Found 17 Results Sorted by Case Date
Page 1 of 2

California – Gynecology – High Grade Dysplasia Scheduled For Follow Up In 6 Months



On 12/31/2013, a 27-year-old female had a pap smear that showed Atypical Squamous Cells of Undetermined Significance (ASCUS) with a positive showing for HPV.  On 1/30/2014, the patient presented to a gynecologist for colposcopy. Biopsies confirmed Cervical Intraepithelial Neoplasia (CIN) 2 at two biopsy sites, and CIN 1 at a single biopsy site with an insufficient endocervical curettage (ECC).

On 2/10/2014, the patient again presented to the gynecologist for a follow-up examination.  The gynecologist diagnosed the patient with Moderate Cervical Dysplasia, CIN 2, and advised the patient to follow-up in 1 year with a PAP/HPV examination.  On 2/28/2014, after speaking with a colleague, the gynecologist telephoned the patient and advised the patient to return in 6 months for an examination of the abnormal PAP.

The Medical Board of California judged that the gynecologist’s conduct departed from the standard of care because she failed to follow-up with the patient sooner than 6-12 months, and in light of the inadequate ECC, failed to proceed with either a diagnostic excisional procedure or an excision/ablation procedure to treat the high grade dysplasia known to the gynecologist.

The Medical Board of California issued a public reprimand and ordered the obstetrician to complete an education course (at least 15 hours) dedicated in the area of diagnosis and patient care in OB/GYN cases.

State: California


Date: August 2017


Specialty: Gynecology


Symptom: N/A


Diagnosis: Gynecological Disease


Medical Error: Delay in diagnosis


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Gynecology – Blood With Urination Not Due To Bleeding From Bladder Or Kidneys



On 4/5/2015, an 80-year-old female presented to a gynecologist with a complaint of pink drainage with urination.  The patient had a prior cystoscopy and a CT through the urology department, which was negative for hematuria. The gynecologist conducted an examination of the patient and noted: (1) no blood in the vagina; and (2) that the vaginal epithelium was atrophic.  The gynecologist did not order a pelvic ultrasound of the patient. The gynecologist failed to evaluate any postmenopausal bleeding with either an endometrial biopsy or an ultrasound of the uterus, and she failed to order or conduct any assessment to exclude malignancy.

On 2/21/2014, the patient was seen by a urologist for continued hematuria.  Cystoscopy was performed and revealed no bleeding from the bladder or kidneys.  On 2/25/2014, the patient was seen by another gynecologist who ordered a pelvic ultrasound that ultimately showed an intrauterine vascular mass.  On 3/3/2014, an endometrial biopsy was performed on the patient by a different provider, which showed adenocarcinoma.

The Medical Board of California judged that the gynecologist’s conduct departed from the standard of care because she failed to evaluate any postmenopausal bleeding with either an endometrial biopsy or an ultrasound of the uterus and to order or conduct any assessment to exclude malignancy.

The Medical Board of California issued a public reprimand and ordered the obstetrician to complete an education course (at least 15 hours) dedicated in the area of diagnosis and patient care in OB/GYN cases.

State: California


Date: August 2017


Specialty: Gynecology


Symptom: Bleeding


Diagnosis: Gynecological (Endometrial, Ovarian, Cervical) Cancer


Medical Error: Failure to order appropriate diagnostic test


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Ophthalmology – Failure To Utilize Optical Coherence Tomography To Evaluate A Patient For Macular Conditions



An ophthalmologist treated a 90-year-old female from 1/26/2012 to 3/12/2014.  The patient presented to the ophthalmologist on 1/26/2012 with complaints of decreased vision and a prior history of Avastin injections.

The ophthalmologist diagnosed the patient with wet macular degeneration, vitreous membranes, posterior vitreous detachments, dry eyes, and previous cataract surgery with intraocular lenses.

The ophthalmologist performed fluorescein and indocyanine angiographies and ultrasonography.  The ophthalmologist performed a Lucentis injection in the right eye.

Over the course of his treatment of the patient, the ophthalmologist performed focal laser treatments in the patient’s left eye six times and in his right eye seven times;  intravitreal Lucentis injections in the patient’s left eye twenty-one times and the patient’s right eye twenty-two times;  intravitreal Avastin injections in both of the patient’s eyes four times;  fundus photos, fluorescein angiography and indocyanine green angiography over forty times, and ultrasounds on both of the patient’s eyes eight times.

The ophthalmologist failed to utilize, or did not create, keep, or maintain adequate, legible documentation of utilizing optical coherence tomography to evaluate the patient.

At all times material to this complaint, the prevailing standard of care dictates that a physician:  perform testing and/or treatment that are medically justified; provide medical justification for the testing and treatment provided to the patient;  utilize optical coherence tomography to evaluate a patient for macular conditions;  and record the lot number and/or other identifying information from used vials of Lucentis.

The ophthalmologist performed focal laser treatment on both of the patient’s eyes excessively and/or without medical justification on one or more occasions.  He also performed fluorescein and indocyanine angiography on the patient’s eyes excessively and/or without medical justification on one or more occasions.  The ophthalmologist performed ultrasounds on both of the patient’s eyes without medical justification on one or more occasions.  He did not document, or did not create, keep, or maintain adequate, legible documentation of the lot number of any other identifying information from any of the vials of Lucentis used during the course of treatment in the patient.  The ophthalmologist did not document, or did not create, keep, or maintain adequate, legible documentation of the patient’s conditions, any changes in the patient’s conditions, and/or medical indications for the testing and treatment.

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

State: Florida


Date: August 2017


Specialty: Ophthalmology


Symptom: Vision Problems


Diagnosis: Ocular Disease


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


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Obstetrics – Missed Indicators Of A Neural Tube Defect



On 2/24/2014, a 36-year-old female presented to an obstetrician for fatigue, breast tenderness, and absence of menstruation.  At the aforementioned visit, the obstetrician diagnosed the patient with amenorrhea and sent her to have blood work.

On 2/25/2014, the patient was notified of her positive pregnancy test.

On 3/20/2014, 3/17/2014, 3/24/2014, 4/24/2014, 8/7/2014, and 9/25/2015, the obstetrician ordered obstetrical ultrasounds and/or sonograms on the patient.

On 4/23/2014 and 8/20/2014, the patient presented to the obstetrician with thick vaginal fluid and bloody discharge and/or morning sickness, nausea, chills, fever, and back pain.

On 5/23/2014, 6/20/2014, 7/16/2014, 8/15/2014, 9/12/2014, 10/13/2014, 10/20/2014, and 10/27/2014, the patient presented to the obstetrician for follow-up visits.

On 11/2/2014, the patient gave birth to her son.  The child was born with a neural tube defect called spina bifida/myelomeningocele.

The obstetrician failed to observe on imaging studies, and follow-up on, known indicators that the patient’s child may have had a neural tube defect, or alternatively, did not create, keep, or maintain adequate legible documentation of observing on imaging studies, and following up on known indicators that the patient’s child may have had a neural tube defect.

The obstetrician failed to order maternal serum alpha-fetoprotein (MSAFP) test, or alternatively, did not create, keep, or maintain adequate legible documentation of ordering a MSAFP test.

The obstetrician failed to order an anatomical survey sonogram, or alternatively, did not create, keep, or maintain adequate legible documentation of ordering an anatomical survey sonogram.

It was requested that the Board order one or more of the following penalties for the obstetrician: 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: August 2017


Specialty: Obstetrics


Symptom: Weakness/Fatigue, Bleeding, Abnormal Vaginal Discharge, Back Pain


Diagnosis: Neurological Disease


Medical Error: Failure to order appropriate diagnostic test, Failure to follow up, Lack of proper documentation


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Family Practice – Unnecessary Excisions Performed For Multiple Lesions



On 6/15/2012, a 47-year-old female presented to a family practitioner with multiple lesions on her back, chest, and arms.

The family practitioner informed the patient that the lesions on her left humerus, right upper abdomen, mid upper back, left anterior mid chest, lower back, right lower back, and/or right upper anterior chest were malignant and/or potentially malignant.

On 7/6/2012, the family practitioner documented that the patient had a history of keloid formation after surgical excision.

On 6/15/2012, the family practitioner excised a lesion on the patient’s left humerus.  The lesion excised from the patient’s left humerus measured approximately 3 mm by 3 mm.  The family practitioner made an excision 4 cm by 4 cm or sixteen square centimeters to excise the lesion on the patient’s left humerus.

On 6/19/2012, a dermatopathology report determined that the excision taken from the patient’s left humerus was not malignant or premalignant.

On 6/27/2012, the family practitioner excised a lesion on the patient’s right upper abdomen.  The lesion on the patient’s right upper abdomen measured 3 mm.   The family practitioner made an excision 7 cm by 6 cm, or forty-two square centimeters to excise the lesion on the patient’s right upper abdomen.

On 6/29/2012, a dermatopathology report determined that the excision taken from the patient’s right upper abdomen was not malignant or premalignant.

On 7/6/2012, the family practitioner excised a lesion the patient’s mid upper back.  The lesion on the patient’s back measured approximately 3 mm.   The family practitioner made an excision 5 cm by 7 cm, or thirty-five square centimeters to excise the lesion on the patient’s mid upper back.

On 7/13/2012, the family practitioner excised a lesion on the patient’s left anterior mid chest.  The lesion on the patient’s left anterior mid chest measured approximately 4 mm by 4 mm.
The family practitioner made an excision 8 cm by 6 cm or forty-eight square centimeters to excise the lesion on the patient’s left anterior mid chest. He referred the patient for radiation treatment to prevent keloid formation.

On 7/20/2012, a dermatopathology report determined that the excision taken from the patient’s left anterior mid chest was not malignant or premalignant.

On 8/3/2012, the family practitioner excised a lesion the patient’s left lower back.  The lesion on the patient’s left lower back measured 5 mm by 4 mm.  The family practitioner made an excision 9 cm by 7 cm or sixty-three square centimeters to excise the lesion on the patient’s left lower back.

On 8/7/2012, a dermatopathology report determined that the excision taken from the patient’s left lower back was not malignant or premalignant.

On 8/10/2012, the family practitioner excised a lesion on the patient’s right lower back.  The lesion on the patient’s right lower back measured 4 mm by 4 mm.  The family practitioner made an excision 9 cm by 8 cm or seventy-two square centimeters to excise the lesion on the patient’s right lower back.

On 8/14/2012, a dermatopathology report determined that the excision taken from the patient’s right lower back was not malignant or premalignant.

On 8/27/2012, the family practitioner excised a lesion on the patient’s right upper anterior chest.  The lesion on the patient’s right upper anterior chest measured 2 mm by 2 mm.   He made an excision 10 cm by 7 cm, or seventy square centimeters to excise the lesion on the patient’s right upper anterior chest.

On 8/29/2012 a dermatopathology report determined that the excision taken from the patient’s right upper anterior chest was not malignant or premalignant.

The Board judged that the family medicine practitioners conduct to be below the minimal standard of competence given that he failed to perform a complete and comprehensive physical examination of the patient’s lesions; adequately consider the characteristics of the lesions, including the size, color, regularity, and degree of pigmentation; refer the patient for consultation with a dermatologist; refrain from diagnosing the patient with malignant and/or potentially malignant lesions without having adequate justification; accurately and appropriately diagnose the patient’s condition; confirm that each of the lesions on the patient was malignant or premalignant prior to excising the lesion; perform a shave biopsy, punch biopsy, or limited excisional biopsy with 1 mm margins on each of the lesions on the patient to determine whether the lesion was malignant or premalignant; make an excision with margins no greater than 5 mm to excise each of the lesion on the patient; refrain from making an excision on the patient without having adequate justification; avoid potential keloid formation on the patient, by making the fewest and/or smallest excisions appropriate and/or justifiable.

The family practitioner agreed to voluntarily cease practicing medicine and agreed to never reapply for licensure as a medical doctor in the state of Florida.

State: Florida


Date: August 2017


Specialty: Family Medicine, Dermatology


Symptom: Dermatological Abnormality


Diagnosis: Dermatological Issues


Medical Error: Unnecessary or excessive treatment or surgery, Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Referral failure to hospital or specialist, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Cardiothoracic Surgery – Failure To Follow Up After Pathology Report Shows Abnormal Lymphadenopathy



On 1/25/2013, a 65-year-old male, underwent an artery bypass grafting procedure on his right leg by a cardiothoracic surgeon at a medical center.

During the course of the procedure, the cardiothoracic surgeon took a biopsy of the patient’s right groin lymph node, which was sent off to pathology for analysis.

The patient was never notified by the cardiothoracic surgeon that a biopsy of the right groin lymph node was taken during the procedure.

The cardiothoracic surgeon should have documented the right groin lymph node biopsy as part of the procedure in the operative report for the procedure but failed to do so.

On 1/29/2013, the pathology report for the biopsied tissue revealed a pathologic diagnosis of mantle cell lymphoma.  The pathology report was sent via facsimile to the cardiothoracic surgeon’s office.  The cardiothoracic surgeon should have listed “abnormal lymphadenopathy” as the post-operative diagnosis and failed to do so.

On 1/30/2013, the patient was discharged from the medical center.

The Board judged the cardiothoracic surgeons conduct to be below the minimal standard of competence given that he should have notified the patient of the pathology results and failed to do so.  He also should have obtained oncologic consultation for the patient and failed to do so.  The cardiothoracic surgeon should have provided the patient’s primary care physician and the referring physician with a copy of the pathology report and failed to do so.

The Board issued a letter of concern against the cardiothoracic surgeon’s license.  The Board ordered that the cardiothoracic surgeon pay a fine of $5,000 against his license and pay reimbursement costs for the case for a minimum of $5,063.26 but not to exceed $7,063.26.  The Board ordered that the cardiothoracic surgeon complete a board approved medical records course and complete five hours of continuing medical education in “risk management.”

State: Florida


Date: August 2017


Specialty: Cardiothoracic Surgery, Oncology


Symptom: N/A


Diagnosis: Cancer


Medical Error: Failure to follow up, Failure of communication with other providers, Referral failure to hospital or specialist, 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



Florida – Radiology – Two Patients With The Same First Name, Last Name, And Year Of Birth



On 12/23/2014, Patient A and Patient B, both 89-year-old females, presented to the radiology department.  Patient A presented for a carotid ultrasound while Patient B presented for a PICC line insertion.  Both patients had the same first name and last name and were born the same year, but were born on different dates.

After undergoing a carotid ultrasound, Patient A was erroneously transported to the special procedures unit for a PICC line insertion.  A radiologist injected the patient with lidocaine in preparation of performing the PICC line insertion.

The radiologist began to insert the PICC line guidewire but stopped when the accompanying nurse recognized that Patient A was not the correct patient.

The radiologist did not create or maintain documentation of properly performing a timeout procedure.

The Medical Board of Florida issued a letter of concern against the radiologist’s license.  Also, the Medical Board of Florida ordered that the radiologist pay a fine of $2,500 against his license and pay reimbursement costs for the case at a minimum of $2,276.31 and not to exceed $4,276.31.  The Medical Board of Florida ordered that the radiologist complete five hours of continuing medical education in “risk management” and complete a one hour lecture on “wrong site surgeries” including information on “wrong patient procedures.”

State: Florida


Date: August 2017


Specialty: Radiology


Symptom: N/A


Diagnosis: N/A


Medical Error: Accidental error, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Plastic Surgery – Excessive Use Of Lidocaine During SmartLipo Results In Severe Complications



On 11/2/2012, a 39-year-old female presented to an internist for skin tightening intervention in the lower abdomen under local anesthesia with mild oral and intramuscular sedation, a procedure commonly known as “smart lipo.”

The patient was given 700 to 800 ml of an IV of various medicines, including lidocaine, and then three injections of 1% lidocaine.

Shortly after administration of the IV of various medicines and the lidocaine shots, the patient began to have a grand mal seizure.  The internist treated the patient with IV fluids and Narcan.

The patient reportedly had normal vital signs at the time, but then had another seizure fifteen minutes later.

According to the internist, ten minutes later, on the third seizure, the internist requested an ambulance.

The internist indicated that the patient, upon the third seizure, lost all pulse and respiration.

According to the EMS staff, the internist did not recognize that the patient was in cardiac arrest upon EMS arrival and was not assisting the patient.

The patient was taken to the emergency room in full cardiac arrest, where she died.

The medical examiner listed the patient’s cause of death as acute lidocaine toxicity due to use of lidocaine in a medical procedure.

The internist failed to adequately prepare or maintain medical records in this case in a way that allowed any medical professionals to adequately know the amount of lidocaine administered to the patient.

The Medical Board of Florida judged the internist’s conduct to be below the minimal standard of competence given that he failed to recognize a lack of blood pressure and administer cardiac support (CPR) upon recognition of a lack of blood pressure.  The internist also administered excess lidocaine that caused the patient’s death due to lidocaine toxicity.

The Medical Board of Florida issued a reprimand against the internist’s license.  The Medical Board of Florida ordered that the internist pay of $5,000 for his license and pay reimbursement costs for the case at a minimum of $10,683.65 and not to exceed $12,683.65.  The Medical Board of Florida ordered that the internist complete a records course, complete ten hours of continuing medical education in liposuction procedures and complete five hours of continuing medical education in “risk management.”

State: Florida


Date: August 2017


Specialty: Plastic Surgery, Internal Medicine


Symptom: N/A


Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Post-operative/Operative Complication


Medical Error: Improper medication management, Underestimation of likelihood or severity, Lack of proper documentation


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Florida – Physician Assistant – Diflucan For Yeast Infection Given With Tacrolimus



A patient received a heart transplant and was on a long-term tacrolimus regimen.

On 10/7/2011, the patient presented to a physician assistant with complaints of an oral yeast infection.  The physician assistant prescribed the patient a two-week course of Diflucan and advised him to return for follow-up three weeks after the 10/7/2011 appointment.

Diflucan is known to potentiate tacrolimus, which causes the tacrolimus to reach toxic levels.

The standard of care required that the physician assistant perform serial monitoring of the patient’s drug levels to ensure that they did not reach a toxic level, starting immediately after the physician assistant prescribed Diflucan.

The physician assistant did not schedule blood testing to monitor the patient’s drug levels and advised the patient to return for a follow-up appointment three weeks after the initial appointment.

The physician assistant voluntarily relinquished his license.

State: Florida


Date: August 2017


Specialty: Physician Assistant


Symptom: N/A


Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Infectious Disease


Medical Error: Improper medication management, Failure to properly monitor patient


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Family Medicine – Improper Prescribing Of Controlled Substances To A Patient With Drug Seeking Behavior, Dependence, and Withdrawals



On 7/13/2006 through 8/6/2013, a family practitioner treated a 37-year-old female for chronic neck and back pain.  The patient presented to the family practitioner with a history of hypertension, depression, anxiety, and back pain from a 2004 motor vehicle accident.

The patient’s medical records from her previous treating physicians indicated that the patient was addicted to Xanax, had attempted suicide via overdose of alcohol and Tylenol in 2004, and was a high-risk patient with regards to controlled substances.

Throughout the course of the treatment, the family practitioner prescribed controlled substances to the patient including Nucynta, Percocet, Xanax, Klonopin, Vicodin, and Soma.

On 10/7/2008, the family practitioner noted that the patient exhibited drug seeking behavior, had undergone physical withdrawals, and was having psychological dependence.  The family practitioner documented “no further controlled substances after this.”

On 10/7/2008, the family practitioner referred the patient to a pain management specialist.

From 10/17/2008 to 5/6/2010, the patient presented to a pain management specialist for her chronic pain.

Beginning on 5/17/2010, the patient discontinued treatment with the pain management specialist and resumed her treatment with the family practitioner for her chronic pain.

From 9/2/2011 through 8/6/2013, the patient presented to the family practitioner approximately every three months.  Despite the patient only presenting every three months, the family practitioner prescribed monthly refills of controlled substances for the patient.  The family practitioner prescribed Nucynta, Percocet, Xanax, Klonopin, Vicodin, and Soma to the patient in various combinations and amounts.

The prevailing standard of care requires that a physician treating a patient for chronic pain prescribe controlled substances appropriately.  The quantity and/or combination of controlled substances the family practitioner prescribed to the patient on one or more occasions from 9/2/2011 through 8/6/2013 were inappropriate.

The prevailing standard of care requires that a physician treating a high-risk patient for chronic pain create and implement an appropriate treatment plan.

The family practitioner did not create or implement, or did not document creating or implementing, an appropriate treatment plan for the patient.  The prevailing standard of care requires that a physician treating a high-risk patient for chronic pain evaluate the patient prior to refilling prescriptions for controlled substances.  On one or more occasions, the family practitioner prescribed multiple refills of controlled substances for the patient at a single office visit.

The prevailing standard of care required that a family physician treating a high-risk patient for chronic pain refer the patient to a chronic pain specialist.  The family practitioner did not refer, or did not document referring, the patient to a chronic pain specialist on or after 9/2/2011.

It was requested that the Board order one or more of the following penalties for the family practitioner: 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: August 2017


Specialty: Family Medicine


Symptom: Head/Neck Pain, Back Pain, Psychiatric Symptoms


Diagnosis: Drug Overdose, Side Effects, or Withdrawal


Medical Error: Improper medication management, Referral failure to hospital or specialist, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Page 1 of 2