Found 137 Results Sorted by Case Date
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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


Symptom: Cough, Back Pain


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 – Contention In Use Of Slides When Diagnosing Metastatic Melanoma



An 82-year-old female presented with swollen lymph nodes under her right arm. She underwent a core needle biopsy on 8/11/2014.  That biopsy failed to provide a sufficient amount of viable tissue from which to arrive at a definitive diagnosis, but the general pathologist was of the opinion that the sample was “suggestive not diagnostic of metastatic melanoma.”

On 8/26/2014, a right axillary lymph node excisional biopsy was performed on the patient and the sample was sent to the general pathologist. Because of the small amount of viable tissue, the general pathologist prepared a portion of the material for flow cytometry and the remainder in touch preparations, a method by which a thin layer of cells is distributed on a slide for examination.  There was insufficient tissue for a frozen section, which consists of a thin slice of tissue cut from a frozen specimen.  The general pathologist ordered eleven special stains and arrived at a diagnosis of malignant melanoma.

A senior pathologist reviewed this file and expressed no concerns about the general pathologist’s final diagnosis; however, she opined that his use of eleven special stains to rule out other forms of cancer was unnecessary.  The senior pathologist testified that the majority of pathologists are able to diagnose melanoma through touch preparations, although many would prefer a frozen section to rely on.  She opined that the tough preparations, in this case, showed such obvious signs of malignant melanoma that no stains were necessary unless the patient had a history of other cancer.  The senior pathologist testified, if that were the case, a single, inexpensive stain to confirm the diagnosis would have been appropriate.  She stated that the general pathologist’s use of eleven stains suggested a lack of knowledge both as to the appearance of malignant melanoma and as to the appropriate use of special stains.  She emphasized the unnecessary expense added to the patient’s treatment because of the use of these stains.

The general pathologist defended his use of stains in this case.  He stressed that this patient had no clinical history of cancers.  He further noted that he does not have the ability to do stains in his own lab and that specimens must be sent out for staining.  The general pathologist explained that the process involves several days and patients are often anxious to receive a diagnosis.  He noted that he orders all stains he might need when he sends slides out so as to avoid having to send them out a second or third time.  The general pathologist reported he has never had an insurer question his use of stains and that he is of the opinion that the number and type of stains to be used are at the discretion of the physician.  He stressed that his diagnosis of malignant melanoma was correct in this case and that a previous punch biopsy performed by an outside facility on a skin lesion on the patient’s right arm had been misdiagnosed as benign.  After the general pathologist’s diagnosis, the facility that reviewed the specimen from the punch biopsy amended its diagnosis accordingly.

Another pathologist agreed with the general pathologist’s diagnosis.  The other pathologist stressed that it is in the pathologist’s prerogative as to how many stains to order.  He noted that the general pathologist received the patient’s slides without a medical history.  The other pathologists admitted that he might have begun with fewer stains, but he appreciated that the general pathologist might have felt the need to order additional stains in order to rule out other types of malignancies.  The other pathologist was unwilling to deem the order of multiple stains a deviation from the stand of care.

The other pathologist further agreed with the general pathologist that misreading the patient’s previous punch biopsy by an outside facility demonstrates the difficulty of diagnosing melanocytic lesions.

The Board was unconvinced that the evidence presented regarding the general pathologist’s use of special stains met the definitions of either professional incompetence or practice harmful or detrimental to the public.  The state argued that the evidence showed a lack of appropriate knowledge as to when and which special stains to use.

For other various allegations, 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 general pathologist was warned that such practice in the future may result in further disciplinary action against his medical license.

For other various allegations, 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: No error found


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



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