Found 22 Results Sorted by Case Date
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Virginia – Gastroenterology – Patient Records Conversation During Colonoscopy



On 4/18/2013, while performing a colonoscopy on a patient, a gastroenterologist made demeaning statements/inferences regarding the patient’s lack of manliness, the nature of a purported rash on the patient’s penis, and the patient being high maintenance.

When the Board was made aware of this occurrence in June 2015 through subsequent media attention, it obtained court documents which revealed that, while being driven home following the procedure, the patient discovered he had inadvertently recorded on his cellular telephone the remarks and conversations by and between the gastroenterologist, the treating anesthesiologist, and the medical assistant during the procedure.

Although the patient never filed a complaint with the Board, court documents revealed that the patient claimed to have suffered distress, embarrassment, and loss of sleep as a result of hearing the remarks.

The gastroenterologist stated that this experience gave him a much greater appreciation and recognition of the need to consistently and diligently exercise greater professionalism and to maintain appropriate decorum for communications in a healthcare setting.  He further stated that he now realizes he must have a greater sensitivity toward his patients and that he will take a more assertive approach toward his medical team to prevent unprofessional events from occurring.

The Board issued the gastroenterologist a reprimand.

State: Virginia


Date: March 2016


Specialty: Gastroenterology


Symptom: N/A


Diagnosis: N/A


Medical Error: Ethics violation


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



California – Vascular Surgery – Surgery For Ischemic Limb With Post-Operative Complications



On 1/27/2009, a 74-year-old female was brought to the emergency department by ambulance.  She was diagnosed with exacerbation of congestive heart failure and admitted to the intensive care unit (ICU) for further care.

Her past medical history was significant for severe coronary, peripheral, cerebrovascular, pulmonary, and renovascular occlusive disease.  The patient also had a history of previous myocardial infarction, hypertension, hyperlipidemia, and chronic obstructive pulmonary disease with more than twenty years of tobacco abuse.  The patient’s past surgical history was significant for heart bypass with porcine aortic valve replacement, carotid endarterectomy, left femoral endarterectomy, renal and iliac stent placements.  In the emergency department, it was noted that the patient had new onset of atrial fibrillation.

On 1/27/2009, the patient complained of left arm pain.

On 1/28/2009, doppler and CT angiogram were performed.

On 1/28/2009, a vascular surgeon saw the patient to evaluate the patient’s left arm acute arterial occlusion.  “Thrombectomy +/- angioplasty” was recommended after cardiac clearance.

At 8:25 a.m. on 1/30/2009, surgery was performed.  Percutaneous thrombectomy with atherectomy, angioplasty, and stent placement were done in multiple arteries of the left upper extremity.  An Angio-seal closure device was used in the right femoral access site.  A 6 mm x 10 cm Viabahn stentgraft was placed into the brachial artery and a 7 mm x 29 mm Cordis Genesis stent was placed into the subclavian artery.  Clinically, the patient’s left hand was significantly worse after surgery and needed reexploration.

On 1/31/2009, the vascular surgeon recommended anticoagulation with heparin on and possible fasciotomy.  Fasciotomy of the left forearm was subsequently performed with no improvement.  The patient’s left forearm experienced clinical deterioration over the next few days.

On 2/2/2009, the patient was transferred to a different hospital by request of her family.  The patient was unstable and required a blood transfusion on arrival.  The patient’s left arm was non-viable, and no blood flow to the left forearm or hand was documented on angiography.

On 2/7/2009, the patient required an amputation just below the left elbow level.

After transfer to this different hospital, the patient also developed ischemic symptoms in both lower extremities.  An attempt at endovascular treatment was unsuccessful.

On 2/10/2009, she underwent open bilateral iliofemoral thromboembolectomies with patch angioplasties.  A malpositioned Angio-seal was found in the right common femoral artery.  This operation was successful and the patient had no further ischemic episodes.

The Board judged the vascular surgeon’s conduct to have fallen below the minimum level of competence for the following reasons:

1) Failing to appropriately assess and document the condition of the patient’s arm and hand.

2) Failing to create an appropriate treatment, plan.

3) Failing to adequately perform a physical exam on the patient.

4) Deferring surgery until 1/30/2009, and not heparinizing the patient while she was awaiting surgery.

5) Using atherectomy in the arm for acute arterial occlusion instead of thrombolysis.

6) Using a stentgraft in the brachial artery rather than suture repair and failing to remove the embolic material in the hand.

7) Delaying transfer of the patient to the other hospital, where thrombolytic therapy was available.

8) Failing to recognize the progressive ischemia of the patient’s hand during the post-operative period.

9) Delaying commencing heparin in the post-operative period.

10) Delaying fasciotomy and lack of re-exploration with palmar arch embolectomy or thrombolysis to address distal embolization in view of a dying hand.

11) Failing to acknowledge the patient’s dead hand, which was documented on her arrival to the other hospital.

12) Failing to recognize a persistent, progressive limb-threatening situation in the post-operative period.

13) Failing to recognize that the patient had right lower extremity ischemia, which is a known and accepted complication after intraluminal placement of the Angio-seal closure device.

14) Failing to adequately note the condition of the patient’s hand during the early post-operative period and whether there had been improvement and then deterioration.

15) Failing to document evidence that the patient’s hand was viable as suggested by the vascular surgeon.

16)  Failing to discuss all options and alternatives.

The Board issued a public reprimand with the stipulation for the vascular surgeon to enroll in a medical record keeping course.

State: California


Date: March 2016


Specialty: Vascular Surgery


Symptom: Extremity Pain


Diagnosis: Acute Ischemic Limb, Cardiovascular Disease, Post-operative/Operative Complication


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


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 3


Link to Original Case File: Download PDF



Virginia – Internal Medicine – Traveling Out Of The Country Without Making Arrangements



An internist closed his practice from 11/2010 to 3/2011 and from 10/28/2011 to 10/25/2012 while traveling out of the country without making arrangements for patient coverage, informing his patients when he would be returning and reopening his practice, and notifying interested parties that the office was to be closed for an extended period of time.

His practice consisted of chronic pain management patients, and he routinely prescribed buprenorphine for narcotic addiction.  During the closure of his office from October 2011 to October 2012, at least one pharmacist and one law enforcement officer attempted to verify questionable prescriptions with the internist by calling and visiting the office on multiple occasions but they were unable to contact the internist.

While he was out of the country, multiple individuals attempted to fill prescriptions for opiates written under the internist’s name.  The internist later identified these prescriptions as fraudulent.

In February 2014, after a robbery at his internal medicine practice, he closed the office indefinitely without providing advance notice to the patients and without providing his patients the instructions for obtaining copies of their medical records.  He put a sign on the door: “Due to a robbery, this practise [sic] has been closed untill [sic] further notice.  Please find another doctor.”

On 2/3/2014, while on one or more telephone calls with a patient, he activated the telephone’s speaker function, which enabled 14 patients in the waiting area to hear both sides of the conversation.  During the conversation, the patient requested an appointment to obtain a prescription for buprenorphine, which the internist had been prescribing to her for 4 months to treat an opioid addiction.  The internist subsequently asked the patients who overheard the conversation to write summaries of what they heard, which he later provided to the Board’s investigator because he believed the patient had falsely accused him of “abuse” and had filed a complaint about him with the Board.  The internist later dismissed the patient from his practice without providing a documented notice to the patient that would allow the patient to obtain the services of another practitioner.

At office visits on 4/30/2013 and 5/14/2013, he prescribed oxycodone and methadone to a patient given that the patient said he had been on 90 mg of oxycodone, 18 mg of diazepam, and 30 mg of methadone daily.  The patient’s statements contradicted the information in his Prescription Monitoring Program file, which revealed that he had not been prescribed those medications in the eight months prior to his 4/30/2013 office visit.  The internist documented that the patient’s urine screen was positive for opiates.

Based on his care of the above patients among others, the Board ordered the suspension of the internist’s license for not less than eighteen months.  He was ordered to surrender his Drug Enforcement Administration certificate.

State: Virginia


Date: March 2016


Specialty: Internal Medicine


Symptom: N/A


Diagnosis: N/A


Medical Error: Ethics violation, Improper medication management


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Family Medicine – Normal Physical And Pelvic Exam With Presentation Of Abdominal Pain And Cramps For 48 Hours



On 1/16/2014, a patient went to a family practitioner’s medical practice with complaint of abdominal pain and cramps.  The patient was accompanied to the appointment by her partner, who was present in the examination room during the entire examination.  The family practitioner’s electronic medical record for this visit indicated that the patient’s chief complaint was “cramps not feeling well”  The Subjective section of the medical record indicated that the patient was there for a “physical exam. Without complaint aside from pelvic cramps.”  The note further stated that the cramps occurred for over 48 hours regardless of menstrual cycle. The patient indicated the cramps included lower abdominal muscle spasms and low back pain.  In the Objective portion of the note, the family practitioner completed all fields indicating that he conducted an entire review of systems and physical examination. The family practitioner specifically noted that the patient’s abdomen was “soft, no tenderness, no masses, BS normal.”  The family practitioner also noted completing a pelvic examination, which was noted as normal. In the Assessment portion of the note, the family practitioner indicated that he performed a physical examination that was normal, completed a pap smear, provided the patient non-steroidal anti-inflammatory medication for the cramps, and suggested that the patient maintain a food log to determine if the cramps were caused by food allergies.  In the plan portion of the note, the family practitioner indicated that he would check the patient’s lab work and to follow-up with her after she completed a food log. There was no differential diagnosis for this patient encounter. The family practitioner did not sign the electronic medical record until 4/14/2014.

Several hours after leaving the family practitioner’s office on 1/16/2014, the patient continued to worsen and went to the emergency department, where she was diagnosed with acute cholecystitis (inflammation of the gallbladder).  The patient was admitted to the hospital and subsequently underwent emergency surgery to remove her gallbladder.

Afte producing the medical records to the Medical Board, the family practitioner placed an addendum in the patient’s medical file on 7/2/2014 indicating that he only conducted a pelvic examination and not a pap smear.  Also, he provided an electronic patient sign-in page that indicated the patient was being seen for a “wellness examination,” and she was having “cramps not feeling well.”

On 11/13/2014, an investigator with the Health Quality Investigation Unit on behalf of the Medical Board interviewed the family practitioner.  During the interview, the family practitioner admitted that he incorrectly charted that he performed a pap smear when he in fact did not conduct a pap smear.  The family practitioner stated that he believed that the patient was only in his office for her annual physical, and he conducted an examination with that as the focus.  The family practitioner could not recall whether anyone else was present in the examination room during the patient’s examination.

The Medical Board of California judged that the family practitioner’s conduct departed from the standard of care because he delayed signing the medical chart until 4/14/2014 almost 4 months after the initial visit as well as completing an addendum to the visit in July and failed to diagnose the patient with acute cholecystitis, that included his failure to document and formulate a differential diagnosis.

The Medical Board of California ordered the family practitioner to surrender his license.

State: California


Date: March 2016


Specialty: Family Medicine, Internal Medicine


Symptom: Abdominal Pain, Back Pain


Diagnosis: Acute Abdomen


Medical Error: Failure to examine or evaluate patient properly, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Radiology – Personal Computer Without FDA 510(k) Certification Used To Interpret Pelvic Radiographic Image



An 87-year-old male was discharged on 7/9/2009 from a medical center after having suffered a heart attack.  On 7/9/2009, the patient was placed in a care center, a skilled nursing facility. According to the medical records for the patient, prepared and maintained by the care center, the patient suffered an unwitnessed fall on 7/13/2009 while walking to the bathroom.  Subsequent evaluation by nursing personnel documented the complaint of right hip pain by the patient. Two radiographic views of the pelvis, both of which evidenced poor quality, were obtained by a mobile radiology service used by the medical center. The views were sent via teleradiology for remote site interpretation by the radiologist.

The internist interpreted these poor quality view of the patient’s pelvis using his personal computer and/or laptop computer.  In 2009, at the time of this occurrence, these devices did not have FDA 510(k) certification for issuing final diagnostic image interpretation reports.  Furthermore, due to the patient’s age, there was particular urgency regarding the certainty of the status of the hip and pelvis. If the hip/pelvis was broken, the consequences could be very serious and even life-threatening.  Despite this, the radiologist interpreted these poor quality views of the patient’s pelvis and issued a preliminary and final report that the patient had moderate osteoarthritic changes of the right hip without fracture or dislocation.

Based upon radiographic interpretation rendered by the radiologist, the patient’s treatment at the care center remained unmodified, and the patient continued to be ambulatory and to receive physical therapy despite the patient’s documented complaints of continual right hip pain.  On 7/17/2009, the patient was discharged to his home by the care center.

On 7/18/2009, the patient returned to the emergency department with the complaint of severe right hip pain in addition to weakness and the inability to walk.  The medical evaluation revealed a right femoral neck fracture and substantial blood loss secondary to the unrecognized fracture of the right hip, which the radiologist failed to identify previously.

On 7/19/2009, following stabilization of the patient, a right hip arthroplasty was performed.  On the morning of 7/22/2009, the patient was found apneic and pulseless, and efforts at cardiopulmonary resuscitation were unsuccessful.

The Medical Board of California judged that the radiologist’s conduct departed from the standard of care because he failed to identify the hip fracture, recognize the poor image quality of the x-rays and not ordering a new x-ray or, in the alternative, another test, such as a CT or MRI exam, and relied on personal laptop computers not properly certified for use in teleradiology.

The Medical Board of California placed the radiologist on probation for 2 years and ordered the radiologist to complete an education course.  The radiologist was also assigned a practice monitor and prohibited from supervising physician assistants.

State: California


Date: March 2016


Specialty: Radiology


Symptom: Joint Pain, Weakness/Fatigue


Diagnosis: Fracture(s)


Medical Error: False negative, Failure to order appropriate diagnostic test


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Colorado – Radiology – PET/CT Scan Read As Negative For Cancer In A Female With An Abnormal Carcinoembryonic Antigen Test



In 2012, a 57-year-old female was found to have an abnormal carcinoembryonic antigen test.  In January 2013, she had a PET/CT scan performed.  A radiologist interpreted the scans as “no PET CT evidence of local or distant metastatic disease.”

Ten months later, the patient had a subsequent PET/CT scan, which revealed an enlarging hypermetabolic mass in the medial segment of the left lobe of the patient’s liver.  The finding was visible on the patient’s January 2013 scans.

The Board judged the radiologist’s conduct as having fallen below the standard of care given failure to correctly interpret the patient’s PET/CT scans, leading to delay in the diagnosis of her liver cancer.

The Board issued a letter of admonition.

State: Colorado


Date: March 2016


Specialty: Radiology


Symptom: N/A


Diagnosis: Cancer


Medical Error: False negative


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Kansas – Obstetrics – History Of Hypertension And Presentation With Vaginal Bleeding And Cramping



On 2/25/2013, a 26-year-old pregnant female with a history of four prior pregnancies, resulting in four prior premature births, presented to the emergency department with complaints of vaginal bleeding and cramping.  The patient was documented to have a history of hypertension and an ultrasound confirmed an intrauterine pregnancy.

The patient was scheduled to see an obstetrician for follow-up care the following morning but failed to keep the appointment.

On 5/30/2013, the obstetrician saw the patient for an appointment.  He designated the appointment as the patient’s first prenatal visit. At the time of the appointment, the patient’s blood pressure was documented as 198/154.

That same day, the obstetrician sent the patient for a sonogram and lab tests with a follow-up appointment to be scheduled in two weeks.  Lab results showed that the patient had a urinalysis protein of 100, but there was no documentation showing the obstetrician reviewed the results or that the patient was contacted with the results.

On 6/4/2013, the patient returned to the obstetrician’s office.  The patient’s blood pressure was documented as 202/136.

The patient was subsequently admitted to a clinic that same day at approximately 5:00 p.m. with hypertension and severe headache.  The obstetrician’s admission diagnosis was documented as severe chronic hypertension, single intrauterine pregnancy at twenty-nine weeks.

The nursing notes for the patient’s admission to the clinic document that the patient arrived from the obstetrician’s office for a non-stress test and labs.  The nursing staff further documented that the patient was experiencing a severe headache with the right side of her head feeling numb.  Her blood pressure was documented at 208/129.

The obstetrician initially ordered pregnancy-induced hypertension lab testing but canceled the ordered labs.  The patient was given labetalol 400 mg by mouth twice daily with the first dose administered at approximately 5:37 p.m.  Two non-stress tests were also completed.

After the administration of Labetalol, the patient’s blood pressure slowly dropped with systolic measurements in the 160’s and diastolic measurements in the 90-100’s.

At 7:20 p.m., the clinic staff informed the obstetrician of the patient’s high blood pressure and requested medication and parameters.  The obstetrician instructed the staff that the patient was to be left alone and do nothing different.

At 8:00 p.m., orders were obtained by the staff to administer Tylenol for the patient’s continued headache.  However, the Tylenol was not effective as the patient continued to complain of a severe headache.

No new orders were issued for the remainder of 6/4/2013, but staff continued to document the patient’s blood pressure and fetal heart tones. The patient’s systolic measurements remained between 170-220’s and diastolic measurements remained in the 100’s.

At 4:47 a.m. on 6/5/2013,  the patient’s fetal heart tones were documented to have decreased to 125 for approximately 140 seconds, and then returned to baseline.  At 5:38 a.m., the patient was given labetalol 400 mg by mouth.

At 8:55 .m., the patient was documented as resting and denied having a headache or pain.

At 10:13 a.m., the obstetrician saw the patient and ordered a twenty-four hour urine protein.

At 3:25 p.m., the patient again complained of a constant, dull headache.  The patient was given Tylenol 1000 mg orally and later complained that she was feeling “shaky all over.”

At or around 4:03 p.m., the staff notified the obstetrician of the patient’s status, including the fact that the patient had an elevated blood pressure in spite of labetalol.  They asked whether the patient should be on bed rest.  The notified the obstetrician of the patient’s complaint of headache, shakiness, and limited voiding.  They asked if these issues could be related to preeclampsia.  The obstetrician gave no new order or diagnosis and stated that he would be on the OB floor in approximately an hour.

At 4:59 p.m., the patient was documented with a continued complaint of a headache when she moved her eyes.

At 5:20 p.m., the obstetrician was in to see the patient and again wrote orders reiterating the patient’s diagnosis of severe chronic hypertension, and ordered an EKG, echocardiogram, ophthalmology consult, continued twenty-four hour urine protein, and labetalol 20 mg IV bolus with a repeat dose of 40 mg IV if the patient’s blood pressure were to be greater than 160/110 after ten minutes, and to continue Labetalol 400 mg by mouth twice daily.

At 5:40 p.m., the obstetrician dictated the patient’s history and physical for her admission.  The obstetrician documented the patient had severe hypertension; had 100 mg/dl of proteinuria; had no headaches, and had “[n]o sign of preeclampsia at this time.”

The patient received an additional 80 mg of labetalol IV at 8:57 p.m. and her blood pressure remained in the severe level above 160/110, only dropping briefly to 185/115 before returning to the 200’s systolic and 120’s to 130’s diastolic.

On or about 6/6/2013, the patient’s blood pressure remained elevated despite receiving labetalol 40 mg IV at 12:57 a.m., 20 mg IV at 2:00 a.m., and 40 mg IV at 4:12 a.m.

The obstetrician was updated on the patient’s blood pressure status, but was not in to see the patient until 10:35 a.m.  At that time, the obstetrician ordered labetalol 400 mg by mouth every eight hours.

The patient’s previously ordered twenty-four urine protein results was 1953 mg/dl.  The obstetrician was notified by staff of the patient’s results and was documented as saying the patient’s protein was good.

The patient’s blood pressure continued to run in the 210-220’s systolic and 120’s-130’s diastolic

At 6:37 p.m., the obstetrician dictated a progress note for the patient documenting the patient as having severe chronic hypertension.  The obstetrician also noted the patient was on labetalol 400 mg three times daily and that the patient’s blood pressure remained high.  The obstetrician planned to continue the patient’s labetalol.

The patient’s blood pressure remained elevated and at 9:58 p.m. the obstetrician was notified of the situation and the patient’s complaint of a headache.  No new orders were given.

At 10:22 p.m., the obstetrician called to check on the patient’s condition.  The patient continued to complain of a headache and had a documented blood pressure of 221/129.

At 10:25 p.m., the obstetrician ordered “hydralazine 10 mg SIVP over 2 min x 1 Now” for the patient’s symptoms.

At 1:08 a.m. on 6/7/2013, the staff again contacted the obstetrician with the patient’s high blood pressure and headache.  The obstetrician gave orders for repeat a hydralazine 10 mg SIVP and for the patient to be started on magnesium sulfate.  Twenty minutes later the obstetrician ordered the magnesium sulfate to be held.

The patient continued to have a headache and at 1:42 a.m. was documented to complain of blurry vision.  The staff notified the obstetrician of the patient’s symptoms and continued headache.

At 5:34 p.m., the fetal heart rate dropped to sixty for two and a half minutes with recovery to the 120’s.

The patient continued to complain of a headache and at 5:49 p.m. the staff documented the patient as stating, “I feel like there is something wrong with me…I just don’t feel myself…headache is not going away and I feel weird.”

At 6:10 p.m., the obstetrician was in to see the patient who was complaining of upper abdominal pain, increasing headache pain and decreased urine output.  The obstetrician ordered the staff to give the patient hydralazine 10 mg SIVP, and magnesium sulfate 4 gm bolus followed by magnesium sulfate 2 gm/hr and betamethasaone intramuscularly.

The obstetrician also decided to transfer the patient to a different medical center for further care.

At 7:58 p.m., the patient was discharged to EMS care for transfer to a medical center.

In the obstetrician’s discharge summary for the patient, he documented that the patient was admitted with a diagnosis of “severe chronic hypertension with superimposed preeclampsia.”  In addition, he noted that he had given the patient three doses of labetalol, but failed to mention the three previous doses given during the early morning hours on 6/6/2013.

The board judged that the obstetrician failed to adhere to applicable stand of care to a degree constituting ordinary and/or gross negligence due to the following omission: the obstetrician delayed involving other specialists to assist the patient’s care and treatment, failed to acknowledge the patient’s proteinuria and high blood pressure, failed to diagnose and treat the patient’s severe preeclampsia, placed the patient at an increased risk for placental abruption, seizures, and renal damage, and stroke, and the obstetrician delayed to transfer the patient to a facility that could care for the patient and her premature infant.

The Board revoked the obstetrician’s license.

State: Kansas


Date: March 2016


Specialty: Obstetrics


Symptom: Bleeding, Headache, Numbness, Abdominal Pain, Vision Problems


Diagnosis: Preeclampsia


Medical Error: Underestimation of likelihood or severity, Delay in proper treatment, Failure to follow up, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



North Carolina – Pediatrics – Testicular Pain, Tenderness, And Swelling With Ultrasound Scheduled In 2 Days



In June 2015, the Board received report of a malpractice settlement payment.

On 08/27/2011, a 14-year-old male presented with pain, tenderness, and swelling of the right testicle for two days.  The internist’s diagnosis was “testicular swelling, rule out hydrocele.”  He prescribed ibuprofen and Augmentin.

The internist scheduled an ultrasound for 08/29/2011, at which time the patient was diagnosed with testicular torsion.  The testicle had become necrotic and was surgically removed on that day.

The independent medical expert judged the internist’s  conduct to be below the minimum standard of competence given failure to order an ultrasound to be done immediately or failure to refer the patient to a urologist on an emergency basis and failure to document a suspicion for testicular torsion.

The Board ordered the internist to be reprimanded and pay a $1,000.00 disciplinary fine.

State: North Carolina


Date: March 2016


Specialty: Pediatrics, Internal Medicine


Symptom: Pelvic/Groin Pain


Diagnosis: Testicular Torsion


Medical Error: Delay in proper treatment, Diagnostic error


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



North Carolina – Orthopedic Surgery – Placement Of Wrong Sided Trochanteric Nail For Hip Fracture Repair



The Board was notified of a professional liability payment made in January 2015 on behalf of an orthopedic surgeon.

On 10/20/2012, in West Virginia, an orthopedic surgeon operated on an 87-year-old female who had recently fractured her right hip.  The orthopedic surgeon used a trochanteric nail to repair the fracture.  The orthopedic surgeon requested that an assistant provide the orthopedic surgeon with a right-sided trochanteric nail.  The orthopedic surgeon was provided with a left-sided trochanteric nail, which was inserted.  This insertion resulted in post-operative pain and complications.

On 10/29/2012, a subsequent surgery was required to replace the wrong sided trochanteric nail and repair the injury caused by placing it.

The Board obtained the patient’s records and sent them to a qualified independent medical expert for review.

The independent medical expert judged the orthopedic surgeon’s conduct to be below the minimum standard of competence given failure to use a “time-out” procedure where the trochanteric nail box was reviewed to ensure that it was the correct side, failure to look at the trochanteric nail prior to insertion to ensure that it was bowed in the proper direction, and failure to take x-rays in the operating room at the end of the operation to verify that the correct trochanteric nail was inserted properly.

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.  A fine of $1,000.00 was issued.

State: North Carolina


Date: March 2016


Specialty: Orthopedic Surgery


Symptom: Extremity Pain


Diagnosis: Post-operative/Operative Complication, Musculoskeletal Disease


Medical Error: Wrong use of medical device


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Urology – Difficulty Voiding And Gross Hematuria With A CD Containing Poor Quality Of Ultrasound Results



On 11/30/2011, a urologist first saw a patient after he was referred to the urologist by his primary care physician.  The patient was a 72-year-old male who complained of difficulty voiding and gross hematuria.  Prior to referring the patient to the urologist, his primary care physician had ordered a pelvic and renal ultrasound.

The urologist was provided with the written report of the pelvic ultrasound ordered by the patient’s primary care physician, which suggested a suspicious mass in the bladder.  Despite this finding, at the 11/3/2011 examination, the urologist failed to obtain any urine markers for bladder cancer.

Although the urologist claims to have been aware that the renal ultrasound was performed, the urologist’s notes from the 11/3/2011 examination make no reference to the renal ultrasound or its report.  His notes also make no mention of any plans to obtain or request the patient’s renal ultrasound or its report.  The renal ultrasound noted a lower right kidney mass.

The urologist claims that the patient subsequently brought him a copy of a CD containing the renal ultrasound results; however, the CD was of poor quality and unreadable.  There is no mention in the patient’s records of the CD or that it was viewed or that any effort was made to obtain an acceptable copy of the renal ultrasound results.

On 11/3/2011, the urologist ordered a cystoscopy, which revealed no masses but an enlarged prostate and a red area with a large blood vessel on the prostate.  The urologist diagnosed the patient with hematuria due to an enlarged prostate and concluded that no other evaluation or testing was required.

On 12/12/2011, the patient had a follow-up visit with the urologist.  The patient was voiding and had not had any subsequent episodes of hematuria.  The urologist’s plan was to see the patient again in six months to a year.  At no point did the urologist view the results of the patient’s renal ultrasound or obtain imaging of the kidneys.  The urologist’s notes do not indicate that he ever considered kidney pathology as the source of the gross hematuria.

After another episode of gross hematuria, the patient was seen on 7/13/2012 by another doctor who had since taken over the urologist’s practice.  The patient also complained of weight loss and weakness.  The treating physician ordered a urine cytology and renal ultrasound.

On 7/18/2012, the patient had an abdominal ultrasound which showed a right renal mass suspicious of renal cell carcinoma.  His primary care physician ordered a CT scan on 7/31/2012, which showed an infiltrated mass in the mid to lower aspect of the right kidney.  His primary care physician then referred the patient to an oncologist.

On 6/4/2014, the patient died due to complications from his cancer.

The Board issued a public reprimand with stipulations for the urologist to complete a medical record keeping course and a continuing medical education course on the topic of diagnosing renal cell cancer.

State: California


Date: March 2016


Specialty: Urology, Family Medicine, Internal Medicine, Oncology


Symptom: Urinary Problems, Bleeding


Diagnosis: Cancer


Medical Error: Diagnostic error, Failure to follow up


Significant Outcome: Death


Case Rating: 2


Link to Original Case File: Download PDF



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