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Florida – Oncology – Rectal Mass And Bloody Stool Misdiagnosed As Cancer Instead Of Endometriosis
On 4/15/2015, a 48-year-old female presented to the Mayo Clinic for an assessment regarding cancer treatment.
The patient presented with a history of a palpable rectal mass and bloody stool. The patient presented to an oncologist after undergoing a colonoscopy and after a CT scan at Borland Grover Clinic revealed tumors suspicious for metastases.
The Borland Grover Clinic took a biopsy of the affected area. Initial pathology indicated suspicion for adenocarcinoma. Borland Grover clinic sent the sample to Cleveland Clinic for confirmation. Cleveland Clinic returned a diagnosis of endometriosis, not cancer.
The oncologist did not obtain the pathology reports from Borland Grover Clinic or Cleveland Clinic. The oncologist diagnosed the patient with rectal cancer with possible spread to the liver, lungs, and mediastinum. The oncologist ordered an endobronchoscopic ultrasound (EBUS). The patient’s EBUS showed some concern for cancer, but the pathologist deemed the results of the EBUS insufficient for a definitive cancer diagnosis.
Despite not having a pathologic diagnosis of cancer, from May to July 2015, the oncologist ordered the patient receive a port placement and three chemotherapy treatments.
Due to continuing rectal pain, on 7/6/2015, the oncologist referred the patient to a colorectal surgeon. As part of his review, the colorectal surgeon obtained the patient’s pathologic results from Borland Grover Clinic and Cleveland Clinic, which showed that the patient had endometriosis and not cancer.
On 7/16/2015, a Mayo Clinic pathologist reviewed the patient’s previous biopsy sample and came to a final diagnosis of endometriosis. On 9/3/2015, two doctors performed a procedure to remove the endometrioma.
The Board judged that the oncologist’s conduct to be below the minimum standard of competence given her failure to obtain a pathologic diagnosis of cancer prior to initiating cancer treatment for the patient.
The Board ordered the oncologist have her license revoked, pay an administrative fine, and have remedial education.
State: Florida
Date: December 2017
Specialty: Oncology, Internal Medicine
Symptom: Blood in Stool, Mass (Breast Mass, Lump, etc.)
Diagnosis: Gynecological Disease
Medical Error: Diagnostic error
Significant Outcome: N/A
Case Rating: 4
Link to Original Case File: Download PDF
California – Gynecology – High Grade Dysplasia Scheduled For Follow Up In 6 Months
On 12/31/2013, a 27-year-old female had a pap smear that showed Atypical Squamous Cells of Undetermined Significance (ASCUS) with a positive showing for HPV. On 1/30/2014, the patient presented to a gynecologist for colposcopy. Biopsies confirmed Cervical Intraepithelial Neoplasia (CIN) 2 at two biopsy sites, and CIN 1 at a single biopsy site with an insufficient endocervical curettage (ECC).
On 2/10/2014, the patient again presented to the gynecologist for a follow-up examination. The gynecologist diagnosed the patient with Moderate Cervical Dysplasia, CIN 2, and advised the patient to follow-up in 1 year with a PAP/HPV examination. On 2/28/2014, after speaking with a colleague, the gynecologist telephoned the patient and advised the patient to return in 6 months for an examination of the abnormal PAP.
The Medical Board of California judged that the gynecologist’s conduct departed from the standard of care because she failed to follow-up with the patient sooner than 6-12 months, and in light of the inadequate ECC, failed to proceed with either a diagnostic excisional procedure or an excision/ablation procedure to treat the high grade dysplasia known to the gynecologist.
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: N/A
Diagnosis: Gynecological Disease
Medical Error: Delay in diagnosis
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
California – Gynecologist – Complications After A Laparoscopic Assisted Vaginal Hysterectomy For Irregular Bleeding And Abdominal Pain
Sometime prior to 2011, a gynecologist began treating a patient with a history of a prior myomectomy in 2011, pre-diabetes, and fibromyalgia.
On 3/8/2011, the patient presented to the gynecologist with complaints of irregular vaginal bleeding with some pain in her right lower quadrant that worsened when she was on her period. The patient informed the gynecologist that she was “ready for a hysterectomy.” Medical records for this visit do not document the extent of the bleeding, whether or not the bleeding contributed to any other symptoms, the patient’s level of pain, or whether or not the pain interfered with the patient’s lifestyle. At the conclusion of this visit, the gynecologist referred the patient for a pelvic ultrasound with plans to follow up after the ultrasound.
On 4/5/2011, the patient had a pelvic ultrasound which showed the uterus was oriented anteverted and located midline. A fibroid was visualized in the right lateral aspect of the uterus that measured 5.3 by 4.2 by 5.3 centimeters. The endometrial stripe measured 12 millimeters. No other fibroids were seen. The left and right ovary were normal. There was no fluid in the cul-de-sac. The fibroid had increased in size compared to a prior ultrasound in 2010.
On 4/11/2011, the patient presented to the gynecologist for a follow-up. The gynecologist went over the results from the ultrasound and discussed possible treatment options. The gynecologist did not recommend or perform an endometrial biopsy to determine the reason for endometrial thickening or repeat the ultrasound to watch this condition. The gynecologist did not consider or document that the irregular bleeding could be caused by endometrial thickening, endometrial hyperplasia, or endometrial polyp. She did not recommend a dilation and curettage. At the conclusion of this visit, a decision was made for the patient to undergo a hysterectomy, which was scheduled to occur on 6/27/2011. The patient indicated that she wanted a bilateral salpingo-oophorectomy, but the gynecologist advised her to leave in the ovaries.
On 6/24/2011, the patient presented to the gynecologist for a preoperative evaluation. The gynecologist offered the patient medical and surgical options and the patient chose a hysterectomy. The gynecologist explained various surgical options, including risk factors and complications. During the physical examination of the patient, the gynecologist noted the patient’s uterus was bulky and that it did not descend well. The gynecologist did not document any observable vaginal bleeding or any pelvic pain with palpation of the pelvic organs. At the conclusion of this visit, the gynecologist had formed a surgical plan to include a total vaginal hysterectomy and depending on whether the uterus was mobile in the operation room, possible laparoscopic assisted vaginal hysterectomy, possible exploratory laparotomy, and possible cystoscopy.
On 6/27/2011, the gynecologist performed a laparoscopic assisted vaginal hysterectomy, bilateral salpingo-oophorectomy, cystoscopy, and lysis of adhesions on the patient. The medical records do not document a specific clinical reason for this choice in surgical technique versus a laparotomy approach.
During the surgery, the gynecologist encountered a web of filmy adhesions that were abundant along the back of both ovaries and continued along the back of the uterus. The adhesions connected the bowel to the uterus and ovaries.
There were also adhesions from the ovaries to the side walls. The gynecologist considered converting to an open procedure but opted to continue with laparoscopic dissection. After dissection of all of the adhesions, the gynecologist obtained a general surgery consultation as a precaution to review the small bowel, which had been adherent, especially near the right ovary. After observation through the monitor only, neither the surgeon nor the gynecologist noted any bowel injuries.
The gynecologist then proceeded with the vaginal hysterectomy portion of the surgery, which progressed “a bit more difficult than average but not remarkably so.”
Upon completion of the vaginal portion of the surgery, the gynecologist returned to the abdominal cavity. Upon doing so, she noted a slight oozing from the round ligament on the left, which she cauterized. The gynecologist then irrigated the pelvis and looked for any bleeding or injury but found none.
Prior to closing, the gynecologist requested a urology consultation. After cystoscopy and examination revealed no injury to the bladder or ureter, the gynecologist completed the procedure. The gynecologist’s detailed operative report does not specifically document the difficulties or complexities she encountered during the over eight-hour operation.
During the first three post-operative days, the patient experienced complications from the surgery that began to worsen. The patient’s symptoms included abdominal pain, distention, lack of appetite, bowel dysfunction, fever, tachycardia, weakness, emesis, and anemia.
After attempting to treat the patient with antibiotics and observation, on 7/5/2011, the patient was taken in for an exploratory laparotomy.
During the surgery, several liters of feces were found in the patient’s abdomen, which were suctioned out. Then, the abdomen was irrigated. Further into the surgery, a 1-centimeter tear in the distal sigmoid and another 3-centimeter tear in the proximal rectum were identified, repaired, and treated with a colostomy.
From 7/5/2011 to 8/1/2011, the patient remained hospitalized and experienced complications including but not limited to nausea, vomiting, fatigue, fever, tachycardia, wound infection, anemia, and significant leukocytosis. During this time period, the patient had to undergo radiological drainage of intraabdominal collections and was on several courses of antibiotics. The patient was discharged from the hospital on 8/1/2011, approximately thirty-five days after her total hysterectomy.
Per the Board, the gynecologist committed gross negligence in her care and treatment of the patient by continuing with a long and complicated abdominal and pelvic surgery through laparoscopy without converting to laparotomy to prevent multiple intraoperative injuries.
In addition, the Board judged the gynecologist’s conduct to be below the minimum level of competence given the performance of a total abdominal hysterectomy and bilateral salpingo-oophorectomy without definitive clinical indication and without consideration of alternative treatments, prior to consideration of a major surgery, and given failure to maintain adequate and accurate records relating to her care and treatment of the patient.
The Board issued a public reprimand with stipulations to complete a medical record keeping course.
State: California
Date: July 2017
Specialty: Gynecology, General Surgery
Symptom: Abdominal Pain, Fever, Gynecological Symptoms, Nausea Or Vomiting, Weakness/Fatigue
Diagnosis: Post-operative/Operative Complication, Gynecological Disease
Medical Error: Procedural error, Unnecessary or excessive treatment or surgery, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
Wisconsin – Gynecology – Pregnancy Test Performed Prior To Hysterectomy Turns Positive
On 12/27/2012, a patient with a history of uterine fibroids by ultrasound, two laparoscopies for adhesiolysis with bladder injury, presented to Gynecologic Oncologist A with complaints of a pelvic mass and endometriosis. It was noted that there was an enlarged tender mass on exam consistent with endometriosis and fibroids and that the patient wanted definitive surgical intervention.
The patient was scheduled for an elective robotic hysterectomy with bilateral salpingo-oophorectomy on 1/17/2013. The patient was planned for pre-operative lab testing, including a pregnancy test, within 72 hours of the scheduled surgery date.
The patient presented on 1/15/2013 to have pre-operative labs drawn. The lab results were logged into the patient’s chart the next day. These lab results included a positive pregnancy test. Registered Nurse A was responsible for collecting lab findings prior to the operation on a form. On that form, the “pregnant” and “lactating” questions were answered with a “no.”
On the day of surgery, Registered Nurse B was responsible for reviewing physician orders and labs. Registered Nurse C did not confirm the results of the patient’s pre-op pregnancy test. Anesthesiologist A signed an anesthesia pre-op order form which called for a pregnancy test on all patients similar to the patient, unless specifically waived. Anesthesiologist A did not obtain a waiver and did not confirm the results of the patient’s pre-op pregnancy test.
Gynecologic Oncologist A performed surgery on patient A, during which it was found that the patient was pregnant.
Anesthesiologist A and Gynecologic Oncologist A were deemed to have engaged in unprofessional conduct by engaging in conduct which increases the risk of danger to the health, welfare, or safety of a patient.
State: Wisconsin
Date: May 2017
Specialty: Gynecology, Anesthesiology
Symptom: Mass (Breast Mass, Lump, etc.), Gynecological Symptoms
Diagnosis: Gynecological Disease
Medical Error: Failure to follow up, Failure of communication with other providers, Lack of proper documentation, Procedural error
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
California – Gynecology – Administration Of Glacial Acetic Acid During A Gynecological Procedure
On 11/30/2011, a patient was prepared for a scheduled diagnostic laparoscopy, fulguration of endometriosis, loop electrosurgical excision procedure (“LEEP”), and r-ov cystectomy (remotely operated vehicle laparoscopic ovarian cyst removal) to be performed by a gynecologist.
On 11/30/2011 at 8:35 a.m., the patient was placed under anesthesia. The gynecologist requested Lugol’s solution (a combination of iodine and potassium iodide in water) from the operating room nurse for use in the patient’s LEEP. However, Lugo’s solution was not available. Therefore, the gynecologist directed the OR nurse to go to obtain a 5% acetic acid from the pharmacy.
When the OR nurse returned to the operating room, she entered through a door approximately fifteen to twenty feet from the operating table where the gynecologist was setting up the patient. The gynecologist asked the OR nurse to read the label to her. The OR nurse read aloud “acetic acid,” but did not read the concentration of the acid. The gynecologist did not ask about the concentration of the solution. The OR nurse poured the solution into a specimen cup. However, instead of bringing 5% acetic acid, the OR nurse brought the gynecologist Glacial acetic acid (a stronger form of acetic acid), obtained from a laboratory.
During the patient’s procedure, the gynecologist applied 5 or 10 cubic centimeters of the Glacial acetic acid solution from the specimen cup directly into the patient’s vagina and cervix, swabbed out the excess, and completed the procedure. The patient was discharged that same day.
On 12/5/2011, the patient was seen for a post-operative visit and was readmitted to the hospital for an examination under anesthesia and wound debridement for second degree burns to her vagina and buttocks. The patient’s records documented a complication of surgery due to thermal or chemical injury. The patient was discharged on 12/6/2011 but was later readmitted on 12/8/2011. There were no further hospitalizations. By 1/10/2012, the patient was noted to have returned to work.
The Board expressed concern that the gynecologist practiced below the standard of care given failure to confirm the concentration of the solution of acetic acid she requested with both visual and verbal validation. She did not use a read-back process with the OR nurse to verify critical information. On 11/30/2011, the gynecologist poured the solution of acetic acid directly into the patient’s vagina and cervix rather than applying the solution to the patient’s body with a cotton swab or a similar application item.
The Board issued a public reprimand and an order that the gynecologist complete no less than 40 hours of continuing medical education on gynecological surgical procedures.
State: California
Date: April 2017
Specialty: Gynecology
Symptom: N/A
Diagnosis: Post-operative/Operative Complication, Gynecological Disease
Medical Error: Accidental Medication Error, Procedural error
Significant Outcome: Hospital Bounce Back
Case Rating: 4
Link to Original Case File: Download PDF
California – Gynecology – Complications After Hysterectomy For Patient With Simple Hyperplasia Without Atypia And A History Of Infraumbilical Midline Incision
A 46-year-old female presented to a gynecologist in July 2011 complaining of vaginal bleeding. The patient had a history of ulcerative colitis and an infraumbilical midline incision. The patient next presented about one month later. The laboratory results included small fibroids, a small polyp, and a small ovarian cyst. Based on these findings, the gynecologist recommended and performed an endometrial biopsy. The result of the endometrial biopsy was simple hyperplasia without atypia. The gynecologist discussed the options for treatment with the patient and offered her medical treatment with repeat endometrial biopsy, dilation, and curettage with ablation, or hysterectomy.
The patient requested a hysterectomy with removal of both ovaries for definitive treatment. The gynecologist obtained consent for a robotic hysterectomy and discussed the risks of the procedure, which included the possibility of finding extensive adhesions that would require an open abdominal hysterectomy as opposed to the laparoscopic approach.
On 10/19/2011, the patient was taken to the operating room, where she underwent a diagnostic laparoscopy and a total abdominal hysterectomy and bilateral salpingo-oophorectomy. The findings at the time of surgery included an enlarged uterus with several small fibroids, normal ovaries, and normal fallopian tubes. There were excessive thick adhesions from the small bowel and omentum to the anterior abdominal wall and the left pelvic sidewall. There were also adhesions in the right upper quadrant from the omentum to the abdominal wall. The gynecologist used a closed technique to enter the abdominal cavity with a Veress needle. The gynecologist placed the patient in maximum Trendelenburg position and then made a small incision in the umbilicus and inserted the Veress needle. After removing the Veress needle, the gynecologist placed a 5 mm trocar and was able to visualize the adhesions. She then placed a second 5 mm trocar under direct visualization in the area clear of adhesions and used monopolar scissors for approximately 5 minutes in the attempt to lyse the adhesions. The gynecologist noted that the adhesions were very thick and extensive and included the bowel. She did not feel as though it was safe to proceed with the robot. The gynecologist removed the instruments and proceeded with an uneventful total abdominal hysterectomy and bilateral salpingo-oophorectomy through a Pfannenstiel incision.
The patient’s post-operative course was eventful. On the first post-operative day, she was noted to have a pulse of 130 bpm. She was in moderate pain despite IV pain medication. A CBC was drawn, which showed a normal WBC count of 3.5, but it showed 50% bands. The bandemia was not noted in the post-operative note. On the second post-operative day, the gynecologist saw the patient again at 2 p.m. and noted that the patient remained on oxygen. Her pulse also remained at 130. The gynecologist ordered an EKG and a chest x-ray, increased the pain medication, and advised the patient to ambulate. A CBC drawn that day was not mentioned in the post-operative note, but it showed a normal WBC count at 4.7 and again showed bandemia of 18%. The gynecologist wrote a discharge order at 2:20 p.m. on that day without any parameters.
Tachycardia persisted, and the patient developed shortness of breath, pain with breathing, and an oxygen saturation level of 82% for which the nursing staff called the Rapid Response Team. The patient was transferred to a critical care bed with the diagnosis of acute hypoxic respiratory failure and peritonitis, and the gynecologist on-call was notified. The gynecologist had signed out to the on-call gynecologist for the weekend. During that weekend, the patient’s condition continued to worsen. A CT scan performed on the evening of 10/22/2011 showed multiple fluid and air collections in the abdomen, mesentery, and abdominal wall. Various medical specialists as well as the gynecologist on-call evaluated the patient throughout the weekend. On the fifth post-operative day, a general surgeon was consulted, who immediately made the diagnosis of a bowel perforation and took the patient to the operating room for a bowel resection. The patient remained in the hospital and was discharged o 11/9/2011.
During the gynecologist’s care, treatment and management of the patient, the gynecologist obtained informed consent and, on multiple occasions, discussed the risks, benefits, and alternatives to the surgery and included the additional risks due to the patient’s earlier bowel surgery. As part of the alternatives to surgery, the gynecologist offered the patient an endometrial ablation, which is contraindicated in the presence of endometrial hyperplasia, as this is considered a precancerous condition. During an interview with representatives of the Medical Board of California, the gynecologist explained that she would no longer operate on this patient, but would refer her to the new gynecologic oncologist at another hospital.
At the time of the interview, the gynecologist was aware that the patient’s condition was precancerous since she would now refer the patient to an oncologist. Simple hyperplasia does not require referral to an oncologist, but, given that the pathology of simple hyperplasia is considered a precancerous condition, the offering of endometrial ablation as an alternative was not appropriate.
Bowel injury is a known complication during the performance of a hysterectomy, whether it is performed laparoscopically or as an open procedure. The risk of bowel injury is increased in a patient who, like this patient, had undergone a previous abdominal or bowel surgery and in a patient with a vertical midline incision.
The standard of care dictates that when the patient is at high risk for bowel injury, the surgeon must take all available precautions in order to avoid this complication and have a high index of suspicion of bowel injury if the patient’s post-operative course is complicated. The gynecologist was well aware of the patient’s higher risk for pelvic adhesions. The patient had a vertical midline incision from a previous colectomy, and on multiple occasions, the gynecologist discussed the high likelihood of adhesions with the patient.
The Medical Board of California judged that the gynecologist’s conduct departed from the standard of care because she did not use a safer technique when inserting the Veress needle, offered her the alternative of endometrial ablation, and failed to recognize in a timely manner that the patient had sustained a bowel injury.
The Medical Board of California placed the obstetrician on probation for 35 months and ordered the obstetrician to complete a medical record-keeping course and education course for at least 40 hours for every year of probation.
State: California
Date: November 2016
Specialty: Gynecology
Symptom: Abnormal Vaginal Bleeding, Pelvic/Groin Pain, Shortness of Breath
Diagnosis: Post-operative/Operative Complication, Gynecological Disease
Medical Error: Procedural error, Diagnostic error, Improper treatment
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
California – Gynecology – Laparotomy And Bilateral Cystectomy For Removal Of Benign Cysts With Subsequent Complication
During February and March of 2010, a patient was seen by her primary care nurse practitioner and was directed to conduct blood work to evaluate various physical symptoms. On 3/24/2010, the patient was seen by her nurse practitioner for evaluation of lab results. During the appointment, the nurse practitioner reviewed blood work results and ordered a pelvic ultrasound. The ultrasound revealed that the patient had very large cysts on both ovaries, measuring approximately 13 cm and 17 cm. The patient was referred to Gynecologist A for treatment of the large cysts and pelvic pain.
On 4/7/2010, the patient emailed Gynecologist A to inform her of the ultrasound results and seek treatment as needed. Gynecologist A recommended surgery to remove the cysts. The surgery was scheduled to take place on 6/2/2010. During a pre-operative appointment with Gynecologist A on 5/19/2010, the patient provided consent for the surgical procedure. The consent form indicated that the patient consented to a bilateral cystectomy, possibly by laparotomy, and the possible need for an oophorectomy. The patient was informed of risks of surgery, including the risk of damage to nearby organs.
On 5/23/2010, the patient presented to the emergency department with acute pelvic pain. She was seen the next day by Gynecologist B, who was aware that the patient’s Gynecologist A was in the operating room that day performing procedures. Gynecologist B telephoned Gynecologist A in the operating room to determine if the patient could be added to the surgical schedule on that day. The patient reported to the emergency department for evaluation and possible surgery.
On the same day, 5/24/2010, Gynecologist A performed surgery on the patient. Gynecologist A performed a laparotomy and a bilateral cystectomy. Gynecologist A sent two specimens of excised tissue to the laboratory for analysis and pathology report. On 5/25/2010, Gynecologist A reported that she conducted an examination under anesthesia, a bilateral ovarian cystectomy, and exploratory laparotomy. Gynecologist A described making a midline incision and removing large cysts from both ovaries. Gynecologist A described the ovaries, fallopian tubes, and uterus as unremarkable.
On 5/26/2010, two days later, a pathologist filed a report of the two specimens Gynecologist A obtained during the surgery. It showed that the first specimen comprised a right ovarian cyst with a fallopian tube densely adherent to the cyst, and the second specimen comprised a left ovarian cyst with a fallopian tube densely adherent to the cyst. The report further indicated all samples were found to be benign.
On 6/7/2010, the patient saw Gynecologist A for a post-operative appointment. Gynecologist A charted and informed the patient that the pathology report and laboratory findings showed that the cysts removed during the surgery had been benign. Gynecologist A did not inform the patient of the pathology report findings that portions of both fallopian tubes had been removed during the surgery.
On 5/14/2013, the patient was seen by a nurse practitioner in the Department of Obstetrics and Gynecology for complaints of pelvic pain and for a referral for infertility evaluation. During this appointment, the nurse practitioner reviewed the reports from the 5/25/2010 surgery and noticed that the surgical specimens obtained during surgery contained the fimbriated ends of both fallopian tubes, likely rendering the patient infertile.
On 6/13/2013, the patient underwent a hysterosalpingogram, which confirmed that her fallopian tubes were abnormal. On 6/25/2013, the nurse practitioner explained to the patient the results of the abnormal hysterosalpingogram, and the laboratory findings that her fallopian tubes had been removed during the 5/24/2010 surgery, which had not been previously disclosed to her.
The Medical Board of California judged that Gynecologist A’s conduct departed from the standard of care because she failed to adequately review and communicate the results of the pathology report showing the patient’s fallopian tubes had been removed during surgery.
The Medical Board of California placed Gynecologist A on probation for 35 months and ordered Gynecologist A to complete a medical record-keeping course, a professionalism program (ethics course), and an education course.
State: California
Date: November 2016
Specialty: Gynecology
Symptom: Pelvic/Groin Pain
Diagnosis: Gynecological Disease
Medical Error: Procedural error, Ethics violation, Failure of communication with patient or patient relations
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 3
Link to Original Case File: Download PDF
Wisconsin – Gynecology – Woman With History Of Breast Cancer, Rectal Cancer, Colorectal Resection, With Post-Menopausal Bleeding
In October 2013, a 62-year-old woman with a history of breast cancer, rectal cancer, colorectal resection, and ileostomy reversal presented to Gynecologist A for post-menopausal bleeding. Abdominal hysterectomy and bilateral salpingo-oophorectomy was recommended and a consent form was signed.
On 10/29/2013, Gynecologist A noted on the ultrasound the presence of a uterus and ovaries. Gynecologist A documented that the patient neither had a uterus nor ovaries.
On 11/25/2013, Gynecologist A performed an exploratory laparotomy with lysis of adhesions on the patient. As documented, Gynecologist A discussed with the patient and the family that she neither had a uterus nor ovaries.
On 3/10/2014, a gynecologist oncologist performed a total abdominal hysterectomy and bilateral salpingo-oophorectomy on the patient. It is not reported if the patient was eventually diagnosed with cancer.
The Board stated that Gynecologist A engaged in unprofessional conduct by increasing risk of harm to the patient. She was reprimanded with order for payment of costs.
State: Wisconsin
Date: November 2016
Specialty: Gynecology
Symptom: Gynecological Symptoms
Diagnosis: Gynecological Disease
Medical Error: Diagnostic error, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
California – Emergency Medicine – Presentation With Headache, Fever, And Abdominal Pain Discharged With 101 F And 140 BPM Vitals
On 7/17/2011 at 11:23 a.m., a 33-year-old female presented to the emergency department with complaints of a headache with fever and was seen by an ED physician. ED records indicated that she was seen the day before by another ED physician with a headache but no fever. Past medical history included an occasional migraine with no mention or neurological consult or CT scan. Vital signs included a temperature of 101 F and a pulse of 140 bpm. Pain scale was 9/10. No abdominal examination was noted. The patient was treated with Demerol and Phenergan 100/25 IM at 11:45 a.m., and pain was noted as 8/10 at 12:40 p.m. without vomiting. Dilaudid 1 mg was given at 1:00 p.m., and at 1:30 p.m., pain was noted to be 5/10. The ED physician diagnosed the patient’s fever as a viral fever but offered no advice concerning taking antipyretics for fever reduction. The patient was discharged at 1:35 p.m. with a fever of 103 F and a pulse of 130 bpm.
The next day, at 1:45 p.m., the patient returned to the emergency department with abdominal pain. This was the fourth emergency department visit in 2 days. Subumbilical pain of a severe nature was noted along with fever, nausea, and vomiting. Past medical history included a hysterectomy and bilateral tubal ligation, facts not included in the ED physician’s history for this patient, but noted by previous and subsequent ED physicians. The patient was afebrile at this time with a pulse of 113 bpm, but with a significantly lower blood pressure. Pain was noted at 10/10. Laboratory studies indicated infection, and a CT scan showed a complex mass in the right lower quadrant. Subsequent pre-operative history indicated that the patient had reported a 3-day history of lower abdominal pain associated with episodes of vomiting and fever. The surgery revealed a right tubo-ovarian abscess.
The Medical Board of California judged that the ED physician’s conduct departed from the standard of care because his final diagnosis did not follow from the patient’s history, physical, and work-up. The ED physician concluded that the patient’s migraine and tachycardia were triggered by a viral fever. The patient reported no symptoms consistent with a viral infection, such as congestion, cough, or nausea/vomiting with diarrhea. The patient had also presented the previous day with a headache but no fever, but it was unclear whether the ED physician knew this. The ED physician did not treat the patient’s fever with antipyretics and did not check for signs of an infectious process elsewhere. It was not clear from the ED physician’s records, however, whether the patient complained to him concerning abdominal pain and nausea/vomiting.
The ED physician inappropriately discharged the patient with abnormal vital signs. Before discharge from the emergency department, all significant vital sign abnormalities should be documented either as resolved (e.g. by treatment) or through an explanation as to why the abnormality was no significant or otherwise pertinent. The patient was discharged with a significant fever of 103 F and a high heart rate of 130 bpm. There was no appropriate explanation as to why it was safe to discharge the patient with this significant tachycardia and remarkable fever. Treatment with IV fluids and antipyretics was indicated and may have been diagnostic in that lack of resolution would have prompted a search for other causes.
For this case and others, the Medical Board of California placed the ED physician on probation for 5 years and ordered the ED physician to complete a medical record keeping course, an education course (at least 40 hours per year of probation), and a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine. The ED physician was assigned a practice monitor and prohibited from supervising physician assistants.
State: California
Date: September 2016
Specialty: Emergency Medicine
Symptom: Headache, Fever, Nausea Or Vomiting, Abdominal Pain
Diagnosis: Gynecological Disease, Sepsis, Acute Abdomen
Medical Error: Improper treatment, Failure to examine or evaluate patient properly, Improper medication management
Significant Outcome: Hospital Bounce Back
Case Rating: 3
Link to Original Case File: Download PDF
Washington – Gynecology – Ingestion Of Prescribed Pill By Physician Prior To Hysterectomy
On 12/16/2014, a patient presented to a gynecologist’s clinic with dysfunctional uterine bleeding (DUB), fibroids, and an enlarged uterus. The gynecologist performed a full history and physical, including a pelvic/abdominal examination. The gynecologist identified fibroids in the uterus and a thickened endometrium. The patient decided to have the gynecologist perform a robotically assisted laparoscopic vaginal hysterectomy.
On 12/17/2014, the gynecologist ingested medication and carried out the initial robotic portion of the scheduled laparoscopy. After performing the initial robotic portion of the laparoscopy, the gynecologist began to display erratic speech and movement. The gynecologist’s medical team noticed the gynecologist’s unusual behavior and called in another physician to assist. The gynecologist admitted that he accidentally ingested his sleeping medication instead of his intended daytime medication. While under the supervision of the assisting physician, the gynecologist proceeded with the dissection of the uterus and accidentally perforated the patient’s bladder. After this error occurred, the assisting physician and the gynecologist mutually agreed to have the assisting physician repair the patient’s bladder. Due to the bladder perforation, the patient was required to have a ureteral stent and intrapersonal drain placed into her pelvis.
The Commission stipulated that the gynecologist reimburse costs to the Commission, write and submit a paper with at least 1000 words, with references, on personal medication management and reporting of sentinel events and/or serious reportable events for surgeons, allow a representative of the Commission to make annual visits to his practice to review his records, and remain in compliance with his five year monitoring agreement with the Washington Physicians Health Program (WPHP).
State: Washington
Date: March 2016
Specialty: Gynecology
Symptom: Gynecological Symptoms
Diagnosis: Post-operative/Operative Complication, Gynecological Disease
Medical Error: Practicing while not being sound physically or mentally, Procedural error
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 1
Link to Original Case File: Download PDF