Found 17 Results Sorted by Case Date
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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



California – Plastic Surgery – Failure To Manage Hypertension And Hypoxia Perioperatively



In 2013, Plastic Surgeon B was an independent contractor providing facial cosmetic surgery services two days a week for a clinic in California.  A 57-year-old male made an appointment at the clinic for 9/7/2013.  The patient was interested in improving the appearance of his lower face and eyes.

The patient filled out a medical history form, on which he checked, “Yes” to the question, “Are you currently undergoing radiation therapy or chemotherapy for cancer?”  There was no additional explanation.  He did not list the name of the primary care physician (PCP) on the form but indicated that his PCP could be contacted for questions.  He indicated that he was taking no medications and had no allergies.  He listed no prior surgeries.

On 9/13/2013, the patient met with Plastic Surgeon A for a pre-operative visit.  Plastic Surgeon A performed a history and physical examination and wrote prescriptions for diazepam 5 mg #20 tablets, Tylenol with oxycodone 10/325 mg #30, and Keflex 500 mg.  Plastic Surgeon A indicated that the patient had hypertension but was not on any medication.  The patient’s blood pressure was noted to be 152/97.  The patient signed informed consent forms for a face and neck-firming procedure as well as blepharoplasty.  Plastic Surgeon A did not co-sign the forms (which are used to indicate that the plastic surgeon had personally reviewed the risks, benefits, and alternatives of the procedures with the patient and answered all questions).  Plastic Surgeon A noted his surgical plan as “Face & neck.  Upper lids skin only.  Possible fat transfer to cheeks.  Fast absorbing suture.”  Plastic Surgeon A did not sign his surgical plan.

Plastic Surgeon A left his position at the clinic, and the patient’s care was transferred to Plastic Surgeon B.  Surgery was rescheduled for 9/26/2013 with Plastic Surgeon B, and a “Meet the Doctor” date of 9/19/2013 was scheduled.  On 9/16/2013, Plastic Surgeon B filled out and signed a History and Physician Examination form on the patient.  The form documented only the facial examination and surgical plan, including lower lid laser.  There is no documentation of vital signs, particularly no blood pressure reading.  The patient signed new informed consent forms for face and neck firming surgery and blepharoplasty by Plastic Surgeon B.  Plastic Surgeon B did not co-sign the informed consent forms indicating that he had personally reviewed the risks, benefits, and alternatives of the procedures with the patient and answered all questions.  There is no consent form for laser resurfacing.

On 9/25/2013, the patient saw Plastic Surgeon B, and Plastic Surgeon B’s notes indicate “Famvir” and “take BP today.”  There is no documentation in the chart that a prescription for Famvir was written or that the drug was dispensed or used by the patient.  There is also no documentation that the patient’s blood pressure was taken.

The patient presented for surgery on 9/26/2013.  Vital signs were taken, and his blood pressure was documented as 177/116 right and 160/95 left.  At 11:30 a.m., the patient was in the surgical suite and was given oral sedation consisting of diazepam 30 mg; lorazepam 1 mg; acetaminophen with hydrocodone 5/325 mg; promethazine 25 mg; clonidine 0.1 mg; and diphenhydramine 25 mg.  Local anesthesia was infiltrated into the facial skin and subcutaneous tissues one hour and fifteen minutes later at 12:45 p.m.  This consisted of 1% lidocaine with 1:100,000 epinephrine (75 ml); 0.25% bupivacaine with 1:200,000 epinephrine (30 ml); normal saline (60 ml); and approximately 1:150,000 epinephrine with the total being approximately 200 ml of local anesthesia infiltrated.

Surgery commenced sometime after 1:00 p.m. on 9/26/2013.  The patient’s pulse rate, oxygen saturation, and blood pressure were monitored automatically throughout the procedure.  The patient remained hypertensive throughout the procedure, and no additional medications were provided for blood pressure control.  The procedure began with the patient’s oxygen saturation at 98%.  At 1:32 p.m., the oxygen saturation dropped to 58% and remained in the 60-70% range until approximately 3:15 p.m., when it returned to the 90% range.  Additional sedating drugs were given between 4:05 p.m. and 4:30 p.m., and oxygen readings fell again into the 50-70% range until the end of the procedure with only occasional readings in the normal range.

Although not documented in the record, Plastic Surgeon B indicated that sometime after 3:00 p.m., he was called upon to attend a post-operative patient who had presented with incisions on her face that had opened, an emergency.  Plastic Surgeon B left the patient in the surgical suite and, after 20 to 30 minutes attending to the emergency patient, Plastic Surgeon B returned to the surgical suite to complete the patient’s surgery.  Neither his departure from the OR nor the names and qualifications of those attending the patient in his absence are documented in the operative note.  Upon Plastic Surgeon B’s return, the patient was given additional oral sedation, as well as more local anesthesia.  The time of injection of an additional 44 ml of local anesthesia was not documented on the Patient Surgery Information Sheet.  The certified surgical technician administered the anesthesia under Plastic Surgeon B’s supervision and assisted in the procedure; Plastic Surgeon B indicated at his subject interview with the Board on 7/30/2015 that a nurse was also present, but this is not documented in the record.  Surgery was completed at approximately 6:00 p.m.  The patient’s final blood pressure was 186/116.  The patient was discharged home at 6:25 p.m.

The operative report on the patient signed by Plastic Surgeon B is a template document that provided no personal detail on the procedure.  For example, the template stated that skin openings were left behind the patient’s ears for expressing fluid, but the post-operative notes stated that the patient had drainage tubes placed bilaterally.  The operative report stated that a lower lid blepharoplasty was performed, but no such procedure was performed on the patient.

Post-operative photographs of the patient were taken on 9/27/2013, but there is no progress note for this visit.  A note for a visit on 9/28/2013 was signed by a technician and noted that the drainage tubes were being left in place; the patient was apparently not seen by a physician on this visit.  On 9/30/2013, the patient was examined by Plastic Surgeon B (although he did not sign the progress note); at this time, the remaining drainage tube was removed; the patient’s blood pressure was recorded as 187/113; advice given to the patient was to rest and relax.  On 10/2/2013, the patient was seen by staff, and his eyelid sutures were removed; the patient’s blood pressure was recorded as 154/94.  On 10/5/2013, the patient’s blood pressure was recorded as 162/105; there is no progress note for this visit, except that an unsigned addendum to the 10/2/2013 visit indicates that the facelift sutures were removed on 10/5/2013.  Post-operative photographs were taken on 10/21/2013, but there is no accompanying progress note.

The patient was dissatisfied with the results of the procedure and the care he received from Plastic Surgeon B.  The patient filed a consumer complaint, which the Board received on 6/23/2014.

The Board judged Plastic Surgeon B’s conduct to be below the minimum level of competence given failure to address the patient’s hypertension, failure to sufficiently address the patient’s episodes of hypoxia during the procedure, and failure to accurately document his encounters with the patient.

The Board notes that performing surgery on a hypertensive patient adds additional risk to the procedure for excessive bleeding, hematoma formation, and stroke.  Such a risk should be mitigated prior to the initiation of any elective procedure.  Per the Board, if a patient becomes hypertensive during a surgical procedure, medications should be provided to the patient to stabilize the blood pressure.

The Board also notes that if a patient becomes hypoxic during a procedure, it is required to assure the oxygen saturation probe is working correctly and to provide exogenous oxygen for the patient to breathe and return his oxygen saturation to the normal range.  There is no documentation that Plastic Surgeon B responded to the patient’s low oxygen saturation.

The Board expressed concern that the patient’s medical record contained numerous instances of unsigned, incomplete, and absent notes.  Vital signs were at times not documented.  A prescription for Famvir was administered but not documented.  There was no documentation of Plastic Surgeon B’s absence from the surgical suite and no indication of personnel that was left in charge of the patient while Plastic Surgeon B addressed another patient’s emergency.  Operative notes were inadequate and inaccurate.

The Board issued a public reprimand with stipulations that Plastic Surgeon B a medical record keeping course and a continuing medical education course in pre-operative patient evaluation, informed consent, and management of intra-operative hypertension and hypoxia.

State: California


Date: August 2017


Specialty: Plastic Surgery


Symptom: N/A


Diagnosis: N/A


Medical Error: Improper treatment, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



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