Found 13 Results Sorted by Case Date
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Florida – Gynecology – CBC Tests Show Neutropenia And Leukopenia At An Annual Gynecological Exam



On 8/15/2013, a 34-year-old female presented to a gynecologist for an annual gynecological exam.  At the exam, the patient expressed concerns about infertility.  The gynecologist and the patient discussed various tests that may be used to address infertility and the gynecologist began ordering tests.

On 2/23/2015, the patient gave blood for a complete blood count (“CBC”) test that was ordered by the gynecologist.

On 3/5/2015, the gynecologist received and signed for the results of the CBC test.  The CBC test indicated the patient had an abnormal white blood cell count, marked leukopenia, and severe neutropenia.

The gynecologist failed to notify the patient of the abnormal results of the CBC test.

The gynecologist failed to ensure that the patient had otherwise established a plan of care to address the abnormal results of the CBC test.

On 5/28/2015, the patient presented to the gynecologist for an annual gynecological exam.  At the exam, it was determined that the patient was pregnant, and the gynecologist ordered blood tests for the patient.  The gynecologist failed to order a repeat CBC test.

On 7/17/2015, the gynecologist received and signed for the results of the repeat CBC test.  The repeat CBC test indicated that the patient’s white blood cell count had decreased further, the neutropenia had worsened, and she now had pancytopenia with a drop in the red blood cell and platelet count.

On 7/30/2015, the gynecologist notified the patient of the results of her repeat CBC test and referred her to a hematologist.

On 8/8/2015, the patient experienced a massive intracranial hemorrhage with herniation, as well as severe pancytopenia.

On 8/12/2015, the patient expired in the hospital.  The fetus was also lost at that point.

The Medical Board of Florida judged the gynecologists conduct to be below the minimal standard of competence given that she failed to ensure that the patient had been notified of the abnormal results of the CBC test.  The gynecologist failed to ensure that the patient had otherwise established, a plan of care to address the abnormal results of the CBC test.  The gynecologist failed to order a repeat CBC test at the patient’s May exam.

The Medical Board of Florida issued a letter of concern against the gynecologist’s license.  The Medical Board of Florida ordered that the gynecologist pay a fine of $8,500 against her license and pay reimbursement costs for the case at a minimum of $3,126.31 and not to exceed $5,126.31.  The Medical Board of Florida ordered that the gynecologist complete five hours of continuing medical education in “risk management.”

State: Florida


Date: December 2017


Specialty: Gynecology, Obstetrics


Symptom: N/A


Diagnosis: Hematological Disease, Intracranial Hemorrhage


Medical Error: Failure to follow up, Delay in proper treatment, Failure of communication with patient or patient relations


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



California – Family Practice – Providing Medical Clearance For A Tummy Tuck Procedure



A family practitioner cleared a patient for a tummy tuck procedures.  The patient had a history of sickle cell anemia and a respiratory infection.

The Board judged the family practitioner’s conduct as having fallen below the minimum level of competence given failure to address the status of the patient’s sickle cell anemia and failure to assess the patient’s respiratory infection.

The Board issued a public letter of reprimand.

State: California


Date: October 2017


Specialty: Family Medicine, Internal Medicine


Symptom: N/A


Diagnosis: Hematological Disease, Infectious Disease


Medical Error: Improper treatment


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Gastroenterology – Complication During Endoscopy With Colonoscopy For Nausea, Vomiting, And Epigastric Pain After Bone Marrow Transplant



On 11/17/2011, a 56-year-old female underwent a colonoscopy performed by a gastroenterologist.  The patient had undergone a bone marrow transplant for chronic lymphocytic leukemia.  After the procedure, the patient complained of nausea, vomiting, and epigastric pain.  An endoscopy was performed the prior day to rule out graft versus host disease or cytomegalovirus infection and the colonoscopy was a part of that procedure.

The gastroenterologist performed the coloscopy to the terminal ileum.  The patient was sedated with midazolam 8 mg IV, fentanyl 175 micrograms IV, and diphenhydramine 50 mg IV in divided doses as the patient exhibited any signs of discomfort.  Biopsies and cultures were obtained and submitted for evaluation.  Pathology results indicated apoptosis of the ileum and right colon, but negative findings for CMV.

During the course of the colonoscopic procedure, full sedation was not achieved.  The patient became drowsy, but she became fully awake during the procedure more than once, complained of pain, and asked that the procedure be stopped.  The gastroenterologist continued and completed the procedure despite the patient’s urgent requests.

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, Anesthesiology, Hematology


Symptom: Abdominal Pain, Nausea Or Vomiting


Diagnosis: Post-operative/Operative Complication, Hematological Disease


Medical Error: Procedural error


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Pediatrics – Fourteen-Year-Old Male With A Hemoglobin Of 8.2



On 7/30/2013, a 14-year-old male was seen by a pediatrician for a well-child assessment.  The pediatrician reviewed the patient’s height, weight, temperature, and blood pressure and administered hearing and vision tests.  She reviewed the patient’s development, including body image, home situation, education, school progress, risk-taking behaviors, sexuality, and mental health.  A complete physical examination was performed.

On 7/30/2013, the patient received a routine HPV immunization.  Routine diagnostic laboratory tests were ordered, including urinalysis.  A hemoglobin test by finger stick was performed.  The patient’s urinalysis test result was normal, but his hemoglobin result of 8.2 was significantly lower than normal.  The pediatrician repeated the hemoglobin test by finger stick but did not order a complete blood count by venipuncture.  The patient’s hemoglobin result was again 8.2.  The pediatrician started the patient on iron supplement therapy and instructed him to follow up in three months.  No additional diagnostic tests were done during this visit.

On 8/18/2013, the clinic received a report that the patient was experiencing shortness of breath and chest pain.  The patient was instructed to go to an emergency room.

At the emergency room, the patient experienced a full cardiac arrest.  His complete blood count revealed severe anemia, with a hemoglobin result of 7.5, a hematocrit of 21, 99 atypical lymphocytes, and a critically low platelet count of 39,000.  The patient’s cause of death was acute lymphoblastic leukemia/lymphoma.

The Board deemed the pediatrician’s level of conduct to be below the standard of care given failure to order a complete blood count by venipuncture for the follow-up blood test, failure to schedule a visit and lab check at an earlier date, and failure to consider other diagnoses in addition to iron deficiency anemia.

The Board issued a public reprimand against the pediatrician.  Stipulations included performing sixty hours of free services to a community or a non-profit organization, conducting 40 hours of continuing medical education, enrolling in a professionalism program, and undergoing a clinical competency assessment program.

State: California


Date: May 2017


Specialty: Pediatrics, Hematology


Symptom: Shortness of Breath, Chest Pain


Diagnosis: Cancer, Hematological Disease


Medical Error: Failure to order appropriate diagnostic test, Delay in proper treatment


Significant Outcome: Death


Case Rating: 5


Link to Original Case File: Download PDF



Arizona – Internal Medicine – Platelet Count Of 1,105,000 Found At A Routine Clinical Visit



The patient was a 77-year-old man with a history of paroxysmal atrial fibrillation, hypertension, hypothyroidism, depression, osteopenia, and Parkinson’s disease, who had been previously treated by an internist at his prior practice.

On 04/25/2014, the patient reestablished care with the internist, who performed a wellness visit.  Labs completed the prior week showed a platelet count of 1,105,000 and further commented that there were 1+ giant platelets and 1+ large platelets.

The physician documented that the labs were reviewed with the patient, but there was no documentation that the physician addressed the patient’s elevated platelet count.

On 06/20/2014, the patient presented to the emergency department with fatigue and tiredness.  He was found to have a hemoglobin of 5.3, hematocrit of 16.7, platelet count of 1155K, and WBC of 16K.  The admitting physician noted that the patient’s prior CBC also showed a platelet count of 1105K.  The patient reported that he had never seen a hematologist or oncologist.  The patient was evaluated by both a GI consultant and hematologist who diagnosed the patient with iron deficiency and reactive thrombocytosis.  The patient was also subsequently diagnosed with myelodysplasia.

The Board judged the internist’s conduct to be below the minimum standard of competence given failure to manage the elevated platelet count level in a timely manner.

On 04/2016, an interim order was issued for the internist to complete a competency evaluation.  The internist appealed.  On 08/04/2016, the Board denied the internist’s appeal of the interim order.  The provider submitted his intention to retire.  Given concern that the internist had also performed below the standard of care in a multitude of cases, the Board elected to restrict his practice and prohibited from practicing medicine in the state of Arizona.  They ordered that he complete and pass a competency evaluation in order to reverse the practice restriction.

State: Arizona


Date: January 2017


Specialty: Internal Medicine


Symptom: Weakness/Fatigue


Diagnosis: Hematological Disease


Medical Error: Failure to follow up


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Pathology – Biopsies Of Patient’s Eleventh, Twelfth, And Thirteenth Thoracic Vertebrae To Evaluate Fractures



On 2/21/2013, a patient had biopsies of his eleventh, twelfth, and thirteenth thoracic vertebrae to evaluate fractures.  On 3/2/2013, a pathologist reviewed the biopsies.  The pathologist provided a diagnosis of no malignancy.  He reviewed slides H and E in making his diagnosis.

In July 2013, slides H and E were sent to an outside laboratory and the outside laboratory determined that the patient suffered from myeloma, a malignant tumor of the bone marrow.  Further immunohistochemistry was conducted which confirmed the diagnosis of myeloma.

The pathologist failed to recognize that a mid to elderly patient with vertebral fractures could be suffering from myeloma and failed to observe the findings on the slides that indicated the presence of myeloma.

Based on this case and others, the Board revoked the pathologist’s license and placed him 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, Hematology, Internal Medicine


Symptom: N/A


Diagnosis: Cancer, Hematological Disease


Medical Error: False negative


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Family Medicine – Patient With Blood Coagulation Disorder Has Anticoagulation Improperly Managed For A Dental Procedure



A patient was diagnosed with a hypercoagulable disorder and was on Coumadin prior to being treated by a family practitioner.

On 1/12/2015, the patient had his INR level checked.  It was noted to be subtherapeutic.  The patient’s Coumadin dosage was increased.  He was advised to have it rechecked in two weeks.

On 1/21/2015, the patient’s dentist requested medical clearance from the family practitioner for dental surgery.  The family practitioner indicated to the dentist that it was acceptable to stop Coumadin six days before surgery, and the patient was given medical clearance.

On 1/29/2015, the patient went to the family practitioner ahead of dental surgery.  The family practitioner discovered that the patient had not yet stopped the Coumadin, even though it should have been stopped two days previously for the upcoming 2/2/2016 scheduled surgery.  The family practitioner then advised the patient to restart the Coumadin the day of the surgery.

The family practitioner never reviewed the patient’s INR levels before the surgery, especially once he knew the Coumadin had not been stopped in time.  The family practitioner never provided bridging therapy, before or after the surgery.

On 2/2/2015, the patient had the dental surgery.  The patient restarted Coumadin on the instructions of the family practitioner.

That afternoon, the patient had bihemispheric strokes resulting in encephalopathy, seizures, and respiratory failure, ultimately leading to death.

An INR level taken in the hospital that evening indicated a non-therapeutic level for a blood clotting disorder.

The Medical Board of Florida judged the family practitioner’s conduct to be below the minimal standard of competence given that he failed to check the INR levels more closely and provide bridging therapy for the blood coagulation disorder.

It was requested that the Medical Board of Florida order one or more of the following penalties for the family practitioner: permanent revocation or suspension of his license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Medical Board of Florida deemed appropriate.

State: Florida


Date: September 2016


Specialty: Family Medicine, Internal Medicine


Symptom: N/A


Diagnosis: Ischemic Stroke, Hematological Disease


Medical Error: Improper medication management, Failure to properly monitor patient


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Virginia – Internal Medicine – Hemodynamically Stable Patient With Hemoglobin Of 4.6



On 6/30/2015, a 57-year-old female had blood work, which revealed that her hemoglobin was at 4.6 gm/dL.  According to the internist who had ordered the blood work, his office telephoned the patient several times regarding the low hemoglobin level.  When the patient did not answer her phone, the internist’s nurse left a message for the patient.  The internist called in a prescription for iron supplements.  The internist said that in a follow-up conversation with the patient and her husband, the patient informed him that she had been staying at a hotel and did not receive the message from his office.

On the morning of 7/7/2015, the patient replied to the previously left messages from the internist’s office.  The patient came to the office later that afternoon, and the internist evaluated her and found her hemodynamically stable.  The internist sent the patient to the lab next door to his office for a type and crossmatch in order to prepare for a transfusion.

The lab report indicated that the patient’s hemoglobin level was critically low at 2.9 gm/dL.  Upon receiving the results, the internist immediately contacted the lab but was not able to reach the technician.  The patient was advised by lab personnel to report to the emergency department.  The patient was admitted to the hospital for immediate treatment and was discharged on 7/9/2015.

The Board noted that the internist did not immediately refer the patient to a gastroenterologist despite a history of gastroesophageal reflux disease and dysphagia in the setting of severe anemia.

The internist stated that should a similar situation arise where the patient is unreachable by phone and is experiencing a medical emergency, he plans to contact the Sheriff’s office to have a deputy go to the patient’s home.

The Board ordered the internist to complete a continuing medical education course on the subject of anemia.

State: Virginia


Date: April 2016


Specialty: Internal Medicine, Family Medicine


Symptom: GI Symptoms (GERD, Abdominal Distention, Dysphagia)


Diagnosis: Hematological Disease


Medical Error: Failure of communication with patient or patient relations, Improper treatment


Significant Outcome: N/A


Case Rating: 5


Link to Original Case File: Download PDF



Virginia – Internal Medicine – Elevated White Blood Cell Count With Immature Granulocytic Cell Population



On 10/28/2013, a patient’s laboratory results, as reviewed by an internist, indicated a markedly elevated white blood cell count and immature granulocytic cell population.  The pathologist’s blood smear review and consultation report noted immature granulocytic cell findings along with nucleated red blood cells and abnormal red blood cell morphology on smear, and suggested “full hematologic evaluation if clinically indicated.”  The internist did not order a full hematologic evaluation for the patient as recommended by the pathologist.

On 12/3/2013, the laboratory blood test results, which the internist reviewed and signed, again indicated a markedly elevated WBC and granulocytic cell population.  The internist again did not order a full hematologic evaluation for the patient.

On 5/28/2014, the patient presented to another physician who ordered laboratory results.  When the blood test results indicated a markedly increased number of white blood cells, the physician referred the patient to a hematologist-oncologist, who diagnosed the patient with a myeloproliferative neoplasm.

The internist stated that she did not order a hematologic evaluation after receiving the 10/28/2013 because she did not believe it was clinically indicated at that time.  The internist had ordered it for 12/13/2013 and reviewed the results and had planned to consider referral to a specialist based on the next lab work results.

The internist stated that she expressed concern to the patient about his white blood cell count during his 1/7/2014 office visit.  At that visit, which was a “sick visit,” the patient informed her that he was leaving the country in eight days for a three-month visit to Vietnam.  The internist stated that she urged the patient to have his blood recheck while he was away and when he was no longer ill.

The Board issued a reprimand and ordered the internist to take a continuing medical education course in the subject of interpreting complete blood count laboratory data.

State: Virginia


Date: January 2016


Specialty: Internal Medicine, Family Medicine


Symptom: N/A


Diagnosis: Hematological Disease


Medical Error: Failure to follow up


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



North Carolina – Pediatrics – Headache, Dizziness, Leg Numbness, And A Platelet Count Of 22,000



A 15-year-old minor presented to a pediatrician with headache, dizziness, leg numbness, fatigue, and malaise.

On 01/29/2013, the patient had his initial office visit with the pediatrician.

On 01/31/2013, the patient returned for lab testing.

The lab work revealed a platelet count of 22,000 (normal 150,000 to 349,000).  The pediatrician stated that he was not notified by his staff of this level, and consequently, he did not address this level.

On 02/21/2013, the pediatrician’s physician assistant wrote, “new lab order for CBC to be drawn in next 1-2 days to recheck platelet levels as latest labs on 1/31/13 shows [sic] critically low levels at 22 per LapCorp [sic] and 27 per Solstas.”

At this point, neither the pediatrician nor the physician assistant had contacted the patient’s parents.

On 02/25/2013, the patient underwent additional lab work, which revealed a platelet count of 14,000.

On 02/26/2013, the pediatrician documented that he had reviewed the patient’s platelet counts.  He did not contact the patient’s mother.  Instead, he requested that the physician assistant contact the patient’s mother “to let her know about this lab and that the patient should be seen by her primary care physician to investigate this finding, possibly referring to a hematologist for evaluation.”

On the same day, the physician assistant contacted the patient’s mother and notified her of the low platelet count.  The patient’s mother, after discussing the matter with the physician assistant and the patient’s primary care physician’s triage nurse, decided to take the patient to the emergency department.  The patient’s mother reported that the patient had been experiencing extreme dizziness and abdominal pain.

The patient presented to the emergency department and was admitted to the hospital.  At this point, the patient’s platelet counts had fallen to 11,000.  The patient was diagnosed with idiopathic thrombocytopenic purpura.  The pediatrician discontinued all therapies and supplements pending the stabilization of the platelet count.  The patient was monitored by a hematologist and her platelet counts stabilized.

The Board judged pediatrician’s conduct to be below the minimum standard of competence given failure to address critically low platelets promptly.

The Board ordered the pediatrician to be reprimanded.

State: North Carolina


Date: November 2015


Specialty: Pediatrics


Symptom: Abdominal Pain, Bleeding


Diagnosis: Hematological Disease


Medical Error: Failure to follow up, Delay in proper treatment


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



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