Found 22 Results Sorted by Case Date
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Florida – Radiology – Mammogram And Ultrasound Of Breast Mass Interpreted As A Cyst



On 6/30/2011, a 50-year-old female presented to a breast center for a bilateral digital diagnostic mammogram with computer-aided detection and right breast ultrasound (“mammogram and ultrasound”) for a palpable abnormality (“mass”).

On 6/30/2011, a radiologist interpreted the mammogram and ultrasound in her final report as follows: “[T]here has been no interval change in the appearance of the breasts with no evidence for malignancy.  At the 7 o’clock position, 7 cm away from the nipple, correlating to the [mass] is a simple cyst….”

The radiologist recommended “[M]ammography and yearly physical examination per ACS guidelines, supplemented with monthly self-examination,  If clinically indicated, the cyst could be aspirated.”  At no time did the radiologist recommend a biopsy of the mass.

The radiologist rated the mammogram as a BI-RADS Category II, “[B]enign.”  A correct interpretation of the mass would have indicated that it had lobular and angular margins, and increased through transmission.  The mammogram should have been rated BI-RADS category V, “[H]ighly suspicious: [A]ppropriate action should be taken.”  The radiologist should have recommended a biopsy of the mass.

On 1/23/2012, the patient was advised by a subsequent treating physician that she had invasive ductal carcinoma, Stage III.

The Board judged the radiologist’s conduct to be below the minimum standard of competence given her failure to correctly interpret the mammogram and ultrasound and recommend a biopsy of the mass.

The Board ordered that the radiologist pay a fine of $6,500 against her license and that the radiologist pay a reimbursement cost to the case of a minimum of $2,924.06 but not to exceed $4,924.06.  The Board ordered that the radiologist complete ten hours of continuing medical education in identification and diagnosis of malignancies with a focus on interpretation of breast imaging studies.

State: Florida


Date: November 2017


Specialty: Radiology


Symptom: N/A


Diagnosis: Breast Cancer


Medical Error: False negative, Failure to order appropriate diagnostic test


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Pathology – Pathologist Concludes Invasive Ductal Carcinoma Present On Specimen Leading To Double Mastectomy



On 6/11/2012, a 47-year-old female presented to a pathology clinic for a right breast core biopsy.

On 6/12/2012, a pathologist reviewed the specimen obtained from the biopsy and dictated his interpretation as “invasive ductal carcinoma, NOS, Nottingham grade 1” on a surgical pathology report.

On 9/6/2012, the patient underwent a double mastectomy to remove breast tissue from both breasts.

In October 2012, the patient was notified that the specimen from her biopsy was erroneously diagnosed and that she never had breast cancer.

On 12/12/2012, the pathologist amended the patient’s surgical pathology report, indicating that the specimen was obtained from a benign adenosis tumor.

The Medical Board of Florida judged the pathologists conduct to be below the minimal standard of competence given that he failed to make a correct pathological interpretation of the specimen obtained from the biopsy.

The Medical Board of Florida issued a letter of concern against the pathologist’s license.  The Medical Board of Florida ordered that the pathologist pay a fine of $8,000 against his license and pay reimbursement costs for the case at a minimum of $3,726.76 and not to exceed $5,726.76.  The Medical Board of Florida also ordered that the pathologist complete ten hours of continuing medical education in identification and diagnosis of malignancies with a focus on the interpretation of pathological reports and complete five hours of continuing medical education in “risk management.”

State: Florida


Date: June 2017


Specialty: Pathology


Symptom: N/A


Diagnosis: Breast Cancer


Medical Error: False positive


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Gynecology – Breast Biopsy Specimen A Malignant, Specimen B Benign



In 2012, a female was followed for routine gynecologic care by a gynecologist.  The patient’s history was significant for a laparoscopic tubal ligation although nulliparous.  The history included that in about 2007, the patient required a right breast biopsy and possibly an aspiration for benign findings.  She subsequently underwent a bilateral breast reduction.  She began menopause and she received hormone replacement therapy in the form of the Combipatch (50/140), which she continued for more than two years.  She had ongoing vulvar lichen sclerosis, treated with steroid cream.  The patient’s mother had pancreatic cancer and passed away in 2010.  The patient’s physical exam was otherwise noteworthy for mild hypertension.

On 8/1/2012, the patient presented for her routine annual exam.  She had been weaning herself from the estrogen hormone patch by cutting them in half.  She had no complaints.  Her physical, including a breast exam, was essentially negative.  Pap testing was deferred.  A mammogram was ordered, but not performed.  The fact that the patient failed to comply with the request was not known to the gynecologist’s office.

In November of 2012, when the patient identified 2 lumps in her right breast, she went for a mammogram.  On 11/16/2012, the mammogram was performed.  Suspicious findings warranted a follow-up ultrasound of the right breast.  The gynecologist’s office also authorized an ultrasound.  Radiology performed directed needle biopsies on an expedited basis.  On 11/20/2012, a radiologist performed 2 needle biopsies.  He noted that the gynecologist’s office was “telephoned with this information,” referring to the expedited biopsy.  This intervention was not noted in the gynecologist’s records.

On 11/26/2012, the patient returned to the gynecologist’s office.  She complained of vaginal irritation and requested the results of her biopsies, which had been performed the previous week.  The patient was diagnosed with recurrent lichen sclerosis and was advised that the pathology results on the breast were not yet available.

On 11/27/2012, the patient called the gynecologist’s office for the test results.  On the same day, Los Alamitos pathology produced a report.  They documented sending copies to the radiologist and the gynecologist at that time.  In that path report, page 1 documented that specimen A was an invasive ductal carcinoma.  This finding was reiterated in the body of the text on page 2, labeled “microscopic description.”  The gynecologist noted review of page 2 of the path report but did not note the diagnosis.

On 11/28/2012, the gynecologist called the patient back and advised her that the biopsy was benign.  The gynecologist advised the patient of the benign biopsy based on the text she referred to regarding the specimen B.  In fact, this was an error by the gynecologist.  The gynecologist claims that this mistake was caused by a transmission error.  There were actually two specimens noted in the report.  Although page 2 details benign findings for specimen B, the report states: “A) Specimen…Histology type: INVASIVE DUCTAL CARCINOMA.”

The gynecologist admitted in a subject interview before the Board that she erred by not reviewing page 1 of the same path report which also identified an “invasive ductal carcinoma, high grade, poorly differentiated” from specimen A.

The patient did not return until 2/12/2013 when she complained of pelvic pressure and back pain.  As an aside, she asked for an opinion of what she thought to be a hematoma at the biopsy site in her right breast.  Examination revealed a firm mass.  The patient was immediately sent to a surgeon for further treatment.  As the gynecologist transferred the records she noted that she had misinterpreted the biopsy results of November and had falsely reassured the patient at that time.  This is documented in the chart on 2/26/2013 as a “breast follow-up,” dictated 2/12/2013.  The patient went on to receive her care from a surgeon and several oncologists for metastatic right breast cancer (Stage III).

The Board expressed concern that the gynecologist was grossly negligent in failing to follow up on important findings of those tests.  She was unaware that the radiology had performed multiple biopsies.

She failed to establish procedures to ensure adequate communication of information between radiology and her office.

There was also concern over a lack of documentation regarding her exam of the breast on 2/12/2013.  There was no mention of a follow-up of the previous breast biopsy or documentation of the exam of the breast on 2/12/2013.  This information was provided in a 2/26/2013 addendum.  Lab work was not routinely “signed-off” and dated with an indication of appropriate analysis.

The Board issued a public reprimand.  She was ordered to take a medical record-keeping course offered by the Physician Assessment and Clinical Education (“PACE”) Program at the University of California San Diego School of Medicine.  She was also ordered to enroll in a professionalism program.

State: California


Date: February 2017


Specialty: Gynecology


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


Diagnosis: Breast Cancer


Medical Error: Accidental error, False negative, Failure of communication with other providers, 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



California – Pathology – Pathologist Changes Report After Another Reviewing Pathologist Has Different Diagnosis



On 1/7/2014, a patient underwent a needle core biopsy of her right breast and axillary lymph node.  The biopsy was performed at three separate sites, multiple cores were obtained, and the specimens were sent to pathology.

On 1/8/2014, Pathologist A reviewed the three specimens.  Pathologist A provided a diagnosis that the three specimens did not contain cancer.

Following  pathologist’s review, a Pathologist B reviewed the slides and an immunohistochemical stain was obtained, which revealed the presence of cancer.

On 1/21/2014, Pathologist A amended his report to show that cancer was present in two of the three samples he had previously misdiagnosed.

Pathologist A failed to correctly diagnose cancer.  Despite obvious evidence of cancer in the lymph node sample and similar cells present in the breast biopsy, Pathologist A failed to properly diagnose cancer in the samples.

Based on this case and others, the Board placed Pathologist A on probation for 35 months with stipulations that Pathologist A complete at least 40 hours of continuing medical education in the areas of deficient practice and undergo monitoring.

The Board restricted Pathologist A’s practice in clinical pathology with the terms that the restriction could be put in abeyance once he found a clinical proctor to proctor him on 50 clinical pathology cases.

State: California


Date: September 2016


Specialty: Pathology


Symptom: N/A


Diagnosis: Breast Cancer


Medical Error: False negative


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Pathology – Fine Needle Aspiration Of Left Breast Read As Negative By Pathologist



In December 2010, a patient underwent a fine needle aspiration of her left breast.  The pathologist reviewed and interpreted the slides created from the procedure.  He failed to identify the presence of any abnormal cells.  Abnormal cells suggesting malignancy were apparent on the slides.

In June 2011, a separate biopsy procedure revealed that the patient had carcinoma of the left breast.

The Board expressed concern that the pathologist deviated from the standard of care.

The Board issued a letter of concern.  He was ordered to pay a fine, complete 5 hours of CME in “Risk Management,” and attend a full day of disciplinary hearings at a regular meeting of the Board of Medicine.

State: Florida


Date: December 2015


Specialty: Pathology


Symptom: N/A


Diagnosis: Breast Cancer


Medical Error: False negative


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



North Carolina – Radiology – Breast Mass Read As Benign On Mammogram



The Board was notified of a professional liability payment.

In April 2010, a 75-year-old female had a screening mammogram read by the radiologist as benign with recommendation to follow-up in one year.

In April 2011, the patient had a screening mammogram that identified a right breast mass that was determined to be cancer.

The Board obtained the patient’s records and sent them to a qualified independent medical expert for review.

The expert judged the radiologist’s conduct to be below the minimum standard of competence given failure to identify the tumor in the patient’s right breast on the April 2010 mammogram and failure to recommend additional studies such as a needle biopsy or an ultrasound.  The expert opined that the tumor was clearly visible, represented a distinct change from previous exams, and was not obscured by any dense breast tissue.

The Board issued a public letter of concern, which was reported to the Federation of State Medical Boards.  It was not reported to the National Practitioner Data Bank.

State: North Carolina


Date: December 2015


Specialty: Radiology


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


Diagnosis: Breast Cancer


Medical Error: False negative


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Virginia – Radiology – Moderate Degree Of Fibroglandular Density Reported On Mammogram



On 4/2/2008, a radiologist read the mammogram results of a 40-year-old female.  The radiologist noted only a “moderate degree of fibroglandular density which is symmetrical and without suspicious appearing mass or calcification.”

He did not detect a parenchymal asymmetry developing in the upper outer quadrant of the patient’s left breast, a change compared to a prior mammogram performed on 2/18/2004, which was available for the radiologist to compare.

The radiologist did not recommend to the patient’s referring physician additional spot compression views, a correlative physical examination, a follow-up ultrasound, or an immediate or annual evaluation.

On 2/16/2009, a mammogram interpreted by another radiologist identified a mass in the upper/outer quadrant of the patient’s left breast suggestive of malignancy.  A biopsy was performed, which revealed invasive ductal adenocarcinoma of the left breast Stage IV with metastasis to the lymph nodes.

The Board issued a reprimand.

State: Virginia


Date: October 2015


Specialty: Radiology


Symptom: N/A


Diagnosis: Breast Cancer


Medical Error: False negative


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Virginia – Radiology – Mass At Edge Of Pectoral Muscle On Mammogram



A 51-year-old female had mammograms performed on 4/2/2009 and 4/14/2010.  For these mammograms, the radiologist did not detect the progressive development of a mass at the edge of the patient’s pectoral muscle on the right mediolateral views.  This mass was apparent when viewed in comparison to the patient’s prior 2/12/2008 mammogram.

The Board notes that although this finding was subtle on the 2009 mammogram, it was clearly evident on the 2010 mammogram.  The radiologist did not recommend further spot and compression views or ultrasound to further evaluate the finding.

On 4/26/2011, the radiologist finally identified an area of focal asymmetry in the right breast and recommended further studies, which revealed breast cancer.

The Board issued a reprimand.

State: Virginia


Date: October 2015


Specialty: Radiology


Symptom: N/A


Diagnosis: Breast Cancer


Medical Error: False negative


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Virginia – Radiology – Irregular Mass With Indistinct Margins And Coarse Calcifications On Mammogram



On 9/28/2007, a radiologist reviewed a 37-year-old female’s mammogram.

He did not identify an irregular mass with possibly indistinct margins and associated coarse calcifications in the upper outer quadrant of the left breast at the junction of zones B and C.

It was noted by the Board that although these calcifications were suggestive of a benign process, the shape, density, and possibly indistinct margins of the mass warranted additional evaluation with spot compression views, a correlative physical examination, and follow-up ultrasound, which the radiologist did not recommend or perform.

On 9/18/2008, a mammogram, interpreted by a different radiologist, revealed a mass that was determined to be malignant.

The Board issued a reprimand.

State: Virginia


Date: October 2015


Specialty: Radiology


Symptom: N/A


Diagnosis: Breast Cancer


Medical Error: False negative


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Virginia – Radiology – Cluster Of Calcifications In The Right Breast



On 9/12/2008, a 47-year-old female had a mammogram.  A radiologist read the mammogram and did not mention a cluster of malignant-type calcifications in the right breast medially.  He did not recommend further evaluation with spot compression magnification views and/or biopsy.

On 9/16/2009, the patient had another mammogram performed again reviewed by the same radiologist, who did not document that the malignant-type calcifications seen in the 2008 study were no longer apparent.

The Board noted that such “disappearing” calcifications may indicate progression of intraductal disease to invasive disease.  Instead, the radiologist reported only “[s]cattered benign appearing calcifications are noted bilaterally.”

On 6/24/2011, another mammogram was performed, which demonstrated two masses with associated malignant-type calcifications medially in the right breast.  One of the masses developed at the site of the malignant-type calcifications apparent in the patient’s 2008 mammogram.

The mammogram also demonstrated a morphologically abnormal lymph node in the right axilla.  The radiologist described these findings as “asymmetry” and failed to make any mention of the morphologically abnormal lymph node.   In the report interpreting the right breast ultrasound performed on the patient on 6/24/2011, he provided measurements for two lymph nodes in the right axilla but did not note any description of their morphologically abnormal imaging features.

The Board issued a reprimand.

State: Virginia


Date: October 2015


Specialty: Radiology


Symptom: N/A


Diagnosis: Breast Cancer


Medical Error: False negative


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



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