Found 66 Results Sorted by Case Date
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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 – Interventional Radiology – Guidewire Found In Patient’s Abdomen Following CT-Guided Percutaneous Drainage



On 8/24/2015, a 63-year-old male presented to a medical center for a CT-guided percutaneous aspiration with possible drainage of an abdominal abscess.

During the course of the procedure, an interventional radiologist placed a guidewire into the operative field.  Once the procedure was completed the patient had stable vital signs and no immediate complications were known.

On 9/12/2015, the patient was re-admitted to the medical center with complaints of abdominal pain.  A subsequent CT scan revealed a foreign body on the left side of the patient’s abdomen.

On 9/15/2015, a general surgeon performed laparoscopic retrieval of the foreign body, at which time a portion of the guidewire, measuring 11.0 centimeters in length, was found and removed intact.

The Board ordered that the interventional radiologist pay a fine of $5,000 against his license and that the radiologist pay reimbursement costs for the case at a minimum of $4,737.16 and not to exceed $6,737.16.  The Board also ordered that the interventional radiologist complete five hours of continuing medical education in “Risk Management”  and that the interventional radiologist complete a one hour lecture/seminar on retained foreign body objects.

State: Florida


Date: November 2017


Specialty: Interventional Radiology


Symptom: Abdominal Pain


Diagnosis: Post-operative/Operative Complication, Acute Abdomen


Medical Error: Retained foreign body after surgery


Significant Outcome: Hospital Bounce Back


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Plastic Surgery – Liposuction Performed On A Patient With Obesity, Diabetes, Hypertension, Asthma, And Human Immunodeficiency Virus



On 1/11/2013, a 50-year-old male presented to a plastic surgeon and underwent liposuction of his chin, upper abdomen, lower abdomen, upper back, and lower back/flanks.

The patient’s medical history included obesity, diabetes, hypertension, asthma, and human immunodeficiency virus (HIV) positive status.

Due to his medical history, the patient was at high risk of complications from the liposuction procedure.

Due to the high risk of complications, the patient was not a candidate for liposuction surgery.

During the liposuction procedure, the plastic surgeon injected tumescent wetting solution into the patient.  The tumescent liposuction technique, as opposed to “dry liposuction,” involves injection of tumescent wetting solution into a patient’s fatty deposits to reduce the amount of blood lost during the procedure.

The standard concentration of tumescent wetting solution used for liposuction is approximately one part epinephrine per 1 million units.  The tumescent wetting solution that the patient injected into the patient did not contain any epinephrine.

During the liposuction procedure, the plastic surgeon perforated the patient’s abdominal cavity and bowel.

On 1/16/2013, the patient presented to the medical center emergency department with complaints of abdominal pain, nausea, and vomiting.

Evaluation revealed that the patient was septic, in acute renal failure, and had free air in his abdomen.

The patient underwent emergent exploratory laparotomy which revealed multiple small bowel perforations, peritonitis, a mesenteric tear, pelvic abscess, and necrotizing fasciitis on the anterior abdominal wall.

The patient underwent release of a small bowel obstruction, small bowel resection, repair of the mesenteric defect, drainage of the pelvic abscess, and radical debridement of the necrotizing fasciitis.

The Medical Board of Florida judged that the plastic surgeon failed to avoid performing the liposuction procedure due to the high risk of complications posed by his medical history.  He failed to use epinephrine in the tumescent wetting solution used for the liposuction procedure.  He also failed to avoid perforating the abdominal cavity and bowel.

The Medical Board of Florida issued a letter of concern against the plastic surgeon’s license.  The Medical Board of Florida ordered that the plastic surgeon pay a fine of $5,000 against his license and pay reimbursement costs for the case at a minimum of $3,090.60 but not to exceed $5,090.60.  The Medical Board of Florida also ordered that the plastic surgeon complete five hours of continuing medical education in the area of “Tumescent Liposuction” and five hours of continuing medical education in “risk management.”

State: Florida


Date: May 2017


Specialty: Plastic Surgery


Symptom: Abdominal Pain, Nausea Or Vomiting


Diagnosis: Procedural Site Infection, Acute Abdomen, Necrotizing Fasciitis, Post-operative/Operative Complication


Medical Error: Unnecessary or excessive treatment or surgery, Improper medication management, Procedural error


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Gynecology – Bilateral Tubal Ligation Error Results In Complications Of Tachycardia, Hypotension, Respiratory Failure, And Hypotension



On 4/21/2014, a gynecologist performed a Cesarean section and bilateral tubal ligation on a 29-year-old female at 36 weeks gestation.

The patient suffered from gestational hypertension associated with right upper quadrant abdominal pain and elevated liver function tests consistent with HELLP (Hemolysis, Elevated Liver Enzymes, and Low Platelet Count) Syndrome.

At 5:00 p.m. on 4/21/2014, the patient became hypotensive and tachycardic and was pale and lethargic.

Between 5:00 p.m. and 6:30 p.m. on 4/21/2014, a critical care consultant diagnosed the patient with acute hemorrhagic shock, possibly due to an intraabdominal bleed, transferred the patient to the ICU, ordered a transfusion of 4 L of blood, and called the gynecologist for a possible exploratory laparotomy to control the bleeding.

At 7:11 p.m., the patient was intubated and placed on ventilation due to respiratory failure.

At 9:10 p.m., an ultrasound examination was performed on the patient’s abdomen and pelvis that revealed moderate fluid in the right and left upper quadrants of the patient’s abdomen.

Immediately following the ultrasound examination, the gynecologist diagnosed the patient with a liver rupture.  The patient’s lab testing results did not support or corroborate the gynecologist’s diagnosed.

The gynecologist called the on-call general surgeon and discussed the patient’s case.  After the conversation, at 9:23 p.m., the gynecologist initiated the transfer of the patient to a medical center.

At 1:45 a.m. on 4/22/2014, the patient was transferred to the medical center with a tachycardic heart rate of 140 beats per minute and a hypotensive blood pressure of 89/44.  The gynecologist and a surgeon performed an exploratory laparotomy on the patient, which revealed that the patient had an arterial bleed from the tubal ligation procedure.

The Medical Board of Florida judged that the gynecologist did not appropriately assess, or did not create or maintain adequate documentation of assessing, the patient’s symptoms and condition. He did not timely diagnose, or did not create or maintain adequate documentation of timely diagnosing, the patient with an intraabdominal bleed and hemorrhagic shock.  The gynecologist did not timely perform or order an exploratory laparotomy based on the patient’s deteriorating vital signs.  He did not timely order an ultrasound examination of the patient’s abdomen and pelvis on the patient’s deteriorating vital signs.  Also, the gynecologist did not timely perform or order an exploratory laparotomy based on the patient’s respiratory failure.  He did not recognize, or did not create or maintain adequate documentation of recognizing, that the fluid in the right and left upper quadrants of the patient’s abdomen, in conjunction with the patient’s other symptoms, indicated an intraabdominal bleed.  He did not perform or order an exploratory laparotomy based on the fluid in the right and left upper quadrants of the patient’s abdomen.  The gynecologist inappropriately diagnosed the patient with a liver rupture when the patient’s lab testing results did not support or corroborate the diagnosis.  He also did not order, or did not create or maintain adequate documentation of ordering, a surgery consultation for a surgeon to physically examine the patient upon diagnosing the patient with liver rupture.  He did not consult, or did not create or maintain adequate documentation of consulting, with one or more other OB/GYNs who might have had experience dealing with a patient with a liver rupture or a patient with similar complications and symptoms as the patient had.  The gynecologist did not timely perform or order an exploratory laparotomy after diagnosing the patient with liver rupture.  He also inappropriately transferred the patient to a medical center when the patient was unstable due to being tachycardic and hypotensive.  The gynecologist did not create or maintain adequate documentation related to his diagnosis and treatment of the patient.

The Medical Board of Florida issued a reprimand against the gynecologist’s license.  The Medical Board of Florida ordered that the gynecologist pay a fine of $22,500 against his license and pay reimbursement costs for the case at a minimum of $4,335.85 and not to exceed $6,335,85.  The Medical Board of Florida also ordered that the gynecologist complete ten hours of continuing medical education in diagnosis management of complications relating to cesarean sections, complete five hours in emergency obstetric care, and complete five hours of continuing medical education in “risk management.”

State: Florida


Date: May 2017


Specialty: Gynecology, Critical Care Medicine, General Surgery


Symptom: Abdominal Pain


Diagnosis: Post-operative/Operative Complication, Acute Abdomen, Hemorrhage


Medical Error: Diagnostic error, Delay in proper treatment, Failure to order appropriate diagnostic test, Referral failure to hospital or specialist, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Gynecology – Increased Pain, Hypotension, Tachycardia, And Tachypnea After Cesarean Section And Bilateral Tubal Ligation



On 7/26/2014, a gynecologist performed a Cesarean section and bilateral tubal ligation on a 32-year-old female.

At 10:30 a.m. on 7/26/2014, the patient complained of increased pain.  After she complained of pain, the patient’s vital signs began deteriorating.

At 1:45 p.m., the patient was transferred to the ICU and a rapid response call was placed to the gynecologist because the patient was diaphoretic, pale, and hypotensive.  From 1:45 p.m. to 2:30 p.m., the patient was hypotensive, tachycardic, and had an increased respiratory rate.

At 2:30 p.m., the gynecologist called the patient’s primary OB/GYN for a consultation regarding her condition.

At 2:45 p.m. the patient was intubated and received a transfusion of 2 L of blood.

At 3:30 p.m., the patient underwent an ultrasound examination that revealed a mild amount of free fluid in the patient’s upper abdomen.

At 4:10 p.m., the patient underwent a CT scan that indicated mild to moderate fluid in the patient’s abdomen, especially adjacent to the liver and along the right paracolic gutter.

Between 7:00 p.m. and 8:52 p.m., the patient received a transfusion of 4 L of blood.  Subsequent to that transfusion, the patient had a hemoglobin level of 8.3

At 9:42 p.m., the patient underwent an exploratory laparotomy that revealed an inferior epigastric bleed, which was repaired.

The Medical Board of Florida judged that the gynecologist did not properly assess, or did not create or maintain adequate documentation of properly assessing the patient’s symptoms and condition.  He did not timely diagnose, or did not create or maintain adequate documentation of timely diagnosing, the patient’s intra abdominal bleed and hemorrhagic shock.  The gynecologist did not timely perform or order an exploratory laparotomy based on the patient’s pain and deteriorating vital signs.  He did not timely perform or order an exploratory laparotomy after the patient was intubated.  Also, the gynecologist did not recognize, or did not create or maintain adequate documentation of recognizing, that the fluid in the patient’s abdomen, in conjunction with the patient’s other symptoms indicated an intra abdominal bleed.  The gynecologist did not timely perform or order an exploratory laparotomy based on the fluid in the patient’s abdomen.  He did not create or maintain adequate progress notes related to his treatment of the patient or maintain adequate documentation elucidating a plan of treatment for the patient.  He did not create or maintain adequate documentation notes related to the diagnosis and treatment of the patient.

The Medical Board of Florida issued a reprimand against the gynecologist’s license.  The Medical Board of Florida ordered that the gynecologist pay a fine of $22,500 against his license and pay reimbursement costs for the case at a minimum of $4,335.85 and not to exceed $6,335,85.  The Medical Board of Florida also ordered that the gynecologist complete ten hours of continuing medical education in diagnosis management of complications relating to cesarean sections, complete five hours in emergency obstetric care, and complete five hours of continuing medical education in “risk management.”

State: Florida


Date: May 2017


Specialty: Gynecology


Symptom: Pain


Diagnosis: Post-operative/Operative Complication, Acute Abdomen, Hemorrhage


Medical Error: Diagnostic error, Delay in proper treatment, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Rhode Island – Radiology – CT Scan After A Laparoscopic Cholecystectomy



In 2013, a patient underwent a laparoscopic cholecystectomy.  A CT scan was ordered.  The radiologist did not detect a bowel perforation that was present on the CT scan.

The Board issued a reprimand with stipulations to pay a fine and complete 8 hours of continuing medical education.

State: Rhode Island


Date: April 2017


Specialty: Radiology


Symptom: N/A


Diagnosis: Acute Abdomen


Medical Error: False negative


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Virginia – Gastroenterology – Colonoscopy With Significant Amount Of Liquid Stool In Bowel



On 2/5/2015, a 50-year-old female underwent a colonoscopy conducted by a gastroenterologist.

Although the gastroenterologist noted a significant amount of liquid stool remaining in the bowel and hard stool adhering to mucosa, he continued the procedure and repeatedly injected saline and air into the bowel in an effort to clear the visual field.

Although the gastroenterologist knew that the suction button on the colonoscopy was continually sticking, thus making the necessary suctioning difficult and/or impossible, the gastroenterologist continued the procedure.

After approximately 31 minutes, the gastroenterologist stopped the procedure when he noted that the patient’s abdomen was distended.  He then ordered x-rays and requested an immediate surgical consultation.

The x-rays revealed free air in the abdomen.  The patient underwent emergency surgery to repair a baro-rupture of her cecum.  Subsequently, the patient developed sepsis and multi-organ failure and died on 2/12/2015.

The gastroenterologist was permanently restricted from performing invasive procedures.

State: Virginia


Date: April 2017


Specialty: Gastroenterology


Symptom: N/A


Diagnosis: Post-operative/Operative Complication, Acute Abdomen


Medical Error: Procedural error


Significant Outcome: Death


Case Rating: 5


Link to Original Case File: Download PDF



Kansas – Physician Assistant – Inappropriate Altering Of Medical Records In A Patient With Diverticulitis



On October 2015, a patient had been hospitalized for eight days with acute sigmoid diverticulitis.

On 11/9/2015, the patient was seen by an internist at a clinic for a hospital follow-up. The internist noted that the patient still had abdominal pain in the left lower quadrant (“LLQ”), but was improved.  Further, the internist noted that the patient had tenderness to palpation to the LLQ and the right lower quadrant (“RLQ”) with no guarding or rebound.  The internist documented that the patient’s diverticulitis was improved and his plan was for the patient to finish taking his prescribed Levaquin.

On 11/13/2015, the patient presented to the emergency department with abdominal pain rated 10/10.   A physician assistant noted that the patient “Does pause episode to speak and answer questions,” and “guards throughout exam.”  The physician assistant’s impression was “Non-Acute Long Standing.”  The physician assistant ordered a “GI-Cocktail” on the ED physician order sheet and then discharged the patient with a diagnosis of abdominal pain with a plan for a CT in the morning.

It is unclear why the physician assistant did not obtain the CT at that time.  At some point, the physician assistant added an untimed order for Dilaudid 2 mg IV to a copy of the original ED physician order sheet.

The patient returned that morning on 11/13/2015 and had a CT scan that indicated bowel perforation and possible entero-colonic fistula.

The physician assistant took the patient to the ED, the patient was crying in pain, and the physician reported that the patient had a CT and needed to be transferred for surgery.

The physician assistant altered the patient’s medical records including the following: altered the time the patient was seen in the ED, changed the diagnosis from “Non-Acute Long Standing” to “Now-Acute/Long Standing” on the emergency physician record, crossed out the checkbox “home” and circled the checkbox “transfer” on the emergency physician record, and crossed out the ED number and wrote “From clinic.”  The physician assistant did not initial the alterations, indicate when the alterations were made, nor why the alterations were made.

The Board judged that the physician assistant likely deceived, defrauded, or caused harm to the patient by inappropriately altering the patient’s medical records.

For this allegation and others, the Board ordered the physician assistant to contact The Center for Personalized Education for Physicians, (“CPEP”) for a competence assessment, follow all recommendations of the CPEP assessment, and complete a medical record keeping seminar.

State: Kansas


Date: April 2017


Specialty: Physician Assistant, Emergency Medicine, Internal Medicine


Symptom: Abdominal Pain


Diagnosis: Acute Abdomen


Medical Error: Ethics violation, Delay in proper treatment, Diagnostic error, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Internal Medicine – History Of Atrial Fibrillation On Warfarin With INR Of 4.3 Started On Levofloxacin



On 3/26/2013, an 80-year-old female presented to a medical center with complaints of epigastric and right upper quadrant pain related to acute diverticulitis.

Upon the patient’s admission to the medical center, her medical records noted a history of atrial fibrillation and seizure disorder.  The records also indicated that she was on warfarin.

On 3/26/2013, the patient’s INR (admission INR) was recorded in the therapeutic range between 2.0 and 3.0.

On 3/26/2013, an internist improperly assessed the daily amount of warfarin that the patient was receiving prior to her admission to the medical center.  The internist increased the amount of the patient’s daily warfarin dosage.

The internist also prescribed Levaquin, an antibiotic, to treat the patient’s diverticulitis.  Levaquin can increase the anticoagulant effect of Warfarin.  On 3/28/2013, the patient’s INR was recorded as 4.3  On 3/29/2013, the patient’s INR was recorded as 8.9.

The administration of vitamin K and/or fresh frozen plasma is associated with anticoagulant reversal or moderation.  On 3/29/2013, the internist facilitated the oral administration of vitamin K to the patient.  Parenteral administration of vitamin K is indicated over oral administration in treating acute coagulopathy of the nature then-exhibited by the patient.

On 4/1/2013, the patient suffered an intracranial hemorrhage.

The internist did not facilitate the administration of fresh frozen plasma until 4/1/2013, after the patient exhibited neurologic change.  He did not facilitate the parenteral administration of vitamin K until 4/2/2013.

On 4/9/2013, the patient died from an intracranial hemorrhage due to Coumadin coagulopathy.

The Medical Board of Florida judged the internists conduct to be below the minimal standard of competence given that he failed to accurately assess the amount of warfarin that the patient was receiving prior to admission and treat with appropriate dosages accordingly.  The internist failed to recognize that the patient’s treatment for an acute infection, ingestion of Levaquin, and age put her at increased risk for acute coagulopathy, and treat accordingly.  He also failed to treat earlier for acute coagulopathy and with more aggressive methods, especially including earlier parenteral vitamin K and/or fresh frozen plasma.

It was requested that the Medical Board of Florida order one or more of the following penalties for the internist: 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: March 2017


Specialty: Internal Medicine


Symptom: Abdominal Pain


Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Cardiac Arrhythmia, Acute Abdomen


Medical Error: Improper medication management, Delay in proper treatment


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



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