Found 17 Results Sorted by Case Date
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Florida – General Surgery – Right Colectomy Of The Patient’s Ascending Colon Instead Of A Left Colectomy Of The Descending Colon



A 49-year-old female presented to a general surgeon for a colonoscopy.  During the colonoscopy the general surgeon documented a 25mm polyp in the patient’s descending colon.  Due to its size, the general surgeon was only able to partially resect the polyp.  He placed a hemostatic clip to prevent bleeding and tattooed the area.

The patient was subsequently referred to the general surgeon for surgical resection of the left colon.

On 7/15/2015, the patient presented to the general surgeon for a preoperative history and physical.  On 7/15/2015, the general surgeon documented that a doctor incompletely resected a polyp in the patient’s colon, and identified the planned procedure as a right colectomy.

On 7/20/2016, the patient presented to the general surgeon at a community hospital.  On 7/20/2016, the general surgeon performed a right colectomy of the patient’s ascending colon.

The Board judged that the general surgeon’s conduct to be below the minimum standard of competence given that he performed a wrong-site procedure when he performed a right colectomy of the patient’s ascending colon instead of a left colectomy of her descending colon.

The Board ordered the general surgeon to pay a fine of $4,015.23.  The general surgeon was ordered to complete five hours of continuing medical education in “Risk Management.”  Also, the Board ordered that the general surgeon present a one hour lecture/seminar on wrong site and/or wrong procedures to medical staff at an approved medical facility.

State: Florida


Date: December 2017


Specialty: General Surgery


Symptom: N/A


Diagnosis: Gastrointestinal Disease


Medical Error: Wrong site procedure


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Interventional Radiology – Pain And Cold Foot After Arteriogram, Angioplasty, And Atherectomy



On 6/26/2015, a patient presented to an interventional radiologist’s outpatient clinic for a left lower extremity arteriogram and intervention for a thrombosed left lower extremity bypass graft, originally placed in 2007.  The patient had an extensive medical history including a renal transplant, diabetes, right leg amputation, and multiple revascularization procedures, including prior thrombectomies of the left lower extremity graft.

The patient reportedly had pain both at rest and with activity, and had a cold left leg prior to and immediately before the procedure.  In order to improve blood flow in the patient’s left leg, the interventional radiologist performed an arteriogram, angioplasty, tPA administration, atherectomy, and stent placement within the left lower extremity, including an attempt to revascularize the native superficial femoral artery.

Images show an initially thrombosed femoral artery to popliteal bypass graft and deep femoral artery.  Further images show balloons inflated in various parts of the graft and native arteries.  Final images show flow through a patent common femoral artery (CFA), bypass graft, and peroneal and anterior tibial arteries.  The deep femoral artery appeared occluded shortly beyond its origin.

After the procedure, a nurse noted the patient’s foot was cold.  The interventional radiologist also assessed the patient post-procedure and found the foot to be cold, both two (2) and four (4) hours post-procedure.  The interventional radiologist recommended to the patient that she travel to the emergency department of a university hospital.

The patient was then driven by her companion two hours to the emergency department, where she was assessed by an ED physician and a vascular surgeon.  She was taken to the operating room where she underwent surgery, which included a left leg above-the-knee amputation and a deep femoral artery thrombectomy.

The Board stated that the standard of care for an interventional radiologist when performing an intervention is to recognize complications and to take appropriate steps to manage them.  Although the patient’s foot was reportedly cold and painful immediately post-procedure, it can take some time for the foot to warm, and pain could be caused by reperfusion.  However, it is clear that two to four hours after the procedure, the interventional radiologist recognized that the patient’s leg had not improved and was worsening and that further care was needed.  Thus, when it became clear to the interventional radiologist that the foot was not improving, he recommended that the patient seek more treatment.

The records of the interventional radiologist’s care of the patient were inadequate in that they do not state whether the patient’s clinical status post-procedure was worse than before the procedure.  A post-procedure pulse examination was lacking which would have helped in determining the patient’s clinical status.

The patient reported to the ED physician that the pain began after the procedure and steadily worsened, which indicates that the patient rethrombosed her bypass graft and deep femoral artery (source of collateral flow) immediately.  This event should have been recognized by the interventional radiologist.

However, the interventional radiologist’s documentation for this patient was inadequate and sparse.  The medical records lacked documentation of the change in the patient’s status post-procedure, the discussion with the patient leading up to the discharge from his center, and the patient’s disposition.  The interventional radiologist discharged the patient to her own care directly from his clinic instead of calling Emergency Medical Services (EMS), which indicates that the interventional radiologist failed to recognize the gravity of what was occurring.

His conduct did not ensure that the patient would be attended continuously until definitive treatment was given.  The patient arrived at the emergency department at approximately 8:00 p.m., two hours after the patient was discharged from the interventional radiologist’s clinic.

Had the process of discharge and transfer occurred earlier, it is possible that the outcome could have been different.  The interventional radiologist failed to communicate with the ED physician ahead of the patient’s arrival.  The interventional radiologist gave the patient a CD of the procedure, a copy of the medical records, and his phone number, as an attempt of communicating with the emergency department personnel regarding the events that occurred at the interventional radiologist’s clinic.

However, the interventional radiologist failed to telephone the ED physicians at the emergency department to give a verbal report on the patient and to provide a more informative transition and preparation for continued care.  In expecting the practitioners at the emergency department to call the interventional radiologist to gain more information, the interventional radiologist improperly sought to shift his responsibility to provide needed information about the patient to the staff at the emergency department.

The interventional radiologist failed to maintain documentation regarding the change in the patient’s status post-procedure, the discussion leading up to the discharge from his center, and the patient’s disposition.  He stated that he was not sure if he documented these events, and if he did, he sent them with the patient.  Documentation sent with the patient has since been lost.  Documentation of a change in the patient’s clinical status was lacking.  The medical records lacked documentation of what was discussed regarding the patient’s disposition and where she was told to go for further care.

The Board judged the interventional radiologist’s conduct to have fallen below the standard of care for the following reasons:

1) The interventional radiologist failed to offer to transport the patient by ambulance or EMS services to ensure that she would be attended continuously until definitive treatment was given. His failure to do so indicates that he failed to understand the gravity of the situation which was occurring.

2) The interventional radiologist failed to adequately communicate with the emergency department, to call ahead of time to inform them that the patient was in transit, and to inform them of the circumstances.

3) The interventional radiologist failed to maintain adequate and accurate records.

The Board issued a public reprimand.

State: California


Date: December 2017


Specialty: Interventional Radiology, Vascular Surgery


Symptom: Extremity Pain


Diagnosis: Acute Ischemic Limb, Post-operative/Operative Complication


Medical Error: Diagnostic error, Delay in proper treatment, Underestimation of likelihood or severity, Failure of communication with other providers, Lack of proper documentation


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Critical Care Medicine – Intensivist Unavailable To Assess Patient With Metabolic Acidosis, Abdominal Pain, And Vomiting



On 10/19/2011 at 5:23 p.m., a 35-year-old male presented to the emergency department at a hospital with a chief complaint of abdominal pain and vomiting, which started approximately five hours before he presented to the hospital.

The patient was admitted to the hospital under the service of an intensivist and was notified of his arrival and condition at 5:35 p.m.

Between the hours of 5:50 p.m. and 7:22 p.m. the intensivist gave verbal orders of Dilaudid and ketorolac to the patient’s nurse.

At 9:20 p.m., the intensivist gave telephonic orders to the patient’s nurse, to place him on his home BIPAP mask.

On 10/20/2011, at 3:15 a.m. a rapid response was called due to an acute change in the patient’s respiratory status.

During the rapid response, an arterial blood gas (“ABG”) was drawn that revealed critical metabolic acidosis.

The intensivist never presented to the emergency room to assess the patient when he demonstrated medically dangerous/life-threatening signs at 3:15 a.m. or any time thereafter.

The intensivist never attended to the patient when his clinical situation was from an unknown cause and when a clear treatment plan had not been determined.

From 3:43 a.m. to 4:15 a.m., the critical care practitioner was contacted approximately five times with information on the patient’s medically unstable and deteriorating condition.

At 3:45 a.m., the patient became short of breath, restless, diaphoretic, and seizure episodes followed.  He was then transported to an intensive care unit.

At 5:25 a.m., a second rapid response was called due to a further decline in the patient’s health.  The rapid response turned into a code blue.

The patient underwent a cardiopulmonary arrest, and the code team was unable to resuscitate him.

On 10/20/2011, the patient expired at 6:25 am.

The autopsy results were consistent with acute hemorrhagic pancreatitis with diffuse pancreatic necrosis.

The Medical Board of Florida judged the intensivist’s conduct to be below the minimal standard of competence given that he failed to presented to the emergency room to assess the patient when the patient demonstrated medically dangerous/life-threatening signs on 10/20/2011 at 3:15 a.m.

The Medical Board of Florida issued a letter of concern against the critical care practitioner’s license.  The Medical Board of Florida ordered that he pay a fine of $7,500 against his license and pay reimbursement costs for the case at a minimum of $4,503.10 and not to exceed $6,503.10.  The Medical Board of Florida ordered that the critical care practitioner complete ten hours of continuing medical education in the area of critical care medicine and complete five hours of continuing medical education in “risk management.”

State: Florida


Date: December 2017


Specialty: Critical Care Medicine, Emergency Medicine, Pulmonology


Symptom: Abdominal Pain, Nausea Or Vomiting


Diagnosis: Gastrointestinal Disease


Medical Error: Failure to properly monitor patient


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Florida – Oncology – Rectal Mass And Bloody Stool Misdiagnosed As Cancer Instead Of Endometriosis



On 4/15/2015, a 48-year-old female presented to the Mayo Clinic for an assessment regarding cancer treatment.

The patient presented with a history of a palpable rectal mass and bloody stool.  The patient presented to an oncologist after undergoing a colonoscopy and after a CT scan at Borland Grover Clinic revealed tumors suspicious for metastases.

The Borland Grover Clinic took a biopsy of the affected area.  Initial pathology indicated suspicion for adenocarcinoma.  Borland Grover clinic sent the sample to Cleveland Clinic for confirmation.  Cleveland Clinic returned a diagnosis of endometriosis, not cancer.

The oncologist did not obtain the pathology reports from Borland Grover Clinic or Cleveland Clinic.  The oncologist diagnosed the patient with rectal cancer with possible spread to the liver, lungs, and mediastinum.  The oncologist ordered an endobronchoscopic ultrasound (EBUS). The patient’s EBUS showed some concern for cancer, but the pathologist deemed the results of the EBUS insufficient for a definitive cancer diagnosis.

Despite not having a pathologic diagnosis of cancer, from May to July 2015, the oncologist ordered the patient receive a port placement and three chemotherapy treatments.

Due to continuing rectal pain, on 7/6/2015, the oncologist referred the patient to a colorectal surgeon.  As part of his review, the colorectal surgeon obtained the patient’s pathologic results from Borland Grover Clinic and Cleveland Clinic, which showed that the patient had endometriosis and not cancer.

On 7/16/2015, a Mayo Clinic pathologist reviewed the patient’s previous biopsy sample and came to a final diagnosis of endometriosis.  On 9/3/2015, two doctors performed a procedure to remove the endometrioma.

The Board judged that the oncologist’s conduct to be below the minimum standard of competence given her failure to obtain a pathologic diagnosis of cancer prior to initiating cancer treatment for the patient.

The Board ordered the oncologist have her license revoked, pay an administrative fine, and have remedial education.

State: Florida


Date: December 2017


Specialty: Oncology, Internal Medicine


Symptom: Blood in Stool, Mass (Breast Mass, Lump, etc.)


Diagnosis: Gynecological Disease


Medical Error: Diagnostic error


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



Florida – Emergency Medicine – Patient With Chest Pain Radiating To The Neck, Throat, And Back Discharged With Instructions To Follow up In 3-5 Days



On 11/15/2013, a patient complained of chest pain radiating to his neck, throat, and across his back.  The patient stated the onset of the pain was noted to be one hour prior to his arrival at the hospital while he was screwing something into the wall, and that the pain was exacerbated by movement.

An ED physician performed an initial EKG, labs, and a chest x-ray on the patient.

The ED physician initially treated the patient with nitroglycerin and a GI cocktail, and subsequently with diazepam, morphine, Toradol, and Dilaudid.

The ED physician’s final assessment of the patient noted that the patient was still complaining of left side neck pain and “trap pain.”

The ED physician discharged the patient with a diagnosis of “musculoskeletal chest pain” and prescribed naproxen, Norco, and diazepam, along with instructions to follow up with him in three to five days.

The patient returned to the hospital the following day in cardiac arrest and expired on 11/16/2013.

The Medical Board of Florida judged the ED physician’s conduct to be below the minimal standard of competence given that he failed to perform a CT of the patient’s chest to evaluate for aortic dissection.  He also failed to adequately document bilateral pulses and/or blood pressures in the patient.  He failed to pursue other etiologies of the patient’s reported pain.  The ED physician failed to admit the patient for further observation.

It was requested that the Medical Board of Florida order one or more of the following penalties for the ED physician: 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 Medical Board of Florida deemed appropriate.

State: Florida


Date: December 2017


Specialty: Emergency Medicine


Symptom: Chest Pain, Back Pain, Chest Pain, Head/Neck Pain


Diagnosis: Aneurysm


Medical Error: Failure to order appropriate diagnostic test, Delay in proper treatment, Failure to examine or evaluate patient properly, Lack of proper documentation


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Florida – Family Medicine – Treatment Of Elevated Blood Pressure And Headaches From Illicit Testosterone Injections



On 2/17/2014, a male patient in his early twenties presented to a family practitioner for medical assessment and/or treatment.

On 2/17/2014, the patient disclosed to the family practitioner that he was obtaining injectable testosterone from a source unknown to the family practitioner.  The patient indicated that he was utilizing the testosterone for bodybuilding purposes.

On 2/17/2014, the patient reported to the family practitioner that he was suffering from headaches and elevated blood pressure.

On 2/17/2014, the family practitioner surmised that the patient’s symptoms were likely the result of excess estrogen production secondary to the patient’s high-dose testosterone use.

On 2/17/2014, the family practitioner wrote the patient a prescription for Anastrozole, an estrogen-blocking substance.

On 2/20/2014, the patient presented to the family practitioner for medical assessment and/or treatment.  The family practitioner continued the patient on Anastrozole.

In February 2014, the family practitioner did not obtain or review any medical records establishing that the patient was experiencing excess estrogen production.  He also did not obtain bloodwork or perform other diagnostic testing to confirm whether the patient was experiencing excess estrogen production.

On 4/6/2014, the patient presented to the family practitioner for medical assessment and/or treatment.  The patient reported to the family practitioner that he was continuing to use testosterone, and that he was continuing to experience headaches.  The family practitioner surmised that the patient’s ongoing headaches were caused by elevated prolactin levels.  The family practitioner wrote the patient a prescription for Cabergoline, a prolactin-blocking substance.

On 4/10/2014, the patient presented to the family practitioner for medical assessment and/or treatment.  The family practitioner continued the patient on Cabergoline.

In April 2014, the family practitioner did not obtain or review any medical records establishing that the patient was experiencing elevated prolactin levels.  He did not obtain bloodwork or perform other diagnostic testing to confirm whether the patient was experiencing elevated prolactin levels.

On one or more occasions between 6/27/2014, and 1/9/2015, the family practitioner prescribed the following substances to the patient: clindamycin, Bactroban ointment, doxycycline, Zithromax, oral prednisone, Neurontin, and diazepam.  On one or more occasions in 2015, the family practitioner also prescribed the patient Anastrozole.

The family practitioner did not keep any contemporaneous medical records regarding the medical assessment and/or treatment that he provided to the patient between 2/17/2014 and 1/9/2015.

To the extent that the family practitioner had medical records regarding the medical assessment and/or treatment that he provided to the patient between 2/17/2014 to 1/9/2015, such records were all created in October 2015.

The Medical Board of Florida issued a letter of concern against the family practitioner’s license.  The Medical Board of Florida ordered that the family practitioner pay a fine of $8,000 and pay reimbursement costs for the case at a minimum of $1,457.57 and not to exceed $3,457.57.  The Medical Board of Florida ordered that the family practitioner complete a drug course, a medical records course, and five hours of continuing medical education in “risk management.”

State: Florida


Date: December 2017


Specialty: Family Medicine, Endocrinology, Internal Medicine


Symptom: Headache


Diagnosis: Drug Overdose, Side Effects, or Withdrawal


Medical Error: Failure to order appropriate diagnostic test, Improper medication management, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Gynecology – Unnecessary Biopsies Performed When Lumps Are Noted on A Patient’s Breasts



Between December 2010 and August 2013, a patient presented to her gynecologist.

On 5/19/2011, the gynecologist found small, smooth, mobile lumps in the patient’s left and right breasts.

On 6/17/2011, the gynecologist performed a right breast biopsy on the patient.  The gynecologist noted that the right breast lump was likely a fibroadenoma.  The biopsied right breast tissue was found to be benign.

On 7/5/2011, the gynecologist performed a left breast biopsy on the  patient.  The gynecologist noted that the left breast lump was likely a fibroadenoma.  The biopsided left breast tissue was found to be benign.

At all times, the patient was at a low risk for having breast cancer.

The Board judged the gynecologist’s conduct to be below the minimum standard of practice given that the prevailing professional standard of care required that the gynecologist medically manage the patient’s left and right breast lumps with breast exams, breast sonographies, and/or mammograms.  The obstetrician’s performance of left and right breast biopsies on the patient was medically unnecessary.

The Board ordered that the gynecologist pay a fine of $16,000 against his license. Also, the Board ordered that the case fine be set at $9,486.57.  The Board ordered that the gynecologist complete five hours of continuing medical education in “Risk Management.”

State: Florida


Date: December 2017


Specialty: Gynecology, Gynecology


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


Diagnosis: N/A


Medical Error: Failure to order appropriate diagnostic test, Unnecessary or excessive treatment or surgery


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Radiology – Gastrografin GI Series Performed to Ascertain GI Leak But No Leak Reported By Radiologist



On 6/23/2014, a 66-year-old male presented to the Physicians Regional Medical Center for gastric bypass surgery.

Following the gastric bypass procedure, on 6/24/2014, a radiologist performed a Gastrografin upper GI series on the patient to ascertain whether there was a leak or obstruction in the patient’s digestive tract.  A leak of contrast material was visible on radiographic images obtained by the radiologist during the procedure;  however, the radiologist failed to detect the leak in the patient’s digestive tract and reported a negative GI series.  The patient was subsequently discharged from the hospital.

Approximately thirty hours after his discharge, the patient returned to the hospital suffering from abdominal pain and sepsis.  It was discovered that the patient had a perforation in his digestive tract.  During surgery to repair this perforation, the patient suffered cardiac arrest and anoxic brain injury.  The patient ultimately expired as a result of these complications on 7/10/2014

The Board judged the radiologist’s conduct to be below the minimum standard of competence given his failure to detect a leak in the patient’s digestive tract during the performance of a Gastrografin upper GI series.

State: Florida


Date: December 2017


Specialty: Radiology


Symptom: N/A


Diagnosis: Acute Abdomen


Medical Error: False negative


Significant Outcome: Death, Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Emergency Medicine – Patient With Intussusception Involving Loop Of Small Bowel Discharged Home With Magnesium Citrate



At 1:45 a.m. on 7/26/2014, a 46-year-old female presented to the emergency department with complaints of severe abdominal pain.  Upon arrival at the emergency department, the patient was evaluated by the ED physician.

The patient complained of severe abdominal pain and stated the pain was “10 out of 10.”  The patient then underwent laboratory studies and a CT scan of the abdomen/pelvis with intravenous and oral contrast.

A radiologist reviewed the CT scan at some time before 4:16 a.m., when he read and signed the preliminary report.  Upon review of the CT scan results the radiologist recorded in the preliminary report “intussusception involving loop of small bowel in the left lower quadrant with involved loops appearing edematous.”  The radiologist relayed the results of the CT scan to the ED physician via teleradiology.

The ED physician recorded the results of the CT scan in the patient’s emergency provider report and noted “thickened loop of small bowel in the left lower quadrant, [m]ay be intussuception [sic].”

At 4:32 a.m. the ED physician discharged the patient to her home with a magnesium citrate prescription and no additional discharge instructions.

At 8:28 a.m. a physician signed the final radiology report and noted “[i]ntussesception involving loop of small bowel in the left lower quadrant” and “preliminary report related to referring physician teleradiology at the time of the exam by the radiologist.”

Later that day, the patient developed worsening pain, and presented to another emergency department, and underwent an emergency surgery for resection of necrotic bowel.

The Board judged the ED physician’s conduct to be below the minimum standard of competence given his failure obtain emergent surgical consultation for further evaluation and treatment and continue hospitalization for operative intervention or ongoing evaluation of abdominal pain.

The Board ordered the ED physician to pay an administrative fine in the amount of $8,000.  Also, the Board ordered the ED physician to complete five hours of continuing medical education in the area of emergency medicine.

State: Florida


Date: December 2017


Specialty: Emergency Medicine


Symptom: Abdominal Pain


Diagnosis: Acute Abdomen


Medical Error: Improper treatment, Referral failure to hospital or specialist


Significant Outcome: Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Orthopedic Surgery – Documentation Error Of Laceration Of Flexor Pollicis Longus Leads To Wrong Site Surgery



On 5/16/2014, a patient presented to an orthopedic outpatient surgery center with a left-hand work-related injury.  During the visit, an orthopedic surgeon properly diagnosed the patient with a flexor pollicis longus (FPL) tendon laceration of her left thumb.

The FPL tendon laceration was confirmed by the MRI scan performed on the patient on 7/3/2014.

On 8/7/2014, during the follow-up visit, the orthopedic surgeon wrongly documented the patient’s injury as an extensor pollicis longus (EPL) tendon laceration in the patient’s medical records

Consequently, on 9/10/2014, the patient presented to the orthopedic surgeon at the center, for an EPL tendon surgery (the wrong site, and/or medically unnecessary procedure) of her left thumb.  During the EPL tendon surgery, the orthopedic surgeon realized that the FPL tendon laceration repair should have been performed on the patient instead.  On 10/10/2014, the orthopedic surgeon performed the FPL tendon laceration repair on the patient’s left thumb.

The Board ordered the orthopedic surgeon pay a fine of $3,000 to the Board. Also, the Board ordered the orthopedic surgeon pay a reimbursement cost of $4,670.40.  The Board ordered that the orthopedic surgeon complete five hours of continuing medical education in “Risk Management.”  The Board ordered that the orthopedic surgeon complete one hour of lecture on wrong site procedure.

State: Florida


Date: December 2017


Specialty: Orthopedic Surgery


Symptom: N/A


Diagnosis: Musculoskeletal Disease, Trauma Injury


Medical Error: Wrong site procedure, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



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