Found 23 Results Sorted by Case Date
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Kansas – Cardiothoracic Surgery – Improper Surgical Procedure Of Abdominal Aortic Aneurysm Results In Anuria And Then Death



A 72-year-old male patient was admitted to a medical center with foot ulcer and foot pain. During the patient’s hospitalization, an ultrasound revealed an 8.5 cm large abdominal aortic aneurysm (AAA).  The patient was subsequently scheduled for surgical repair.

On 10/24/2010, a cardiothoracic surgeon admitted the patient to a medical center and completed a history and physical.  The cardiothoracic surgeon also signed pre-operative orders at that time.

On 10/25/2010, the cardiothoracic surgeon performed an endovascular AAA stent repair on the patient using an Endologix stent graft.  After surgery, the cardiothoracic surgeon returned to Wichita, Kansas.  The cardiothoracic surgeon’s first assistant an ARNP, signed the post-operative orders and monitored the patient’s recovery along with other hospital staff.

Post-surgery the patient began to have decreased urine output on 10/26/2010.  The patient was oliguric and then anuric.  The patient failed to respond to large doses of diuretics so a nephrologist was consulted for dialysis.

A CT scan on 10/26/2010 showed bilateral renal artery occlusion and segmental occlusion of the proximal superior mesenteric artery.

Eventually the patient was transferred to Wichita, Kansas for further care where he later died on 10/29/2010.

The Board judged the cardiothoracic surgeon’s conduct to be below the minimum standard of competence given his failure to perform proper endovascular surgery on the patient

The Board ordered that the cardiothoracic surgeon have a cardiac surgeon and/or radiologist with adequate experience in endovascular abdominal aortic aneurysm repair participate and assist the cardiothoracic surgeon on his next ten endovascular abdominal aortic aneurysm repair cases.  Also, the Board ordered that the cardiothoracic surgeon complete at least eight hours of continuing medical education courses with emphasis on endovascular abdominal aortic aneurysm repair.

State: Kansas


Date: June 2016


Specialty: Cardiothoracic Surgery, Nephrology


Symptom: Pain


Diagnosis: Aneurysm, Renal Disease


Medical Error: Procedural error


Significant Outcome: Death


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Family Medicine – Discharge Errors In Managing Mentally Handicapped Patient Admitted For A Left Arm Fracture



On 8/22/2010, a 42-year-old mentally handicapped male patient presented to a medical center for surgical repair of a broken left arm.

A family practitioner served as the primary care physician and served as the attending physician during the patient’s hospital stay.

The patient was adamantly opposed to treatment and was ultimately intubated and sedated with propofol and morphine prior to surgery.

The patient was kept sedated and intubated for a total of five days in the intensive care unit after surgery.

On 8/27/2010, the patient was extubated.

Upon extubation, the patient immediately became uncooperative and disruptive with the hospital medical staff.

The patient was discharged from the hospital.

The Medical Board of Florida judged the family practitioner’s conduct to be below the minimal standard of competence given that the family practitioner failed to order any pain medication for the patient prior to discharge.  He failed to order a psychiatric consultation for the patient prior to discharge.  He failed to develop a safe and adequate medication regimen for the patient prior to discharge.  The family practitioner failed to develop an appropriate discharge plan that included admission to an appropriate nursing care facility.  He failed to create or maintain records that document any progress notes for the patient from 8/25/2010 through 8/27/2010.

The Medical Board of Florida issued a letter of concern against the family practitioner’s license.  The Medical Board of Florida ordered the family practitioner to pay a fine of $5,000 against his license and pay reimbursement costs for the case at a minimum of $9,107.05 and not to exceed $11,107.05.  The Medical Board of Florida also ordered the family practitioner to complete five hours of continuing medical education in mental health conditions and five hours of continuing medical education in “risk management.”

State: Florida


Date: June 2016


Specialty: Family Medicine, Hospitalist, Internal Medicine


Symptom: N/A


Diagnosis: Fracture(s)


Medical Error: Improper medication management, Referral failure to hospital or specialist, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



North Carolina – Psychiatry – Patient Expresses Suicidal Intent If He Were To Be Arrested



The North Carolina Medical Board was notified of an action taken by the Florida Board of Medicine against a psychiatrist’s medical license.

On 09/20/2012, a patient was arrested and charged with indecent exposure.  The patient indicated that if he were to be arrested, he would commit suicide.  The patient was involuntarily brought to the hospital where an ED physician was employed.

The psychiatrist admitted the patient for overnight observation and the following morning determined that the patient was not a suicide risk and discharged him back to the police.  The next day, the patient committed suicide.

On 03/13/2015, as a result of the patient’s suicide and information provided to the Florida Board, an administrative complaint was filed against the psychiatrist alleging that the psychiatrist had not performed a thorough examination of the patient.

On 08/18/2015, the complaint was resolved by a Final Order and Settlement Agreement.  In this agreement, it was noted that the psychiatrist was issued a letter of concern, ordered the psychiatrist to complete continuing medical education in risk management, and ordered to pay a fine.

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.

State: North Carolina


Date: June 2016


Specialty: Psychiatry


Symptom: Psychiatric Symptoms


Diagnosis: Psychiatric Disorder


Medical Error: Underestimation of likelihood or severity


Significant Outcome: Death


Case Rating: 2


Link to Original Case File: Download PDF



North Carolina – General Surgery – Removal Of The Wrong Adrenal Gland



The Board was notified of a professional liability payment made on 09/08/2015.

On 05/05/2009, a patient presented to the general surgeon’s office following a referral from the patient’s endocrinologist for surgical removal of a right sided adrenal mass.  Following the examination, the general surgeon mistakenly dictated that the mass was located in the left adrenal gland.  On 06/01/2009, the patient underwent surgery and the left, rather than the right, adrenal gland was removed.

The Board expressed concern that the general surgeon removed the wrong adrenal gland.

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.

State: North Carolina


Date: June 2016


Specialty: General Surgery


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


Diagnosis: N/A


Medical Error: Wrong site procedure


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Anesthesiology – Midazolam, Fentanyl, And Promethazine Administered As Anesthesia For Radial Endarterectomy And Ligation Of An Upper Arm Fistula



On 3/3/2011, a 72-year-old male came under an anesthesiologist’s care for pre-operative and intra-operative anesthesia.  The patient had a recent history of having been admitted to the hospital on 2/28/2011 with complaints of left arm pain thought to be related to an upper arm fistula.  The patient had a medical history significant for end-stage renal disease, diabetes, cardiac rhythm disturbance with placement of automatic implantable cardioverter defibrillator/pacemaker (AICD), peripheral vascular disease, and coronary artery disease with stent placement.

The operative procedure planned for the patient on 3/3/2011 was a radial endarterectomy and ligation of the upper arm fistula.  The anesthesiologist was charged with administering monitored anesthesia care (MAC).  He positioned the patient and rendered the patient’s AICD inactive with a magnet.  In an interview with the Medical Board of California investigator, the anesthesiologist stated that he administered 1 mg midazolam, 100 ug of fentanyl in divided doses, and 6.25 mg promethazine intravenously, but the promethazine dose and time were not stated in the anesthesia record.  The procedure continued with administration of lidocaine by the vascular surgeon and initial incision.  Early after the start of the surgery, at 4:06 p.m., the patient went into pulse electrical activity.  A Code Blue was called.  The patient was intubated, and CPR was started, but the resuscitation was unsuccessful.  The patient was pronounced dead at 4:46 p.m.  An autopsy determined the cause of death to be cardiac arrest.

The post-code peer review of the patient’s care showed the fact that several entries were heavily lined out to the degree that the entries couldn’t be read.  A forensic handwriting expert was consulted and reported that “the original handwritten entry was heavily obliterated to the extent that the paper fiber was torn from the numerous and heavy pen strokes.”  The expert opined that one entry might partially read “p-h-e” with “either an ‘r’, ‘g’, or ‘y’.”  Other entries could not be deciphered due to “the absence of sufficient observable portions of the letters or numerals.”

At the first peer review meeting, the anesthesiologist stated that the lined out entry was phenylephrine and denied that he administered promethazine to the patient.  The anesthesiologist explained that in the tumult that followed the calling of Code Blue, he became confused in his record keeping and lined out the entries.  In subsequent explanations, the anesthesiologist stated that the lined out entry was Phenergan and that he crossed the entry on that line out because it erroneously included Versed, a drug already listed on another line.  The anesthesiologist stated that he wanted to eliminate the possible interpretation that he had administered Versed twice, so he lined out both Versed and Phenergan, but forgot to write Phenergan back into the record.  The anesthesiologist acknowledged that his record keeping was poor, but denied any fraudulent intent in altering the medical record.  In response to peer criticism, he insisted that Phenergan was an appropriate drug to use in the procedure.

The Medical Board of California judged that the anesthesiologist’s treatment of the patient departed from the standard of care because he elected to use Phenergan (promethazine) to provide sedation for a geriatric patient with multiple serious medical problems and a history of cardiac problems and altered the patient’s anesthesia record.  The anesthesiologist’s medical records for this patient were also inadequate and inaccurate with multiple missing and undecipherable entries.

The Medical Board of California issued a public reprimand and ordered the anesthesiologist to complete a medical record-keeping course.

State: California


Date: June 2016


Specialty: Anesthesiology


Symptom: N/A


Diagnosis: Post-operative/Operative Complication, Cardiovascular Disease


Medical Error: Improper medication management, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



California – Gynecology – Vault Procedure And TOT Sling For Utero-Vaginal Prolapse



On 5/24/2012, a gynecologist undertook the care and treatment of a 71-year-old female for utero-vaginal prolapse.  At the 6/8/2012 appointment, the gynecologist told the patient that she must have surgery and that a vault procedure was less risky than a hysterectomy.  The patient underwent testing on 7/11/2012, and as a result of this testing, the gynecologist told the patient that she would need a TOT sling procedure as part of her surgery.

On 8/21/2012, the patient returned to the gynecologist’s office for a pre-operative visit, where she signed an informed consent form where the TOT sling was crossed out on the form.  It was the patient’s understanding that the TOT sling procedure was crossed out by her and initialed by the gynecologist to document that this procedure would not be performed.

On 8/27/2012, the gynecologist performed the vault procedure and accidentally also did the TOT sling procedure on the patient.  As a result of the TOT sling procedure, the patient was in a lot of nerve pain, and she required a corrective procedure to remove the TOT sling.

The Medical Board of California judged that the gynecologist’s conduct departed from the standard of care because he performed an unnecessary procedure, the TOT sling, without the patient’s consent.

The Medical Board of California issued a public reprimand and ordered the gynecologist to complete a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California


Date: June 2016


Specialty: Gynecology


Symptom: Pain, Gynecological Symptoms


Diagnosis: Post-operative/Operative Complication


Medical Error: Accidental error, Unnecessary or excessive treatment or surgery


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Colorado – Radiology – MRI Read As Spinal Stenosis With Missed Diagnosis



In March 2013, a patient had an MRI performed.  A radiologist read the MRI as showing spinal stenosis.  The patient was diagnosed one year later with a thoracic spinal tumor.  The finding was visible on the March 2013 MRI, which revealed approximately 1.5 cm tail of a benign fibrous epidural thoracic tumor at the level of T6-T8 with the small extension down to the level of T9-T10.

The Board judged the radiologist’s conduct as having fallen below the minimum level of competence given failure to interpret the patient’s MRI as revealing a thoracic spinal tumor.

The Board issued a letter of admonition.

State: Colorado


Date: June 2016


Specialty: Radiology


Symptom: N/A


Diagnosis: Neurological Disease


Medical Error: False negative


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



North Carolina – Orthopedic Surgery – Wrong Sided Knee Implant Discovered After Cement Affixes To Prosthetic



The Board was notified of a professional liability payment made in August 2015.

In September 2012, an orthopedic surgeon performed a total knee replacement on the patient’s left knee.  During the surgery, the orthopedic surgeon discovered that the knee implant representative attending the surgery brought the wrong component to the operating room (right instead of left) and, despite being checked preoperatively by the operating room team, this was not discovered until after the orthopedic surgeon had applied cement to affix the prosthetic.  The orthopedic surgeon completed the surgeon with the wrong sided component in place because he believed that the bone cement had almost completely hardened and removing the wrong sided component could have caused bone damage.  The orthopedic surgeon immediately informed the patient of this complication after the surgery.  Eventually, the patient developed patellar instability, a complication which required revision surgery by another surgeon.

The Board obtained the patient’s records and sent them to a qualified independent medical expert for review.  The independent medical expert judged orthopedic surgeon’s conduct to be below the minimum standard of competence.  The expert felt the orthopedic surgeon should have personally verified the implant component was correct prior to insertion in the patient.  He should have revised the patient’s incorrect implant once the error was recognized during surgery.  The Board noted that the orthopedic surgeon disputed this concern given that he felt it was better practice to leave the component in because the cement had hardened and removal would have likely caused damage to the bone.  Lastly, the expert felt that the orthopedic surgeon should have better documented the event in the hospital medical records.

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.

State: North Carolina


Date: June 2016


Specialty: Orthopedic Surgery


Symptom: Joint Pain


Diagnosis: Post-operative/Operative Complication


Medical Error: Wrong site procedure, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Obstetrics – Rupturing Membranes And Placing IUPC Without Informed Consent



At 1:30 a.m. on 3/11/2013, a patient was admitted to the hospital for induction of labor.  The patient had group B streptococcus colonization and an obstetrician wanted to treat her with antibiotics prior to inducing labor.  This was the patient’s third pregnancy with the obstetrician as her attending obstetrician.  The patient wanted to have a natural delivery and had obtained the services of a doula to be present during the delivery.  The patient also requested a natural delivery nurse (Nurse A) to be present during the delivery and a registered nurse (Nurse B) was also assigned to care for the patient.  The patient’s husband was also present for the birth.

At 7:30 a.m. on 3/11/2013, the patient was evaluated by Nurse B.  The patient was dilated two to three centimeters and the cervix was mid-position.  Nurse B explained the delivery process to the patient and also told the patient that the contractions could be monitored by placing an intrauterine pressure catheter (IUPC).  The patient told Nurse B that she did not want the IUPC or other medical intervention.

At 10:30 a.m. on 3/11/2013, the obstetrician came to evaluate the patient.  The obstetrician appeared agitated and rushed while examining the patient (presumably per the patient or the nurse).  The obstetrician stated that the patient was posterior and he could not locate the cervix.  The obstetrician’s examination seemed rough and hurried.

The obstetrician’s plan was to rupture the patient’s membranes and to insert an IUPC to monitor the uterine contractions.  Nurse B told the obstetrician that the patient did not want the IUPC inserted.  The obstetrician stated to Nurse B, “We’re going to get this done, and I am going to insert the IUPC.”

The obstetrician asked Nurse B to give him the IUPC.  Nurse B again told the obstetrician that the patient did not want the IUPC.  The obstetrician demanded Nurse B to give him the IUPC, and she did so.

The patient told the obstetrician that she did not want him to rupture the membrane or insert the IUPC.  The obstetrician replied to the patient “yes, you do.”  Despite the patient’s refusal to give her consent, the obstetrician proceeded to push the patient’s legs apart forcefully, rupture the membranes, and insert the IUPC.  During this time, the patient was screaming out “that hurts.”

The obstetrician left the patient’s room at which time the patient told Nurse B that she did not feel safe in the obstetrician’s care.  The patient requested that the obstetrician be removed as her physician, and he was.

The Board judged the obstetrician’s conduct as having fallen below the standard of care given that he ruptured a patient’s membranes and inserted an IUPC without the patient’s consent.  In addition, during his interview with the investigator, he stated that the patient did not offer “resistance from me doing a pelvic exam and rupture the bag or placing the pressure catheter.  At no time did she say that she did not want me to do exactly as I explained to her.”  Initially, the Board believed these statements were dishonest; although, after further investigation, it was noted that the evidence did not establish that the obstetrician engaged in dishonesty.

The Board issued a public reprimand with the stipulation that the obstetrician complete a course in patient-physician communication.

State: California


Date: June 2016


Specialty: Obstetrics


Symptom: N/A


Diagnosis: N/A


Medical Error: Ethics violation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Arizona – Radiologist – Symptoms Of Pain, Sprain, Right Leg Numbness, And Thigh Burning With Incidental Finding On Lumbar X-Ray



On 10/05/2012, a 65-year-old man presented to the emergency department with “pain, sprain, right leg numbness, and thigh burning”  The radiologist’s report documented degenerative changes of the lumbar spine, right hip, and right knee.

On 04/22/2014, the patient was found unresponsive with apnea, asystole, and a Glasgow coma score of 3.  Emergency medical technicians administered cardiopulmonary resuscitation and transported him to an emergency department

A CT scan showed a ruptured large fusiform abdominal aortic aneurysm of the mid- to distal abdominal aorta/aortic bifurcation and a large associated retroperitoneal hematoma.  The patient was transferred to another hospital where he died later that day.

The Board’s consultant reviewed the radiograph taken on 10/05/2012 and noted that the image clearly shows an abdominal aortic aneurysm with calcified AP diameter of 9.6 cm on the coned-down view of the lumbosacral junction.  The consultant noted that on the full lateral view, which is collimated, only the calcified posterior wall of the abdominal aorta is visualized.

The Board judged the radiologist’s conduct to be below the minimum standard of competence given failure to identify and report the abdominal aortic aneurysm on the lumbar spine x-ray.

The Board ordered the radiologist to be reprimanded.

State: Arizona


Date: June 2016


Specialty: Radiology


Symptom: Extremity Pain, Numbness


Diagnosis: Aneurysm


Medical Error: False negative


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



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