head, but shoulder dystocia was encountered.  Obstetrician A was not successful in her attempts to free the shoulders and called for assistance.

Obstetrician B arrived at 7:38 a.m. and was able to deliver the posterior arm and free the shoulders to complete delivery at 7:45 a.m.  The time lapse between delivery of the fetal head and body was 15 minutes. The patient was then returned to Obstetrician A’s care. Placental delivery occurred approximately 4 minutes later.  Obstetrician A repaired a 1st degree perineal laceration and placed a vaginal pack due to some continued “oozing.” She then left the room to complete her charting. In her delivery note, Obstetrician A documented that the interval between delivery of the head and the body was “<90 seconds.”  Obstetrician A documented that she had performed a bimanual exam after placental delivery and that the vaginal vault was “inspected and noted free of foreign objects.” Estimated blood loss for delivery was charted by Obstetrician A as “>500 [ml],” and a complication was noted as “maternal hemorrhage, patient received methergine and ephedrine x2, two IV lines opened.”

At 7:49 a.m., about 4 minutes after placental delivery, the patient became hypotensive with a blood pressure of 83/44 and a pulse of 95.  At 7:57 a.m., the patient had a pulse of 115. Per Obstetrician A’s instructions, ephedrine was given to the patient three times between 7:54 a.m. and 8:16 am. For persistent hypotension, methergine was administered at 8:38 a.m. for postpartum hemorrhage.

At 9:00 a.m., the patient’s blood pressure was 71/41, pulse 140, and the nurse requested that Obstetrician A return to assess the patient.  At 9:03 a.m., 47 minutes after the last dose of ephedrine 10 mg, Obstetrician A returned to see the patient. After removing the vaginal packing, Obstetrician A noted heavy vaginal bleeding with large clots and suspected a cervical laceration.  Despite the additional medication, the patient’s blood pressure remained low and tachycardia was sustained between approximately 9:00 to 9:23 a.m. (53-66/32-40, pulse 133-141). At 9:23 a.m., when the patient’s blood pressure was 53/32, pulse 141, the nurse activated a “state OB team Bravo” code.

The patient was taken emergently to the operating room and arrived there at 9:33 a.m.  Transfusion was begun at 9:35 a.m., nearly 2 hours after the hemorrhage had begun. At 9:35 a.m., Obstetrician A reportedly identified a left cervical laceration and repaired a 5 cm defect.  She placed vaginal packing again, and then left the room to wash her hands. When the nurses were repositioning the patient, heavy bleeding was again noted, and Obstetrician A was called. Obstetrician A returned and attempted to identify the bleeding source.

While Obstetrician A was attempting to determine the source of the bleeding, Obstetrician B, who resolved the shoulder dystocia, returned to assist at 10:50 a.m.  Obstetrician B performed a bimanual exam, during which he ascertained that no normal cervix was palpable, and in the lower part of the uterus he was able to feel a defect in the paracervical tissue likely communicating with the broad ligament on the left side.  The two obstetricians agreed that emergent laparotomy with hysterectomy was necessary and called for a gynecologic oncologist for surgical assistance. At that point, the patient had been transfused 6 units of packed red blood cells, 4 units of fresh frozen plasma, and 1 unit of cryoprecipitate.

The gynecologic oncologist arrived in the operating room at 11:20 a.m. to assist the two obstetricians.  After performing a bimanual exam, the gynecologic oncologist confirmed Obstetrician B’s finding of the left paracervical defect and uterine rupture and noted that she could pass her hand directly from the patient’s vagina into her abdomen.  The gynecologic oncologist began a laparotomy at 11:32 a.m. and immediately noted approximately 4 L of blood in the abdomen. The patient’s blood pressure acutely dropped, her heart rhythm deteriorated to ventricular tachycardia, and Code Blue was called at 11:33 a.m.  A team of physicians and anesthesiologist worked collaboratively to perform transfusion, resuscitative, and surgical efforts. The gynecologic oncologist described the following injuries to the patient’s uterus and vagina: posterior uterine perforation defect of approximately 8 cm, perforation of lower uterine segment also lateral to the vagina extending into the broad ligament, and a 10 cm defect extending from the vaginal vault all the way down to the left pelvic sidewall.

The gynecologic oncologist began a hysterectomy on the patient at 1:00 p.m.  Additionally, she performed removal of the left ovary and repaired the vaginal laceration.  The patient exhibited disseminated intravascular coagulation and had ongoing bleeding. By the conclusion of the surgery, the patient had received a total of 73 units of packed red blood cells, 40 units of fresh frozen plasma, 11 units of platelets, 750 ml of 5% albumin, and approximately 20 L of normal saline.  After surgery, the patient was transported to the surgical ICU at 5:00 p.m. The patient subsequently went into cardiac arrest and was pronounced dead at 6:48 p.m.

The Medical Board of California judged that Obstetrician A’s conduct departed from the standard of care because she induced the patient and allowed her to labor and undergo vaginal delivery while knowing that the estimated fetal weight was 14 lb 9 oz and/or that the patient had experienced problems with shoulder dystocia in a previous vaginal delivery with a smaller fetus, failed to diagnose uterine rupture in a timely manner, failed to recognize the clinical signs and symptoms of massive postpartum hemorrhage (namely, ongoing bleeding with hypotension and tachycardia), and failed to treat massive hemorrhage promptly.

For this case and others, the Medical Board of California placed Obstetrician A on probation for 7 years and ordered Obstetrician A to complete a medical record keeping course, a professionalism program (ethics course), an education course (at least 40 hours per year for each year of probation), and a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.  Obstetrician A was also ordered to have a psychiatric evaluation and receive psychotherapy. Obstetrician A was required to have a practice monitor.

State: California

Date: September 2015

Specialty: Obstetrics

Symptom: N/A

Diagnosis: Obstetrical Hemorrhage

Medical Error: Improper treatment, Delay in diagnosis, Underestimation of likelihood or severity, Lack of proper documentation

Significant Outcome: Death

Case Rating: 5

Link to Original Case File: Download PDF

A 34-year-old female with severe mental retardation accompanied by her mother presented to a gynecologist during February 2012 with complaints of abdominal pain, dysmenorrhea, and heavy, long menstrual periods.  Imaging confirmed the presence of a large 30 cm by 8 cm by 22 cm uterus with masses consistent with uterine fibroids. The patient’s uterus was firm and filled her pelvis, extending above the umbilicus. Based on the gynecologist’s examination of, and tests performed on, the patient, the gynecologist decided, with the consent of the patient’s mother, to proceed with a total abdominal hysterectomy on 3/21/2012.

On 3/31/2012, the gynecologist began surgery at 2:08 p.m. with the assistance of another gynecologist.  The gynecologist performed a 12 cm low transverse (Pfannenstiel) incision. This incision was not adequate to perform the surgery, and the gynecologist converted the incision to a T-shape by creating a vertical midline incision.

During the course of the surgery and dissection, before a gynecologic oncologist arrived to assist, a clamp was inadvertently placed on the patient’s right ureter.  When it was recognized, the clamp was quickly removed.

The gynecologist called for a gynecologic oncologist to assist with the surgery.  The gynecologic oncologist noted inadequate surgical exposure for the size of the fibroid uterus and extended the vertical midline incision cephalad.  The physicians proceeded with, and completed, the patient’s hysterectomy. At the conclusion of the hysterectomy, the gynecologic oncologist noted that the patient’s right ureter appeared denuded over the course of a 2 cm segment.  The obstetrician then divulged that a clamp had been inadvertently placed across the ureter prior to the gynecologic oncologist’s arrival, more than 1 hour previously. The gynecologic oncologist consulted with a urologist, and a ureteral stent was placed.  The remainder of the operation proceeded uneventfully.

The Medical Board of California judged that the gynecologist’s conduct departed from the standard of care because she failed to make an adequate incision at the start of surgery and/or making a 12 cm low transverse incision for the removal of a large, firm, fibroid-filled uterus, which limited mobility and visualization and also extended above the patient’s umbilicus.  The gynecologist also failed to communicate the occurrence of the patient’s ureteral crush injury to the gynecologic oncologist in a prompt and/or timely manner.

For this case and others, the Medical Board of California placed the gynecologist on probation for 7 years and ordered the gynecologist to complete a medical record keeping course, a professionalism program (ethics course), an education course (at least 40 hours per year for each year of probation), and a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.  The gynecologist was also ordered to have a psychiatric evaluation and receive psychotherapy. The gynecologist was required to have a practice monitor.

State: California

Date: September 2015

Specialty: Gynecology

Symptom: Abdominal Pain, Gynecological Symptoms, Abnormal Vaginal Bleeding

Diagnosis: Gynecological Disease

Medical Error: Procedural error, Failure of communication with other providers, Delay in proper treatment

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

A 36-year-old female, who had one prior delivery by Cesarean section, presented to the hospital on 7/22/2010 at 36 weeks 3 days gestation complaining of painful regular uterine contractions.  The patient had been receiving prenatal care with her regular physician and was known to have a 10 cm fibroid in her lower uterine segment.

On 7/22/2010, an obstetrician was the physician on call and covering for the patient’s regular physician that day.  The patient arrived at the labor and delivery ward and was admitted to triage at 9:07 a.m. on 7/22/2012. She was examined by a nurse at 9:31 a.m. and found to be in active labor.  The patient reported that the fetus had been in the breech position earlier during the pregnancy, but the fetal presentation could not be determined by the nurse. Nursing notes documented that the obstetrician was at the patient’s bedside, discussing Cesarean section, planned incision, and her known uterine fibroids at 10:15 a.m.  At that time, the patient was prepared for surgery. Spinal anesthetic was complete at 10:20 a.m. The obstetrician entered a history and physical for the patient and signed this note at 10:26 a.m. The surgery started at 10:34 a.m.

The history and physical note completed by the obstetrician on 7/22/2010 at 10:26 a.m. made no mention of any vaginal or complete pelvic exam, an ultrasound being done after admission to check for fetal position, any detailed information about the patient’s fibroids, such as size, number, and/or location, documentation of informed consent for the surgery, any critical assessment of surgical risks in light of the patient’s large fibroid, any reference to the obstetrician having reviewed the patient’s prenatal chart of previous ultrasound imaging, and critical analysis for her surgical plan.  The obstetrician also did not consult with the patient’s regular physician before proceeding with surgery.

When dealing with an enlarged fibroid uterus, particularly in pregnancy, having adequate surgical exposure is critical to optimize care and minimize maternal and fetal risks.  A vertical skin incision would be the appropriate choice in these circumstances.

At 10:34 a.m., the obstetrician made a low transverse Pfannenstiel skin incision with another physician as her assistant.  She then noted that the baby was not breech, but vertex with the head somewhat entrapped behind the large uterine fibroid in the lower uterus.  The obstetrician encountered difficulty delivering the baby due to the lack of exposure and space and made a vertical midline incision on the patient’s skin down through the fascia allowing greater exposure of the uterus.  Delivery time was 10:50 a.m.

After the delivery, the obstetrician noted extensive bleeding from the classical uterine incision site.  A perinatologist was called in to assist. The obstetrician and assisting physicians decided that, in order to be able to close the uterine incision, removal of the 10 cm lower uterine fibroid was the best decision.  The obstetrician performed removal of the fibroid, followed by closing the uterine incision in layers. When hemostasis was assured, an intraperitoneal drain was placed in the left lower quadrant, and all fascial and subcutaneous layers were closed.  The obstetrician closed the low transverse and vertical midline (inverted T incision) with staples and applied a pressure dressing.

The Cesarean section was completed at 1:02 p.m.  The patient’s pre-operative hemoglobin was 13.5, and postoperatively, it was 7.5, indicating that the patient had lost approximately half of her blood volume with surgery.  The obstetrician recorded an estimated blood loss of 1500 ml during the patient’s surgery. The patient was transferred to the recovery room, where she was monitored. The nurse noted oozing from the incision area that gradually increased over the course of observation.

At 1:30 p.m., the patient’s blood pressure was 91/52 and her pulse was 122.  The obstetrician was paged by the nurse at 1:49 p.m. At 2:00 p.m., the patient’s blood pressure was 77/46 and pulse 112.  A CBC was returned at 2:15 p.m. with hemoglobin 7.5, hematocrit 21, and platelets 124. Coagulation studies were consistent with DIC.  From approximately 2:15 p.m. to 2:32 p.m., the patient continued to have hypotension, with a blood pressure ranging from 76-89/44-51 and a pulse range of 106 to 122.  At 2:32 p.m., transfusion of 2 units of packed red blood cells was started, as ordered by the anesthesiologist for the patient’s Cesarean section.

At 2:50 p.m., “state OB Team Bravo” code was called when the patient’s blood pressure was 64/29 and pulse 104.  Moderate oozing and bleeding was noted from her surgical incision, blood filled the surgical drain, the patient was having vaginal bleeding, and her abdomen was becoming distended.  CBC returned at 3:13 p.m. with hemoglobin 8.1 and platelets 109. Transfusion of the second unit of blood was complete by 3:21 p.m. The perinatologist performed a bedside ultrasound at 3:25 p.m., which confirmed large hemoperitoneum.  The decision was made to return to the operating room for exploratory laparotomy with likely hysterectomy. The gynecologic oncologist was called to assist.

The obstetrician arrived back at the patient’s bedside and/or again became directly involved in her care at 3:25 p.m.  After her arrival, the obstetrician took the patient for surgery with the gynecologic oncologist. At 4:24 p.m., CBC returned with hemoglobin 6.7 and platelets 84.  Surgery on the patient began at 4:30 p.m. Upon entry into the abdomen, the gynecologic oncologist noted 3-4 L of blood with continuous oozing from various surfaces of the uterine incision.  The gynecologic oncologist performed a hysterectomy with the obstetrician assisting. The gynecologic oncologist recorded an estimated intraoperative blood loss at approximately 1 L. During the surgery, the patient received a total of 8 units of packed red blood cells, 8 units of fresh frozen plasma, 1 unit of cryoprecipitate, and 1 platelet pack.

The Medical Board of California judged that the obstetrician’s conduct departed from the standard of care because she failed to recognize massive blood loss and the emergent need for transfusion and management during the patient’s Cesarean section and/or during her immediate post-operative period as well as failed to respond in a timely manner when she was paged at or around 1:49 p.m. in connection with a critical post-operative patient.  The obstetrician also failed to evaluate and examine the patient completely and/or adequately prior to starting her Cesarean section on 7/22/2010, and incorrectly made a low transverse incision.

For this case and others, the Medical Board of California placed the obstetrician on probation for 7 years and ordered the gynecologist to complete a medical record keeping course, a professionalism program (ethics course), an education course (at least 40 hours per year for each year of probation), and a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.  The obstetrician was also ordered to have a psychiatric evaluation and receive psychotherapy. The obstetrician was required to have a practice monitor.

State: California

Date: September 2015

Specialty: Obstetrics

Symptom: GI Symptoms (GERD, Abdominal Distention, Dysphagia), Abnormal Vaginal Bleeding, Wound Drainage

Diagnosis: Obstetrical Hemorrhage, Gynecological Disease

Medical Error: Delay in diagnosis, Failure to examine or evaluate patient properly, Failure of communication with other providers, Lack of proper documentation, Procedural error

Significant Outcome: N/A

Case Rating: 4

Link to Original Case File: Download PDF

A 28-year-old female was seen by an obstetrician, who was covering the patient’s usual obstetrician, on 10/19/2012.  The patient had one prior vaginal delivery. On 10/19/2012, the patient was admitted to labor and delivery at 11:00 a.m.  The obstetrician was at the patient’s bedside and/or was informed by a nurse at 12:12 p.m. that the patient’s cervix was 8 cm dilated, completely effaced, and zero station.  Spontaneous rupture of membranes occurred at 12:14 p.m. An hour later, her cervical exam was unchanged, the obstetrician ordered Pitocin for labor augmentation. The obstetrician left the hospital and went to the office to see patients.

At 3:32 p.m., the patient’s cervix was 9.5 cm dilated, at which time the nurse contacted the obstetrician and informed her of this.  According to the nurse’s note in the patient’s medical chart, the obstetrician told the nurse that the patient “may start pushing when ready,” and that she is “at office 10 minutes away.”  The patient began pushing at 4:00 p.m. At 5:11 p.m., the obstetrician was paged. 2 minutes later, when she responded, the nurse asked her to come evaluate the patient since the baby was not descending as expected, and the nurse thought the patient might need help.  At 5:25 p.m., the nurse again spoke to the obstetrician and informed her that the patient was going to deliver and that the obstetrician was needed immediately. The obstetrician informed the nurse that she was on her way, but was stuck in traffic due to heavy rain. The obstetrician instructed the nurse to call the “doc in the box” if needed for delivery.  Spontaneous delivery occurred at 5:31 p.m. with the nurse present. The obstetrician arrived at 5:47 p.m.

The Medical Board of California judged that the obstetrician’s conduct departed from the standard of care because she failed to be in attendance for the patient’s delivery.

For this case and others, the Medical Board of California placed the obstetrician on probation for 7 years and ordered the gynecologist to complete a medical record keeping course, a professionalism program (ethics course), an education course (at least 40 hours per year for each year of probation), and a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.  The obstetrician was also ordered to have a psychiatric evaluation and receive psychotherapy. The obstetrician was required to have a practice monitor.

State: California

Date: September 2015

Specialty: Obstetrics

Symptom: N/A

Diagnosis: N/A

Medical Error: Ethics violation

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

A 17-year-old female presented to a hospital emergency department on 5/3/2011 with complaints of 3 days of left lower quadrant pain.  She reported that the pain was similar to what she had experienced in the past when she had undergone laparoscopy with ovarian cystectomy in 2008 for ovarian cyst with torsion.

The ED physician consulted with a gynecologist, who was covering as the “doc in the box” that evening.  The gynecologist’s plan after assessing the patient was to take her to surgery for laparoscopy, left ovarian cystectomy, and possible laparotomy.  During the surgical procedure, which started at 3:51 a.m., the gynecologist encountered difficulty gaining laparoscopic access and, instead, converted the procedure to a laparotomy.  The gynecologist did not consult with a surgical colleague, who may have been able to gain laparoscopic access.

At the start of the surgical procedure on the patient, the gynecologist ordered the antibiotic, cefazolin 2 g, to be administered by anesthesia for prophylaxis.  The gynecologist later ordered a second dose of cefazolin for the patient. The 2 orders of cefazolin placed by the obstetrician were not indicated for the patient’s procedure.

The Medical Board of California judged that the gynecologist’s conduct departed from the standard of care because she failed to consult with a surgical colleague prior to abandoning attempts at laparoscopy and converting to laparotomy during the patient’s surgery and ordered the antibiotic cefazolin for the patient in circumstances in which it was no indicated.

For this case and others, the Medical Board of California placed the gynecologist on probation for 7 years and ordered the gynecologist to complete a medical record keeping course, a professionalism program (ethics course), an education course (at least 40 hours per year for each year of probation), and a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.  The gynecologist was also ordered to have a psychiatric evaluation and receive psychotherapy. The gynecologist was required to have a practice monitor.

State: California

Date: September 2015

Specialty: Gynecology

Symptom: Abdominal Pain

Diagnosis: N/A

Medical Error: Failure of communication with other providers, Improper medication management, Unnecessary or excessive treatment or surgery

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF