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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
California – Internal Medicine – Rectal Cancer With Metastatic Disease, Fall, And A Perineal Wound
In July 2013, a patient was diagnosed with rectal cancer with metastasis to the liver. He was treated with chemotherapy. His course was complicated by colovesical fistula and scrotal abscess.
On 2/4/2014, the patient underwent a laparoscopic diverting colostomy. He had further chemotherapy after this operation.
On 7/7/2014, the patient went to Internist A’s office. At that time, the patient’s medication regimen included a fentanyl patch, hydrocodone-acetaminophen, hydromorphone, valium, zolpidem, and oxycodone-acetaminophen. Adderall was not listed as a prescribed medication in the patient’s medical records.
On 7/22/2014, the patient was admitted to the medical center after a fall at home. The accompanying diagnosis included syncope, dehydration, volume depletion, generalized weakness, and perineal wound. During that hospital stay, the patient was found to have streptococcal bacteremia, for which he was treated with intravenous antibiotics. In the emergency department’s record from the medical center, Adderall was listed in his prior to admission medication list. It was continued in the inpatient setting and carried over with his discharge orders at the time of transfer to a skilled nursing facility. Internist A did not perform a medication reconciliation when the patient’s care was transitioned.
On 8/2/2014, the patient was discharged from the hospital. At that time, his medication regimen was as follows: Adderall 20 mg daily; zolpidem 10 mg at bedtime; fentanyl patch 25 mcg every 72 hours; oxycodone 10-20 mg every 4 hours as needed; and diazepam 5 mg daily as needed. Based on the patient’s wife’s concern, the physician covering for Internist A discontinued the Adderall and the fentanyl patch. However, the discharge summary makes no mention of discharge medications. The patient was transitioned to a skilled nursing facility for continuation of intravenous antibiotics. He received physical therapy/occupational therapy there and intravenous antibiotics. He subsequently developed a fever.
On 9/18/2014, the patient was transferred back to the emergency department for tachycardia and was admitted to the hospital.
On 9/25/2014, the patient was discharged home with his spouse under hospice care. On 10/1/2014, the patient expired at home.
While at the skilled nursing facility, the patient’s wife was concerned that the patient was on too many medications, that he was not required to ambulate, and that is dentures were lost, which impaired his oral intake. During this period of time, the patient’s wife made multiple phone calls to Internist A, attempting to express her concerns about the care provided to her husband, but was unable to speak to Internist A. Internist A failed to communicate with the wife regarding her husband’s condition.
The Board felt that Internist A had practiced below the standard of care given failure to perform medication reconciliation at transitions of care. He failed to fulfill his responsibility as a treating clinician to update the patient’s wife. He failed to maintain accurate and adequate medical records. The patient’s perineal wound was not mentioned in his admissions notes or in subsequent follow-up notes.
The Board issued a reprimand against Internist A. He was ordered to comply with attending a course in medical record keeping.
State: California
Date: February 2017
Specialty: Internal Medicine, Hospitalist
Symptom: Weakness/Fatigue, Fever
Diagnosis: Sepsis, Colon Cancer
Medical Error: Failure of communication with patient or patient relations, Improper medication management, Lack of proper documentation
Significant Outcome: Hospital Bounce Back
Case Rating: 1
Link to Original Case File: Download PDF
Florida – General Surgery – Endocatch Bag Left In Patient’s Abdomen During Bowel Resection And Not Added To Surgical Count
On 5/11/2015, a patient underwent a routine colonoscopy. The colonoscopy revealed a small colon polyp; a subsequent biopsy of the polyp revealed it to be colon cancer.
On 5/18/2015, the patient presented to a hospital for bowel resection to be performed by a general surgeon.
During the course of the procedure, the general surgeon removed a portion of omentum and requested an endocatch bag, which was not added to the surgical count, to temporarily store the omentum.
The contents of the endocatch bag were too large to remove through the endocatch, and the general surgeon released the endocatch bag into the patient’s abdomen to be removed at the end of the procedure through the extraction site.
At the conclusion of the procedure the extraction site was closed and the endocatch bag was not removed from the patient’s body.
On 5/19/2015, the general surgeon verified with staff that the endocatch bag had not been removed and the patient was returned to surgery where the endocatch bag was successfully removed.
The general surgeon left a foreign body in a patient by leaving an endocatch bag inside the patient during a bowel resection procedure on 5/18/2015.
The Medical Board of Florida issued a letter of concern against the general surgeon’s license. The Medical Board of Florida ordered that he pay a fine of $4,000 against his license and pay reimbursement costs for the case at a minimum of $1,563.30 and not to exceed $3,563.30. The Medical Board of Florida also ordered that the general surgeon complete five hours of continuing medical education in “risk management” and complete a one-hour lecture/seminar on retained foreign body objects.
State: Florida
Date: December 2016
Specialty: General Surgery
Symptom: N/A
Diagnosis: Post-operative/Operative Complication, Colon Cancer
Medical Error: Retained foreign body after surgery
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
Wisconsin – General Surgery – Colorectal Mass, Bleeding, And Abdominal Discomfort With Subsequent Abdominal Perineal Resection And Colonoscopy
On 8/24/2009, a 39-year-old woman was referred to Surgeon A for a colorectal mass, bleeding, and abdominal discomfort. A rectal exam was not documented. The plan stated: “I will try to get the report from [Physician A] about the colonoscopic examination. In the meantime, we will go ahead and order a CT of the abdomen and pelvis.”
On 8/25/2009, after obtaining CT and colonoscopy pathology results, the following noted: “CT rectal mass, etiology? She needs biopsy before doing surgery. I will talk to [Physician A] … Pathology report at Columbia St. Mary.”
“It is adenocarcinoma, the lesion is very low, and needs abdominoperineal resection and permanent colostomy. The procedure is explained to her. She is willing to have surgery.”
On 8/26/2009, a consent form was signed and the surgeon performed an abdominal perineal resection with permanent colostomy. On 8/29/2009, the patient saw an oncologist, and on 9/4/2009, she saw a radiation oncologist. Subsequently, adjuvant therapies of chemotherapy and radiation were recommended and performed.
On 2/1/2009, the patient underwent revision of colostomy performed by Surgeon B.
Surgeon A was deemed to have fallen below the standard of minimal competence given that he failed to determine the exact location of the tumor within the rectum and did not perform a sphincter sparing surgery, which should have avoided the needed for a permanent colostomy. Surgeon A failed to offer Patient A the option of preoperative radiation and chemotherapy. He failed to recommend an oncology consultation prior to the initial surgery.
State: Wisconsin
Date: October 2016
Specialty: General Surgery, Gastroenterology, Oncology
Symptom: Abdominal Pain, Bleeding, Mass (Breast Mass, Lump, etc.)
Diagnosis: Colon Cancer
Medical Error: Unnecessary or excessive treatment or surgery, Diagnostic error, Failure of communication with other providers, Failure of communication with patient or patient relations
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 2
Link to Original Case File: Download PDF
California – Pathology – Colonoscopy Revealing Mass Of The Sigmoid Colon Along With A Vaginal Mass
In July 2013, a colonoscopy revealed that the patient had an adenocarcinoma involving the sigmoid colon. A vaginal mass was also detected and biopsied, which also revealed adenocarcinoma. Immunohistochemistry supported a vaginal primary.
On 10/8/2013, the patient underwent an exploratory laparotomy, lysis of adhesions, rectosigmoid colectomy with end-to-end anastomosis, proximal vaginectomy, and optimal tumor debulking. Specimens were collected and sent to pathology.
On 10/10/2013, a pathologist received the specimens. The pathologist failed to adequately document the original surgery in his pathology report or the importance of the primary cancer being in the vagina and its margins of resection. The pathologist instead analyzed the specimens as if he were reviewing a primary sigmoid colon cancer when in fact the sigmoid colon was secondarily involved by direct extension.
Per the Board, the pathologist failed to not provide adequate microscopic description and failed to evaluate the vaginal margins.
On 12/2/2013, the specimens were reexamined by another pathologist after concerns were raised with the initial pathologist’s pathology report. The new pathologist examined six additional slides in order to properly evaluate the vaginal margins. The pathology report was amended to indicate a vaginal carcinoma.
The initial pathologist incorrectly treated the mass as if it was a colon carcinoma rather than a vaginal carcinoma. He failed to take adequate sampling, failed to take appropriate margins, and failed to correctly identify the main residual tumor. The patient’s radiation therapy was delayed as a result of the misdiagnosis.
Based on this case and others, the Board placed the pathologist’s license on probation for 35 months with stipulations that the pathologist complete at least 40 hours of continuing medical education in the areas of deficient practice and undergo monitoring.
The Board restricted the pathologist’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, General Surgery, Gynecology
Symptom: Mass (Breast Mass, Lump, etc.)
Diagnosis: Gynecological (Endometrial, Ovarian, Cervical) Cancer, Colon Cancer
Medical Error: Diagnostic error, Lack of proper documentation, Procedural error
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
Washington – Urology – 5 And ½ Hours Long Partial Nephrectomy Operation
In June 2013, a 55-year-old male underwent an open hemicolectomy to remove colon cancer. Subsequent CT imaging revealed a 3.5 cm mass on the patient’s left kidney. PET scan imaging suggested that the kidney mass was not a metastasis of the colon cancer.
The patient was referred to a surgeon to address the mass on his left kidney. The surgeon elected to proceed directly to surgery. On 9/18/2013, the surgeon performed an open left partial nephrectomy in an attempt to remove the kidney mass. He experienced some difficulty in identifying the kidney mass during surgery and was assisted by a radiologist who performed an intraoperative ultrasound to help confirm the mass. However, post-operative pathology testing identified the excised tissue as normal kidney tissue. Subsequent abdominal imaging confirmed that the kidney tumor remained.
The surgeon’s unsuccessful operation took approximately 5 and ½ hours, including 62 minutes of ischemia due to clamping. The length of the surgery and the period of ischemia were excessive and created increased risk to the patient.
A subsequent treating surgeon biopsied the now 4 cm left kidney mass, which was confirmed by pathology testing to be clear cell renal carcinoma. In June 2013, the subsequent treating surgeon performed a laparoscopic, robotic-assisted surgical procedure to remove the patient’s left kidney (radical nephrectomy).
The Commission stipulated the surgeon reimburse costs to the Commission, allow a representative of the Commission to conduct annual practice reviews of his patient charts, have a proctor for all partial and radical nephrectomies, complete a course on the diagnosis and treatment of renal cancer, and write and submit a paper of at least 1000 words discussing this course and its application to his practice.
State: Washington
Date: January 2016
Symptom: N/A
Diagnosis: Cancer, Colon Cancer
Medical Error: Procedural error
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
Colorado – Radiology – CT Scan Of Abdomen And Pelvis Read As Mild Pelvic Inflammation And Probable Ileus
In October 2007, a 44-year-old female presented to the emergency department with complaints of abdominal pain and vomiting. A computerized tomography (CT) scan of the patient’s abdomen and pelvis was obtained for evaluation of the patient’s symptoms.
The radiologist interpreted a “preliminary report” of the CT scan as “mild pelvic inflammation, which may be secondary to menses or pelvic inflammatory disease. Consider pelvic ultrasound for further evaluation.” In addition, prominent loops of small bowel were noted, consistent with probable “ileus.”
The patient was later diagnosed with metastatic colorectal cancer in 2008. The finding was visible on the patient’s 2007 CT scan.
The Board judged the radiologist’s conduct as having fallen below the minimum level of competence given failure to correctly interpret the patient’s 2007 CT scan as metastatic colorectal cancer.
A Board issued a letter of admonition.
State: Colorado
Date: December 2015
Specialty: Radiology
Symptom: Abdominal Pain, Nausea Or Vomiting
Diagnosis: Colon Cancer
Medical Error: Diagnostic error
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
California – General Surgery – Abdominal Pain, Nausea, Vomiting, And Low White Blood Cell Count After Laparoscopic High Anterior Resection
On 5/9/2011, a general surgeon performed a laparoscopic high anterior resection with a takedown of the splenic flexure on a 57-year-old female with sigmoid colon cancer. The patient was discharged on 5/12/2011 and readmitted on 5/14/2011 with a sudden onset of abdominal pain, nausea, and vomiting. The patient’s white blood count (WBC) was 2.2, which was abnormally low and suggested a bad infection. The general surgeon treated the patient conservatively for 8 days with antibiotics.
On 5/15/2011, a CT scan showed a possible anastomotic leak with free air and fluid. A repeat CT scan on 5/16/2011 suggested peritonitis. On 5/22/2011, another surgeon reviewed the two earlier CT scans, saw that the patient’s WBC had risen to 20.5, and after ordering a new CT scan that showed a 15 cm abscess, decided to perform surgery on the patient to stop her persistent anastomotic leak. On 8/22/2013, when the general surgeon was interviewed by a Medical Board investigator, he conceded that he should have re-operated on the patient earlier.
In the operative report of the patient for 5/9/2011 procedure, the general surgeon failed to state how many ports were used, where the trocars were inserted, the distance of the anastomosis from the anal verge, how large an extraction incision was made, and where the extraction incision was located.
The Medical Board of California judged that the general surgeon’s conduct departed from the standard of care because he delayed in re-operating to correct the persistent anastomotic leak in the patient, and he failed to maintain accurate records.
The Medical Board of California issued a public reprimand and ordered the general surgeon to complete a medical record-keeping course and clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.
State: California
Date: June 2015
Specialty: General Surgery
Symptom: Nausea Or Vomiting, Abdominal Pain
Diagnosis: Post-operative/Operative Complication, Colon Cancer
Medical Error: Delay in proper treatment, Lack of proper documentation
Significant Outcome: Hospital Bounce Back
Case Rating: 3
Link to Original Case File: Download PDF
California – Family Medicine – Recurring Hemorrhoids And Blood In the Stool
A family practitioner saw a patient for various medical reasons from 1986 to 2009 with the first visit on 8/24/1984. During the period of 1986-2009, the patient also saw the family practitioner at least once a year for treatment of seasonal allergies. The family practitioner treated the patient’s allergies with non-sedating antihistamines and nasal steroids. During the period of 1986-2009, the family practitioner gave the patient yearly injections of steroids.
On 5/16/2000, the patient, who was 56-years-old, presented to the hospital complaining of chest pain. Another physician noted that his physical examination was unremarkable. A rectal examination showed external hemorrhoid, normal sphincter tone, mildly enlarged prostate, and a “ring” appreciated on rectal exam as well as heme-positive stool. The physician recommended a colonoscopy. The family practitioner saw the patient on 10/21/2003 for an evaluation. The family practitioner noted that the patient had been going to an outpatient clinic for a period of time and was not back under the care of the family practitioner. The family practitioner noted to recheck his blood studies in about a week.
On 11/5/2003, the family practitioner saw the patient and noted that the patient “has some rectal bleeding, appears to be hemorrhoidal.” The family practitioner also noted that “[the patient] is quite spooky and it is difficult to do a rectal on him” The family practitioner administered Procto-HC Cream for hemorrhoids and scheduled the patient for a colonoscopy for 12/8/2003 at 7:45 a.m. On 11/11/2003, the family practitioner saw the patient for an injured right toe. The x-rays were negative.
The colonoscopy scheduled for 12/8/2003 was canceled by the family practitioner. The family practitioner did not communicate to the patient why the colonoscopy was canceled nor did he try to reschedule the colonoscopy. On 7/2/2004, the family practitioner saw the patient for a complete physical examination. At this time, the patient was 61-years-old and presented with a chief complaint of “arthritis, recent shoulder surgery.” The physical examination was unremarkable. The family practitioner documented an enlarged prostate that was “typical for age and no other masses.”
On 2/18/2005, the family practitioner saw the patient, who presented with allergies, which began in the spring. The family practitioner noted that the review of systems was unremarkable. The family practitioner noted that the patient denied abdominal pain, melena, or bright red blood, nausea, vomiting, diarrhea, or constipation. The family practitioner didn’t document that he performed a rectal examination at this visit. The family practitioner noted: “Assessment: Allergic Rhinitis. Plan: Depo Medrol 80mg IM.”
The family practitioner next saw the patient on 2/23/2005. He documented that the “exam shows some hemorrhoid tissue. Prostate is slightly enlarged but palpates smoothly.” Lab work showed that the patient was positive for occult blood. On 3/25/2005, the family practitioner noted “patient in for review of lab studies. He is feeling better than he has in years.” The family practitioner didn’t discuss the positive occult blood report.
On 4/17/2006, the family practitioner saw the patient for a complete physical examination. The patient presented with a chief complaint of “some hemorrhoid irritation and bleeding at times and mild hypertension that is well controlled.” The physical examination was unremarkable. The family practitioner noted that the rectal examination was “negative, except for some hemorrhoidal tissue and somewhat enlarged prostate. No other masses.” The family practitioner prescribed Procto-HC cream to use for hemorrhoids.
On 5/8/2007, the family practitioner saw the patient for a complete physical examination. At this time, the patient was 64-years-old and had elevated lipids and a decrease in urinary stream. The family practitioner suspected the decrease in urinary stream was caused by allergy medication and noted the rectal examination was “negative, except for slightly enlarged prostate, but smooth and PSA was normal.” On 5/8/2008, the family practitioner saw the patient for a complete medical examination. The patient’s note for this visit listed in the rectal examination that the patient “shows very tight sphincter with perhaps some slight enlargement of prostate.” The patient next saw the family practitioner on 4/13/2009 for strain of the right knee related to playing softball.
On 7/16/2009, the family practitioner saw the patient at which time the patient’s chief complaint was chronic pain and swelling on the right knee and some erection difficulties. The family practitioner noted the rectal examination was “Negative exam. No masses noted.”
On 1/1/2010, the patient saw Physician A for rectal pain. Physician A noted that the patient “…just got back from Las Vegas and he feels like he has to go to the bathroom six to eight times a day and does not completely void very well, though he does get the stool out without too much difficulty.” Physician A noted that he suspected a “thrombosed hemorrhoid,” but did not see any evidence of that and, instead, on the rectal exam, observed a “nearly, if not circumferential firm mass that has reddish ting [sic] on it.” Physician A noted that he suspected rectal cancer and thought it was past being able to do a colonoscopy.
On 2/1/2010, the patient was seen in consultation by Physician B after the referral from Physician A. The patient had a chief complaint of probable rectal cancer adenocarcinoma. On the note under “history of present illness,” Physician B wrote that the patient reported that he had suffered from intermittent bleeding rectally for a long time, attributed to hemorrhoids. The patient had never had a colonoscopy. For several months, there was more frequent bleeding with bowel movements and some mid-sacral pain. Physician B performed a rectal exam and noted that there was an “annular ulcerating firm lesion starting at the top of the sphincter, highly suspicious for a lower third rectal cancer.” Physician B scheduled the patient for a colonoscopy and biopsy within the week.
On 2/2/2010, the patient underwent a CT scan of the abdomen and pelvis with contrast. The findings were “rectal cancer in a 55-year-old.” Impressions were noted as “circumferential thickening of the rectosigmoid junction. Suggestion of infiltrate change in the perirectal fat. Small nodularity seen with one node slightly enlarged suggesting the possibility of early adenopathy to the left pelvic sidewall area.”
On 2/5/2010, Physician B performed a colonoscopy and discovered a mass in the rectum that was 6 cm long and was palpated 4-10 cm from the anal verge. The mass was circumferential with residual lumen around 1.5 cm in diameter. The mass was biopsied. The pathology report on the biopsy reported “a poorly differentiated adenocarcinoma, focus suspicious for lymphovascular invasion.” A lower endoscopic ultrasound was done on 2/19/2010. A rectal mass was found. There was an extension of the mass into adjacent structures including internal and external anal sphincter muscles and prostate. Multiple malignant-appearing lymph nodes in the perirectal region, in the left iliac region and adjacent to the rectal mass, were also observed. The patient underwent preoperative radiation to shrink his tumor. The patient later required diverting colostomy in May 2010 and later hemodialysis. At the time of surgery, his cancer was noted to have invaded the local tissues and was deemed unresectable. The patient passed away on 6/22/2010.
The Medical Board of California judged that the family practitioner committed gross negligence in his care and treatment of the patient because he failed to provide appropriate colon cancer screening despite multiple opportunities to do so, diagnose colon cancer, evaluate and document undiagnosed rectal bleeding as a problem on the medical history form provided for that purpose, reschedule a colonoscopy that was ordered for rectal bleeding, properly address allergies on serial evaluations, and refer the patient to an allergy specialist despite non-response of the patient to daily nasal steroid and antihistamines.
The Medical Board of California ordered the family practitioner to surrender his license.
State: California
Date: March 2015
Specialty: Family Medicine, Internal Medicine
Symptom: Blood in Stool, Allergic Reaction Symptoms, Chest Pain, Extremity Pain, Joint Pain, Pelvic/Groin Pain, Urinary Problems
Diagnosis: Colon Cancer
Medical Error: Failure to order appropriate diagnostic test, Failure to examine or evaluate patient properly, Referral failure to hospital or specialist, Failure of communication with patient or patient relations, Failure to follow up, Lack of proper documentation
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF
Virginia – Family Medicine – Progressive Anemia With Right Flank Pain
A 71-year-old female had been the patient of a family practitioner from April 1981 to April 2008. On December 2006, the family practitioner diagnosed the patient with mild anemia. In January 2008, the family practitioner noted that the anemia had worsened and became significant.
The family practitioner claimed that the patient had refused to undergo regularly scheduled screenings. However, he failed to document these alleged discussions regarding the necessity of further testing and her refusal.
On 3/23/2007, the patient complained of pain in her right flank. Although the patient had a history of back pain, she began to have consistent complaints requiring 1-2 monthly follow-up visits to the family practitioner.
In March 2008, the family practitioner ordered a pelvic CT scan, which revealed numerous liver lesions and a cecal mass. She also had another mass in her cervical region and enlarged ileocolic lymph nodes. Subsequent colonoscopy revealed advanced stage colon cancer.
The Board issued a reprimand against the family practitioner.
State: Virginia
Date: February 2015
Specialty: Family Medicine
Symptom: Abdominal Pain
Diagnosis: Colon Cancer, Hematological Disease
Medical Error: Failure to order appropriate diagnostic test, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF