Found 16 Results Sorted by Case Date
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Vermont – Psychiatry – Pediatrician Prescribes A Combination Of An SSRI And A Benzodiazepine



A pediatrician first met a patient in 2010 when conducting a routine college physical.  In 2011, the pediatrician started the patient on Prozac (fluoxetine) 10 mg daily after the patient started reporting that he was having problems with depression.  After a month, the patient indicated that the medication was working “a little” and denied any side effects, the pediatrician prescribed another 30 tablets of Prozac 20 mg with no refills.

The pediatrician did not see the patient again until 1/30/2014 when the patient came in for a physical exam.  The pediatrician documented that the patient was doing well and was off Prozac.

On 1/22/2015, the patient again came in to see the pediatrician for a physical exam.  The patient was experiencing decreased energy levels, sleeping well, having some difficulty with depression and occasional panic attacks.  The patient was noted as stating that the Prozac he had taken previously did not really help.  The notes document that education and counseling were done, but there was no comment on suicidality.

The pediatrician started the patient on Prozac 40 mg once a day, 30 tablets with no refills, because he had tolerated the 20 mg dose in the past with no side effects.  The patient was also prescribed Xanax (alprazolam), 0.25 mg, 5 tablets with no refills, and was told to take one as needed.

On 1/29/2015, the patient was seen by the pediatrician to follow up on his anxiety and depression.  The patient reported that he was still having panic attacks, for which he took 2 of the 0.25 mg Xanax, and that overall his depression was worse, but that he was dealing more with anxiety than depression.  The patient indicated that he was tolerating the Prozac well.  The patient denied any suicidal ideation or planning.  The pediatrician prescribed the patient Klonopin (clonazepam) 1.0 mg, two times a day, 60 tablets with no refills and increased his Xanax prescription to 0.5 mg as needed, five tablets with no refills.  The pediatrician documented that he provided education and counseling and referred the patient to psychiatry, although the patient indicated that he did not want to go.

On 1/31/2015, the patient reported losing most of his Xanax at work.  The pediatrician advised the patient to stay on Prozac and Klonopin and to save the few Xanax he had for severe panic attacks.  The pediatrician advised the patient that he would look into getting the patient to see a psychiatrist and that he would figure out what to do with the Xanax the following week, but in the meantime, the patient could go to the emergency department or call the pediatrician if he had a panic attack.  The patient agreed to this plan.

During this time, the mother observed changes in the patient’s behavior, including slurring of words, wobbling on his feet, and sleepiness and the patient also became erratic and volatile.  This was not brought to the attention of the pediatrician.

On the morning of 2/2/2015,  the patient called his mother from work and advised they were sending him home because his behavior was similar to someone who was intoxicated.  It was also claimed the patient met with a pharmacist at work, who allegedly told him that the dose of Klonopin was too high and he should cut the dose in half.

The patient returned home and continued to exhibit erratic, volatile, and irrational behavior.  The patient also advised his mother that he tried to cut his wrist and glued it shut.  None of these events were told to the pediatrician and the patient did not show the cut to the pediatrician during the appointment on 1/29/2015 appointment.  The patient made an appointment with another doctor, but could not get in until 2/6/2015.  The patient’s mother asked the patient if he wanted to go to the emergency department but the patient declined, indicating that he had a plan (to cut the dose of Klonopin in half).  That evening the patient had an argument with his girlfriend and committed suicide.

Prozac (fluoxetine) packaging contains a “Black Box” warning for patients up to 21 years of age that indicates there is a very small chance of an adverse reaction that can make the patient more agitated and prone to increased suicidal thoughts.  The patient’s medical chart does not indicate whether the pediatrician explained the Black Box warning to the patient.

The pediatrician retired from the practice of medicine in Fall 2016 as previously planned and for reasons totally unrelated to the allegations in this matter.  He is not currently practicing medicine in the State of Vermont.

The Board judged the pediatrician’s conduct to be below the minimum standard of competence given his failure to maintain adequate and comprehensive medical records, his improper prescribing of an unusually high dose of Prozac, Xanax, and Klonopin, and his failure to conform to the essential standards of acceptable and prevailing practice.

The Board ordered that the pediatrician be reprimanded, pay a fine, and if he applies for a license renewal, he must take a continuing education course on psychotropic medications and retain the services of a practice monitor for a minimum of two years.

State: Vermont


Date: July 2017


Specialty: Psychiatry, Pediatrics


Symptom: Psychiatric Symptoms


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


Medical Error: Improper medication management, Lack of proper documentation


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



New York – Physician Assistant – Lack Of Lab Work For Routine Visit For A 37-Year-Old Female



On 11/3/2008, a 37-year-old female presented to a physician assistant for a physical and PAP smear.  During the examination, the physician assistant performed a pelvic examination and found normal female genitalia without lesion or discharge.  A PAP smear was obtained without incident.  The physician assistant’s examination of the patient’s abdomen revealed the abdomen was soft and nontender.  The physician assistant’s plan was to reassess the patient in three months unless otherwise indicated.

The physician assistant did not order the patient to undergo any lab work, such as an hCG test.

On 11/12/2008, the patient presented to the hospital with a full-term pregnancy and delivered a baby on the same date.

The Board judged that the physician assistant’s medical care of the patient deviated from accepted standards of care given failure to recognize signs of pregnancy.

State: New York


Date: July 2017


Specialty: Physician Assistant, Family Medicine, Internal Medicine, Obstetrics


Symptom: N/A


Diagnosis: N/A


Medical Error: Failure to order appropriate diagnostic test, Failure to examine or evaluate patient properly


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Urology – Fluorescence In Situ Hybridization Ordered For A Patient With Incomplete Bladder Emptying And Renal Cysts



From 4/25/2012 to 1/29/2014, a 66-year-old female was treated by a urologist for incomplete bladder emptying and renal cysts.

On 4/25/2012 and 1/15/2014, the patient underwent urinalysis tests which returned negative for blood in the urine.

On 1/15/2014, the patient underwent fluorescence in situ hybridization (FISH) ordered by the urologist, which returned negative.

At all times material to this complaint, the patient displayed no indications to receive FISH testing.

The Board judged the urologist’s conduct to be below the minimal standard of competence given that he failed to document his plan to order FISH testing in the patient’s medical records and that the urologist’s ordering of FISH testing for the patient was medically unnecessary.

It was requested that the Board 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 Board deemed appropriate.

State: Florida


Date: July 2017


Specialty: Urology


Symptom: Urinary Problems


Diagnosis: Urological Disease


Medical Error: Unnecessary or excessive diagnostic tests, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



New York – Physician Assistant – History Of Bipolar Disorder With Concern For Irregular Menses



On 8/13/2007, a 21-year-old female presented to a physician assistant for follow up treatment of bipolar disorder and concern for irregular menses.

During the examination, the patient advised the physician assistant that her most recent period was the prior November and that she had not had a gynecological examination in ten years. The physician assistant examined the patient’s abdomen, which he found to be benign.  In regard to the patient’s complaints of irregular menses, the physician assistant ordered a variety of blood work and stated that he would follow up with the patient in three months, unless otherwise indicated.  The blood work that he ordered did not include a hCG test.

On 8/16/2007, the patient arrived at the emergency department with a full-term pregnancy and delivered her baby on that same day.

The Board judged that the physician assistant’s medical care deviated from accepted standards of care given failure to perform an adequate physical examination, given failure to order a hCG test, and given failure to recognize signs of pregnancy.

State: New York


Date: July 2017


Specialty: Physician Assistant, Family Medicine, Internal Medicine


Symptom: Gynecological Symptoms


Diagnosis: N/A


Medical Error: Failure to order appropriate diagnostic test, Failure to examine or evaluate patient properly


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



North Carolina – Vascular Surgery – Abdominal Aortic Aneurysm 8.3 cm In Size With Large Type I Endoleak



On 3/31/12, a 76-year-old male with a history of heart disease, chronic obstructive pulmonary disease (COPD), prior endovascular repair of a large abdominal aortic aneurysm (AAA) in 2010 at an outside hospital (OSH) presented to the VA Medical Center emergency department with complaints of back, flank, and hip pain.

On 4/1/12 in the early morning, the patient had a CT scan with contrast which revealed an 8.3 cm AAA with large Type I endoleak.  There was retroperitoneal stranding consistent with an aneurysm rupture.  At 7:45 a.m., these findings were communicated to the emergency department physician.

At 8:00 a.m., the patient was evaluated by a vascular surgeon.  Based on the vascular surgeon’s interpretation of the CT films and the patient’s clinical presentation, the vascular surgeon recommended admission for observation with a follow-up consultation with orthopedic surgery and interventional radiology.

The patient was admitted to the medical ward for the next three days during which he continued to have severe ongoing pain that was managed with pain medications.

On 4/4/12, the patient had a precipitous decline in his clinical status with severe hemodynamic compromise.  A repeat CT scan demonstrated a ruptured AAA with aortocaval fistula.  The patient was taken to the operation room where the vascular surgeon performed an open repair of the aortocaval fistula and ruptured AAA.  However, the patient suffered extensive operative blood loss, perioperative myocardial infarction, and neurological injury.

The patient survived the procedure but remained critically ill.  Over the next several days, the patient improved to a certain degree, but it was felt that the patient had suffered brain injury with little chance for meaningful recovery.

On 4/9/12, supportive measures were withdrawn, and the patient died.

In January 2017, the Board received information regarding a medical malpractice lawsuit settlement payment related to the care provided by the vascular surgeon to the patient.

The Board obtained the patient’s records and sent them to a qualified independent medical expert for review.  The independent medical expert judged the vascular surgeon’s conduct to be below the minimum standard of competence given failure to adequately diagnose and aggressively treat the patient’s symptomatic, ruptured AAA despite evidence of the patient’s life-threatening condition.

The vascular surgeon was reprimanded.

The Board reported the Consent Order to the Federation of State Medical Boards.and the National Practitioner Data Bank.

State: North Carolina


Date: July 2017


Specialty: Vascular Surgery, Emergency Medicine


Symptom: Back Pain, Pelvic/Groin Pain


Diagnosis: Aneurysm, Post-operative/Operative Complication


Medical Error: Delay in proper treatment


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



North Carolina – Internal Medicine – Three Emergency Department Visits With Persistent Severe Headache And A Negative CT Head Scan



The Board was notified of a professional liability payment paid on 3/8/16.

A 48-year-old female presented to the emergency department three times over the course of two days with complaints of severe headache.

During the 7/28/12 visit, she had a non-contrast CT head, which was reported as normal.  The patient’s headache was treated as an acute migraine attack.  She was discharged with anti-migraine, anti-nausea, and anti-anxiety medications.

On 7/29/12, the patient returned with persistent symptoms, was treated symptomatically, and discharged.  Later that day, the patient again returned to the emergency department with continuing headache and persistent nausea and vomiting.

The patient was admitted to the hospital under the care of an internist.  The patient was started on maintenance IV fluids to treat dehydration and was treated for the underlying migraine with analgesics and antiemetic.

During the internist’s care of the patient, the internist did not order a spinal tap or additional CT scan, instead relying on the 7/28/12 emergency department CT scan.

On hospitalization day three, the patient was discharged with anti-migraine and anti-nausea medications, and was advised to follow up with her primary care physician or neurologist within a week.

On 8/2/12, the day after discharge, the patient returned to the emergency department with a continuing headache and a CT scan of her head showed intracranial hemorrhage in the right temporal lobe.

The patient was then airlifted to a tertiary care center and had clipping of a brain aneurysm/hematoma removal and ventriculoperitoneal shunt placement.

The Board obtained the patient’s records and sent them to a qualified independent medical expert for review.

The independent medical expert judged the internist’s conduct to be below the minimum standard of competence given failure to provide adequate care for severe persistent headache with normal neurological exam.  The medical expert found that the internist failed to perform a lumbar puncture and repeat imaging or seek neurology input.

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: July 2017


Specialty: Internal Medicine, Hospitalist


Symptom: Headache, Nausea Or Vomiting


Diagnosis: Intracranial Hemorrhage


Medical Error: False negative, Delay in proper treatment, Failure to order appropriate diagnostic test, Underestimation of likelihood or severity


Significant Outcome: Permanent Loss Of Functional Status Or Organ, Hospital Bounce Back


Case Rating: 4


Link to Original Case File: Download PDF



Florida – Gynecology – Hormone Replacement Therapy, A History Of Heart Disease, And Elevated Glucose Levels



On 5/16/2014, a 47-year-old female presented to a gynecologist for a routine gynecological exam.  The patient had a significant history of heart disease, including a quadruple bypass surgery in 2009.

The patient had complaints of hot flashes, inability to lose weight, insomnia, night sweats, irritability, and mild bladder leakage.  The gynecologist diagnosed the patient as menopausal.  The gynecologist recommended hormone replacement therapy.  He ordered hormone and thyroid level lab work.  He did not order tests for cholesterol levels or basic metabolic status, despite the patient’s metabolic lab result, dated 2/6/2012, indicating an abnormally high glucose level.

On 6/11/2014, the patient presented to the gynecologist for follow-up.  The gynecologist prescribed compounded creams containing the hormones estrogen, progesterone, and testosterone.  He also prescribed Armour Thyroid, a thyroid hormone replacement drug containing the hormones T3 and T4.

At all times material to this complaint, the prevailing standard of care dictated that a physician prescribing hormone replacement therapy to a patient with a significant history of heart disease obtain appropriate medical clearance prior to prescribing such therapies.

The gynecologist did not obtain medical clearance prior to prescribing hormone replacement therapy to the patient, despite a significant history of heart disease.

The prevailing standard of care dictated that a physician prescribing hormone replacement therapy to a patient with a prior abnormal glucose value order or obtain sufficient blood work prior to prescribing hormone replacement therapy.

The gynecologist did not obtain sufficient blood work prior to prescribing hormone replacement therapy to the patient, despite the patient’s prior abnormal glucose value.

At all times material to this complaint, the prevailing standard of care dictated that a physician discuss the full risks and benefits of hormone replacement therapy with the patient prior to initiating the treatment.  The gynecologist failed to discuss, or did not create or maintain adequate, legible documentation of discussing the full risks and benefits of hormone replacement therapy with the patient.

The Board issued a letter of concern against the gynecologist’s license.  The Board ordered that the gynecologist pay a fine of $5,000 against his license and pay reimbursement costs for the case for a minimum of $7,244.87 and not to exceed $9,244.87.  Also, the Board ordered that gynecologist complete ten hours of continuing medical education in “hormone replacement therapy” and five hours of continuing medical education in “risk management.”

State: Florida


Date: July 2017


Specialty: Gynecology


Symptom: Urinary Problems


Diagnosis: N/A


Medical Error: Failure to order appropriate diagnostic test, Failure of communication with patient or patient relations, Improper medication management


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Nebraska – Family Medicine – Excessive X-Rays And Antibiotics For Sinus Infection And Pneumonia



A family practitioner treated a 32-year-old female, for approximately 10 years.  The patient had a mechanical mitral valve and was on Coumadin therapy.  The family practitioner diagnosed her with sinus infections and pneumonia repeatedly.  He ordered nine sinus x-rays, eight chest x-rays, and 29 prothrombin time tests, the majority of which were subtherapeutic, during a one-year period.  The patient was a chronic smoker, and there was nothing in the chart to indicate smoking cessation counseling was tried.  The patient was treated with Biaxin (from one to four weeks at a time), 13 Rocephin injections, Levaquin for three weeks, Bactrim for one month, Keflex for two days and 10 days and Diflucan, Levaquin and Rocephin treatments simultaneously.

The family practitioner’s use of repeated sinus x-rays for the patient, which have questionable medical value under these circumstances, constituted substandard medical care.

Also, the family practitioner’s use of antibiotic therapy for the patient, there being no evidence that such therapy has a recognized medical benefit under the circumstances, constituted substandard medical care.

Finally, the family practitioner’s failure to refer the patient for pulmonary evaluations, after repeated visits with the same symptoms, constituted substandard of medical care.

For these allegations and others, the Board judged that the family practitioner’s methodology of practice overall and the specific negligent acts of his practice constituted negligence.  The Board ordered that the family practitioner have his license censured, have a practice monitor to review his practice on a quarterly basis for one year, pay a fine, and complete review courses on the following subjects: Eye, Nose, and Throat practice and referral, Endocrinology, Immunology and Immune Systems, indications for the need of radiographs and the appropriate use of radiology consultations.

State: Nebraska


Date: July 2017


Specialty: Family Medicine


Symptom: N/A


Diagnosis: Pneumonia, Infectious Disease


Medical Error: Improper medication management, Unnecessary or excessive diagnostic tests, Failure of communication with other providers, Unnecessary or excessive treatment or surgery


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Gynecologist – Complications After A Laparoscopic Assisted Vaginal Hysterectomy For Irregular Bleeding And Abdominal Pain



Sometime prior to 2011, a gynecologist began treating a patient with a history of a prior myomectomy in 2011, pre-diabetes, and fibromyalgia.

On 3/8/2011, the patient presented to the gynecologist with complaints of irregular vaginal bleeding with some pain in her right lower quadrant that worsened when she was on her period.  The patient informed the gynecologist that she was “ready for a hysterectomy.”  Medical records for this visit do not document the extent of the bleeding, whether or not the bleeding contributed to any other symptoms, the patient’s level of pain, or whether or not the pain interfered with the patient’s lifestyle.  At the conclusion of this visit, the gynecologist referred the patient for a pelvic ultrasound with plans to follow up after the ultrasound.

On 4/5/2011, the patient had a pelvic ultrasound which showed the uterus was oriented anteverted and located midline.  A fibroid was visualized in the right lateral aspect of the uterus that measured 5.3 by 4.2 by 5.3 centimeters.  The endometrial stripe measured 12 millimeters.  No other fibroids were seen.  The left and right ovary were normal.  There was no fluid in the cul-de-sac.  The fibroid had increased in size compared to a prior ultrasound in 2010.

On 4/11/2011, the patient presented to the gynecologist for a follow-up.  The gynecologist went over the results from the ultrasound and discussed possible treatment options.  The gynecologist did not recommend or perform an endometrial biopsy to determine the reason for endometrial thickening or repeat the ultrasound to watch this condition.  The gynecologist did not consider or document that the irregular bleeding could be caused by endometrial thickening, endometrial hyperplasia, or endometrial polyp.  She did not recommend a dilation and curettage.  At the conclusion of this visit, a decision was made for the patient to undergo a hysterectomy, which was scheduled to occur on 6/27/2011.  The patient indicated that she wanted a bilateral salpingo-oophorectomy, but the gynecologist advised her to leave in the ovaries.

On 6/24/2011, the patient presented to the gynecologist for a preoperative evaluation.  The gynecologist offered the patient medical and surgical options and the patient chose a hysterectomy.  The gynecologist explained various surgical options, including risk factors and complications.  During the physical examination of the patient, the gynecologist noted the patient’s uterus was bulky and that it did not descend well.  The gynecologist did not document any observable vaginal bleeding or any pelvic pain with palpation of the pelvic organs.  At the conclusion of this visit, the gynecologist had formed a surgical plan to include a total vaginal hysterectomy and depending on whether the uterus was mobile in the operation room, possible laparoscopic assisted vaginal hysterectomy, possible exploratory laparotomy, and possible cystoscopy.

On 6/27/2011, the gynecologist performed a laparoscopic assisted vaginal hysterectomy, bilateral salpingo-oophorectomy, cystoscopy, and lysis of adhesions on the patient.  The medical records do not document a specific clinical reason for this choice in surgical technique versus a laparotomy approach.

During the surgery, the gynecologist encountered a web of filmy adhesions that were abundant along the back of both ovaries and continued along the back of the uterus.  The adhesions connected the bowel to the uterus and ovaries.

There were also adhesions from the ovaries to the side walls.  The gynecologist considered converting to an open procedure but opted to continue with laparoscopic dissection.  After dissection of all of the adhesions, the gynecologist obtained a general surgery consultation as a precaution to review the small bowel, which had been adherent, especially near the right ovary.  After observation through the monitor only, neither the surgeon nor the gynecologist noted any bowel injuries.

The gynecologist then proceeded with the vaginal hysterectomy portion of the surgery, which progressed “a bit more difficult than average but not remarkably so.”

Upon completion of the vaginal portion of the surgery, the gynecologist returned to the abdominal cavity.  Upon doing so, she noted a slight oozing from the round ligament on the left, which she cauterized.  The gynecologist then irrigated the pelvis and looked for any bleeding or injury but found none.

Prior to closing, the gynecologist requested a urology consultation.  After cystoscopy and examination revealed no injury to the bladder or ureter, the gynecologist completed the procedure.  The gynecologist’s detailed operative report does not specifically document the difficulties or complexities she encountered during the over eight-hour operation.

During the first three post-operative days, the patient experienced complications from the surgery that began to worsen.  The patient’s symptoms included abdominal pain, distention, lack of appetite, bowel dysfunction, fever, tachycardia, weakness, emesis, and anemia.

After attempting to treat the patient with antibiotics and observation, on 7/5/2011, the patient was taken in for an exploratory laparotomy.

During the surgery, several liters of feces were found in the patient’s abdomen, which were suctioned out.  Then, the abdomen was irrigated.  Further into the surgery, a 1-centimeter tear in the distal sigmoid and another 3-centimeter tear in the proximal rectum were identified, repaired, and treated with a colostomy.

From 7/5/2011 to 8/1/2011, the patient remained hospitalized and experienced complications including but not limited to nausea, vomiting, fatigue, fever, tachycardia, wound infection, anemia, and significant leukocytosis.  During this time period, the patient had to undergo radiological drainage of intraabdominal collections and was on several courses of antibiotics.  The patient was discharged from the hospital on 8/1/2011, approximately thirty-five days after her total hysterectomy.

Per the Board, the gynecologist committed gross negligence in her care and treatment of the patient by continuing with a long and complicated abdominal and pelvic surgery through laparoscopy without converting to laparotomy to prevent multiple intraoperative injuries.

In addition, the Board judged the gynecologist’s conduct to be below the minimum level of competence given the performance of a total abdominal hysterectomy and bilateral salpingo-oophorectomy without definitive clinical indication and without consideration of alternative treatments, prior to consideration of a major surgery, and given failure to maintain adequate and accurate records relating to her care and treatment of the patient.

The Board issued a public reprimand with stipulations to complete a medical record keeping course.

State: California


Date: July 2017


Specialty: Gynecology, General Surgery


Symptom: Abdominal Pain, Fever, Gynecological Symptoms, Nausea Or Vomiting, Weakness/Fatigue


Diagnosis: Post-operative/Operative Complication, Gynecological Disease


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


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Neurosurgery – Laminotomy And Foraminotomy Performed At One Level Lower Than Intended



On 12/9/2015, a patient presented to a neurosurgeon at the Laser Spine Institute with complaints of lower back pain and bilateral lower leg pain.

The neurosurgeon reviewed a previous MRI result for the patient which indicated that the patient had a lumbarized sacrum, foraminal stenosis at L5-S1 bilaterally, and L4-5 facet hypertrophy.

The neurosurgeon also reviewed previous nerve root block results, which indicated 20% relief at L5 and 80% relief when performed at L4-5.

The neurosurgeon recommended that the patient undergo a right laminotomy and foraminotomy at the L4-5 level.

On 12/11/2015, the patient returned for the recommended procedure.  The neurosurgeon performed a right laminotomy and foraminotomy on the patient at what he thought was the L4-5 previously identified at the 12/9/2015 visit.

The neurosurgeon relied on intraoperative imaging to find the operative level.

Due to the patient’s vertebral anatomy, on 12/11/2015, the neurosurgeon actually performed the procedure one level below the level he previously identified on the 12/9/2015 visit.  The level the neurosurgeon performed the procedure was the incorrect site and was not the site the neurosurgeon identified as the operative level at the 12/9/2015 visit.

On 2/24/2016, the neurosurgeon performed a second right laminotomy and foraminotomy on the patient, this time at the correct site, which was one level above the surgery he performed on 12/11/2015, and the same level he identified at the 12/9/2015 visit.

It was requested that the Board order one or more of the following penalties for the neurosurgeon: 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 Board deemed appropriate.

State: Florida


Date: July 2017


Specialty: Neurosurgery, Orthopedic Surgery


Symptom: Back Pain, Extremity Pain


Diagnosis: Spinal Injury Or Disorder


Medical Error: Wrong site procedure


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



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