Found 28 Results Sorted by Case Date
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North Carolina – General Surgery – Alcohol Based Solution For Surgical Prep And Electrocautery Device Causes Complications During Lipoma Removal



The Board was notified of a professional liability payment made on 7/17/2015.

In preparation for the removal of a lipoma on a patient’s posterior neck, the surgery area and the hairline were treated with an alcohol based antibacterial solution called DuraPrep.  Although the manufacturer’s recommended drying time is two to three minutes, the general surgeon allowed the DuraPrep to dry for approximately ten minutes.  The general surgeon also blotted the patient’s neckline with a sponge.  Seeing no visible residue on the blotting sponge, the patient’s head was covered with a drape.  During the procedure, which was performed using open oxygen under monitored anesthesia care, strands of the patient’s hair covered with DuraPrep solution residue were ignited from the electrocautery.  The oxygen, which had accumulated under the drapes, served as a fire accelerant.  The patient was transferred by air with an endotracheal intubation to a burn center for flash burns to the midface, nose, mouth, eyelids, and right ear.

The Board believed the general surgeon responded appropriately to the intraoperative emergency and noted that the general surgeon sustained second degree burns to his hand trying to extinguish the flame.  The Board also acknowledged the general surgeon and his operating team’s rapid response minimized harm to the patient.

The cause of the fire was multifactorial; however, the Board believed the surgeon was ultimately responsible for the patient’s safety during the operation.  They recommended that in similar cases, the general surgeon should use a non-alcohol based skin prep, allow additional drying time, or use a non-sparking cautery, minimize the use of open oxygen, and use draping techniques that would allow adequate ventilation when open oxygen is used.  The Board acknowledged that the general surgeon received additional training in surgical fire prevention and safety.

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: October 2016


Specialty: General Surgery


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


Diagnosis: Post-operative/Operative Complication


Medical Error: Procedural error


Significant Outcome: N/A


Case Rating: 5


Link to Original Case File: Download PDF



California – Dermatology – Rosacea Treated With Intense Pulsed Light Treatment



On 5/5/2011, a patient presented to a cosmetic laser clinic.  At this initial appointment, a nurse recommended that the patient receive Intense Pulsed Light treatment (“IPL”) utilizing the Lumenis One machine to treat rosacea, redness, and discoloration on his neck and chest.  On 5/5/2011, a dermatologist approved the nurse’s treatment recommendations.  The proposed IPL treatments were to be administered over three clinical visits.  The patient was not informed of the potential risk of severe burn and significant scarring associated with IPL treatment.

On 5/16/2011, the patient underwent his first IPL treatment without any adverse outcome.

On 8/15/2011, the dermatologist performed the second IPL treatment on the patient’s neck and chest using the Lumenis One machine.  At the time that respondent performed the second IPL on the patient, she had not previously reviewed the clinic’s written IPL protocol.  The dermatologist did not adjust the settings on the Lumenis One machine and instead relied on the preset settings.  The patient complained of extreme pain during this administration of the IPL treatment.  The patient asked the dermatologist to stop the IPL treatment at least four times during the course of the treatment.  The dermatologist did not stop the treatment, but only hesitated momentarily to wait for the patient to regain his composure.

The dermatologist continually made comments to coax the patient to proceed with the IPL treatment.  The dermatologist did not adjust the settings on the Lumenis One machine during the course of the IPL treatment.

On 8/15/2011, following the IPL treatment, the patient observed two large purple spots with blistering on his chest.

On 8/19/2011, the patient returned to the clinic for an IPL follow-up appointment with the dermatologist.  During this visit, the dermatologist diagnosed the patient with post-IPL second-degree burns to the neck and chest area.

On 6/7/2012, the patient returned to the clinic for an IPL follow-up appointment with the dermatologist.  The dermatologist noted that the patient had hypopigmented rectangles on his chest.

The dermatologist failed to adequately inform the patient of the potential risks of IPL treatment including burns and scarring.  The dermatologist failed to read the protocol governing the Lumenis One machine prior to treating the patient and failed to adjust the machine to a lower energy prior to treating the patient.

The Board issued a reprimand to the dermatologist and ordered the dermatologist to enroll in a clinical in-service training provided by the vendor of the IPL medical device.

State: California


Date: October 2016


Specialty: Dermatology


Symptom: Dermatological Abnormality


Diagnosis: Dermatological Issues


Medical Error: Procedural error


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Kansas – Pediatrics – Unnecessary Use of Azithromycin In Viral Infection



On 2/27/2013, a 13-year-old female presented to a pediatrician for follow-up five days after a visit to the emergency department where she had complained of chest pain and had an abnormal D-dimer lab value.  No patient education was documented related to the significance of the finding or the risk of a pulmonary embolism.  The patient record appeared to have been signed with a stamp and not dated.

On 4/24/2013, the patient presented with complains of bilateral ear pain and sore throat.  The patient’s past medical history stated “Significant for allergies.”  However, at her previous appointment, it listed only left knee injury. There was no other information contained in her past medical history.  The record was electronically signed by an advanced practice registered nurse (“APRN”) on 5/23/2013.

On 10/21/2013, the patient was seen by the APRN with complaints of vomiting, diarrhea, and abdominal cramping. At this appointment, the patient’s past medical history stated, “Noncontributory.”  The APRN documented putting the patient on Phenergan 25 mg tablets #40 one by mouth every eight hours as needed, Bentyl 20 mg #40 one by mouth every eight hours as needed, and acidophilus tablets #20 one by mouth twice daily for ten days.  The record was electronically signed by the APRN on 11/15/2013.

On 1/28/2014, the patient presented with cough, sore throat, hoarseness, body aches, and headache.  Vitals were taken and documented within normal limits; however, no blood pressure or heart rate was documented.  The patient was positive for cervical lymphadenopathy and flu A, rhonchi and wheezing were noted, and the pediatrician prescribed azithromycin.  Azithromycin is not indicated for a viral infection and not otherwise justified in the absence of a non-current bacterial infection.

The patient record was signed electronically by the APRN on 3/19/2014.

The Board judged the pediatrician’s conduct to be below the minimum standard of competence given his failure to keep written medical records which accurately describe the services rendered to the patient, including patient histories, pertinent findings, examination results and test results.  Also, the pediatrician prescribed, dispensed, and administered or distributed a prescription drug, in an improper or inappropriate manner.

The Board ordered that the pediatrician attend and successfully complete the Medical Record Keeping Seminar at the Center for Personalized Education for Physicians (“CPEP”). Also, the Board ordered that the pediatrician hire a medical scribe. Finally, the Board ordered that the pediatrician have another pediatrician monitor his work.

State: Kansas


Date: October 2016


Specialty: Pediatrics, Emergency Medicine


Symptom: Cough, Headache, Pain


Diagnosis: Infectious Disease


Medical Error: Improper medication management, Failure of communication with patient or patient relations, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Kansas – Obstetrics – Administering Vaccines In A Pregnant Patient Without Consent



On 3/6/2013, a patient presented for a newborn screening. No pregnancy or labor and delivery history were documented.  A family history was documented; however, no detail of family history was documented.  The patient was not seen until eleven days after discharge.

On 7/3/2013, the patient presented to the obstetrician for her four month well exam.  At that appointment, the patient was administered the following vaccines: Hib, PEDIARIX, PCV 13, and Rota.  No consent form for the aforementioned vaccines was found in the record.

On 9/10/2013, the patient presented to the obstetrician for her six-month exam.  The obstetrician electronically signed the record on 9/27/2013, approximately seventeen days later.

The Board judged the obstetrician’s conduct to be below the minimum standard of competence given his failure to describe the services rendered to the patient.

The Board ordered that the obstetrician attend and successfully complete the Medical Record Keeping Seminar at Center for Personalized Education for Physicians (“CPEP”). Also, the Board ordered that the obstetrician hire a medical scribe. Finally, the Board ordered that the obstetrician have another obstetrician monitor his work.

State: Kansas


Date: October 2016


Specialty: Obstetrics


Symptom: N/A


Diagnosis: N/A


Medical Error: Failure of communication with patient or patient relations, Ethics violation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Kansas – Pediatrics – Improper Documentation In A Patient With Cough, Wheezing, and Runny Nose



On 12/5/2012, a newborn patient presented for his two-week check.  No family history, pregnancy, or labor and delivery history were documented.  The patient was not seen until thirty-three days after discharge.

The patient was seen only a total of three times by six months of age.  The medical record did not discuss why immunizations were late.  The plan/treatment section of the record was word-for-word the same information as in other patient records.

On 8/26/2013 a pediatrician saw the patient.  The pediatrician documented the patient had a cough, wheezing, and a runny nose.  No other information regarding an exam was given outside of the patient’s vitals being taken.  The pediatrician administered Microephrine 0.2 ml in the office.  The record appears to have been stamped in the pediatrician’s signature, but there was no corresponding date.

On 9/3/2013, the patient presented to the pediatrician after being admitted to the hospital the week prior with croup, bronchiolitis, and respiratory distress.  No information regarding the patient’s hospital stay was found in the pediatrician’s record.

The Board judged the pediatrician’s conduct to be below the minimum standard of competence given his failure to keep written medical records which accurately describe the services rendered to the patient, including patient histories, pertinent findings, examination results and test results.

The Board ordered that the pediatrician attend and successfully complete the Medical Record Keeping Seminar at Center for Personalized Education for Physicians (“CPEP”). Also, the Board ordered that the pediatrician hire a medical scribe. Finally, the Board ordered that the pediatrician have a pediatrician to monitor his work.

State: Kansas


Date: October 2016


Specialty: Pediatrics


Symptom: Cough


Diagnosis: N/A


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


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Kansas – Pediatrics – Improper Documentation For Reactive Airway Disease And Improper Use of Bactrim



On 2/4/2013 a 7-year-old female presented to a pediatrician and saw the advanced practice registered nurse (“APRN”).  The patient presented with chief complaints of allergies, congestion, and diarrhea.  The patient was prescribed albuterol, Qvar 40 mcg, Bactrim, and triamcinolone.  The Bactrim was prescribed inappropriately for diarrhea.  The pediatrician agreed but thought that he had perhaps forgotten to document otitis media.

On 2/19/2013, the pediatrician saw the patient for a follow-up appointment.  The pediatrician documented that the patient was there for a follow-up for her asthma, even though the patient previously presented with reactive airway disease.  The pediatrician did not document his thought process in how reactive airway disease developed in asthma.  The pediatrician did not electronically sign the record until 4/11/2013.

On 6/11/2013, the patient presented to the pediatrician for a school physical.  The pediatrician failed to document the patient’s asthma.  In the school health examination, the pediatrician stamped signature appears on the form with the date 6/11/2013.  The pediatrician stamped the document “No” to the question, “Is this student subject to any condition which might cause a possible classroom emergency such as seizures, fainting, diarrhea, diabetes, asthma, allergies, etc.”

The Board judged the pediatrician’s conduct to be below the minimum standard of competence given his failure to keep written medical records, and inappropriately prescribing a medication.

The Board ordered that the pediatrician attend and successfully complete the Medical Record Keeping Seminar at Center for Personalized Education for Physicians (“CPEP”). Also, the Board ordered that the pediatrician hire a medical scribe. Finally, the Board ordered that the pediatrician have a pediatrician monitor his work.

State: Kansas


Date: October 2016


Specialty: Pediatrics


Symptom: Allergic Reaction Symptoms, Diarrhea


Diagnosis: Asthma


Medical Error: Lack of proper documentation, Improper medication management


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Kansas – Pediatrics – Inability To Diagnose Patient And Use of Improper Medications Due To A Lack of Documentation/Diagnostic Testing



On 2/19/2013, a 17-month-old male presented to a pediatrician’s office for his fifteen-month check.  The pediatrician documented a past medical history of transposition of great vessels at three weeks and open heart surgery.  During the appointment, the pediatrician failed to document family history entirely.  The pediatrician’s section is word-for-word the same information as in other patient records.  The pediatrician failed to provide a detail of treatment plan unique to the patient

On 4/10/2013, the patient presented with a chief complaint of progressively worsening cough with concerns for respiratory syncytial virus, and bronchiolitis.  The review of systems documented ENT evaluation and did not assess the heart. No pulse oximetry was performed.  The physical assessment did not document any GI, musculoskeletal, or skin assessments.

On 5/2/2013, the patient presented for nasal congestion and cough for the last two to three days.  No review of systems was documented.  No oximetry was performed.  It is unclear whether budesonide and albuterol were prescribed, although the pediatrician indicated treatments of budesonide and albuterol in his plan.

On 5/13/2013, the patient presented for coughing coupled with wheezing and rales in the chest.  No pulse oximetry was performed.  The pediatrician signed the patient’s record electronically ten days following the patient visit.

On 6/13/2013, the patient presented with chief complaints of croupy cough, very phlegmy, audible wheezing, rales in the chest, and low-grade fever.  No pulse oximetry was performed.  The pediatrician failed to document his impression regarding why the patient has had the same symptoms since 4/10/2013.

The pediatrician signed the patient record electronically on 7/9/2014.

The pediatrician eventually administered Rocephin and IV methylprednisolone, which was identified as being inappropriate.

The Board judged the pediatrician’s conduct to be below the minimum standard of competence given his failure to keep written medical records and given his failure to prescribe appropriate medications for the patient’s diagnosis.

The Board ordered that the pediatrician attend and successfully complete the Medical Record Keeping Seminar at Center for Personalized Education for Physicians (“CPEP”). Also, the Board ordered that the pediatrician hire a medical scribe. Finally, the Board ordered that the pediatrician have another pediatrician monitor his work.

State: Kansas


Date: October 2016


Specialty: Pediatrics


Symptom: Cough, Fever


Diagnosis: Pulmonary Disease


Medical Error: Improper medication management, Failure to order appropriate diagnostic test, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Urology – Insertion Of Catheter Without Removing Protective Sheath During A Cystoscopy-Assisted Balloon Dilation And Stenting Procedure



On 9/15/2014, a patient presented to a urologist for a cystoscopy-assisted balloon dilation and stenting procedure to correct a stricture in his left ureter.

The urologist performed the cystoscopy-assisted balloon dilation and stenting of the patient’s left ureteral stricture.

The cystoscopy-assisted balloon dilation and stenting procedure required the urologist to utilize a catheter to move a balloon and stent into place in the patient’s left ureter.

The catheter utilized by the urologist for the patient’s procedure was equipped with a protective catheter sheath.  This sheath had to be removed prior to the insertion of the catheter into the patient’s ureter.

Neither the urologist nor his support staff removed the protective catheter sheath from the catheter prior to the insertion of the catheter into the patient’s ureter.

The urologist successfully placed the stent into the patient’s left ureter during the cystoscopy-assisted balloon dilation and stenting procedure, but following the procedure the patient experienced intense persistent pain with accompanying nausea.

On 12/11/2014, an exploratory ureteroscopy was performed on the patient’s left ureter.  This procedure revealed the presence of the protective catheter sheath from the cystoscopy-assisted balloon dilation and stenting procedure performed by the urologist on 9/15/2014.  The sheath was successfully removed the patient’s left ureter and the patient’s pain and nausea subsided.

The Medical Board of Florida judged the urologist’s conduct to be below the minimal standard of competence given that he left a foreign body in a patient.

It was requested that the Medical Board of Florida order one or more of the following penalties for the urologist: permanent revocation or suspension of his license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Medical Board of Florida deemed appropriate.

State: Florida


Date: October 2016


Specialty: Urology


Symptom: Pain, Nausea Or Vomiting


Diagnosis: Post-operative/Operative Complication


Medical Error: Retained foreign body after surgery


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Emergency Medicine – Chest Pain, Shortness Of Breath, Left Bundle Branch Block On EKG



On 1/19/2014 at 4:40 a.m., a patient arrived at the emergency department complaining of shortness of breath and weeks of intermittent chest pain.

At 4:50 a.m., an ED physician evaluated the patient.  The patient was hypotensive, mildly tachycardic, tachypneic, and hypothermic.  He had rales, rhonchi, and a few wheezes.  The ED physician documented “Today, his pain is less,” but otherwise did not document any further description of the patient’s pain.

In his dictated note, the ED physician explained that he was concerned with the patient suffering septic shock.  In a subsequently written narrative, the differential diagnosis was expanded to include cardiac causes.

Laboratory studies were ordered along with an EKG, a troponin level, and a brain natriuretic peptide level.  The EKG was performed timely and was abnormal.  While the ED physician identified a left bundle block pattern (“LBBP”) in his dictated notes, he neither offered further interpretation of the EKG nor referenced criteria known to be helpful in identifying myocardial infarction in those with an LBBP on EKG.  The ED physician wrote that the EKG showed an LBBP “consistent with a myocardial infarction…”

The small community hospital where the patient presented had an ST-elevated myocardial infarction (“STEMI”) protocol in collaboration with a larger regional hospital better equipped to handle patients with cardiac emergencies.  Once activated, the protocol provides for rapid transportation of the patient to the larger hospital by ambulance.  The ED physician did not activate this protocol.

45 minutes after the EKG was performed, the troponin and BNP results indicated myocardial infarction and congestive heart failure.  A subsequent chest x-ray revealed pulmonary edema.  At this point, the ED physician called the on-call cardiologist to discuss transfer of the patient for treatment at a larger regional hospital.

The Board issued a reprimand and expressed concern that the ED physician departed from the standard of care by failing to obtain and document a more robust history and failing to more promptly consult cardiology regarding the patient’s abnormal EKG.

The Board ordered 40 hours of continuing medical education.

State: California


Date: October 2016


Specialty: Emergency Medicine, Cardiology, Internal Medicine


Symptom: Chest Pain, Shortness of Breath


Diagnosis: Acute Myocardial Infarction, Heart Failure


Medical Error: Delay in proper treatment, 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



Florida – Ophthalmology – Multiple Medical Errors In A Patient With Numerous Ocular Complications



An ophthalmologist treated a 48-year-old female from 2/2/2009 to 10/24/2014.

On 10/29/2013, the ophthalmologist documented a diagnosis of proliferative diabetic retinopathy with diabetic macular edema in both eyes, wet macular degeneration in both eyes, vitreous hemorrhage with posterior vitreous detachment in both eyes, subretinal macular hemorrhage in both eyes, posterior change intraocular lens in the right eye, cataract in the left eye, and dry eye syndrome in both eyes.

From 10/29/2013 to 10/24/2014, the ophthalmologist performed panretinal laser treatment on the patient’s eyes four times; intravitreal Avastin injections in both eyes twelve times; focal laser treatments in the patient’s left eye four times, and the patient’s right eye three times; fluorescein angiography and indocyanine green angiography twenty-six times; ultrasonography five times; and intravitreal injection of antibiotics in the right eye.

The Medical Board of Florida judged the ophthalmologist’s conduct to be below the minimal standard of competence given that the ophthalmologist failed to utilize, or did not create, keep or maintain adequate, legible documentation of utilizing, optical coherence tomography to evaluate the patient.  The ophthalmologist incorrectly or falsely diagnosed the patient with wet macular degeneration.  He performed intravitreal Avastin injections on the patient’s eyes without medical justification on one or more occasions.  He performed focal laser treatments, panretinal laser photocoagulation, fluorescein and indocyanine green angiography, and ultrasounds on the patient’s eyes excessively or without medical justification on one or more occasions.”  He failed to utilize optical coherence tomography to evaluate the patient.  He did not document the lot number or any other identifying information from any of the vials of Lucentis used during his treatment of the patient.

It was requested that the Medical Board of Florida order one or more of the following penalties for the ophthalmologist: permanent revocation or suspension of his license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Medical Board of Florida deemed appropriate.

State: Florida


Date: October 2016


Specialty: Ophthalmology


Symptom: N/A


Diagnosis: Ocular Disease


Medical Error: Unnecessary or excessive treatment or surgery, Diagnostic error, Failure to order appropriate diagnostic test, Unnecessary or excessive diagnostic tests, Improper medication management, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



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