Found 97 Results Sorted by Case Date
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Florida – General Surgery – Right Colectomy Of The Patient’s Ascending Colon Instead Of A Left Colectomy Of The Descending Colon



A 49-year-old female presented to a general surgeon for a colonoscopy.  During the colonoscopy the general surgeon documented a 25mm polyp in the patient’s descending colon.  Due to its size, the general surgeon was only able to partially resect the polyp.  He placed a hemostatic clip to prevent bleeding and tattooed the area.

The patient was subsequently referred to the general surgeon for surgical resection of the left colon.

On 7/15/2015, the patient presented to the general surgeon for a preoperative history and physical.  On 7/15/2015, the general surgeon documented that a doctor incompletely resected a polyp in the patient’s colon, and identified the planned procedure as a right colectomy.

On 7/20/2016, the patient presented to the general surgeon at a community hospital.  On 7/20/2016, the general surgeon performed a right colectomy of the patient’s ascending colon.

The Board judged that the general surgeon’s conduct to be below the minimum standard of competence given that he performed a wrong-site procedure when he performed a right colectomy of the patient’s ascending colon instead of a left colectomy of her descending colon.

The Board ordered the general surgeon to pay a fine of $4,015.23.  The general surgeon was ordered to complete five hours of continuing medical education in “Risk Management.”  Also, the Board ordered that the general surgeon present a one hour lecture/seminar on wrong site and/or wrong procedures to medical staff at an approved medical facility.

State: Florida


Date: December 2017


Specialty: General Surgery


Symptom: N/A


Diagnosis: Gastrointestinal Disease


Medical Error: Wrong site procedure


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Critical Care Medicine – Intensivist Unavailable To Assess Patient With Metabolic Acidosis, Abdominal Pain, And Vomiting



On 10/19/2011 at 5:23 p.m., a 35-year-old male presented to the emergency department at a hospital with a chief complaint of abdominal pain and vomiting, which started approximately five hours before he presented to the hospital.

The patient was admitted to the hospital under the service of an intensivist and was notified of his arrival and condition at 5:35 p.m.

Between the hours of 5:50 p.m. and 7:22 p.m. the intensivist gave verbal orders of Dilaudid and ketorolac to the patient’s nurse.

At 9:20 p.m., the intensivist gave telephonic orders to the patient’s nurse, to place him on his home BIPAP mask.

On 10/20/2011, at 3:15 a.m. a rapid response was called due to an acute change in the patient’s respiratory status.

During the rapid response, an arterial blood gas (“ABG”) was drawn that revealed critical metabolic acidosis.

The intensivist never presented to the emergency room to assess the patient when he demonstrated medically dangerous/life-threatening signs at 3:15 a.m. or any time thereafter.

The intensivist never attended to the patient when his clinical situation was from an unknown cause and when a clear treatment plan had not been determined.

From 3:43 a.m. to 4:15 a.m., the critical care practitioner was contacted approximately five times with information on the patient’s medically unstable and deteriorating condition.

At 3:45 a.m., the patient became short of breath, restless, diaphoretic, and seizure episodes followed.  He was then transported to an intensive care unit.

At 5:25 a.m., a second rapid response was called due to a further decline in the patient’s health.  The rapid response turned into a code blue.

The patient underwent a cardiopulmonary arrest, and the code team was unable to resuscitate him.

On 10/20/2011, the patient expired at 6:25 am.

The autopsy results were consistent with acute hemorrhagic pancreatitis with diffuse pancreatic necrosis.

The Medical Board of Florida judged the intensivist’s conduct to be below the minimal standard of competence given that he failed to presented to the emergency room to assess the patient when the patient demonstrated medically dangerous/life-threatening signs on 10/20/2011 at 3:15 a.m.

The Medical Board of Florida issued a letter of concern against the critical care practitioner’s license.  The Medical Board of Florida ordered that he pay a fine of $7,500 against his license and pay reimbursement costs for the case at a minimum of $4,503.10 and not to exceed $6,503.10.  The Medical Board of Florida ordered that the critical care practitioner complete ten hours of continuing medical education in the area of critical care medicine and complete five hours of continuing medical education in “risk management.”

State: Florida


Date: December 2017


Specialty: Critical Care Medicine, Emergency Medicine, Pulmonology


Symptom: Abdominal Pain, Nausea Or Vomiting


Diagnosis: Gastrointestinal Disease


Medical Error: Failure to properly monitor patient


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Florida – Radiology – Gastrografin GI Series Performed to Ascertain GI Leak But No Leak Reported By Radiologist



On 6/23/2014, a 66-year-old male presented to the Physicians Regional Medical Center for gastric bypass surgery.

Following the gastric bypass procedure, on 6/24/2014, a radiologist performed a Gastrografin upper GI series on the patient to ascertain whether there was a leak or obstruction in the patient’s digestive tract.  A leak of contrast material was visible on radiographic images obtained by the radiologist during the procedure;  however, the radiologist failed to detect the leak in the patient’s digestive tract and reported a negative GI series.  The patient was subsequently discharged from the hospital.

Approximately thirty hours after his discharge, the patient returned to the hospital suffering from abdominal pain and sepsis.  It was discovered that the patient had a perforation in his digestive tract.  During surgery to repair this perforation, the patient suffered cardiac arrest and anoxic brain injury.  The patient ultimately expired as a result of these complications on 7/10/2014

The Board judged the radiologist’s conduct to be below the minimum standard of competence given his failure to detect a leak in the patient’s digestive tract during the performance of a Gastrografin upper GI series.

State: Florida


Date: December 2017


Specialty: Radiology


Symptom: N/A


Diagnosis: Acute Abdomen


Medical Error: False negative


Significant Outcome: Death, Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Emergency Medicine – Patient With Intussusception Involving Loop Of Small Bowel Discharged Home With Magnesium Citrate



At 1:45 a.m. on 7/26/2014, a 46-year-old female presented to the emergency department with complaints of severe abdominal pain.  Upon arrival at the emergency department, the patient was evaluated by the ED physician.

The patient complained of severe abdominal pain and stated the pain was “10 out of 10.”  The patient then underwent laboratory studies and a CT scan of the abdomen/pelvis with intravenous and oral contrast.

A radiologist reviewed the CT scan at some time before 4:16 a.m., when he read and signed the preliminary report.  Upon review of the CT scan results the radiologist recorded in the preliminary report “intussusception involving loop of small bowel in the left lower quadrant with involved loops appearing edematous.”  The radiologist relayed the results of the CT scan to the ED physician via teleradiology.

The ED physician recorded the results of the CT scan in the patient’s emergency provider report and noted “thickened loop of small bowel in the left lower quadrant, [m]ay be intussuception [sic].”

At 4:32 a.m. the ED physician discharged the patient to her home with a magnesium citrate prescription and no additional discharge instructions.

At 8:28 a.m. a physician signed the final radiology report and noted “[i]ntussesception involving loop of small bowel in the left lower quadrant” and “preliminary report related to referring physician teleradiology at the time of the exam by the radiologist.”

Later that day, the patient developed worsening pain, and presented to another emergency department, and underwent an emergency surgery for resection of necrotic bowel.

The Board judged the ED physician’s conduct to be below the minimum standard of competence given his failure obtain emergent surgical consultation for further evaluation and treatment and continue hospitalization for operative intervention or ongoing evaluation of abdominal pain.

The Board ordered the ED physician to pay an administrative fine in the amount of $8,000.  Also, the Board ordered the ED physician to complete five hours of continuing medical education in the area of emergency medicine.

State: Florida


Date: December 2017


Specialty: Emergency Medicine


Symptom: Abdominal Pain


Diagnosis: Acute Abdomen


Medical Error: Improper treatment, Referral failure to hospital or specialist


Significant Outcome: Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Interventional Radiology – Guidewire Found In Patient’s Abdomen Following CT-Guided Percutaneous Drainage



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

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

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

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

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

State: Florida


Date: November 2017


Specialty: Interventional Radiology


Symptom: Abdominal Pain


Diagnosis: Post-operative/Operative Complication, Acute Abdomen


Medical Error: Retained foreign body after surgery


Significant Outcome: Hospital Bounce Back


Case Rating: 2


Link to Original Case File: Download PDF



California – Gastroenterology – Endoscopy In High Risk Patient With Esophageal Scleroderma Results In Complications



A 69-year-old male with diffuse systemic sclerosis, interstitial lung disease, end stage renal disease on hemodialysis, anemia, hypertension, hypoalbuminemia, secondary hypothyroidism, and gastric antral vascular ectasia (“GAVE”) had been referred to a gastroenterology clinic for evaluation of recurrent problems with weight loss and dysphagia.  It was assumed that the patient’s disease had progressed to esophageal scleroderma and that a percutaneous endoscopic gastrostomy (“PEG”) would be necessary to bypass his esophagus and would allow him to take in adequate nutrition without swallowing.  The patient was referred to the gastroenterology clinic for evaluation and a PEG.

On 6/25/2012, the gastroenterologist ordered a PEG, and she scheduled an esophagogastroduodenoscopy (“EGD” or upper endoscopy) and esophageal manometry for the afternoon of 6/25/2012, both elective, non-emergent diagnostic procedures, scheduled to be done on an outpatient basis.  On 6/23/2012 or 6/24/2012, the patient had been discharged from the hospital on antibiotics with home oxygen administration after treatment for aspiration pneumonia.

The gastroenterologist performed a pre-endoscopy history and physical examination in the early afternoon of 6/25/2012 and noted that the patient had active diffuse scleroderma complicated by renal crisis, diffuse systemic sclerosis, interstitial lung disease, GAVE with multiple cauterizations, and end stage kidney disease.  In past medical history, she listed “scleroderma renal crisis, “Started dialysis December 30, 2011,” and “Pneumonia. Admitted to er 6/24/12.”  She noted that the patient had had multiple upper endoscopies for gastrointestinal bleeding prior to this EGD.  Her physical examination listed “Lungs: Clear Auscultation. Clear percussion and Normal Symmetry and Expansion.”  She noted that she, not an anesthesiologist, was ordering sedation.

Sedation was to be administered by a registered nurse.  The gastroenterologist listed Airway as Class 2 and ASA Level (American Society of Anesthesiologists physical status classification system) as 3 (severe systemic disease).

On 6/25/2012 at 2:48 p.m. and ending at approximately 3:15 p.m., the gastroenterologist performed an upper endoscopy on the patient and took biopsies.  Nursing records indicate that sedation consisted of midazolam, 7 mg, administered over the 22 minutes; fentanyl, 175 mcg administered over the 22 minutes, and Cetacaine spray applied to the throat prior to the procedure.

The patient was transferred from the endoscopy procedure room to the recovery area under the care of a registered nurse.  The nurse noted that the patient was unresponsive to verbal and painful stimuli, with blood pressure 108/70, heart rate 86, and O2 saturation 89% on 2 liters delivered by nasal cannula.  A face mask was applied at 10 liters O2 and oxygen saturation went up to 97%.  When the gastroenterologist was notified, she ordered reversal medications: flumazenil 0.25 mg IVP over 15 seconds and Narcan 0.4 mg IVP at 3:40 p.m., and the patient was still unresponsive.  A second dose of flumazenil 0.25 mg IVP was given at 3:43 p.m., and the patient became responsive at 3:44 p.m.  Once the patient was responsive, the gastroenterologist performed the esophageal manometry procedure.  No time is entered in the medical record for this procedure although the gastroenterologist acknowledges that it was done and the results are recorded.

The gastroenterologist was later notified by nursing staff of concerns with the patient’s breath sounds, and the gastroenterologist noted stridor at 4:26 p.m.  She was notified at 5:19 p.m. that the patient’s oxygen saturation was 89% on 5 liters oxygen delivered by nasal cannula.  At 5:20 p.m., the gastroenterologist ordered a chest x-ray due to the inability to wean the patient off oxygen after the endoscopy.  A face mask was applied at 10 liters oxygen at 5:21 p.m., and oxygen saturation went up to 93%.  The chest x-ray indicated “a dense retrocardiac opacity and a left pleural effusion” and a “volume loss in the left lung with mild shift of the mediastinum towards the left.”

After the manometry procedure in the recovery room, the patient’s oxygen saturation was monitored, and when the oxygen saturation remained above 90% for 30 minutes on room air, the patient met endoscopy discharge criteria.  The patient was discharged home with instructions concerning any complications that might arise.

The gastroenterologist states that she arranged to admit the patient to the hospital, but the patient left against medical advice (AMA).  Neither notation of this nor a signed AMA release was found in the record.  Pathology results revealed gastritis and the manometry procedure revealed a condition consistent with esophageal scleroderma.

On 6/27/2012, the patient presented to the emergency department with shortness of breath and cough.  Chest x-ray showed new right lung patchy opacities, and the patient was cachectic.  He was admitted to the intensive care unit for treatment of pneumonia.  The admission diagnosis was “most likely persistent pneumonia, likely aspiration due to esophageal dysmotility.”  The patient failed to improve despite intensive hospital care.  Although the gastroenterologist had scheduled a PEG for 7/2/2012, it was decided that the patient would not go through with the procedure.  Instead, it was decided that the medical team would provide palliative care for the patient.

On 7/4/2012, the patient died with the cause of death listed as aspiration pneumonia due to esophageal dysmotility and end-stage scleroderma with severe malnutrition as a contributing factor.

The Board deemed the gastroenterologist’s conduct as falling below the standard of care for the following reasons:

1) The gastroenterologist failed to provide an accurate analysis of the patient’s suitability for the endoscopic and manometry procedures.

2) She classified the patient as an ASA Level 3, which denotes an individual with stable multiple system disease that limits daily activity without immediate danger of death.

3) At the time of the EGD and manometry done by the gastroenterologist, the patient had just been released from another hospital, where he had been treated for aspiration pneumonia and discharged on antibiotics and home oxygen.

4) By reason of the patient’s recent aspiration pneumonia and the necessity for home oxygen administration, his ongoing scleroderma renal crisis which necessitated hemodialysis, his persistent interstitial lung disease, and his frequent bleeding and cauterizations for GAVE, his condition was not stable, and elective procedures at this time were contraindicated.  The patient’s classification was clearly ASA level 4, which denotes an individual with severe, incapacitating disease, poorly controlled or end-stage, at risk for death due to organ failure.

5) The gastroenterologist failed to provide for an anesthesiology consultation, given the patient’s unstable and life-threatening condition, and instead elected to provide conscious sedation directed by the gastroenterologist and administered by a registered nurse.  The level of sedation administered to the patient during the upper endoscopy procedure was relatively large for an individual with so many co-morbid conditions, and an anesthesiologist or nurse anesthetist should have been in attendance.

6) Since both procedures were elective, the gastroenterologist failed to reschedule the procedures for a time when the patient was stable and able to tolerate conscious sedation directed by the gastroenterologist and administered by a nurse.

7) The patient had a very unstable post-procedure course in the recovery room.  He was unresponsive to verbal and painful stimuli and oxygen saturation was below 90%.  Reversal medications had to be administered before the patient became responsive.  When the patient became responsive, the gastroenterologist performed the esophageal manometry in the recovery room.  This procedure was unnecessary to determine the need for a PEG and further endangered the health of the patient.

8) The respondent approved sending the patient home with instructions after his oxygen saturation was above 93% for 30 minutes.  The patient was a very high-risk patient for elective procedures and had had a very unstable post-procedure course in the recovery room, including the development or exacerbation of pneumonia.  Under these circumstances, in conjunction with his numerous co-morbidities, it was unsafe to send the patient home.  There was no record found of the patient leaving the clinic AMA.

The Board issued a public reprimand against the gastroenterologist.  Stipulations included continuing medical education in the topics of pre-operative patient evaluation, informed consent, sedation, and medical record keeping.

State: California


Date: May 2017


Specialty: Gastroenterology, Hospitalist, Internal Medicine


Symptom: GI Symptoms (GERD, Abdominal Distention, Dysphagia), Cough, Shortness of Breath, Weight Loss


Diagnosis: Gastrointestinal Disease, Pneumonia, Pulmonary Disease


Medical Error: Unnecessary or excessive treatment or surgery, Failure of communication with other providers, Lack of proper documentation


Significant Outcome: Death, Hospital Bounce Back


Case Rating: 5


Link to Original Case File: Download PDF



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



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

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

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

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

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

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

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

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

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

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

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

State: Florida


Date: May 2017


Specialty: Gynecology


Symptom: Pain


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


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


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



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



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

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

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

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

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

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

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

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

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

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

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

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

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

State: Florida


Date: May 2017


Specialty: Plastic Surgery


Symptom: Abdominal Pain, Nausea Or Vomiting


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


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


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



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



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

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

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

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

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

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

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

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

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

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

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

State: Florida


Date: May 2017


Specialty: Gynecology, Critical Care Medicine, General Surgery


Symptom: Abdominal Pain


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


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


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Rhode Island – Radiology – CT Scan After A Laparoscopic Cholecystectomy



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

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

State: Rhode Island


Date: April 2017


Specialty: Radiology


Symptom: N/A


Diagnosis: Acute Abdomen


Medical Error: False negative


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



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