Found 28 Results Sorted by Case Date
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Virginia – Family Practice – Prescription Of A Higher Dose Of Oxycodone Than Previously Prescribed



From June 2014 to January 2015, a family practitioner treated a 52-year-old female for complaints of chronic neck, back, knee, and elbow pain.

In November 2009, the family practitioner began treating the patient for unclear diagnoses with oxycodone, gabapentin, and alprazolam until late March 2014, when his license was temporarily restricted from prescribing those medications.

After the restrictions on his license had been lifted, the family practitioner resumed treating the patient on 6/6/2014.

That day, she reported that during the interim she had been prescribed medications by her primary care provider (“PCP”).  However, the family practitioner neither requested records from the patient’s PCP nor confirming her report by reviewing the Virginia Prescription Monitoring Program.

On 6/14/2014, without such confirmatory information, the family practitioner prescribed oxycodone at a dose of 120 mg/day down from 240 mg/day which he had prescribed her previously without documenting how he determined the dosage and without instructing the patient on medication titration.  He did not obtain any diagnostic studies to determine the cause of the pain.

Between 6/6/2014 and January 2015, the family practitioner failed to adequately monitor and manage the patient’s medication use.  He did not order any urine drug screens.  He did not conduct any pill counts.  He did not review data from the Virginia Prescription Monitoring Program.  If reviewed, it would have shown that the patient’s PCP prescribed between 60 mg and 90 mg a day.

The family practitioner saw the patient 10 times and prescribed her oxycodone with doses escalating up to 180 mg/day.  He did not refer her to any specialists despite the fact that she had a history of heart disease and was hospitalized several times since 2009 for COPD.  Between 6/4/2014 and 1/21/2015, the patient fell at least three times.

On 1/21/2015, the family practitioner prescribed the patient oxycodone 30 mg, 180 pills.

On 2/7/2015, the patient was found dead at home.  Law enforcement officers found two marijuana pipes in her bedroom along with “multiple prescription bottles and a saucer with a straw and pill residue…laying on the nightstand by [her] bed.”  On her death certificate, cause of death was noted to be oxycodone and alprazolam intoxication.  The manner of death was “Snorting abuse of prescribed pharmaceutical opioid.”  Blood toxicology revealed 0.368 mg/L of oxycodone.

The Board indefinitely suspended the family practitioner’s license.

State: Virginia


Date: February 2017


Specialty: Family Medicine, 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



Virginia – Family Practice – Prescription Of Oxycodone At High Doses



In December 2009, a family practitioner began treatment for a 38-year-old male given a diagnosis of post-laminectomy syndrome.  He continued to regularly prescribe oxycodone, alprazolam, and baclofen until late March 2014, when the family practitioner was temporarily restricted from prescribing Schedule II and III medications.

After the restrictions on his license had been lifted, the family practitioner resumed treating the patient at an office visit on 6/9/2014.

On 6/9/2014, he did not document any change in the patient’s functional abilities since he had last seen him in March.  The family practitioner did not order a urine drug screen, review the patient’s Prescription Monitoring Program (“PMP”) record, or document how the patient had treated his pain in the interim period.

The family practitioner resumed prescribing oxycodone at 240 mg/day down from 480 mg/day prior to the gap in treatment.  The family practitioner did not document instructing the patient on medication titration, although the patient informed the family practitioner that in his absence, he “had to cut [his]meds back so far that its [sic] hard to get out of bed.”

In the 6-month period from 6/9/2014 to December 2014, the family practitioner did not order any drug screens, did not check the patient’s PMP record, did not communicate with the patient’s PCP or psychiatrist to independently confirm what medications other providers were prescribing, and did not conduct any pill counts.

On 1/27/2015, the patient was found dead at home in his bed with “multiple prescription pill bottles clutched in [his] right hand” and with “[p]araphernalia such as pill cutter and spoons found at bedside.”  One unlabeled pill bottle with multiple orange pills, all cut in half and later identified as 60 mg oxycodone, was also present.  The death certificate noted the cause of death as being from oxycodone and clonazepam intoxication.  Blood toxicology revealed an oxycodone level of 0.374 mg/L.

The Board indefinitely suspended the family practitioner’s license based on this case and multiple others.

State: Virginia


Date: February 2017


Specialty: Family Medicine, 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



California – Gynecology – Breast Biopsy Specimen A Malignant, Specimen B Benign



In 2012, a female was followed for routine gynecologic care by a gynecologist.  The patient’s history was significant for a laparoscopic tubal ligation although nulliparous.  The history included that in about 2007, the patient required a right breast biopsy and possibly an aspiration for benign findings.  She subsequently underwent a bilateral breast reduction.  She began menopause and she received hormone replacement therapy in the form of the Combipatch (50/140), which she continued for more than two years.  She had ongoing vulvar lichen sclerosis, treated with steroid cream.  The patient’s mother had pancreatic cancer and passed away in 2010.  The patient’s physical exam was otherwise noteworthy for mild hypertension.

On 8/1/2012, the patient presented for her routine annual exam.  She had been weaning herself from the estrogen hormone patch by cutting them in half.  She had no complaints.  Her physical, including a breast exam, was essentially negative.  Pap testing was deferred.  A mammogram was ordered, but not performed.  The fact that the patient failed to comply with the request was not known to the gynecologist’s office.

In November of 2012, when the patient identified 2 lumps in her right breast, she went for a mammogram.  On 11/16/2012, the mammogram was performed.  Suspicious findings warranted a follow-up ultrasound of the right breast.  The gynecologist’s office also authorized an ultrasound.  Radiology performed directed needle biopsies on an expedited basis.  On 11/20/2012, a radiologist performed 2 needle biopsies.  He noted that the gynecologist’s office was “telephoned with this information,” referring to the expedited biopsy.  This intervention was not noted in the gynecologist’s records.

On 11/26/2012, the patient returned to the gynecologist’s office.  She complained of vaginal irritation and requested the results of her biopsies, which had been performed the previous week.  The patient was diagnosed with recurrent lichen sclerosis and was advised that the pathology results on the breast were not yet available.

On 11/27/2012, the patient called the gynecologist’s office for the test results.  On the same day, Los Alamitos pathology produced a report.  They documented sending copies to the radiologist and the gynecologist at that time.  In that path report, page 1 documented that specimen A was an invasive ductal carcinoma.  This finding was reiterated in the body of the text on page 2, labeled “microscopic description.”  The gynecologist noted review of page 2 of the path report but did not note the diagnosis.

On 11/28/2012, the gynecologist called the patient back and advised her that the biopsy was benign.  The gynecologist advised the patient of the benign biopsy based on the text she referred to regarding the specimen B.  In fact, this was an error by the gynecologist.  The gynecologist claims that this mistake was caused by a transmission error.  There were actually two specimens noted in the report.  Although page 2 details benign findings for specimen B, the report states: “A) Specimen…Histology type: INVASIVE DUCTAL CARCINOMA.”

The gynecologist admitted in a subject interview before the Board that she erred by not reviewing page 1 of the same path report which also identified an “invasive ductal carcinoma, high grade, poorly differentiated” from specimen A.

The patient did not return until 2/12/2013 when she complained of pelvic pressure and back pain.  As an aside, she asked for an opinion of what she thought to be a hematoma at the biopsy site in her right breast.  Examination revealed a firm mass.  The patient was immediately sent to a surgeon for further treatment.  As the gynecologist transferred the records she noted that she had misinterpreted the biopsy results of November and had falsely reassured the patient at that time.  This is documented in the chart on 2/26/2013 as a “breast follow-up,” dictated 2/12/2013.  The patient went on to receive her care from a surgeon and several oncologists for metastatic right breast cancer (Stage III).

The Board expressed concern that the gynecologist was grossly negligent in failing to follow up on important findings of those tests.  She was unaware that the radiology had performed multiple biopsies.

She failed to establish procedures to ensure adequate communication of information between radiology and her office.

There was also concern over a lack of documentation regarding her exam of the breast on 2/12/2013.  There was no mention of a follow-up of the previous breast biopsy or documentation of the exam of the breast on 2/12/2013.  This information was provided in a 2/26/2013 addendum.  Lab work was not routinely “signed-off” and dated with an indication of appropriate analysis.

The Board issued a public reprimand.  She was ordered to take a medical record-keeping course offered by the Physician Assessment and Clinical Education (“PACE”) Program at the University of California San Diego School of Medicine.  She was also ordered to enroll in a professionalism program.

State: California


Date: February 2017


Specialty: Gynecology


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


Diagnosis: Breast Cancer


Medical Error: Accidental error, False negative, Failure of communication with other providers, Failure of communication with patient or patient relations, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



California – Plastic Surgery – History Of Anemia, Depression, Obesity, With Smart-Lipo Done For Weight Loss



On or about 9/18/2014, a 32-year-old female went to Physician A’s Roseville facility for a Smart-Lipo consultation.  On the patient registration form, the patient indicated that she was interested in Smart-Lipo to her upper and lower abdomen, hips, waist/flank area, back bra rolls, outer thighs, and upper arms.  She indicated she had a history of anemia, cold sores, keloid scarring, irregular periods, and depression.  On the “Smart-Lipo History Intake” form,” the patient indicated she was 5’ 1/2” tall and weighed 178 pounds.  Under a list of possible medical conditions that the patient has or has had, the patient circled chest pain, recent weight loss or gain, cold sores, back pain, difficulty swallowing, depression, and heart murmur, Lap-Band surgery (2008), removal of the Lap-Band (2011), gastric sleeve (2013), and removal of her gallbladder (2014).  The patient indicated she took Latuda for depression and has an ultrasound of her heart done every five years.

There was also a “Smart-Lipo Medical History and Intake” form completed by the patient on 3/10/2011. On this form, the patient indicated she was 5’1′ and weighed 209 pounds.  She also noted that she had a heart murmur “normal,” chest pain “normal,” back pain, weakness to her arms, and had the Lap-Band placed in 2008. It is not clear from the medical records what procedure the patient was undergoing in 2011 and there were no medical records for any procedure during that time.

On or about 12/9/2014, the patient completed a second “Smart-Lipo History Intake” form.  On this form, she now indicated that she was suffering from anemia and “microvalve prolapse.”  She also listed her height as 5’1″ with a weight of 190 pounds.  On the “Pre-Operative Screening” form, the patient stated she was taking Adderall, lansoprazole, and Latuda.  The patient’s weight was noted at 193.5 pounds with a Body Mass Index (BMI) of 36.6.  Measurements were also taken of the areas where surgery was to be performed.  Blood was also collected for standard blood testing, as well as an EKG.  The patient also completed a Smart-Lipo “Pre-Operative Screening” form/High BMI consent form.  The form explains what a high BMI is, what obesity is, and why an obese patient should have Smart-Lipo performed.

Additionally, the form states that the patient must obtain medical clearance from her primary care provider before Physician A will perform the procedure.  Physician A admitted during the interview with investigators on behalf of the Board that she never obtained medical clearance from any of the patient’s medical providers, despite the notation on the form.  The informed consent forms were completed by the patient and a LVN.  Physician A never went through the informed consent forms or discussed the risks and benefits of the surgery with the patient before the day of surgery.  The records also do not contain any documentation that Physician A even discussed the risks and benefits of the surgery with the patient at any time.  On or about 12/16/2014, Physician A performed Smart-Lipo on the patient’s hips, upper arm, upper and lower abdomen, and waist/flanks.  On the pre-printed Smart-Lipo OR Package form, it was noted that the patient “had a light meal before coming.”  The Nurse Practitioner checking in the patient did not document exactly what the “light meal” consisted of or when it was consumed.  Physician A wrote that the patient had keloid scarring but the location of the scarring is not legible.  She also wrote that the patient was planning on having a tummy tuck in the future and had excessive skin laxity on her abdomen.  Physician A listed the patient as ASA Category I.  Prior to surgery, pictures were taken of the patient showing “bat wing deformity of the arms (hanging skin), truncal obesity, and smooth abdominal skin contour with small keloids.”

When the patient was interviewed by an investigator on behalf of the Board, she indicated that she believed she was having a procedure to lose weight and improve her body contour.  She did not know or understand that she would have permanent wrinkles on her skin after the surgery.

According to the progress note, the procedure started at 1:00 p.m. and finished at 3:25 p.m.  About 30 minutes into the procedure the patient complained of eight out of ten pain, and the comment portion of the note read “VV (2-3 sec).”  About an hour and twenty minutes into the procedure, the patient reported pain on a scale of four out of ten.  During the two hour fifteen minute surgery, the patient’s vital signs were not continuously monitored.  During Physician A’s subject interview on 3/15/2016, Physician A initially did not know what “VV (2-3 sec)” meant; however, she eventually stated that she believed it meant the patient had a vasovagal episode, meaning she passed out during the procedure.  This is generally caused by sudden drops of blood pressure and heart rate.  According to the progress note, 10.72 liters (10,720 ml) of tumescent fluid (combination of lidocaine, epinephrine, sodium bicarbonate, and saline) was infused into the patient’s body, containing 3,090 mg of lidocaine (the safe dose of lidocaine should never exceed 3,076.5 mg of lidocaine).  4,240 ml of fluid was removed from the patient’s arms and abdomen, of which 1,900 ml was fat, leaving 6,470 ml of tumescent fluid remaining in the patient.  The medical record fails to indicate where and how much fat was removed from each region Physician A performed Smart-Lipo Surgery on.

There is no indication in the medical record that Physician A warmed the tumescent fluid to body temperature before infusing it into the patient.  There was also no indication in the medical record that Physician A utilized compression boots during the surgery.  The patient was discharged from the facility at 3:40 p.m., following a 30 minute observation period.

On or about 12/17/2014, the patient returned for her follow-up appointment.  She indicated she was weak, her pain over the night was a six out of ten, approximately two cups of fluid drained from the surgical sites, and she was light headed.  It is difficult to determine from the medical record whether Physician A even saw the patient, but it does not appear that she did.

On or about 1/16/2015, the patient returned for her one month follow-up appointment.  Measurements were taken, along with a height and weight.  Patient still weighed 193 pounds with a BMI of 36.5.  In response to the question “How do you feel about your results?” the patient answered “good.”

On or about 6//2015, the patient returned for her six month follow-up appointment.  The patient reported that while she had seen improvements, she was not happy with the results of the Smart-Lipo surgery.  Measurements were taken along with the patient’s weight, showing a seven pound weight gain.  Physician A wrote “skin laxity is an issue, will pursue tummy tuck.”  Physician A did not recommend a revision surgery and the patient never returned.

According to the patient, Physician A told her “she wasn’t a good candidate for Smart-Lipo to begin with.”  She also complained that at the six month post-procedure mark she gained seven pounds, her arms looked the same, and her stomach was deformed and protruded from her abdomen.

Pictures were taken of the patient at several visits; however, none of the photographs are dated making it impossible to determine the progress of the patient’s recovery.

The Board judged Physician A’s conduct to have fallen below the standard of care given failure to maintain adequate and accurate medical records, failure to document a physical examination prior to procedures, failure to document a discussion on the risks and benefits, and failure to document the amount of fat aspirated.

The Board noted that Physician A’s selection of the patient for Smart-Lipo was a departure in the standard of care given that the procedure is not for weight loss but for contouring of small areas, the patient was not ASA Class I, and the patient was taking medications contraindicated with the use of epinephrine.  The patient ate prior to a major surgery, although Physician A perceived the surgery to be minor and allowed the surgery to commence.  Physician A failed to warm the tumescent fluid to body temperature to avoid life threatening arrhythmias.  Physician A infused 10.72 liters of tumescent fluid, leaving 6.47 liters in the patient, an unsafe amount to leave in a patient without observing the patient overnight to ensure that the fluid that remained in the subcutaneous spaces did not shift through the body and cause congestive failure.  Vital signs were not continuously monitored during the entire procedure.

In addition, Physician A demonstrated a lack of knowledge or understanding of the risks posed by infusing large amounts of tumescent fluid containing lidocaine while the patient was on Latuda and Adderall, a potentially fatal drug interaction

Lastly, Physician A demonstrated a lack of knowledge or understanding by performing Smart-Lipo on patients for weight-loss purposes and in using a tape measure to try to gauge pre and post-procedure progress.

Given this instance and multiple others, the Board placed Physician A on four years of probation with stipulations to complete 25 hours of continuing medical education per year in any areas of deficient practice or knowledge, complete a medical record keeping course, complete an ethics course, 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, and undergo clinical monitoring.  Physician A was prohibited from performing liposuction or laser skin treatments.

State: California


Date: February 2017


Specialty: Plastic Surgery


Symptom: N/A


Diagnosis: Post-operative/Operative Complication


Medical Error: Improper medication management, Failure of communication with patient or patient relations, Failure to properly monitor patient, Lack of proper documentation, Procedural error


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Arizona – Obstetrics – Pregnancy With Elevated Blood Pressure And Proteinuria



On 02/02/2015, a 37-year old-woman was evaluated for vaginal bleeding in the emergency department.

On 02/04/2015, she established care with an obstetrician.  She had received prenatal care on two prior occasions from other providers.  An ultrasound was performed and a sub-chorionic hemorrhage was identified along with fibroids.  Blood pressure was noted to be 139/79.

On 03/18/2015, she was noted to have elevated blood pressure at an appointment with the obstetrician.

On 04/14/2015, the blood pressure was elevated and 2+ protein was present.  The obstetrician sent the patient to her family practitioner for evaluation, and the family practitioner then sent the patient to the hospital, where she was treated with labetalol and discharged with no further evaluation.

On 04/16/2015, the patient was seen at the obstetrician’s office with continued significantly high blood pressure.  The obstetrician ordered a 24-hour urine and pregnancy induced hypertension labs.  The patient then went home.

On 04/17/2015, the lab studies showed significant abnormalities consistent with severe pregnancy induced hypertension.  The patient went to the hospital.  She subsequently had an intrauterine fetal death at approximately 22 weeks gestation with delivery.

The Board judged obstetrician’s conduct to be below the minimum standard of competence given failure to evaluate the patient for preeclampsia with a history and physical, serial blood pressure evaluations, and laboratory studies.  He failed to admit the patient to a hospital for treatment.

The Board ordered the obstetrician be reprimanded, be placed on probation for a period of 6 months, and take 5 hours of CME in hypertensive disorders in pregnancy.

State: Arizona


Date: February 2017


Specialty: Obstetrics


Symptom: Gynecological Symptoms


Diagnosis: Preeclampsia


Medical Error: Diagnostic error


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



California – Plastic Surgery – Liposuction And Mini Tummy Tuck With Complications



On 8/22/2014, Physician A first saw a patient when she responded to a Vietnamese magazine advertisement placed by Physician A.  The records reflect that at the initial visit, the patient paid a two-hundred dollar consultation fee and a two-hundred eighty dollar fee for botox injections.

At the initial visit, the patient completed the medical history forms and a consent for botox injections.  Physician A’s physical examination notes indicated that the patient was normal, except for a right lower abdominal appendectomy scar and loose skin.  The notes reflected that Physician A marked the patient’s abdomen where he would remove fat, described his laser liposuction technique, and the mode of anesthesia employed.  Physician A’s documented surgical plan was tumescent liposuction with fat transfer to the hands and the removal of excess lower abdominal skin.  He injected botox at that visit.

Physician A provided a price quote of three thousand dollars for “lipo full abdomen and love handles” and a mini tummy tuck for an additional three thousand five hundred dollars.  The documentation indicates that Physician A told the patient there would be a scar the size of which was dependent upon the amount of skin removed.

Physician A had not received any formal training in cosmetic plastic surgery.  There has been no documentation that Physician A had competed any residency program in any specialty successfully.

Physician A’s records indicated that the patient returned on 9/9/2014, bringing a friend to see the plastic surgeon.  At that visit, the patient complained to Physician A about the prior botox injections, and Physician A performed a free “touch-up” botox injection on the patient.  Physician A also mentioned performing a “mini tummy tuck” and fat grafting to the patient’s hands, in addition to the liposuction he described at her first visit.

Physician A next saw the patient on 10/9/2014, and she was again advised of the surgery and risks of scars and infection.

Physician A next saw the patient on 10/13/2014 to undergo the procedures outlined above and was assured by Physician A that the mini tummy tuck scars would be small.  The patient signed a consent for full abdominal/love handles tumescent liposuction/laser lypolysis and mini tuck.  She also signed the treatment record on the possible surgical scar line.  There is no consent for fat grafting to the hands.

Physician A’s records indicated that the surgery was performed on 10/13/2014.  At 12:30 p.m., prior to surgery, the patient was given lorazepam 2 mg, 2 tabs of diphenhydramine 25 mg, 2 tabs of cephalexin 500 mg, and hydromorphone 4 mg.  Clonidine 0.1 mg was given at 12:48 p.m. and again at 1:05 p.m.  The procedure started at 1:00 p.m. and ended at 4:30 p.m.  The records indicated that vital signs were taken every 15 to 30 minutes and were stable, except for an increased blood pressure at the beginning and end of the procedure.

Physician A’s records indicated that for the liposuction of the abdomen and love handles, 3.8 liters of normal saline was infiltrated and 2.5 liters was aspirated.  Total fat removed was 1.5 liters and total lidocaine used was 1500 mg.  The operative report in the medical records was a printed standard paragraph followed by “liposuction performed under local without complications.”  The records also indicated that a small flap was removed and closed with 3-0 PDS suture deep layer and “subQ.”

Following the procedure, the patient was instructed to return to Physician A’s clinic “in 1-2 weeks for suture removal.”  There was no description in the records of the fat grafting procedure to the hands, how the fat was processed for the transfer, or details of the mini tummy tuck.  The patient woke up in a different room and stated that she recalled no blood pressure, heart rate, weight or other monitoring devices placed on her during the procedure.

The patient was discharged into the care of her husband with a stool softener, pain medication, and an antibiotic.  The patient reported that she felt dizzy and weak for two or three days following the procedure.  When the patient removed the surgical dressing, she reported that she was shocked to see a 10 inch long scar along her lower abdomen.  A photo labeled “post op day 7” showed a fresh transverse Pfannenstiel type of scar whose lateral ends are about the level of the mid-femoral triangle.  The patient called Physician A’s office to complain about the scar and was told to wait 2 weeks before coming in, at which time the sutures would be removed.  The patient called almost daily to be seen but was told to wait the full 2 weeks.

The patient returned to Physician A’s office on 10/20/2014, at which time the swelling had decreased, the bruising had resolved, and there were no indentations. The patient was advised to continue wearing the pressure garment.  According to the patient, after Physician A removed the sutures, Physician A denied ever having said that the scar would be smaller than it actually was.  The patient reported that she left his office after that conversation and never returned.

The patient stated she was out of work for two months due to pain that finally resolved.

Physician A’s records did not reflect the patient’s complaints.  Physician A said he did not chart any complaints in his notes because the patient did not voice any complaints.

Undated photos from the file showed an undulating transverse infraumbilical pink slightly hypertrophic scar, infraumbilical stretch marks, loss of the supraumbilical fat as compared to preoperative photographs (also in the file), and persistent supraumbilical skin excess that completely covered the umbilicus with multiple fine horizontal rhytides just above the umbilicus.  The horizontal fold at the level of the umbilicus was no longer present because the fat had been removed.

Physician A’s notes did not indicate that he ever informed the patient of the potential negative outcome from the suggested procedures, evidencing a lack of knowledge on the part of Physician A of the indications of a mini tummy tuck as opposed to an abdominoplasty.

Physician A first saw the patient on 8/22/2014 when he performed a physical examination and history.  The documentation reflected that on 10/13/2014, the day of surgery, no physical examination was performed prior to that surgery.  Thus, more than 30 days had elapsed since the patient’s physical examination took place.

Physician A’s notes indicated that the patient was a 53-year-old female who was operated upon without a medical clearance or a recent CBC blood test.

Physician A’s notes indicated that 1.5 liters of material was aspirated from the patient.  Intravenous access and monitoring (pulse oximeter, blood pressure measurement, fluid loss/replacement monitoring/recording, and electrocardiogram) are required for aspiration of 2000 cubic centimeters or more.

Physician A did not have admitting privileges at a local general acute care hospital and did not have a written transfer agreement with such a hospital or a licensed physician with admitting privileges at such a hospital.

Physician A’s notes indicated that no medical record documentation of fluids infused, aspirate quantity, procedure duration, and the nature of the procedure performed were properly maintained.

Physician A’s notes indicated that regulatory discharge criteria were not met and that no ACLS certified staff person was present until the patient was discharged.

Physician A’s notes indicated that medication logs were not kept in that there are no such logs in the medical records produced.  Unlicensed medical assistants appeared to have had unsupervised and unfettered access to controlled substances and other medications.

Physician A’s facility was not an accredited facility and lacked the necessary equipment for accreditation.

The Board judged Physician A’s conduct as having fallen below the standard of care given failure to take an appropriate medical history and perform a physical examination within 30 days prior to a procedure, given the performance of a 2.5 liter liposuction and mini tummy tuck in a non-accredited facility without IV access and without admitting privileges at a local general acute care hospital, and given the performance of a mini tummy tuck when the indication was questionable.

Physician A was placed on probation for five years with stipulations to complete 40 hours annually of continuing medical education in areas of deficient practice or knowledge, a prescribing practices course, a medical record keeping course, a professionalism program, and a clinical training program equivalent to the Physician Assessment and Clinical Education Program.  He was ordered to undergo clinical monitoring.  He was prohibited from performing any procedures requiring sedation, performing body liposuction, and performing a mini tummy tuck.

State: California


Date: February 2017


Specialty: Plastic Surgery


Symptom: N/A


Diagnosis: N/A


Medical Error: Procedural error, Ethics violation, Unnecessary or excessive treatment or surgery, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Washington – Orthopedic Surgery – Bilateral Shoulder Pain After A Motor Vehicle Accident And Repair Attempt Of Os Acromiale



On 1/4/2011, a patient was involved with a head on motor vehicle collision.  The patient sought care the following day at a hospital.

On 1/20/2011, the patient followed up with his primary care provider (PCP).  A magnetic resonance imaging (MRI) of the patient’s right shoulder was performed.  The MRI showed an abnormal rotator cuff, areas of a partial tear, and an injury to the tendon.

On 2/3/2011, the patient presented to an orthopedic surgeon’s clinic with complaints of right shoulder pain.  The orthopedic surgeon reviewed the previous MRI and performed a physical examination.  The orthopedic surgeon diagnosed the patient with rotator cuff tendinosis with possible tear, degenerative arthritis of the acromioclavicular joint, and inflammation of the tendon around the biceps muscle.

For the following four months, the orthopedic surgeon continued to see the patient.  Though the orthopedic surgeon encouraged the patient to engage in conservative treatment, including physical therapy, the patient’s pain did not completely resolve.

On 6/1/2011, the patient complained of pain in both of his shoulders.  The orthopedic surgeon discussed surgical options with the patient.  The patient consented to have surgery.

On 6/9/2011, the orthopedic surgeon performed right shoulder surgery.  During the surgery, the orthopedic surgeon discovered the patient had an unfused os acromiale (a developmental aberration in which the acromion fails to fuse).  Without the patient’s consent, the orthopedic surgeon decided to attempt to repair the os acromiale.  The orthopedic surgeon claims he placed two pins within the acromion and a screw down the center.  K wires (stainless steel sharpened pins) were cut and placed.

On 7/6/2011, the patient had x-rays taken of his right shoulder.  The orthopedic surgeon believed the x-rays showed the hardware was placed appropriately in the patient’s shoulder.  Later, the patient saw a different physician, who took a new set of x-rays and believed the hardware was angled inappropriately and the wires were loose.  He also believed based on the new x-rays that the screw thread appeared to be just barely in the bone.

Following the patient’s surgery, the patient continued to experience varying degrees of shoulder pain and soreness. On 9/9/2011, the orthopedic surgeon took x-ray images of the patient’s left shoulder, which revealed the patient had bilateral os acromiale.

On 11/21/2011, x-rays were taken of the patient’s right shoulder and showed the screw had pulled out, the bone had not fused, and the wire was broken.  The orthopedic surgeon had allegedly failed to appropriately place the original fixation and should have been aware of this when reviewing earlier x-ray images.

The Commission stipulated the orthopedic surgeon reimburse costs to the Commission and write and submit a paper of at least 1000 words with annotated bibliography on the diagnosis and proper treatment of os acromiale.

State: Washington


Date: February 2017


Specialty: Orthopedic Surgery


Symptom: Extremity Pain


Diagnosis: Musculoskeletal Disease


Medical Error: Procedural error, Diagnostic error, Ethics violation


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Washington – Neurosurgery – Misplaced Pedicle Screws



A 55-year-old woman with long-standing lower back pain, Patient A, was diagnosed with slipping vertebral bones that resulted in lumbar stenosis and foraminal stenosis.

On 6/26/2014, a neurosurgeon performed lumbar fusion surgery on Patient A.  Patient A’s post-operative course was marked by considerable pain and slow recovery.  Patient A was referred to an orthopedic surgeon at another hospital when her pain did not diminish as expected.  Radiologic images were interpreted as showing misplaced pedicle screws from the lumbar fusion surgery performed by the neurosurgeon.

On 10/22/2014, Patient A underwent a repeat fusion operation with replacement screws.  The operative report notes detailed screw misplacement from the initial surgery.  Patient A underwent a third surgery on 11/4/2014, because of ongoing pain, after which she made improvement.

Patient B was a 19-year-old man with chronic low back and leg pain caused by a collapsed disc.  On 2/13/2014, the neurosurgeon performed lumbar fusion surgery on Patient B.  Patient B’s post-operative course was marked by some relief, but he experienced new pain in his left leg.

Patient B was also referred to the orthopedic surgeon at the other hospital.  Patient B underwent a repeat fusion operation with replacement screws.  Radiologic images and operative report notes documented misplaced pedicle screws from the lumbar fusion surgery performed by the neurosurgeon.

The Commission stipulated the neurosurgeon reimburse costs to the Commission, complete fifty hours of continuing education covering the subject of spine surgeries, including the interpretation of imaging studies of pedicle screw replacement, attend two spine conferences, and complete a total of one hundred proctored spine instrumentation procedures with Commission approved surgeons.

State: Washington


Date: February 2017


Specialty: Neurosurgery, Orthopedic Surgery


Symptom: Back Pain


Diagnosis: Spinal Injury Or Disorder


Medical Error: Procedural error


Significant Outcome: N/A


Case Rating: 1


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