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New Jersey – Gastroenterology – Pathology Diagnoses Polyp Removed During Colonoscopy As Adenocarcinoma
A payment of $775,000 had been made on the gastroenterologist’s behalf to settle a civil malpractice action brought against him by a patient.
It was alleged the gastroenterologist failed to follow-up on pathology results that revealed cancer after he had performed a colonoscopy on the patient, which led to a delay in the diagnosis of colorectal cancer.
On 8/12/2009, a 55-year-old woman presented to a gastroenterologist with complaints of abdominal pain and rectal bleeding. The patient’s medical history revealed a family history of colon cancer. The gastroenterologist recommended that the patient have a diagnostic colonoscopy to evaluate her persistent rectal symptoms.
On 9/17/2009, the gastroenterologist performed a colonoscopy on the patient. During the procedure, the gastroenterologist identified internal hemorrhoids associated with a sessile polyp in the mid-rectum. The gastroenterologist removed the polyp and submitted the specimen for pathologic analysis. The patient was discharged from the hospital on 9/17/2009.
On 9/18/2009, pathology diagnosed the polyp to be a moderately differentiated adenocarcinoma arising within a tubular adenoma. On 10/6/2009, the gastroenterologist entered a progress note in the patient’s hospital chart directly documenting the finding of adenocarcinoma made in the pathology report. Despite entering that chart note, the gastroenterologist never advised the patient of the finding of adenocarcinoma that had been made.
The gastroenterologist thereafter had no further contact with the patient until he saw her in his office on 8/23/2010, approximately eleven months after the colonoscopy had been performed. At that visit, the gastroenterologist diagnosed the patient with hemorrhoids and prescribed steroid suppositories; however, he once again failed to inform her of the finding of cancer that had been made following the September 2009 colonoscopy. Additionally, the gastroenterologist did not then recommend that the patient schedule a repeat colonoscopy.
The patient ultimately had a repeat colonoscopy performed by another physician on 4/27/2011. Following that procedure, she was found to have an invasive carcinoma of the mid-rectum, and she commenced receiving treatment for colon cancer.
When appearing before the panel, the gastroenterologist testified that he was aware of the pathology findings that had been made following the colonoscopy but did not specifically advise the patient of those findings because he considered the pathology findings to be “benign.” The gastroenterologist further testified that he was confident that he had removed the entirety of the rectal polyp at the time of the colonoscopy. The gastroenterologist maintains that, after completing the colonoscopy, he advised the patient that she would need to see him again in “about” a year, but there is no documentation in either the gastroenterologist’s medical record or the hospital chart which memorializes respondent’s having advised the patient to have a repeat colonoscopy within one year. Further, although the gastroenterologist entered a note in the patient’s hospital chart on 10/6/2009 documenting the pathology findings, he failed to record the pathology findings in his office medical record, and he failed to obtain and/or maintain a copy of the pathology report in his office record.
The Board judged the gastroenterologist’s conduct to have fallen below the standard of care given failure to document that he advised the patient to have a repeat colonoscopy performed within one year of the date on which the original colonoscopy was performed and failure to have documented the pathology findings of adenocarcinoma in his office record.
The Board assessed a fine against the gastroenterologist with stipulations to complete courses in medical record keeping and medical ethics.
State: New Jersey
Date: March 3017
Specialty: Gastroenterology
Symptom: Blood in Stool, Abdominal Pain
Diagnosis: Colon Cancer
Medical Error: Failure to follow up, Failure of communication with patient or patient relations, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
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 – Family Medicine – Diagnosis Of Deep Cellular Fibrous Histiocytoma With A Differential Diagnosis Of Myofibroblastic Sarcoma
On 3/28/2014, a patient presented to a family practitioner with complaints of a right forearm mass.
On 4/4/2014, the family practitioner excised a 3-4 cm mass from the patient’s right forearm. The family practitioner sent the specimen out for review by a pathologist.
On 4/15/2014, the pathologist via a pathology report listed a diagnosis of deep cellular fibrous histiocytoma with a differential diagnosis of low grade myofibroblastic sarcoma. The pathology report further stated that re-excision was ‘“strongly recommended.”
On 4/16/2014, at a follow-up appointment, the family practitioner informed the patient that the mass was benign. He informed the patient that a wait-and-see approach would be appropriate, and, if the mass returned, further excision would be recommended. The family practitioner did not inform the patient of the differential diagnosis listed on the pathology report. He also did not advise the patient that a re-excision was strongly recommended by the pathologist.
On 1/30/2015, the mass on the patient’s forearm returned and was larger.
On 3/5/2015, a general surgeon performed a second excision on the patient.
On 3/11/2015, the pathology report of the second excision stated a diagnosis of high grade myxofibrosarcoma.
The Board judged the family practitioners conduct to be below the minimum standard of competence given that he failed to fully inform the patient of the pathology report findings and advise the patient that re-excision wass strongly recommended.
It was requested that the Board order one or more of the following penalties for the family practitioner: permanent revocation or suspension of his license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Board deemed appropriate.
State: Florida
Date: November 2017
Specialty: Family Medicine
Symptom: Mass (Breast Mass, Lump, etc.)
Diagnosis: Cancer
Medical Error: Underestimation of likelihood or severity, Failure of communication with patient or patient relations
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
California – Radiology – Back Pain With Subsequent MRI And Missed Incidental Finding
In 2009, a patient with a history of smoking developed back pain. Her primary care physician sent her to a hospital for two MRIs of her spine: one on 3/9/2009 and another on 4/13/2009. Radiologist A at the hospital obtained the MRI images and sent them to a teleradiology company for review. Radiologist B at the teleradiology company reviewed the MRIs. Neither of his reports mentioned any lung abnormalities.
In 2010, the patient developed a cough and was sent to the hospital for a chest x-ray. Radiologist A reviewed the x-ray and reported that he found no significant pathology.
After suffering from continued bouts of coughing, the patient was sent to the hospital for another chest x-ray in 2012. Radiologist A reviewed the x-ray and reported that he found no significant pathology.
In 2013, Radiologist A received a chest x-ray for asthma. Radiologist A reviewed the x-ray and found a mass on the patient’s right lung. Radiologist A recommended that the patient undergo a computed tomography (CT) scan. The CT scan revealed a 4.8 by 2.5 centimeter mass, which was subsequently identified as cancerous. The patient was diagnosed with unresectable Stage IIIA non-small cell lung cancer metastatic to the lymph nodes. The patient underwent 33 radiation treatments and multiple rounds of chemotherapy.
In January 2014, the patient filed a complaint against Radiologist A and Radiologist B asserting medical malpractice. She claimed that her lung cancer diagnosis was delayed by four years given failure to detect the mass when they reviewed her MRIs and chest x-rays.
In November 2015, prior to the start of the trial, the patient began to have breathing issues, balance problems, dizziness, and difficulty with memory. On 11/3/2015, her primary care physician ordered a CT scan, which revealed that the cancer had metastasized to her brain.
On 11/13/2015, the jury returned a verdict in favor of the patient with liability spread equally among Radiologist A and Radiologist B. The jury awarded the patient a total of $3 million.
The California Board issued a public reprimand against Radiologist B given his failure to report the medical malpractice case to the Hawaiian Board.
State: California
Date: October 2017
Specialty: Radiology
Diagnosis: Lung Cancer
Medical Error: False negative
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
California – Gynecology – Blood With Urination Not Due To Bleeding From Bladder Or Kidneys
On 4/5/2015, an 80-year-old female presented to a gynecologist with a complaint of pink drainage with urination. The patient had a prior cystoscopy and a CT through the urology department, which was negative for hematuria. The gynecologist conducted an examination of the patient and noted: (1) no blood in the vagina; and (2) that the vaginal epithelium was atrophic. The gynecologist did not order a pelvic ultrasound of the patient. The gynecologist failed to evaluate any postmenopausal bleeding with either an endometrial biopsy or an ultrasound of the uterus, and she failed to order or conduct any assessment to exclude malignancy.
On 2/21/2014, the patient was seen by a urologist for continued hematuria. Cystoscopy was performed and revealed no bleeding from the bladder or kidneys. On 2/25/2014, the patient was seen by another gynecologist who ordered a pelvic ultrasound that ultimately showed an intrauterine vascular mass. On 3/3/2014, an endometrial biopsy was performed on the patient by a different provider, which showed adenocarcinoma.
The Medical Board of California judged that the gynecologist’s conduct departed from the standard of care because she failed to evaluate any postmenopausal bleeding with either an endometrial biopsy or an ultrasound of the uterus and to order or conduct any assessment to exclude malignancy.
The Medical Board of California issued a public reprimand and ordered the obstetrician to complete an education course (at least 15 hours) dedicated in the area of diagnosis and patient care in OB/GYN cases.
State: California
Date: August 2017
Specialty: Gynecology
Symptom: Bleeding
Diagnosis: Gynecological (Endometrial, Ovarian, Cervical) Cancer
Medical Error: Failure to order appropriate diagnostic test
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Cardiothoracic Surgery – Failure To Follow Up After Pathology Report Shows Abnormal Lymphadenopathy
On 1/25/2013, a 65-year-old male, underwent an artery bypass grafting procedure on his right leg by a cardiothoracic surgeon at a medical center.
During the course of the procedure, the cardiothoracic surgeon took a biopsy of the patient’s right groin lymph node, which was sent off to pathology for analysis.
The patient was never notified by the cardiothoracic surgeon that a biopsy of the right groin lymph node was taken during the procedure.
The cardiothoracic surgeon should have documented the right groin lymph node biopsy as part of the procedure in the operative report for the procedure but failed to do so.
On 1/29/2013, the pathology report for the biopsied tissue revealed a pathologic diagnosis of mantle cell lymphoma. The pathology report was sent via facsimile to the cardiothoracic surgeon’s office. The cardiothoracic surgeon should have listed “abnormal lymphadenopathy” as the post-operative diagnosis and failed to do so.
On 1/30/2013, the patient was discharged from the medical center.
The Board judged the cardiothoracic surgeons conduct to be below the minimal standard of competence given that he should have notified the patient of the pathology results and failed to do so. He also should have obtained oncologic consultation for the patient and failed to do so. The cardiothoracic surgeon should have provided the patient’s primary care physician and the referring physician with a copy of the pathology report and failed to do so.
The Board issued a letter of concern against the cardiothoracic surgeon’s license. The Board ordered that the cardiothoracic surgeon pay a fine of $5,000 against his license and pay reimbursement costs for the case for a minimum of $5,063.26 but not to exceed $7,063.26. The Board ordered that the cardiothoracic surgeon complete a board approved medical records course and complete five hours of continuing medical education in “risk management.”
State: Florida
Date: August 2017
Specialty: Cardiothoracic Surgery, Oncology
Symptom: N/A
Diagnosis: Cancer
Medical Error: Failure to follow up, Failure of communication with other providers, Referral failure to hospital or specialist, Failure of communication with patient or patient relations, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 4
Link to Original Case File: Download PDF
Florida – Gynecology – MRI Reveals Two Adjacent Large Intraperitoneal Complex Cystic Masses With Plan For Removal
On 11/19/2013, a 44-year-old female presented to a gynecologist for abdominal/pelvic discomfort.
The gynecologist performed an ultrasound and reported a “large ovarian cyst 14 cm in greatest extent… simple in nature.” The gynecologist ordered additional imaging of the patient’s abdomen and pelvis to further evaluate the cyst.
The patient was scheduled for surgical removal of the cyst to be performed by the gynecologist on 11/27/2013.
On 11/22/2013, an MRI of the patient’s pelvis was performed, which indicated the presence of “two adjacent large intraperitoneal complex cystic masses.”
On 11/27/2013, preoperatively, the gynecologist indicated that he read the history and physical and examined the patient and that there were “no changes.”
After receiving and reviewing the MRI report, the gynecologist failed to further evaluate, or alternatively, did not create, keep, or maintain adequate legible documentation of evaluating, whether a malignancy was present.
Prior to the surgery on 11/27/2013, the gynecologist failed to discuss, or alternatively, did not create, keep, or maintain adequate legible documentation of discussing, with the patient her desired plan-of-care in the event that the cysts contained malignant cells.
The gynecologist attempted to remove the cysts laparoscopically, by intentionally puncturing and aspirating the cysts. Prior to intentionally puncturing the cysts, the gynecologist did not place the cysts into a specimen bag to prevent contamination in the event that the cysts contained malignant cells. During the procedure, the contents of the cysts spilled into the patient’s abdominal cavity.
Intraoperatively, the procedure was converted to a laparotomy and the gynecologist removed the patient’s left ovary in its entirety and sent it to pathology. The pathology report indicated that the specimen was “of at least low malignant potential” indicating possible higher grade abnormality.
Accordingly, the gynecologist performed a total abdominal hysterectomy and removal of the right ovary.
The Board judged the gynecologist’s conduct to be below the minimal standard of competence given that he failed to further evaluate, preoperatively, to determine whether a malignancy was present, proceed with the correct surgical approach on 11/27/2013, by performing a laparotomy and removing the cysts intact, or by placing a specimen bag around the cysts prior to intentionally puncturing and aspirating the cysts, and discussing with the patient, preoperatively, to determine the patient’s desired plan-of-care for the possibility of malignancy.
It was requested that the Board order one or more of the following penalties for the gynecologist: permanent revocation or suspension of his license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Board deemed appropriate.
State: Florida
Date: July 2017
Specialty: Gynecology
Symptom: Abdominal Pain, Mass (Breast Mass, Lump, etc.)
Diagnosis: Gynecological (Endometrial, Ovarian, Cervical) Cancer
Medical Error: Underestimation of likelihood or severity, Failure of communication with patient or patient relations, Procedural error
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Urology – Failure to Follow-Up On Chest X-Rays Ordered In A Patient With Micro Hematuria And Stone Disease
A urologist treated a patient from 2/3/2011 to 3/4/2011.
On 2/3/2011, the patient first presented to the urologist with micro hematuria and stone disease.
On 2/9/2011, the urologist ordered pre-operative blood work and chest x-rays for the patient.
The radiology report of the chest x-ray dated 2/9/2011 revealed a “newly developed 2.5 cm irregular contoured nodule located in the right lower lobe” that was “suspicious for potential malignancy and chest CT correlation [was] recommended…”
The urologist did not review the 2/9/2011 chest x-ray or radiology report and subsequently did not notify the patient and the patient’s primary care physician of the radiology findings.
On July 2012, the patient’s primary care physician ordered a chest x-ray, which demonstrated a 5 cm mass with metastasis.
A medical malpractice lawsuit was filed against the urologist.
The Board judged the urologist conduct to be below the minimal standard of competence given that he failed to review the chest x-ray and radiology report that were ordered by his staff and inform the patient and the patient’s primary care physician of the findings of the chest x-ray.
It was requested that the Board order one or more of the following penalties for the urologist: permanent revocation or suspension of his license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Board deemed appropriate.
State: Florida
Date: July 2017
Specialty: Urology
Symptom: Urinary Problems
Diagnosis: Urological Disease, Cancer, Renal Disease
Medical Error: Failure to follow up
Significant Outcome: N/A
Case Rating: 4
Link to Original Case File: Download PDF
Florida – Pathology – Gallbladder Malignancy Confirmed In Wrong Patient
On 5/4/2015, Patient A underwent a laparoscopic gallbladder removal. Following the procedure, a pathologist reviewed what she thought was the patient’s gallbladder specimen for malignancy.
The gallbladder specimen the pathologist reviewed actually belonged to a different patient, Patient B.
The pathologist determined that the specimen for Patient B was malignant.
The pathologist erroneously reported that Patient A’s gallbladder specimen was cancerous. The pathologist did not confirm that the specimen belonged to Patient A prior to reporting her diagnosis.
Following the pathologist’s erroneous diagnosis, in July 2015, Patient A underwent two chemotherapy treatments.
On 8/14/2015, the pathologist reviewed Patient A’s actual gallbladder specimen to confirm her prior diagnosis. At that time the pathologist discovered her error and correctly reported that Patient A’s gallbladder specimen was benign.
The Board judged the pathologist’s conduct to be below the minimum standard of competence given that she failed to confirm that Patient A’s identify matched the gallbladder specimen she reviewed prior to reporting that Patient A’s gallbladder was cancerous.
It was requested that the Board order one or more of the following penalties for the pathologist: permanent revocation or suspension of her license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Board deemed appropriate.
State: Florida
Date: July 2017
Specialty: Pathology
Symptom: N/A
Diagnosis: Cancer
Medical Error: Accidental error, False positive
Significant Outcome: N/A
Case Rating: 4
Link to Original Case File: Download PDF
Iowa – Pathology – Squamous Cell Carcinoma Misdiagnosed As Keratoacanthoma
A 49-year-old female underwent a punch biopsy of the left labia on 7/15/2014. The specimen was delivered to a general pathologist who issued a pathology report diagnosing keratoacanthoma (“KA”). Under the “COMMENT” portion of the report, the general pathologist noted, “The specimen shows changes of a well-differentiated squamous cell carcinoma.”
The slides examined by the general pathologist were subsequently reread by another pathologist of Iowa Pathology Associates, who confirmed his diagnosis with a dermatopathologist and another pathologist. The dermatopathologist arrived at a diagnosis of a well-differentiated squamous cell carcinoma with a 0.85 cm depth of invasion.
A senior pathologist reviewed this file and arrived at the opinion that the general pathologist diagnosis of KA, in this case, demonstrated a lack of professional competency and knowledge. The senior pathologist emphasized the correct diagnosis here was well-differentiated squamous cell carcinoma. She explained that a KA, as diagnosed by the general pathologist, is a lesion of sun-exposed skin, generally found in the elderly. It is shaped like a wart and protrudes up from the skin surface, whereas this lesion was not protruding and was located on the vulva. The senior pathologist acknowledged that some authorities believe a KA is a form of well-differentiated squamous cell carcinoma, but she opined the term should never be used to describe the type of lesion involved in this case.
At the hearing, the senior pathologist further explained that a KA is marked by a dome shape and a keratin core. The sample in this case did not show those characteristics. The senior pathologist stated that even more telling was the location of the tumor: KAs are found on skin that is exposed to the sun and the fact that this sample was of vulvar tissue should have led the general pathologist to the conclusion that it was not a KA. The senior pathologist noted that while vulvar KAs have been reported in the literature, they are extremely rare.
The senior pathologist testified that the misdiagnosis in this case could have resulted in the patient receiving inappropriate treatment. She explained that KAs do not usually metastasize and excision of the lesion with an adequate margin is the accepted treatment for such a tumor. Squamous cell carcinoma, on the other hand, may develop lymph node metastasis and the accepted treatment is therefore much more aggressive, and may involve removal of lymph nodes and chemotherapy. The senior pathologist offered her opinion that the general pathologist’s misuse of terminology demonstrated a lack of substantial knowledge or ability.
A surgical pathologist with Iowa Pathology Associates testified at the hearing. He was asked to review the patient’s biopsy because of a concern the KA diagnosis provided by the general pathologist was incorrect. The surgical pathologist noted that while a KA can look quite similar to squamous cell carcinoma, KAs are not found on the vulva. He testified that he shared this biopsy with colleagues who had 250 years of combined experience and not one of them had ever seen a KA on vulvar tissue. The surgical pathologist disagreed with the suggestion that this was simply a matter of semantics. He stated that, while one might use the the terms KA and squamous cell carcinoma interchangeably if one is speaking of skin on the arm or another sun-exposed area, that is simply not the case with vulvar tissue. The surgical pathologist also emphasized that this was a deeply invasive tumor, 0.85cm, requiring much more aggressive action than would be required for a KA.
A dermatopathologist also testified at the hearing that he reviewed the slides from the patient’s biopsy at the surgical pathologist’s request. He agreed with the surgical pathologist and the senior pathologist that KAs are not found in vulvar tissue and are restricted to sun-exposed skin. The dermatopathologist expressed his opinion that this was not a difficult diagnosis to make.
The general pathologist argued that the difference between his diagnosis and that of the Iowa Pathology Associates was only a matter of semantics. He testified that some authorities use the terms KA and squamous cell carcinoma interchangeably. He stressed that he used the term “well-differentiated squamous cell carcinoma” in the comment section of his report. The general pathologist testified that, while KAs are generally found on sun-exposed skin, there have been reports in the literature of vulvar KAs.
In response to questions as to why he did not report the depth of the lesion, the general pathologist explained that he did not do so because the sample was from a punch biopsy. He noted that he recommended the entire lesion be excised, which would have allowed him to make a concrete diagnosis of the sample and the depth of the tumor.
Another reviewing pathologist agreed with the general pathologist and refused to characterize the general pathologist’s conclusions as a misdiagnosis. He testified the dispute in this case was involving terminology only and did not rise to a breach of the standard of care. He noted that, in addition to providing the diagnosis of KA, the general pathologist authored a comment in his report stating that the biopsy showed a well-differentiated squamous cell carcinoma. The reviewing pathologist testified that many authorities consider a KA to be a low grade invasive, well-differentiated squamous cell carcinoma, while others regard it as a unique lesion. The reviewing pathologist emphasized that even though the general pathologist did not refer to the depth of the lesion, he recommended complete excision. The reviewing pathologist opined that the general pathologist met the standard of care in this case.
The Board did not accept the general pathologist’s and the reviewing pathologist’s portrayals of the dispute surrounding the patient’s diagnosis as one of semantics only. The evidence is clear that the lesion in this case was not a KA, which is nearly always found on sun-exposed skin. The evidence is also clear that, while some authorities believe a KA is a form of well-differentiated squamous cell carcinoma and use of the terms interchangeably when referring to a lesion on sun-exposed skin, the term “KA” is not used to refer to such a lesion in vulvar tissue. Further, while the literature does contain a few instances of KAs on the vulva, those occurrences are exceedingly rare and happening upon such a case would be remarkable. The general pathologist’s diagnosis in this case demonstrated an obvious lack of knowledge and departure from the standard of care applicable to the general pathologist. The Board found that the general pathologist’s actions in this case amounted to professional incompetence and practice harmful and detrimental to the public.
For this allegation and others, the Board judged the general pathologist’s conduct to be below the minimum standard of competence given (his/her) lack of professional competency and practice that was harmful or detrimental to the public. The pathologist was warned that such practice in the future may result in further disciplinary action against his medical license.
For this allegation and others, the Board ordered the general pathologist to arrange in the auditing of 5% of his cases by outside pathology laboratory approved by the Board and ensure that the auditing entity submits a report to the Board on a quarterly basis. He was also ordered to obtain consultation with a board-certified dermatopathologist in all suspected melanoma cases and author a paper discussing the diagnostic criteria for well-differentiated squamous cell carcinoma and keratoacanthoma in vulvar tissue.
State: Iowa
Date: June 2017
Specialty: Pathology
Symptom: N/A
Diagnosis: Cancer
Medical Error: Diagnostic error
Significant Outcome: N/A
Case Rating: 4
Link to Original Case File: Download PDF