Found 16 Results Sorted by Case Date
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Virginia – Neurosurgery – All-Terrain Vehicle Rollover Accident Causes L1 Compression Fracture



On 1/19/2008, a 32-year-old man suffered an L1 compression fracture following an all-terrain vehicle rollover accident.  He saw a neurosurgeon who placed him in a rigid back brace and prescribed pain medications.  The patient’s fracture appeared to be clinically stable and appeared to be improving.  The Board deemed the long-term risk of developing a kyphotic deformity low in this patient.

On 3/7/2008,  the neurosurgeon performed a kyphoplasty of the spine the patient.  During the kyphoplasty, the vertebral body was too dense to accept the cement.  As a consequence, the cement extruded out of the fracture plans into the epidural space.

The neurosurgeon addressed this complication by performing a posterior laminectomy and decompression of the thecal sac.  The Board stated that the laminectomy procedure subjected the patient to a far greater risk for development of kyphosis than had existed prior to the kyphoplasty.

The Board considered the surgery unwarranted and issued a reprimand.  The neurosurgeon was ordered to complete 10 hours of continuing medical education in the subject of patient selection for spinal surgery.

State: Virginia


Date: November 2017


Specialty: Neurosurgery


Symptom: Back Pain


Diagnosis: Spinal Injury Or Disorder, Fracture(s)


Medical Error: Unnecessary or excessive treatment or surgery, Procedural error


Significant Outcome: N/A


Case Rating: 5


Link to Original Case File: Download PDF



Florida – Family Medicine – Recurrent Chest Pain Diagnosed As Esophageal Spasm



On 8/27/2012 a 47-year-old female presented with complaints of hypertension, possible hyperlipidemia, and pain in her foot.  A family practitioner assessed the patient and diagnosed her with poor control of her hypertension and reinforced medical advice for the patient to increase her lisinopril.  Additionally, the family practitioner waited for the results of the previous laboratory work and recommended conservative management and stretching for the foot and ankle.

On 4/1/2013, the patient again presented to the family practitioner to address difficulties with concurrent chest pain.  The patient stated the chest pains were very severe and “stopped her in her tracks at times.”  The patient stated that she felt she was having a heart attack, although she reportedly realized that that was not the case.  The family practitioner deemed the chest pain was likely an esophageal spasm, for which he prescribed the patient Librax (chlordiazepoxide/clidinium) and recommended that she see a gastroenterologist for an endoscopy if the medication failed to provide relief.  The family practitioner also assessed the patient for hypertension and instructed the patient to stop taking hydrochlorothiazide.  The family practitioner provided the patient with a trial of Dyrenium (triamterene).

On 4/12/2013, the patient complained of chest pain and suffered a cardiac arrest.  Upon EMS arrival, the patient was unstable and unresponsive.  The patient was transported to a hospital where she was later pronounced deceased.

The Board judged the family practitioners conduct to be below the minimal standard of competence given that he failed to conduct an adequate history, which included a risk factor assessment for a patient complaining of chest pain, to order or perform an EKG on a patient complaining of chest pain, and send a patient complaining of chest pain to an emergency room or an expedited outpatient facility for a chest pain evaluation.

The Board ordered that the family practitioner pay a fine of $5,000 against his license and pay reimbursement costs for a minimum of $2,122.00 and not to exceed $4,122.00.  The Board also ordered that the family practitioner complete ten hours of continuing medical education in diagnosis in cardiology and five hours of continuing medical education in “Risk Management.”

State: Florida


Date: November 2017


Specialty: Family Medicine


Symptom: Chest Pain, Extremity Pain


Diagnosis: Cardiovascular Disease


Medical Error: Diagnostic error, Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Referral failure to hospital or specialist


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Internal Medicine – Retained Guide Wire Found After Replacement Of Dialysis Catheter



On 3/19/2015, a patient presented to a hospital with complaints of chest pain, history of acute stent thrombosis, and renal failure.

On 3/21/2015, a physician referred the patient to an internist for replacement of temporary dialysis catheter to address her acute kidney failure.  The internist placed a double-lumen dialysis catheter in the patient’s left subclavian vein.

Due to the catheter not functioning properly, another physician performed a catheter exchange procedure on the patient on 3/23/2015.  After the procedure, the inspection of the catheter revealed that the guide wire remained in one of the lumens of the catheter.

Neither the internist nor his staff removed the guide wire from the catheter prior to the insertion of the catheter into the patient’s left subclavian vein.

The Board judged the internist’s conduct to be below the minimum standard of competence given that he left a foreign body in a patient.

The Board ordered that the internist pay a fine of $3,500 against his license and pay reimbursement costs for the case for a minimum of $3,419.35 and not to exceed $5,419.35.  The Board also ordered that the internist complete five hours of continuing education in “Risk Management” and complete a lecture/seminar on retained foreign body objects to medical staff.

State: Florida


Date: November 2017


Specialty: Internal Medicine, Nephrology


Symptom: Chest Pain


Diagnosis: Renal Disease


Medical Error: Retained foreign body after surgery


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Neurosurgery – Cervical Microdiscectomy At Levels C5/7 And C6/7 Instead Of Levels C4/5 And C5/6



On 11/17/2014, a patient presented to a neurosurgeon for an anterior cervical microdiscectomy for decompression with allograft fusion at cervical levels C4/5 and C5/6.  During the procedure, it was discovered that the initial localization x-ray was misinterpreted and that the neurosurgeon performed the fusion at cervical levels C5/7 and C6/7 instead of cervical levels C4/5 and C5/6.  After the neurosurgeon discovered the error, he proceeded to perform the fusion at the correct cervical levels, C4/5 and C5/6.

The Board judged the neurosurgeons conduct to be below the minimum standard of competence given that he performed the procedure on the wrong site.

The Board ordered that the neurosurgeon pay a fine of $5,000 against his license and pay reimbursement costs of a minimum of $1,859.22 but not to exceed $3,859.22.  The Board also ordered that the neurosurgeon complete five hours of continuing medical education in “Risk Management” and complete a one hour lecture/seminar on wrong site surgeries.

State: Florida


Date: November 2017


Specialty: Neurosurgery


Symptom: N/A


Diagnosis: Spinal Injury Or Disorder


Medical Error: Wrong site procedure


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Internal Medicine – Inadequate Monitoring For Post-Operative Care After Thyroid Lobectomy



On 8/12/2011, a patient was admitted to a medical center for post-operative care after a right thyroid lobectomy.

The patient presented with multiple risk factors for coronary artery disease, including obesity and tobacco use.  She had a prolonged and difficult time with extubation after the surgery and complained of shortness of breath.

An internist was consulted for medical management.  The internist diagnosed the patient with questionable and mild pulmonary edema.  The internist’s plan of care for the patient was to admit her to the hospital, obtain ventilation/perfusion (V/Q) scan, perform cardiology and deep vein thrombosis evaluations, and perform peptic ulcer disease prophylaxis.  The internist did not order telemetry monitoring for the patient.

On 8/12/2011, the patient was found slumped over the left side of her hospital bed and unresponsive. Staff initiated resuscitative efforts but they were unsuccessful and the patient expired.

The Board judged the internists conduct to be below the minimum standard of competence given that he failed to order telemetry monitoring for her upon her admission to the medical center.

The Board ordered that the internist pay a fine of $5,000 against his license and pay reimbursement costs for the case for a minimum of $2,378.85 and not to exceed $4,378.85.  The Board also ordered that the internist complete five hours of continuing medical education in “Risk Management” and complete a one hour lecture/seminar on “Risk Management.”

State: Florida


Date: November 2017


Specialty: Internal Medicine


Symptom: Shortness of Breath


Diagnosis: Pulmonary Disease


Medical Error: Failure to properly monitor patient


Significant Outcome: Death


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Anesthesiology – Proceeding With A Colonoscopy With A Non-Functioning End Tidal CO2 Monitor



A 59-year-old female presented to an anesthesiologist during her colonoscopy.  The anesthesiologist conducted a pre-operative anesthesia assessment of the patient.  She was then transported to the procedure room where a certified registered nurse anesthetist (“CRNA”) was to provide total intravenous anesthesia to the patient.

The end-tidal CO2 monitor (“ETCO2 monitor”) located in the scheduled procedure room was non-functional on the day before the surgery and a functioning ETCO2 monitor had not been received on the day of the surgery.

The anesthesiologist instructed the CRNA to proceed with the anesthesia without the ETCO2 monitor.  The anesthesiologist did not delay the procedure or postpone it for another date to allow time to obtain a functioning ETCO2 monitor.  The anesthesiologist did not transfer the patient to another procedure room that had a functioning ETCO2 monitor.  The anesthesiologist did not implement additional precautionary measures by closely monitoring the patient with his presence since he elected to proceed without an ETCO2 monitor as recommended by the ASA (American Society of Anesthesiologists).  The anesthesiologist was not present in the procedure room during the procedure.

The CRNA experienced difficulties with the patient’s airway soon after the induction of anesthesia.  The oral airway was inserted to assist the patient’s breathing, and the amount of oxygen flow was increased to help with the falling oxygen saturation.  Despite the increase in the amount of oxygen flow, the CRNS reported transient desaturations and reported repositioning the pulse oximeter numerous times throughout the procedure.

The patient developed bradycardia, which culminated to intubation and cardiac arrest, and the anesthesiologist’s presence was requested in the procedure room.  The anesthesiologist started chest compressions and resuscitated the patient.

The Board judged the anesthesiologist’s conduct to be below the minimum standard of competence given that he should have delayed the procedure, or postponed it for another date to allow time to obtain a functioning ETCO2 monitor.  He should also have transferred the patient to another procedure room that had a functioning ETCO2 monitor and implemented additional precautionary measures by closely monitoring the patient with since he elected to proceed without an ETCO2 monitor.

The Board ordered that the anesthesiologist pay a fine of $5,000 against his license and pay reimbursement costs for the case for a minimum of $6,841.07 and not to exceed $8,841.07.  The Board also ordered that the anesthesiologist complete five hours of continuing medical education in general anesthesia and complete five hours of continuing medical education in “Risk Management.”

State: Florida


Date: November 2017


Specialty: Anesthesiology


Symptom: N/A


Diagnosis: Post-operative/Operative Complication


Medical Error: Failure to properly monitor patient


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Obstetrics – Obstetrician Unavailable During Labor With Fetal Heart Decelerations



On 1/24/2014 a 21-year-old female presented to a hospital with spontaneous rupture of membranes and meconium-stained amniotic fluid at about thirty-nine weeks of pregnancy.

Upon admission, the patient was placed on a fetal monitor, which documented variable decelerations of the fetal heart rate.  In response to the monitor tracings, an obstetrician ordered the administration of intravenous fluids.  Shortly thereafter, the obstetrician ordered the performance of an amnioinfusion.

Over the next couple of hours, the fetal monitor began documenting recurrent late fetal heart rate decelerations and loss of fetal heart rate variability, indicative of probable insufficient fetal oxygenation.  The obstetrician was notified of the recurrent late fetal heart rate decelerations and loss of fetal heart rate variability.

In response to the monitor tracings, the obstetrician ordered the rate of IV fluid administration increased.  Despite the monitor tracings indicating probable fetal distress, the obstetrician did not diagnose, or did not document diagnosing, fetal intolerance to labor and allowed the trial of labor to continue.

At some point in time between 6:15 p.m. and 7:30 p.m., the obstetrician decided to manage the trial of labor from outside of the hospital.  Based on the patient’s presentation, the obstetrician should have continued to manage the trial of labor, in person, at the hospital. The fetal monitor continued to document recurrent late fetal heart rate decelerations and a loss of fetal heart rate variability over the next several hours.  The obstetrician was notified of the recurrent late fetal heart rate decelerations and loss of fetal heart rate variability on multiple occasions during that time span.  Despite the monitor tracings indicating probably continued fetal distress, the obstetrician did not promptly return to the hospital to deliver the baby.

Shortly after midnight on 12/25/2014, the obstetrician was again notified of the recurrent late fetal heart rate decelerations and loss of fetal heart rate variability.  At 1:28 a.m., the obstetrician returned to the hospital, presented to the delivery room, and shortly thereafter delivered the baby.

The baby was in full cardiac arrest at the time of delivery.  Efforts to resuscitate the baby were abandoned after about 20 minutes.  The final diagnosis was stillborn.

The obstetrician did not dictate or write any progress notes during the trial of labor.

The Board judged the obstetrician’s conduct to be below the minimum standard of competence given that she failed to diagnose fetal intolerance to labor, manage the trial of labor, in person, at the hospital, and promptly return to the hospital and deliver the baby upon receiving continued reports of probably fetal distress.

The Board ordered that the obstetrician pay a fine of $5,000 against her license and pay reimbursement costs for the case at a minimum of $3,949.77 and not to exceed $5,949.77.  The Board also ordered that the obstetrician complete five hours continuing medical education in the area of obstetric medicine and five hours of continuing medical education in “Risk Management.”

State: Florida


Date: November 2017


Specialty: Obstetrics


Symptom: N/A


Diagnosis: Obstetrical Complication


Medical Error: Diagnostic error, Failure to properly monitor patient, Lack of proper documentation


Significant Outcome: Death


Case Rating: 2


Link to Original Case File: Download PDF



California – Obstetrics – Induction For A Patient With A Bishop Score Of 4 And Continued Pitocin Use Despite Fetal Heart Tracing Abnormalities



A 24-year-old female was transferred from a physician to an obstetrician.  The patient first saw the obstetrician on 6/24/2009, and she was due with her first child in July 2009.  Her patient chart listed her at 120 lbs and 4’0” tall, but when she came to see the obstetrician, she weighed 170 lbs.

The patient was seen by the obstetrician twice in June and every week in July until 7/27/2009.  The patient was scheduled to be induced 7/29/2009. There was nothing in the records about her bony pelvic exam or pelvic adequacy for vaginal delivery.  The obstetrician did not do an ultrasound. The patient was admitted to the hospital on 7/29/2009. There was no risk assessment, no estimate fetal size, no ultrasound ordered, and a Bishop score of 4.

The patient was started on Pitocin at 9:30 a.m. and had made no progress by 6:00 p.m. that evening.  The patient was allowed to rest, and the next morning, on 7/30/2009 at 7:30 a.m., Pitocin was started again.  During this time, it was noted that she had “reactive” fetal heart tracings. The nurses did not place an order for an internal fetal monitor.  When the fetal heart tones were low, the Pitocin should be turned off. If the mother keeps having contractions, the baby gets no rest, which is what likely occurred in this case.

At 8:18 p.m., she was only dilated 4-5 cm.  The patient had spontaneous rupture of the membranes with thick meconium noticed.  At 8:50 p.m., the patient was dilated to 8 cm, 0 station. There was no mention of a possible Cesarean section in the notes.  On 7/31/2009, a female infant weighing 9 lbs 5 oz was delivered using a vacuum because a shoulder dystocia was encountered. Unfortunately, the baby was deceased.

The Medical Board of California judged that the obstetrician’s conduct departed from the standard of care because he failed to estimate the fetal size, fetal lie, and pelvic adequacy.  The obstetrician also did not mention the application of a fetal electrode. This is important because the obstetrician did not know if the heart rate was coming from the mother or the baby; thus, an internal electrode would have been an accurate way to measure the baby’s heart rate.  Review of the fetal monitor strips showed back to back contractions and inadequate recordings. During labor and delivery, Pitocin should have been stopped in the contractions showed a low fetal heart rate and tachysystole (no rest between contractions). This patient was also a poor candidate for induction because she had a Bishop score of 4.  When the membranes were ruptured with 3+ meconium, this should have alerted the obstetrician that the baby was somehow compromised and action by the obstetrician was required. Also, the patient was a transfer patient, but the obstetrician did not order lab studies or an ultrasound. There were many errors which lead to the untimely demise of this baby.  Had there been an estimate of fetal weight, or an ultrasound performed within 6 weeks of induction of labor, the obstetrician would have known the patient was having a big baby, and the obstetrician might have performed a Cesarean section.

The Medical Board of California issued a public reprimand and ordered the obstetrician to complete a clinical competence assessment program.

State: California


Date: November 2017


Specialty: Obstetrics


Symptom: N/A


Diagnosis: Obstetrical Complication


Medical Error: Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Failure to properly monitor patient, Improper treatment, Improper medication management


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Florida – Ophthalmology – Persistent Pain And Inflammation In The Right Eye Following Cataract Surgery



On 12/4/2013, a 78-year-old female presented to an ophthalmologist for phacoemulsification with posterior chamber implant (“cataract surgery”) on her right eye.

During the cataract surgery, the patient experienced a posterior capsule tear, a known complication and an accepted risk associated with cataract surgeries.

On 2/3/2014, the patient presented to the ophthalmologist for an examination, and the ophthalmologist noted inflammation in the patient’s operative eye.

On 3/27/2014, the patient presented to the ophthalmologist for an examination, and the ophthalmologist noted inflammation in the patient’s operative eye.

On 4/8/2014, the patient presented to the ophthalmologist for an examination, and the ophthalmologist noted that the patient experienced post-operative chronic iritis in her operative eye.

On 5/6/2014, the patient presented to the ophthalmologist for a follow-up examination of her operative eye.

On 8/14/2014, the patient presented to the ophthalmologist for a follow-up examination of her operative eye.

On 9/18/2014, the patient presented to the ophthalmologist and reported throbbing pain in her operative eye.

Despite knowing that the patient experienced a complicated cataract surgery, followed by persistent inflammation in her operative eye, the ophthalmologist did not perform a dilated examination until 9/18/2014.

Despite knowing the patient experienced a complicated cataract surgery, followed by persistent inflammation in her operative eye, the ophthalmologist did not refer her to a retina specialist.

The Board judged the ophthalmologist’s conduct to be below the minimum standard of competence given his failure to perform a dilated examination on the patient’s operative eye to investigate the causes of persistent post-operative inflammation within a reasonable time after the cataract surgery.  The ophthalmologist also failed to refer the patient to a retina specialist to investigate the causes of persistent post-operative inflammation within a reasonable time after cataract surgery.

The Board ordered that the ophthalmologist pay a fine of $2,500 against his license and that the ophthalmologist pay reimbursement costs for the case for a minimum of $4,634.56 but not to exceed $6.634.56.  The Board also ordered that the ophthalmologist complete five hours of continuing medical education in post-operative care and complete one hour of continuing medical education in “Risk Management.”

State: Florida


Date: November 2017


Specialty: Ophthalmology


Symptom: Head/Neck Pain, Swelling


Diagnosis: Post-operative/Operative Complication, Ocular Disease


Medical Error: Failure to examine or evaluate patient properly, Referral failure to hospital or specialist


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Family Medicine – Patient With Kidney Stone Started On Morphine Along With Fluoxetine And Promethazine



A 27-year-old female was a patient of a family practitioner.  On 2/11/2014, the patient started complaining to the family practitioner about a potential kidney stone.

The family practitioner had records indicating that the patient was being treated with tramadol, Percocet, fluoxetine, and promethazine.

On 5/12/2014, the family practitioner prescribed morphine 60 mg, extended release, to the patient, to be taken twice a day, but the family practitioner never adequately documented medical justification for the prescription.  The standard starting dose for morphine is 15 mg every eight to twelve hours.

The patient was also taking fluoxetine and promethazine and the family practitioner signed a CVS form indicating the patient could start morphine despite possible contraindications.

The family practitioner did not take additional precautions to monitor the patient, despite her taking fluoxetine and promethazine in combination with morphine.

At 5:25 p.m. on 5/14/2014, the patient’s husband found her unresponsive in the bedroom and 911 was called immediately.

The patient ultimately was transported to a hospital and diagnosed with poisoning by opiates and related narcotics.

The Board judged the family practitioners conduct to be below the minimum standard of competence given his failure to prescribe morphine for medically justified reasons.  The family practitioner failed to start with an initial dose of morphine at 15 mg every eight to twelve hours.  The family practitioner failed to take additional precautions regarding monitoring for central nervous system or respiratory depression when the morphine was prescribed with the fluoxetine and promethazine.  The Board judged that the family practitioner failed to adequately create or maintain medical records that justified the course of treatment for the patient.

The Board ordered that the family practitioner have a reprimand against his license.  The Board ordered that the family physician pay a fine against his license of $7,500 and that the family practitioner pay reimbursement costs for the case between a minimum of $820.04 and a maximum of $2,820.04.  The Board ordered that the family practitioner complete a drug prescribing course and a medical records course and that the family practitioner complete five hours of continuing medical education in nephrology.

State: Florida


Date: November 2017


Specialty: Family Medicine, Internal Medicine


Symptom: Abdominal Pain


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


Medical Error: Improper medication management, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



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