Found 26 Results Sorted by Case Date
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California – General Surgery – Five Vulvar Surgeries And Breast Tattoo Removals Conducted For Cosmetic Alteration



In December 2008, a 30-year-old female presented to a general surgeon for removal of breast tattoos.  A 12/1/2008 document entitled “comprehensive examination” does not include an adequate history of the present illness, obstetrical history, gynecological history, or past surgical history.  The patient presented to the general surgeon for three tattoo removal visits.  The last of those presentations was on 1/27/2009.

On 1/27/2009, at her visit with the general surgeon, the patient made complaints related to the fullness and asymmetry in the area above the pudendal cleft of her left vulva as well as a pudendal flap and excessive skin.  At this time, the patient had a history of eight vaginal deliveries.

The patient returned one day later on 1/28/2009 to have the first of what would ultimately be five vulvar surgeries to remove the areas identified above.  The surgery was documented with an operative note and included a surgical consent.  The surgery did not include a complete history and physical.  No record of the patient’s last menstrual cycle, method of contraception, or whether the general surgeon performed a pregnancy test preoperatively, was documented.  There was no documentation of a discussion related to the known risks of scarring and dyspareunia.

Following the first surgery, the general surgery referred to the patient’s skin as “mucosal skin tags” and he believed them to be from trauma “from multiple deliveries.”

On 2/24/2009, a second surgery was performed.  The surgery was documented with an operative note and included a surgical consent.  The surgery did not include a complete history and physical.  No record of the patient’s last menstrual cycle, method of contraception, or whether the general surgeon performed a pregnancy test preoperatively, was documented.  There was no discussion related to the function of the vulva.  The surgery appeared to be for cosmetic reasons alone.  There was no documentation of a discussion related to the known risks of scarring and dyspareunia.

Three additional surgeries were performed on 4/2/2010, 5/6/2011, and 5/17/2011.  Like the two before, each was documented with an operative note and included a surgical consent.  The surgery did not include a complete history and physical.  No record of the patient’s last menstrual cycle method of contraception, or whether the general surgeon performed a pregnancy test preoperatively was documented.  There was no discussion related to the function of the vulva.  The surgery appeared to be for cosmetic reasons alone.  There was no documentation of a discussion related to the known risks of scarring and dyspareunia.

During each of the five surgeries, the general surgeon removed varying portions of the patient’s labia minora, labia majora, and clitoral hood.  The end result was complete removal of the labia minora and almost complete removal of the clitoral hood.

As a result of the multiple procedures, the patient was left with excessive scar tissue and complete exposure of the clitoris.  This led to vulvar pain, dryness, bleeding, inability to have sexual intercourse, difficulty urinating, and urine that did not flow in a continuous stream.  The patient presented to a plastic surgeon and gynecologist for repair.

The Board judged the general surgeon’s conduct as having fallen below the standard of care given the performance of procedures with disregard of normal anatomy and physiology, disregard of the scar tissue that would form around the introitus and that would leave the clitoris exposed with complete removal of the clitoral hood, and failure to refer the patient to a specialist.

The Board issued a public reprimand with the stipulation to complete at least 20 hours of continuing medical education in correcting areas of deficiency.

State: California


Date: November 2016


Specialty: General Surgery, Gynecology, Plastic Surgery


Symptom: N/A


Diagnosis: N/A


Medical Error: Procedural error, Failure to examine or evaluate patient properly, Referral failure to hospital or specialist, Improper treatment


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 4


Link to Original Case File: Download PDF



California – Family Practice – Patient With Multiple Psychiatric Conditions And A Low Platelet Count Placed On Enbrel For Rheumatoid Arthritis



On 11/17/2008, a family practitioner first began treating the patient.  The family practitioner treated the patient for anxiety, panic disorder, neuropathic pain from an old left thigh stab wound, post-traumatic stress disorder, bipolar disorder, chronic insomnia, obesity, and hypothyroidism.

On 7/18/2013, the patient was seen in an emergency department.  The laboratory results from that visit indicated that the patient had a very low platelet count of 63,000 versus a normal platelet count of 140,000 to 150,000.  The laboratory results also stated that the mean corpuscular volume (MCV) was found to be 106.6.  The MCV is the average volume of red cells in a specimen.

On 7/19/2013, the patient was treated by the family practitioner.  The medical notes for that visit state that the patient “returns for follow up on an ER visit yesterday for abdominal pain.”  The notes also state, “Labs reveal macrocytic RBC indices.”

Red blood cell (RBC) indices are part of the complete blood count (CBC) test.  The indices also include MCV, hemoglobin amount per red blood cell (MCH), and the amount of hemoglobin relative to the size of the cell (hemoglobin concentration) per red blood cell (MCHC).

The MCV, MCH, and MCHC were all recorded in the patient’s laboratory results from the 7/18/2013 emergency department visit.

On 8/9/2013, the patient commenced treatment for rheumatoid arthritis by using the drug Enbrel, which was prescribed by the family practitioner, even though Enbrel can cause a low platelet count and even though the family practitioner knew or should have known that as of 7/19/2013, the patient’s platelet count was low.

On 10/8/2013, the patient informed the family practitioner that another clinic treating the patient noted that the patient’s platelet count was dropping and advised the patient to go directly to the hospital for a blood draw.  The family practitioner then discontinued the patient’s use of Enbrel, writing, “discussed fact that thrombocytopenia is a rare but recognized adverse side effect of Enbrel treatment.”

Additionally, any patient treated with Enbrel should have a Tuberculosis (TB) skin test prior to commencing therapy in order to confirm the absence of disease.

Contrary to standards, the family practitioner provided no documentation for the required pretreatment negative tuberculin skin test prior to the commencement of treatment with Enbrel.  In fact, not until 9/17/2014, more than one month after treatment with Enbrel commenced, was a negative TB skin test noted in the patient’s medical record.

On 10/18/2011, the family practitioner noted in the patient’s medical records that the patient was positive for hepatitis C.  Yet, the family practitioner never referred the patient to a liver specialist for hepatitis C.

The family practitioner allowed the patient to dictate the treatment by prescribing, on multiple occasions, medications that the patient had requested.

On 7/8/2009, the family practitioner prescribed clonidine for the patient for insomnia.  Clonidine is a drug normally used to treat hypertension, but it has been effectively used in low doses to treat insomnia in children on ADHD medications.  At that time, the patient’s blood pressure was charted as 110/60.

On 7/15/2009, the family practitioner discontinued the patient’s use of clonidine when the patient reported that the medicine was not effective for sleep and that it caused dizziness.  On that same date, the patient’s blood pressure was charted as 80/60.

Between 7/8/2009 and 7/15/2009, the patient was using the following medications with the family practitioner’s knowledge: fluoxetine, diphenhydramine, clonidine, and olanzapine.

On 8/16/2011, the family practitioner prescribed Saphris for the patient for insomnia, even though insomnia is a known side effect of Saphris.  By 9/9/2011, the patient stopped taking Saphris after claiming to have developed a tolerance for the medication.

The Board judged the family practitioner’s conduct as having fallen below the standard of care for multiple patients given failure to record a physical exam in the progress notes, failure to revise and update assessments or plans for those patients, and failure to include a problem list or medication list in his progress notes.

The family practitioner was placed on probation for 5 years with the stipulations of completing 40 hours annually of continuing medical education in the areas of deficient practice, a prescribing practices course at the Physician Assessment and Clinical Education Program, a medical record keeping course, an ethics course, a clinical training program equivalent to the Physician Assessment and Clinical Education Program, and undergo clinical practice monitoring.

State: California


Date: November 2016


Specialty: Family Medicine, Internal Medicine, Psychiatry


Symptom: Psychiatric Symptoms, Dizziness


Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Psychiatric Disorder


Medical Error: Improper medication management


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Family Practice – Elevated Glucose Levels In A Patient On Aripiprazole, Asenapine, Quetiapine, And Olanzapine



On 11/6/2007, a family practitioner first began treating a patient and continued treating the patient until at least 6/9/2014.

On 12/21/2009, the family practitioner noted in the patient’s medical records that the patient was diabetic, writing “Lab-Spot glucose 242.”  A level of 200 mg/dL or higher often means one has diabetes.

On 1/11/2010, the next exam noted in the patient’s records, the family practitioner noted a refill was needed for glipizide.  However, there is no record that the patient was ever prescribed glipizide prior to this date.

During the course of treatment from the family practitioner, the patient was also prescribed aripiprazole, quetiapine, asenapine, and olanzapine for bipolar disorder.  Aripiprazole, asenapine, and olanzapine can cause or worsen diabetes.  According to medical notes, on 6/13/2011, the family practitioner was treating the patient with both aripiprazole and olanzapine as well as glipizide, which was to control diabetes.

On 7/11/2011, the patient’s blood sugars were noted to be in the 400 range, while 100 to 110 is considered to be the normal range for blood sugars in an individual.  The family practitioner started the patient on insulin glargine to address diabetes on a daily basis.

In an interview that occurred on 10/1/2015, the family practitioner admitted that the family practitioner had no idea if the patient was taking the prescribed medications while under his care.

The Board judged the family practitioner’s conduct as having fallen below the standard of care for multiple patients given failure to record a physical exam in the progress notes, failure to revise and update assessments or plans for those patients, and failure to include a problem list or medication list in his progress notes.  In addition, the family practitioner’s repeated, excessive and/or inappropriate prescribing of large doses of multiple strong antipsychotic medication and antidepressants to the patient with no regard or concern for drug interactions constituted a lack of knowledge and/or unprofessional conduct.

The family practitioner was placed on probation for 5 years with the stipulations of completing 40 hours annually of continuing medical education in the areas of deficient practice, a prescribing practices course at the Physician Assessment and Clinical Education Program, a medical record keeping course, an ethics course, a clinical training program equivalent to the Physician Assessment and Clinical Education Program, and undergo clinical practice monitoring.

State: California


Date: November 2016


Specialty: Family Medicine, Internal Medicine, Psychiatry


Symptom: N/A


Diagnosis: Diabetes, Psychiatric Disorder


Medical Error: Improper medication management, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Family Medicine – Chest Pain, Elevated LDL, Elevated C-Reactive Protein, And Abnormal Electrocardiogram



On 9/17/2012, a 57-year-old male and long-time patient of a family practitioner presented to the family practitioner with complaints of chest pain and tightness and shortness of breath while exercising on a treadmill.  The family practitioner ordered an electrocardiogram, chest x-ray, and laboratory studies. The patient’s blood pressure at this visit was 150/110. The patient’s laboratory tests indicated an LDL of 162 and significantly elevated cardio C-reactive protein.  The patient’s electrocardiogram revealed wave changes consistent with an anterior infarct and as well as anterolateral ischemia. The family practitioner did not advise the patient to modify his lifestyle, did not initiate anti-hypertension medications or medications for elevated lipids, and did not order re-evaluation of the patient’s blood pressure or lipid levels.  The family practitioner failed to properly address the patient’s complaints of chest pain and tightness, his multiple cardiac risk factors, and his abnormal electrocardiogram and laboratory test results. The family practitioner did not order the patient to the emergency department to urgently refer the patient for stress testing and cardiology consultation.

On 9/25/2012, the patient collapsed and died while working out at 24 Hour Fitness.  The cause of death was atherosclerotic cardiovascular disease. On 5/7/2015, the family practitioner was interviewed as part of the investigation of the care and treatment he provided the patient.  The family practitioner admitted that the patient’s medical records spanning several years were lost or improperly destroyed.

The Medical Board of California judged that the family practitioner’s conduct departed from the standard of care because he failed to properly evaluate and treat the patient’s exertional chest pain in the setting of multiple cardiac risk factors and abnormal electrocardiogram and laboratory findings.

The Medical Board of California issued a public reprimand and ordered the family practitioner 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: November 2016


Specialty: Family Medicine, Internal Medicine


Symptom: Chest Pain, Shortness of Breath


Diagnosis: Cardiovascular Disease


Medical Error: Failure to follow up, Diagnostic error


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Internal Medicine – Undiagnosed Fever, Urinary Retention, And Hematuria Results In Death



On 12/23/2013, a 63-year-old male presented to a medical center with complaints of fever, insomnia, urinary retention, and hematuria, lasting the past six days.

Upon admission to the medical center, the patient was examined by an internist, and the internist diagnosed the patient with a urinary tract infection and urinary retention.

Based on this diagnosis, the internist ordered the administration of ceftriaxone, the placement of a Foley catheter, a urinalysis work-up, and a consultation with a urologist.

The patient’s urinalysis came back negative, and the Foley catheter enabled the patient’s bladder to void.

While a consultation with a urologist was ordered, it was never actually completed.

There was no documentation in the patient’s medical records that indicated the underlying causes of the patient’s urinary retention, hematuria, fever, and pain.

The internist failed to perform and failed to document performing an examination of the patient’s abdomen, lower back, kidneys, and genitourinary system that was sufficiently detailed enough to confirm or rule out the possible underlying causes of the patient’s urinary retention, hematuria, fever, and pain.

The internist failed to order and failed to document ordering additional laboratory and imaging testing of the patient’s abdomen, lower back, kidneys, and genitourinary system, after the patient’s urinalysis came back negative.

The internist failed to follow up on and failed to document following up on the urology consultation and the urology consultation results ordered for the patient.

The internist stated in his discharge summary that the patient “was seen by urology and workup was negative.”

On 12/25/2013, the patient was discharged from the hospital with instructions to follow up with his primary care physician and an outpatient urology practice.

On 12/28/2013, the patient’s condition deteriorated and he expired in his home as a result of undiagnosed peritonitis.

The Medical Board of Florida judged the internist’s conduct to be below the minimal standard of competence given that he failed to perform an examination of the patient’s abdomen, lower back, kidneys, and genitourinary system that was sufficiently detailed enough to confirm or rule out the possible underlying causes of the patient’s urinary retention, hematuria, fever, and pain.  The internist also failed to follow up on additional laboratory and imaging testing of the patient’s abdomen, lower back, kidneys, and genitourinary system until the underlying causes of the patient’s urinary retention, hematuria, fever, and pain was determined.  The internist failed to follow up on the urology consultation and/or results of the urology consultation that was ordered for the patient.  Also, the internist failed to reevaluate and reassess the patient’s condition prior to his discharge from the hospital.

The Medical Board of Florida issued a letter of concern against the internist’s license. Also, the Medical Board of Florida ordered that the internist pay a fine of $8,000 against his license and pay reimbursement costs for the case at a minimum of 3,462.89 and not to exceed $5,462.89.  The Medical Board of Florida ordered that the internist complete five hours of continuing medical education in the “diagnosis and treatment of urinary retention and hyponatremia” and complete five hours of continuing medical education in “risk management.”

State: Florida


Date: November 2016


Specialty: Internal Medicine, Urology


Symptom: Fever, Bleeding, Pain, Urinary Problems


Diagnosis: Infectious Disease, Urological Disease


Medical Error: Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Failure of communication with other providers, Failure to follow up, Lack of proper documentation


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



Florida – General Surgery – Lump And Pain After Procedure To Strip Greater Saphenous Vein And Ligate Saphenofemoral Junction



On 9/9/2011, a general surgeon performed a greater saphenous vein stripping, a ligation of the saphenofemoral junction, and phlebectomies on a patient’s right leg.

On 9/12/2011, the third post-operative day, the patient reported pain and redness.

The next day, on 9/13/2011, the patient called the general surgeon’s office and complained of throbbing pain in her right leg and groin.  The patient was instructed to use a heating pad, to elevate her leg as much as possible, and to call if symptoms escalate.

The next day, on 9/14/2011, at a follow-up appointment with the general surgeon, the patient reported increased pain secondary to a hematoma.  The patient was instructed to follow up in one week.

Six days later, on 9/19/2011.  The patient called the general surgeon’s and complained of increased pain in her right leg and a lump in her right groin area.  The patient was instructed to go to a radiology center for a stat right leg ultrasound.

The patient presented for a venogram, which revealed total occlusion of the right common femoral vein with extravasation.

The patient was transferred to a medical center on 9/23/2011.  A physician performed a right groin evacuation of the hematoma and exploration of the right common femoral vein.  The physician found that during the original surgery, the general surgeon had ligated and transected the common femoral vein instead of the greater saphenous vein.

As a result of the injury, the patient continues to experience pain and swelling to her right leg.

The Medical Board of Florida judged the general surgeon’s conduct to be below the minimum standard of competence given that he failed to clearly identify the saphenofemoral junction and then ligate, transect, and strip the greater saphenous vein.  The general surgeon also failed to further investigate the patient’s pain and hematoma at the time of her complaints, including ordering a venous ultrasound of the leg.  The general surgeon did not correctly identify and ligate the greater saphenous vein.  Instead, he ligated and transected the common femoral vein.  The general surgeon did not adequately investigate and evaluate the patient’s post-operative pain and hematoma.  Instead, he waited seven days before advising the patient to obtain a venous ultrasound.

The Medical Board of Florida issued a letter of concern against the general surgeon’s license.  The Medical Board of Florida ordered that the general surgeon pay a fine of $10,000 against his license and pay reimbursement costs for the case at a minimum of $8,070.79 and not to exceed $10,070.79.  The Medical Board of Florida also ordered that the general surgeon complete a medical records course, complete five hours of continuing medical education in vascular surgery, and complete five hours of continuing medical education in “risk management.”

State: Florida


Date: November 2016


Specialty: General Surgery


Symptom: Pelvic/Groin Pain, Mass (Breast Mass, Lump, etc.), Extremity Pain, Swelling


Diagnosis: Post-operative/Operative Complication, Cardiovascular Disease


Medical Error: Wrong site procedure, Delay in proper treatment, Failure to order appropriate diagnostic test


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



Florida – Emergency Medicine – Pleuritic Shortness Of Breath, Dry Cough, Nausea, Abdominal Distention, Hypoactive Bowel Sounds, And Right-Sided Abdominal Tenderness



On 5/31/2012, a 76-year-old male presented to the emergency department with complaints of pleuritic shortness of breath, dry cough, and nausea.

The patient was admitted for acute hypoxic and hyperbaric respiratory failure as well as COPD exacerbation by an ED physician.

On 6/6/2012, the patient reported a new symptom of abdominal pain.  The patient had abdominal distention, hypoactive bowel sounds, and right-sided abdominal tenderness.

On 6/6/2012, a nurse practitioner advised that an abdominal x-ray should be ordered.

The ED physician did not create an adequate history, perform a proper examination, or correctly document the ordering of an abdominal x-ray for the patient on 6/6/2012.

On 6/8/2012, a consultant physician for the patient raised a concern of possible ischemic bowel.

The ED physician did not order, or did not create or maintain adequate, legible documentation of ordering, a CT scan of the patient’s abdomen on 6/8/2012.

The Medical Board of Florida issued a reprimand against the ED physician’s license.  The Medical Board of Florida issued a fine of $10,000 against the ED physician’s license and pay reimbursement costs for the case at a minimum of $4,269.46 and not to exceed $6,269.64.  The Medical Board of Florida ordered that the ED physician complete five hours of continuing medical education in the area of “patient evaluation and monitoring in the hospital setting” and complete a records course.  The Medical Board of Florida placed the ED physician’s license on probation for a period of one year and required the ED physician to be indirectly supervised by a monitor during this period.

State: Florida


Date: November 2016


Specialty: Emergency Medicine, Internal Medicine


Symptom: Shortness of Breath, Cough, Nausea Or Vomiting, Abdominal Pain


Diagnosis: Acute Abdomen


Medical Error: Failure to order appropriate diagnostic test, 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 – Gynecology – Trichloroacetic Acid Administered Instead Of Acetic Acid During Routine Vaginal Procedure



On 9/29/2014, a patient presented to the health department to a gynecologist for a routine vaginal procedure.

The gynecologist asked the nurse assisting him to hand him acetic acid to prepare for the procedure.  However, the nurse gave the gynecologist trichloroacetic acid by mistake.

The gynecologist used a cotton swab to apply the trichloroacetic acid to the patient’s vaginal area.

The patient began to experience extreme burning, and the gynecologist immediately washed the patient’s vaginal area.  The patient sustained burns and sloughing of skin to the surface and inside her vagina.  The gynecologist applied lidocaine gel to the area.

On 9/30/2014, the patient returned to the health department with complaints of pain and bleeding as a result of the burns.  She was examined and given lidocaine for the pain.

The Medical Board of Florida judged the gynecologist’s conduct to be below the minimal standard of competence given that he applied the wrong medication, trichloroacetic acid, to her vagina and cervix instead of acetic acid.

The Medical Board of Florida issued a letter of concern against the gynecologist’s license.  The Medical Board of Florida ordered that the gynecologist pay a fine of $2,500 for his license and pay reimbursement costs for the case at a minimum of $2,757.86 and not to exceed $4,757.86.  The Medical Board of Florida also ordered that gynecologist complete five hours of continuing medical education in gynecology and complete five hours of continuing medical education in “risk management.”

State: Florida


Date: November 2016


Specialty: Gynecology


Symptom: Pain, Bleeding


Diagnosis: N/A


Medical Error: Accidental Medication Error


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Gynecology – Complications After Hysterectomy For Patient With Simple Hyperplasia Without Atypia And A History Of Infraumbilical Midline Incision



A 46-year-old female presented to a gynecologist in July 2011 complaining of vaginal bleeding.  The patient had a history of ulcerative colitis and an infraumbilical midline incision. The patient next presented about one month later.  The laboratory results included small fibroids, a small polyp, and a small ovarian cyst. Based on these findings, the gynecologist recommended and performed an endometrial biopsy.  The result of the endometrial biopsy was simple hyperplasia without atypia. The gynecologist discussed the options for treatment with the patient and offered her medical treatment with repeat endometrial biopsy, dilation, and curettage with ablation, or hysterectomy.

The patient requested a hysterectomy with removal of both ovaries for definitive treatment.  The gynecologist obtained consent for a robotic hysterectomy and discussed the risks of the procedure, which included the possibility of finding extensive adhesions that would require an open abdominal hysterectomy as opposed to the laparoscopic approach.

On 10/19/2011, the patient was taken to the operating room, where she underwent a diagnostic laparoscopy and a total abdominal hysterectomy and bilateral salpingo-oophorectomy.  The findings at the time of surgery included an enlarged uterus with several small fibroids, normal ovaries, and normal fallopian tubes. There were excessive thick adhesions from the small bowel and omentum to the anterior abdominal wall and the left pelvic sidewall.  There were also adhesions in the right upper quadrant from the omentum to the abdominal wall. The gynecologist used a closed technique to enter the abdominal cavity with a Veress needle. The gynecologist placed the patient in maximum Trendelenburg position and then made a small incision in the umbilicus and inserted the Veress needle.  After removing the Veress needle, the gynecologist placed a 5 mm trocar and was able to visualize the adhesions. She then placed a second 5 mm trocar under direct visualization in the area clear of adhesions and used monopolar scissors for approximately 5 minutes in the attempt to lyse the adhesions. The gynecologist noted that the adhesions were very thick and extensive and included the bowel. She did not feel as though it was safe to proceed with the robot.  The gynecologist removed the instruments and proceeded with an uneventful total abdominal hysterectomy and bilateral salpingo-oophorectomy through a Pfannenstiel incision.

The patient’s post-operative course was eventful.  On the first post-operative day, she was noted to have a pulse of 130 bpm.  She was in moderate pain despite IV pain medication. A CBC was drawn, which showed a normal WBC count of 3.5, but it showed 50% bands.  The bandemia was not noted in the post-operative note. On the second post-operative day, the gynecologist saw the patient again at 2 p.m. and noted that the patient remained on oxygen.  Her pulse also remained at 130. The gynecologist ordered an EKG and a chest x-ray, increased the pain medication, and advised the patient to ambulate. A CBC drawn that day was not mentioned in the post-operative note, but it showed a normal WBC count at 4.7 and again showed bandemia of 18%.  The gynecologist wrote a discharge order at 2:20 p.m. on that day without any parameters.

Tachycardia persisted, and the patient developed shortness of breath, pain with breathing, and an oxygen saturation level of 82% for which the nursing staff called the Rapid Response Team.  The patient was transferred to a critical care bed with the diagnosis of acute hypoxic respiratory failure and peritonitis, and the gynecologist on-call was notified. The gynecologist had signed out to the on-call gynecologist for the weekend.  During that weekend, the patient’s condition continued to worsen. A CT scan performed on the evening of 10/22/2011 showed multiple fluid and air collections in the abdomen, mesentery, and abdominal wall. Various medical specialists as well as the gynecologist on-call evaluated the patient throughout the weekend.  On the fifth post-operative day, a general surgeon was consulted, who immediately made the diagnosis of a bowel perforation and took the patient to the operating room for a bowel resection. The patient remained in the hospital and was discharged o 11/9/2011.

During the gynecologist’s care, treatment and management of the patient, the gynecologist obtained informed consent and, on multiple occasions, discussed the risks, benefits, and alternatives to the surgery and included the additional risks due to the patient’s earlier bowel surgery.  As part of the alternatives to surgery, the gynecologist offered the patient an endometrial ablation, which is contraindicated in the presence of endometrial hyperplasia, as this is considered a precancerous condition. During an interview with representatives of the Medical Board of California, the gynecologist explained that she would no longer operate on this patient, but would refer her to the new gynecologic oncologist at another hospital.

At the time of the interview, the gynecologist was aware that the patient’s condition was precancerous since she would now refer the patient to an oncologist.  Simple hyperplasia does not require referral to an oncologist, but, given that the pathology of simple hyperplasia is considered a precancerous condition, the offering of endometrial ablation as an alternative was not appropriate.

Bowel injury is a known complication during the performance of a hysterectomy, whether it is performed laparoscopically or as an open procedure.  The risk of bowel injury is increased in a patient who, like this patient, had undergone a previous abdominal or bowel surgery and in a patient with a vertical midline incision.

The standard of care dictates that when the patient is at high risk for bowel injury, the surgeon must take all available precautions in order to avoid this complication and have a high index of suspicion of bowel injury if the patient’s post-operative course is complicated.  The gynecologist was well aware of the patient’s higher risk for pelvic adhesions. The patient had a vertical midline incision from a previous colectomy, and on multiple occasions, the gynecologist discussed the high likelihood of adhesions with the patient.

The Medical Board of California judged that the gynecologist’s conduct departed from the standard of care because she did not use a safer technique when inserting the Veress needle, offered her the alternative of endometrial ablation, and failed to recognize in a timely manner that the patient had sustained a bowel injury.

The Medical Board of California placed the obstetrician on probation for 35 months and ordered the obstetrician to complete a medical record-keeping course and education course for at least 40 hours for every year of probation.

State: California


Date: November 2016


Specialty: Gynecology


Symptom: Abnormal Vaginal Bleeding, Pelvic/Groin Pain, Shortness of Breath


Diagnosis: Post-operative/Operative Complication, Gynecological Disease


Medical Error: Procedural error, Diagnostic error, Improper treatment


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



North Carolina – General Surgery – Unintentional Creation Of A Colovaginal Anastomosis



The Board was notified of a professional liability payment made on 12/15/2015.

In 2012, a 51-year-old female, presented to a general surgeon with recurrent diverticulitis and a history of multiple prior abdominal and gynecological surgeries. As a result of the patient’s history and symptoms, the general surgeon performed a partial sigmoid colectomy, or bowel resection. Two days postoperatively, the patient began to exhibit symptoms consistent with a colovaginal anastomosis, an erroneous connection of the patient’s colon to her vagina rather than her rectum as intended. When the error was discovered, the general surgeon immediately notified the patient and advised her of the need for corrective surgery. The patient returned to surgery where the general surgeon corrected the error.

The Board submitted the patient’s medical records to an independent expert for review. The expert noted the creation of a colovaginal anastomosis is an avoidable surgical error.  Specifically, the expert stated that by visually and manually inspecting the proper placement of the stapler this error can be prevented. The expert remarked that the general surgeon’s care of Patient A after the error was discovered was “exemplary”. The expert also applauded the general surgeon for immediately notifying the patient of the mistake.

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: November 2016


Specialty: General Surgery


Symptom: N/A


Diagnosis: Post-operative/Operative Complication


Medical Error: Procedural error


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



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