Found 20 Results Sorted by Case Date
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California – General Surgery – Complications After Laparoscopic Cholecystectomy For Symptomatic Cholelithiasis



On 6/30/2011, a 28-year-old female presented to General Surgeon A on referral from her obstetrician for gallstones.  General Surgeon A performed a history and physical examination and diagnosed symptomatic cholelithiasis and recommended a laparoscopic cholecystectomy.

On 8/4/2011, General Surgeon A performed a laparoscopic cholecystectomy on the patient at the hospital.  General Surgeon A’s operative report described the patient’s gallbladder as “inflamed and difficult.” General Surgeon A’s operative report further noted that the procedure took 2.5 hours, that he could not identify the cystic duct/common bile duct junction due to adhesions and inflammation, and that the patient had an aberrant right hepatic artery.  General Surgeon A did not perform a cholangiogram. The patient was discharged home after the surgery.

On 8/5/2011, the patient’s mother called General Surgeon A’s office and requested stronger pain medication due to the patient’s severe pain.  The patient presented to the emergency department with complaints of severe abdominal pain and nausea. The patient’s examination revealed a temperature of 100.7 F, heart rate of 89, elevated WBC count of 19,000, abnormal liver function tests with total bilirubin of 1.7, and extreme abdominal tenderness in the epigastric area.  A CT scan and radiology report indicated a possible bile leak and recommended a HIDA scan for further evaluation. General Surgeon A was contacted and notified of the patient’s admission to the hospital where the patient received antibiotics and intravenous fluids.

On 8/6/2011, General Surgeon A saw the patient at the hospital.  He noted that the patient’s “pain is improving and she has no more nausea.”  General Surgeon A did not interpret the patient’s CT findings or elevated liver function test results.  The patient’s liver function test on 8/6/2011 revealed a further elevation in bilirubin to 2.6 and an alkaline phosphate measurement of 129.

On 8/7/2011, General Surgeon A saw the patient at the hospital.  General Surgeon A’s note for that visit indicated that the patient’s abdomen was nondistended with no tenderness on physical examination.  General Surgeon A ordered continuation of PCA for pain, but did not order any diagnostic testing.

On 8/8/2011, General Surgeon A discharged the patient from the hospital.  General Surgeon A’s discharge summary indicated the patient felt better, and her pain was improved.  He prescribed Percocet for pain. The patient’s total bilirubin at discharge was 2.2. General Surgeon A dictated his discharge summary on 8/28/2011, 51 days after the patient was discharged.

On 8/18/2011, the patient presented to the emergency department at the hospital with complaints of pain, weakness, and nausea for 5 days.  Diagnostic testing revealed that the patient’s bilirubin was 3.7, and her WBC count was elevated to 21,000. A CT scan revealed a large amount of ascites in the abdomen and pelvis.  General Surgeon A’s colleague evaluated the patient and diagnosed a possible bile duct injury and transferred the patient to a gastroenterologist at another hospital.

On 8/19/2011, the patient underwent a CT scan of the abdomen and pelvis that revealed a large amount of ascites.  As a result of these findings, two drains were placed by an interventional radiologist. The gastroenterologist obtained a hepatobiliary surgical consult with General Surgeon B who recommended a percutaneous transhepatic cholangiogram (PTHC) and ordered antibiotics for the patient.

On 8/22/2011, the patient underwent a PTHC that revealed leakage of the common bile duct.  A pigtail catheter was placed to collect the leakage. On 8/25/2011, the patient was discharged home with a PICC line and drains in place to allow her inflammation to resolve prior to surgery to repair the common bile duct.  On 9/20/2011, General Surgeon B performed a surgical repair of the patient’s common bile duct. General Surgeon B found a complete transection of the patient’s bile duct. After further treatment and a difficult course of recovery, the patient began to feel better in December 2011.

The Medical Board of California judged that General Surgeon A’s conduct departed from the standard of care because he failed to recognize the significant intraoperative complication of common bile duct transection during the laparoscopic cholecystectomy procedure, perform a timely work-up for possible bile leak or common bile duct injury after performing a laparoscopic cholecystectomy on the patient, and maintain adequate and accurate medical records.

The Medical Board of California placed General Surgeon A on probation for 2 years and ordered the general surgeon 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: August 2016


Specialty: General Surgery


Symptom: Abdominal Pain, Nausea Or Vomiting, Weakness/Fatigue


Diagnosis: Post-operative/Operative Complication, Acute Abdomen


Medical Error: Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Lack of proper documentation, Procedural error


Significant Outcome: Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



Arizona – Internal Medicine – Failure To Follow Up On Chest X-Ray Showing Lung Nodules



In August 2002, a patient was established with his primary care physician, an internist.  The patient had a history of coronary artery disease, degenerative joint disease, diabetes mellitus type 2, obstructive uropathy, resection of an epididymal cyst, and hypothyroidism.  The patient had a procedural history of multiple percutaneous coronary stent placements, a single vessel coronary artery bypass graft, and total knee arthroplasties.

In 2002, a chest x-ray revealed that the patient had a granuloma in the right base along with nodules suggesting granulomas in the right upper lobe.  Chest x-rays taken in 2005 revealed no changes.

On 08/08/2007, the patient presented to a hospital emergency department with chest pain.  A chest x-ray showed a right upper lobe pulmonary nodule that was larger than in 2005.  The ED physician interpreted the x-ray as showing no change, and there was no follow-up scheduled.

On 02/04/2008, the patient was again seen in the emergency department for chest pain.  A chest x-ray again showed an enlarging density in the right upper lobe.  The patient was instructed to follow up with his internist regarding the possibility of lung cancer.

On 10/21/2009, the patient saw his primary care physician, the internist, and told him that he had been informed about a spot on his lung in February of 2008.  The internist ordered a chest x-ray, which revealed a right upper lobe mass.

Although the internist saw the patient on 01/20/2010 and several times during the next several months, there was no further reference in the patient’s chart of the mass until 07/23/2012, when the patient presented to the internist with films and reports from a chest x-ray and CT scan from an out-of-state hospital demonstrating a tumor.  Appropriate diagnostic studies and treatments were then instituted.

On 02/20/2013, the tumor and the mediastinal lymph nodes were resected.  Post-operatively, the patient developed severe lactic acidosis with acute renal failure, acute respiratory distress syndrome, and ischemia of his intestines.

On 02/23/2013, the patient died.

The Board judged the internist’s conduct to be below the minimum standard of competence given failure to follow up on the enlarging lung nodule and failure to perform further diagnostic studies.

The Board ordered the internist to be reprimanded.

State: Arizona


Date: August 2016


Specialty: Internal Medicine


Symptom: Chest Pain


Diagnosis: Lung Cancer


Medical Error: Failure to follow up


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



California – Gynecology – Inappropriate Remarks During Annual Gynecological Examination



On 1/3/2014, a patient presented to a gynecologist for an annual gynecological examination.  During the gynecologist’s examination, of the patient’s breasts, he commented that she had enlarged breasts like “Dolly Parton.”  While the gynecologist was conducting the patient’s pelvic examination, he commented that she “looked like a virgin.” Following the gynecologist’s pelvic examination, he assessed the patient with Candida vaginitis (a yeast infection).

During the course of the Board’s investigation of the patient’s complaint of inappropriate conduct by the gynecologist, the gynecologist admitted that he made the statements to the patient and explained that the “enlarged breasts” comment was to relax and befriend her, and the looked “like a virgin” comment was because she was small and required a small speculum.

The Medical Board of California judged that the obstetrician’s conduct departed from the standard of care because he engaged in sexual innuendo and breached her trust.  The standard of care for breast and pelvic examinations is to inform the patient that she is going to be examined and to obtain her consent.  The standard of care does not include making comments regarding the size of the patient’s breasts or to make comparisons to celebrities or virgins.  The standard of care requires that a practitioner who diagnoses a patient with Candida vaginitis have supporting physical examination evidence of vaginal candidiasis or microscopy to support the diagnosis and that the practitioner counsel the patient regarding the diagnosis.  With respect to the patient, the gynecologist further departed from the standard of care by failing to provide any supporting physical examination evidence of Candida vaginitis or microscopy to support the diagnosis. The gynecologist, when asked to read his progress notes for the patient, had difficulty deciphering his handwriting.

For this case and others, the Medical Board of California placed the gynecologist on probation for 35 months and ordered the gynecologist to complete a medical record keeping course, an education course, a professionalism program (ethics course), and a professionalism boundaries program.  The obstetrician was also prohibited from supervising physician assistants.

State: California


Date: August 2016


Specialty: Gynecology


Symptom: N/A


Diagnosis: N/A


Medical Error: Ethics violation, Diagnostic error, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Obstetrics – Shoulder Impaction With Seven Attempts Using A Vacuum



On 1/9/2010, a patient first presented to an obstetrician for prenatal care.  At that time, the patient was 28 years old, and it was her first pregnancy. Her estimated date of delivery was 6/8/2010.  She presented to the obstetrician’s office for 11 prenatal visits: 1/9/2010, 1/22/2010, 2/19/2010, 3/19/2010, 4/2/2010, 4/7/2010, 5/1/2010, 5/15/2010, 5/21/2010, 5/29/2010, and 6/30/2010.  At each prenatal visit, the patient was examined by the obstetrician and had an obstetrical ultrasound. Her prenatal course was essentially unremarkable without noted risk factors for shoulder dystocia.

On 6/5/2010, at 12:38 a.m., the patient presented to the hospital with an onset of labor.  Examination at 12:46 a.m. revealed that she was 4.0 cm dilated and 90% effaced at -2 station.  Over the next approximate 12 hours, the patient’s labor progressed and at 11:38 p.m., she was 10 cm dilated and 100% effaced at 0 station.  The obstetrician was updated regarding the patient’s status. The obstetrician arrived at the delivery room at 12:10 p.m. Fetal heart rate tracings revealed a baseline heart rate of 140 with moderate variability.  At 12:14 p.m., a prolonged deceleration occurred for approximately 4 minutes with a return to the established baseline for approximately 3 minutes, followed by another prolonged deceleration for 8 minutes. At 12:24 p.m., the patient verbally consented to the use of a vacuum to assist delivery.  The obstetrician’s progress note reflected 4 pulls with the vacuum with no detachments, but video of the delivery shows 7 pulls with the vacuum. The obstetrician encountered an impacted shoulder. The obstetrician stated that there would be a shoulder dystocia, but did not announce it to the entire obstetrical team or call for help.  The patient was in McRoberts position (hips flexed back onto her abdomen to help the baby’s shoulder slip under her pubic bone by enlarging the pelvic outlet), but no suprapubic pressure was applied. The obstetrician rotated the fetal head from occiput anterior (facing down) to occiput posterior (facing up) for suctioning of nares and mouth.  The obstetrician claimed that “[he] felt the axilla on the right arm. And [he] gently retracted on the post axilla, and the arm delivered very easily with the support of the humerus with [his] left index finger.” Video of the delivery showed that the posterior arm was not delivered before the rest of the body, and the obstetrician was seen rotating the head and applying traction to the fetal head and shoulders.  At 12:35 p.m., the obstetrician delivered a 3,262-gram female infant with decreased tone noted in the left arm.

With respect to the documentation of the patient’s labor and delivery, in an undated, untimed, partly illegible, and incomplete, note entitled “MD Progress Note,” the obstetrician documented the vacuum delivery.  A delivery note dated 6/5/2010 and timed at 1:00 p.m. by the obstetrician was absent of documentation of a shoulder dystocia being communicated to the obstetrical team, whether the patient’s analgesia was adequate, and whether or not a pediatrician or a Neonatal Intensive Care Unit team was present in the room.  The note did not reflect which shoulder was impacted nor did it reflect the maneuvers utilized during delivery.

The standard of care for prenatal obstetrical ultrasound is for the practitioner to have ultrasounds performed when there is a valid medical indication.  The obstetrician performed an ultrasound for fetal growth at each of the patient’s prenatal visits without indication. The standard of care for a practitioner encountering a shoulder dystocia at the time of delivery requires that the practitioner alert the entire obstetrical team of a shoulder dystocia, as well as to call for the application of suprapubic pressure while the patient is in the McRobert’s position.  The standard of care further requires attempts at rotational maneuvers before the use of traction of the fetal head and shoulder.

The Medical Board of California judged that the obstetrician’s conduct departed from the standard of care because he performed an ultrasound at each of the patient’s prenatal visits without medical indication, did not announce a shoulder dystocia at the time of delivery, did not apply suprapubic pressure with McRobert’s position, and did not attempt rotational maneuvers before the use of traction of the fetal head and shoulder.

The Medical Board of California placed the obstetrician on probation for 35 months and ordered the obstetrician to complete a medical record keeping course, an education course, a professionalism program (ethics course), and a professionalism boundaries program.  The obstetrician was also prohibited from supervising physician assistants.

State: California


Date: August 2016


Specialty: Obstetrics


Symptom: N/A


Diagnosis: Obstetrical Complication


Medical Error: Procedural error, Unnecessary or excessive diagnostic tests, Failure of communication with other providers, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



North Carolina – Endocrinology – Concern Raised Over Dosing Of Norditropin For Short Stature



The Board received a complaint regarding the care of a patient.

On 04/03/2013, an 8-year-old boy was referred to an endocrinologist for the evaluation of possible low testosterone.  The boy weighed 20.4 kg and was 46 inches tall.  The endocrinologist examined the patient and noted that he had significant short stature.  He recommended laboratory and radiographic testing in order to develop a definitive plan of care.

On 05/01/2013, the endocrinologist reviewed the patient’s laboratory results with the patient’s parents and explained that the patient’s bone age was approximately 66 months, yet his chronological age was 98 months.  The endocrinologist decided to obtain a growth hormone stimulation test, which was done in June 2013.

On 07/08/2013, the patient presented to the endocrinologist for a follow-up.  The patient weighed 21.1 kg and was 46.5 inches tall.  The endocrinologist reviewed the patient’s laboratory and radiographic results and diagnosed growth hormone deficiency.  The endocrinologist prescribed the growth hormone drug Norditropin (somatropin [rDNA origin] injection).  This treatment involved the patient’s parents injecting the drug Norditropin into the patient’s body.

On 08/16/2013, Norditropin was started on the patient at a dose of 0.6 mg daily (0.23 mg/kg/week).

On 11/27/2013, the patient presented for a follow-up.  The parents mentioned no problems with injecting the Norditropin.  Height was 46.75 inches.  The patient’s Insulin-Like Growth Factor I (“IGF-1”) was 98 ng/ml (normal for this age was 49-351).  The endocrinologist increased the patient’s Norditropin dose to 1.4 mg daily (0.45 mg/kg/week) for one month and then 2 mg daily (0.64 mg/kg/week) until the patient’s next follow-up visit.

On 01/27/2014, the patient presented for a follow-up.  Height was 47.75 inches.  IGF-1 was 146 ng/ml (normal for age was 72-323).  The endocrinologist increased the patient’s Norditropin dose to 3 mg daily (0.9 mg/kg/week).

On 04/07/2014, the patient, now 9 years old, presented for a follow-up.  Height was 48.25 inches and IGF-1 was 210 ng/ml (normal for age was 84-362).  His dose was increased to 4 mg (1.1 mg/kg/week).

On 06/11/2014, the patient presented for a follow-up.  Height was 50 inches and IGF-1 was 203 ng/ml (normal for age was 84-362).  The endocrinologist recommended increasing the Norditropin to 6 mg daily (1.59 mg/kg/week) and wrote prescriptive instructions to that effect.  However, the specialty pharmacy that had been providing the patient’s Norditropin refused to fill the prescription at that dose and the patient never received the 6 mg daily dose.

On 08/06/2014, the patient went to see a pediatric endocrinologist physician who has specialty training and certification in the field of pediatric endocrinology.  This physician lowered the patient’s Norditropin dosage as follows:

“For management of the short stature, I have decreased the growth hormone (Norditropin) to 1.1 mg at night time (0.300 mg/kg/wk as recommended for children with growth hormone deficiency).”

This pediatric endocrinologist treated the patient three months later on 11/3/2014 and noted that he had grown 2 cm (0.79 inches) on the 1.1 mg Norditropin dosage.

The Board obtained the patient’s records and sent them to two qualified independent medical experts for review.  The independent medical experts judged the endocrinologist’s conduct to be below the minimum standard of competence given failure to prescribe the correct Norditropin dosage to the patient.  They did not think the endocrinologist should have increased the dosage based solely on the patient’s IGF-1 levels.  The endocrinologist disagreed with the experts.  The Board notes that the patient was not harmed by the IGF-1, although they acknowledged that there was potential harm if high dose Norditropin therapy is administered in the long term.

The endocrinologist had his care reviewed by three independent medical experts who felt that the care of the endocrinologist was within the standard of care.  One expert wrote that the care of the patient was “evidence-based and follows standard of care.”  One of those experts was the pediatric endocrinologist who lowered the dose of Norditropin from 4 to 1.1 mg.  It is noted that this expert has worked with the endocrinologist over eight years and the endocrinologist referred patients to this expert.  She wrote that her adjustment of the dose “does not imply that [your]dosage was wrong or outside the standard of care” and wrote that the endocrinologist was “a dedicated doctor who provides elite care to his patients.”

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: August 2016


Specialty: Endocrinology, Pediatrics


Symptom: N/A


Diagnosis: N/A


Medical Error: Improper medication management


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



North Carolina – Family Practice – Prescribing Antibiotics For Ear Pain Without A Full Evaluation



A complaint was filed against a family practitioner by a pediatrician concerning a telephone conversation the family practitioner had with one of her patients.

The mother of a five-year-old contacted the family practitioner by telephone for a consultation.  The patient’s mother informed the family practitioner that her daughter had developed ear pain after approximately seven days of head congestion.  Based on the patient’s symptoms as reported by her mother during the telephone conversation, the family practitioner diagnosed the patient with otitis media and prescribed antibiotics.

The Board obtained the patient’s records and sent them to a qualified independent medical expert for review.  The expert expressed concern with the family practitioner’s failure to obtain an appropriate history, which should have included sick contacts, prior ear infections, daycare exposure, and smoke exposure – all of which increase the risk of otitis media.  The expert reviewer opined that it is not the standard of care to prescribe antibiotics for every patient with ear pain and cold symptoms.  There was no evidence the family practitioner reviewed medication allergies prior to prescribing the patient antibiotics.

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: August 2016


Specialty: Pediatrics, Family Medicine


Symptom: Head/Neck Pain


Diagnosis: N/A


Medical Error: Failure to examine or evaluate patient properly


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Virginia – Internal Medicine – Prescription Of Oxycodone 30 mg 150 Pills While Patient Obtaining Diazepam From Another Provider



On 4/12/2011, a patient began his treatment at a clinic.  He failed several drug screens.  A note in his medical record indicates that he was called for a pill count on 6/27/2012.  The patient indicated that his medication had been stolen and he had no pills to be counted.

On 11/6/2012, an internist first treated the patient.  He prescribed the patient oxycodone 30 mg, 150 pills.

A patient assessment form from 5/20/2013 is blank as are several other assessment forms in the medical records.  A report from the West Virginia Board of Pharmacy shows that the internist prescribed the same medication to the patient on a monthly basis.  However, the assessment form allowed the patient to request to skip actually seeing the doctor on each visit.

On 7/15/2013, the patient was treated at the clinic.  He requested to skip seeing the doctor.  Other than a check mark indicating “Continue present regimen,” the assessment form is essentially blank.  However, the patient received a prescription written by the internist on this date for oxycodone 30 mg, 150 pills.  The report from the West Virginia Board of Pharmacy indicates that this prescription was intended to last 25 days.

The prescription would indicate that the oxycodone 30 mg would be taken 6 times daily for a total of 180 mg of oxycodone per day.

Medical records for the patient revealed that he was receiving a prescription from another physician for diazepam 10 mg to be taken twice daily.

On 7/18/2013, the patient died from a combination of oxycodone, alprazolam, diazepam, hydroxyzine, and gabapentin intoxication.

The Board expressed concern over the internist’s care of the patient.  During the period that he treated the patient, the internist did not know that the patient had obtained a controlled substance from another physician.

State: Virginia


Date: August 2016


Specialty: Internal Medicine


Symptom: N/A


Diagnosis: Drug Addiction, Drug Overdose, Side Effects, or Withdrawal


Medical Error: Improper medication management


Significant Outcome: Death


Case Rating: 1


Link to Original Case File: Download PDF



Nevada – Emergency Medicine – Right Pleural Effusion, Ascites, And Transaminitis In A Pediatric Patient



On 10/16/2014, the Nevada Board of Medical Examiners (Nevada Board) filed a complaint against an ED physician.

On 3/25/2012, a 12-year-old female presented to the emergency department of a hospital in Nevada.  The radiologist’s interpretations of both an abdominal ultrasound and a computerized tomography scan of the patient indicated a “right pleural effusion” and a “small amount of ascites.”

Blood testing revealed a total bilirubin of 2, aspartate aminotransferase of 205, an alanine aminotransferase of 337, and an alkaline phosphatase of 66.  Her white blood cell count was 13.1 with a normal differential and an elevated hemoglobin of 15.4.  The patient had a decreased carbon dioxide level of 16 and a mildly elevated creatinine level of 1.13.

On 3/26/2012, the patient returned to the emergency department the next day where she was treated by an ED physician.  She presented with new onset of peripheral edema, a mildly diminished pulse oximetry, persistent tachycardia, and a cough that had lasted for three weeks.

According to the complaint, given the known presence of pleural effusion, ascites, and transaminitis, coupled with laboratory evidence of renal insufficiency, the ED physician should have considered congestive heart failure as the possible etiology of the patient’s symptoms.

The patient’s medical chart lacks any evidence demonstrating that the ED physician carried out the standard diagnostic evaluation for possible congestive heart failure by ordering a chest x-ray and an electrocardiogram.

Accordingly, the complaint alleges that the ED physician failed to use the reasonable care, skill, or knowledge ordinarily used under similar circumstances when she failed to order this diagnostic testing.  The complaint also alleges that the ED physician failed to maintain accurate and/or complete medical records relating to the diagnosis, treatment, and care of the patient.

On 9/9/2016, the Nevada Board entered a settlement agreement with the ED physician, in which the ED physician admitted to the medical records violation alleged in the complaint.  As part of the Nevada Settlement Agreement, the ED physician consented to the following discipline:

1) Reimbursement of the costs of investigation and prosecution

2) Completion of five hours of continuing medical education related to medical records, emergency-related practices, and preventing malpractice

3) Reporting of the agreement as discipline to the National Practitioner Data Bank

State: Nevada


Date: August 2016


Specialty: Emergency Medicine, Pediatrics


Symptom: Swelling, Cough, Shortness of Breath


Diagnosis: Heart Failure


Medical Error: Failure to order appropriate diagnostic test


Significant Outcome: Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Orthopedic Surgery – Lack Of Justification For Surgery For Right Carpal Tunnel Release And Decompression Of The Ulnar Nerve At The Canal Of Guyon



On 1/3/2014, a 32-year-old female presented to an orthopedic surgeon for a “Pre-Op” exam.  The orthopedic surgeon obtained a history for the patient’s “Pre-Op” exam.  The orthopedic surgeon documented that the patient suffered right wrist pain, that her symptoms were unchanged, that her pain increased with cold weather, and that she had no complaints of numbness or tingling.

The orthopedic surgeon also performed a physical exam at the patient’s “Pre-Op” exam.  The orthopedic surgeon documented that the patient’s motor and sensory function and pulses were intact in her upper extremities; she had no right upper extremity atrophy; her upper extremity neurovascular examination was normal; she had moderate first dorsal compartment discomfort in her right wrist.

The orthopedic surgeon diagnosed the patient with tenosynovitis of the wrist and obtained a written consent to perform a release of the first dorsal compartment in her right wrist.

The patient had no symptoms indicative of ulnar and/or median nerve compression at either of the carpal tunnel or the Canal of Guyon at the “Pre-Op” exam.

The orthopedic surgeon’s physical exam at the patient’s “Pre-Op” exam did not reveal any signs indicative of ulnar and/or median nerve compression at either the carpal tunnel or the Canal of Guyon.

On 1/16/2014, the patient presented to a surgery center for the orthopedic surgeon to perform the first dorsal compartment release.  Prior to the administration of sedation, the orthopedic surgeon and the patient spoke in the pre-operative area.  At that time, the patient advised the orthopedic surgeon that, in addition to the first dorsal compartment symptoms, she was experiencing symptoms of right-hand numbness and tingling.  In response, the orthopedic surgeon suggested performing right wrist ulnar and median nerve releases in addition to the planned first dorsal compartment release.  The patient gave verbal consent for the orthopedic surgeon to perform the right wrist ulnar and median nerve releases.

The orthopedic surgeon did not assess, or did not document assessing, the degree of severity of the patient’s complaints of right-hand numbness and tingling on the day of and prior to performing the surgery for right carpal tunnel release and decompression of the ulnar nerve at the Canal of Guyon.

The orthopedic surgeon did not perform, or did not document performing, a physical exam of the patient’s right wrist and hand on the day of the and prior to performing surgery for right carpal tunnel release and decompression of the ulnar nerve at the Canal of Guyon.

The orthopedic surgeon did not adequately assess, or did not document adequately assessing, the patient’s complaints and symptoms that would support a pre-operative diagnosis of ulnar and/or median tunnel syndrome.

The orthopedic surgeon did not recommend, or did not document recommending, that the patient pursue a course of non-operative treatment on the day of and prior to performing surgery for right carpal tunnel release and decompression of the ulnar nerve at the Canal of Guyon.

The orthopedic surgeon did not have, or did not document having, a pre-operative medical justification for performing surgery for right carpal tunnel release and/or decompression of the ulnar nerve at the Canal of Guyon.

Immediately prior to surgery, the orthopedic surgeon performed a time-out, also known as a pause, for the first dorsal compartment release procedure.

The orthopedic surgeon failed to perform a time-out for either the right carpal tunnel release or decompression of the ulnar nerve at the Canal of Guyon prior to initiating the procedures.

The Medical Board of Florida issued a letter of concern against the orthopedic surgeon’s license.  The Medical Board of Florida ordered that the orthopedic surgeon pay a fine of $10,000 against his license and pay reimbursement costs for the case at a minimum of $4,759.65 and not to exceed $6,759.65.  The Medical Board of Florida ordered that the orthopedic surgeon complete a medical records course and complete five hours of continuing medical education in “risk management.”

State: Florida


Date: August 2016


Specialty: Orthopedic Surgery


Symptom: Extremity Pain, Numbness


Diagnosis: Musculoskeletal Disease


Medical Error: Unnecessary or excessive treatment or surgery, Failure to examine or evaluate patient properly, Lack of proper documentation, Procedural error


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Family Medicine – Urology Referral 2 Years After Lab Results Show An Elevated PSA



On 4/25/2011, a 54-year-old male presented to a family practitioner.  The patient reported that he had not seen a physician in several years.

During the initial office visit, the family practitioner performed a physical examination of the patient.  During the physical examination, the family practitioner should have performed a digital rectal exam on the patient but failed to do so.

On 4/25/2011, the family practitioner ordered labs for the patient, which subsequently were collected on 4/29/2011.  The lab results revealed that the patient had an elevated PSA of 9.9

In May 2011, the family practitioner’s office received the patient’s lab results via facsimile; however, those results were never discussed with the patient.

The family practitioner should have referred the patient to a urologist for further evaluation of the elevated PSA level but failed to do so.

On 3/29/2012, the patient returned to the family practitioner’s office with complaints of right shoulder pain.  At that time, the family practitioner failed to discuss the elevated PSA level from the labs taken on 4/29/2011.

On 4/24/2013, the patient presented to the family practitioner for an established patient annual exam.  At that time, the family practitioner failed to discuss the elevated PSA level from the labs taken on the 4/29/2011 appointment; however, the family practitioner did diagnose the patient with benign prostatic hypertrophy and referred him to a urologist for further evaluation.

On 5/9/2013, lab results for the patient revealed a PSA level of 14.8.  The patient was subsequently seen by a urologist who diagnosed the patient with prostate cancer.

The Medical Board of Florida judged the family practitioner’s conduct to be below the minimal standard of competence given that she failed to perform a digital rectal exam on the patient during the initial examination on 4/11/2011.  She also failed to refer the patient to a urologist for further evaluation of the elevated PSA which was collected on 4/29/2011.

The Medical Board of Florida issued a letter of concern against the family practitioner’s license.  The Medical Board of Florida ordered that the family practitioner pay a fine of $4,000 against his license and pay reimbursement costs for the case at a minimum of $3,391.79 and not to exceed $5,391.79.  The Medical Board of Florida ordered that the family practitioner complete an FMA laws and rules course, complete five hours of continuing medical education in urological conditions, and complete five hours of continuing medical education in risk management.

State: Florida


Date: August 2016


Specialty: Family Medicine, Internal Medicine, Urology


Symptom: Joint Pain


Diagnosis: Prostate Cancer


Medical Error: Failure to follow up, Failure to examine or evaluate patient properly, Referral failure to hospital or specialist


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



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