Found 28 Results Sorted by Case Date
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California – Otolaryngology – Public Letter Of Reprimand For Delayed Care And Failure To Inform Patient Of Potential Complication Of Epistaxis Treatment



An otolaryngologist failed to inform a patient of the potential for a septal perforation during treatment for epistaxis.

In another patient, there was a delay in care.  The otolaryngologist made an initial diagnosis of a nasopharyngeal mass.  However, there was a prolonged period of time between that initial diagnosis and when the biopsy was actually performed.

These actions were deemed to have constituted gross negligence and repeated negligent acts.

A Public Letter of Reprimand was issued against him.

State: California


Date: June 2017


Specialty: Otolaryngology


Symptom: Bleeding, Mass (Breast Mass, Lump, etc.)


Diagnosis: Hemorrhage, Post-operative/Operative Complication


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


Significant Outcome: N/A


Case Rating: 1


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



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 – Radiology – Radiologist Reports Negative Findings On A CT Scan For A Pediatric Patient Who Fell Down A Flight Of Stairs



A 30-month-old boy presented to the emergency department on 8/29/2011, after falling down a flight of stairs.

Following his presentation to the emergency department, a CT scan of the patient’s brain and neck was performed, and a radiologist interpreted the results of the scan as negative.

On 9/1/2011, the patient presented to his pediatrician with significant neurological problems.  Based on the patient’s symptoms, the patient’s pediatrician contacted the radiologist to discuss the case.

As part of his discussion with the patient’s pediatrician, the radiologist re-reviewed the patient’s CT scan and determined that his previous negative findings were incorrect.  The radiologist noted that a “subtle but focal increased density within the spinal cord” was evident on the patient’s CT scan.

Based on this finding, the radiologist coordinated with the patient’s pediatrician to have the patient returned to the emergency department for evaluation and treatment.

In preparation for the patient’s return to the emergency department, the radiologist attached an addendum to his previous report that explained that he failed to identify a hematoma within the patient’s spinal cord.

Upon the patient’s return to the emergency department, the patient was given additional imaging studies.  These studies revealed that the hematoma within the patient’s spinal cord had grown since the original CT scan.

Based on this finding, the patient underwent surgical evacuation of the hematoma.  The patient’s hematoma was successfully evacuated, but the patient ultimately left functionally quadriplegic as a result of damage already caused by the bleed.

The Medical Board of Florida judged the radiologist’s conduct to be below the minimal standard of competence given that he failed to correctly interpret the patient’s CT scan and identify the hematoma within the patient’s spinal cord.  The radiologist was unable to correctly interpret the patient’s CT scan, and the standard of care required him to refer the patient’s CT scan results to a pediatric radiologist or a neuroradiologist for review.

The Medical Board of Florida issued a letter of concern against the radiologist’s license.  The Medical Board of Florida ordered that the radiologist pay a fine of $5,500 against his license and pay reimbursement costs for the case at a minimum of $3,190.96 and not to exceed $5,190.96.  The Medical Board of Florida also ordered that the radiologist complete five hours of continuing medical education in the area of “pediatric radiology” and complete five hours of continuing medical education in the area of “diagnosis and treatment of hematoma.”

State: Florida


Date: December 2016


Specialty: Radiology, Pediatrics


Symptom: N/A


Diagnosis: Hemorrhage, Spinal Injury Or Disorder


Medical Error: False negative, Referral failure to hospital or specialist


Significant Outcome: Permanent Loss Of Functional Status Or Organ, Hospital Bounce Back


Case Rating: 4


Link to Original Case File: Download PDF



California – Hospitalist – Syncope After Cholecystectomy And Wedge Liver Biopsy



On 1/17/2011, a 40-year-old female with a history of hepatitis, gallstones, hypertension, diabetes, and obesity was admitted to a medical center for obstructive jaundice.

On 1/19/2011, a hospitalist performed a pre-operative evaluation of the patient.  The hospitalist noted that the patient had a blood pressure at 91/56, a heart rate at 51 beats per minute, and a hemoglobin level of 11.3 gm/dl.  The hospitalist diagnosed the patient with “Acute on Chronic Cholecystitis” and noted the patient would proceed with a cholecystectomy.

On 1/19/2011, a general surgeon performed a laparoscopic cholecystectomy with intraoperative cholangiogram and wedge liver biopsy on the patient.

At 2:50 a.m. on 1/20/2011, the patient’s hemoglobin level was noted at 11.3 gm/dl.

At 1:10 p.m., the patient fainted on the way out of the bathroom.  Subsequent to this episode, the patient was awake, lethargic, and registered a blood pressure of 80/53 at 1:14 p.m.  The patient was placed in the Trendelenburg position.  The general surgeon was contacted and left orders for one liter of normal saline.  The hospitalist, as the on-duty hospitalist, was also contacted.  He ordered a hemoglobin and hematocrit, cardiac enzymes, and an EKG.  He ordered 125 ml/hr of fluid to be started after the 1 liter bolus ordered by the general surgeon.

At 1:14 p.m., the patient’s hemoglobin was noted to be at 9.3 gm/dl.  It is assumed that this hemoglobin level was obtained prior to 1:14 p.m., as the hemoglobin result obtained after the patient had fainted would have unlikely been available for review by 1:14 p.m.

At 4:25 p.m., the hospitalist saw the patient for persistent low blood pressure and altered mental status.  The hospitalist noted that the previously ordered fluid boluses had not improved the patient’s blood pressure.  The hospitalist documented a blood pressure of 77/50, heart rate of 118, and a hemoglobin of 9.3.  The hospitalist additionally noted that the patient was pale and lethargic.  The hospitalist diagnosed the patient with “shock, possibly hypovolemic.”  The hospitalist made the following orders: transfer to the intensive care unit (ICU), start pressors, initiate a PICC line, start antibiotics, and control blood sugar.  The hospitalist requested a complete blood count and a complete metabolic panel for the following morning.

At 4:50 p.m. on 1/20/2011, a rapid response was called, and the patient was transferred to the ICU.  At approximately 6:32 p.m., the patient coded.

At 7:05 p.m., the hospitalist gave verbal orders for “crossmatch 2 units now; if not available transfuse 2 units uncrossed STAT.”  The patient never received the transfusion and expired at approximately 7:23 p.m.  The hospitalist claimed she contacted the general surgeon after the patient’s transfer to the intensive care unit.  This call is not documented in the patient’s medical records.

On 1/22/2011, the hospitalist dictated a discharge summary that stated, “[w]e think the patient have had a DIC and sepsis.”  The hospitalist does not document the possibility of hemorrhagic shock in her discharge summary.

The Board judged the hospitalist as having committed gross negligence given failure to promptly evaluate the patient in light of her syncope, severe hypotension, and altered mental state; failure to consider the possible causes of hypovolemic shock; and failure to consider hemorrhagic shock as a possibility given the patient’s recent surgery and declining hemoglobin.

The Board placed the hospitalist on probation for three years with stipulations to complete 40 hours annually of continuing medical education in the subjects of hemorrhagic shock and diagnostic medicine, complete a medical record keeping course, and undergo clinical practice monitoring while on probation.

State: California


Date: November 2016


Specialty: Hospitalist, General Surgery, Internal Medicine


Symptom: Syncope, Confusion, Weakness/Fatigue


Diagnosis: Post-operative/Operative Complication, Hemorrhage


Medical Error: Diagnostic error, Delay in proper treatment, Failure of communication with other providers, Improper treatment, Lack of proper documentation


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



California – Emergency Medicine – Syncope And A History Of Menorrhagia



On 6/6/2012, a 47-year-old female was transported to the emergency department by EMT’s for a brief syncopal episode.  The patient had been sitting in a chair and had lost consciousness, falling to the floor, but she recovered consciousness right away.  The patient had a medical history of menorrhagia and current bleeding (10-15 pads per day in the nurse’s notes). EMT’s noted tachycardia.  An ED physician’s history of the patient only noted prodromal lightheadedness, 2-3 seconds loss of consciousness, and the fall. He did not mention the current bleeding, and although he indicated a head injury in the record, nothing was mentioned concerning examination, diagnosis or treatment.  The ED physician did note that the patient’s gynecologist had recommended a hysterectomy. The ED physician’s review of systems was checked normal, which was inaccurate because menstrual history was included, and the patient was presently experiencing a very heavy menstrual period, consistent with past episodes of menorrhagia.  Vital signs were low blood pressure at 120/49 mmHg and elevated heart rate at 94 bpm, rising from 96 to 106 from supine to standing on orthostatic measurement. No positives were noted on physical examination except for “pale conjunctiva” and “pale palms.” No pelvic or rectal examination was documented. The ED physician ordered normal saline IV at 150 mL per hour.  Laboratory studies were returned with hemoglobin and hematocrit of 6.4 g/dL (extremely low) and 18.9% (very low).

The ED physician called the on-call family practitioner at 5:18 p.m., and the consultant was at bedside at 6:10 p.m.  The patient was admitted with improved vital signs. The consultant immediately ordered the transfusion of 3 units of blood.  The patient’s hemorrhaging continued after admission, so the following day, she underwent the previously recommended hysterectomy.

The Medical Board of California judged that the ED physician’s conduct departed from the standard of care because his medical examination was inappropriately limited.  The ED physician failed to perform an appropriate history and physical examination and appropriate medical tests as needed to evaluate for potentially life-threatening illness.  The ED physician’s notations appeared to indicate he may have been unaware of the current menstrual bleeding in the patient that was documented in the nurse’s notes, and he did not do a pelvic examination.  Although the ED physician noted a head injury, there was no indication that it was examined or treated. Neither the head injury nor the ongoing bleeding was addressed. The ED physician’s final diagnosis was syncope and anemia with no specific cause.  He failed to adequately examine and document findings pertinent to the patient’s presentation.

The ED physician’s final diagnosis was syncope and anemia, but syncope was a symptom of ongoing hemorrhage, not a diagnosis, and the ED physician did not document the apparent cause for the anemia.  The patient had hemorrhaged to the point where she fainted from hypotension. The ED physician consulted the on-call family practitioner when the appropriate consult would have been a gynecologist. The ED physician did not appreciate that syncope was a symptom of menorrhagia/hemorrhage, not a diagnosis.

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: Syncope, Abnormal Vaginal Bleeding


Diagnosis: Hemorrhage


Medical Error: Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Referral failure to hospital or specialist, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – General Surgery – Active Bleed In Obese Patient After Laparoscopic Cholecystectomy For Right Upper Quadrant Pain



On 2/6/2013, a general surgeon treated a 48-year-old obese female who was admitted to the hospital via the emergency department that same day.  The patient complained of severe epigastric and right upper quadrant pain. She was initially admitted to the emergency department for chest pain, but the pain changed to the upper right quadrant.  The patient reported that her mother had a laparoscopic cholecystectomy. She stated that in retrospect, she did not remember fatty food intolerance other than pain for the last 3 to 4 days in the right mid to lower quadrant and severely that day in the right upper quadrant and epigastrium radiating to the back.  Her previous surgeries included remote gastric banding, diaphragmatic hernia repair, and hysterectomy. Physical examinations and appropriate diagnostic work-up confirmed cholecystitis as the cause of her symptoms.

On 2/7/2013, the general surgeon performed a laparoscopic cholecystectomy on the patient for acute cholecystitis.  The general surgeon noted that the patient had extensive plastered adhesions to the anterior abdominal wall, right upper quadrant from her prior surgery.  The patient had severe acute cholecystitis with a large amount of adhesions to the gall bladder also from omentum. Total surgery time was documented to be 1 hour.

The general surgeon initially thought that the laparoscopic cholecystectomy was done without incident, but approximately 4 hours after surgery, the patient was brought back to the operating room because of bleeding.  The surgery took another hour. During that surgery, 1500 ml of blood was found. The general surgeon documented that there was no bleeding from the cystic artery or the cystic duct area. He noted that the gallbladder fossa was not bleeding, and despite copious irrigation and attempts to find active bleeding from all the areas of adhesions, both on the abdominal wall and on the omentum, no active bleeding was seen.  The general surgeon failed to convert the laparoscopy to an open procedure to identify the source of bleeding.

The patient continued to bleed after the operation.  Her hematocrit level was 31 after the second operation on 2/7/2013.  Hematocrit decreased to 26 on 2/8/2013. Hematocrit decreased to 18 on 2/9/2013.  On 2/10/2013, the general surgeon discharged the patient. At discharge, the patient had expanding abdominal wall hematoma, falling hematocrit, and tachycardia with the heart rate between 92 and 114.  The patient’s hematocrit was 25 after additional blood was given.

The Medical Board of California judged that the general surgeon’s conduct departed from the standard of care because he failed to identify the source of bleeding despite massive blood loss, failed to convert the laparoscopic procedure to an open operation given unclear site of bleeding, and discharged the patient despite expanding abdominal wall hematoma, falling hematocrit, and tachycardia with the heart rate between 92 and 114.

The Medical Board of California ordered the general surgeon to surrender his license.

State: California


Date: September 2016


Specialty: General Surgery


Symptom: Abdominal Pain, Back Pain, Chest Pain


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


Medical Error: Procedural error, Improper treatment


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Virginia – Emergency Medicine – Hip Fracture And Head Laceration With A History Of Thrombocytosis



On 3/5/2015 at 2:24 a.m., a patient arrived with a fractured hip and head laceration.  The patient’s emergency department record documents a history of thrombocytosis.

At 3:33 a.m., a complete blood count (“CBC”) done in the emergency department revealed a hemoglobin of 12.2 and a hematocrit of 39.5.  Platelet count was 1380.

At 6:13 a.m., the internist agreed to be the patient’s attending physician, and the medical records indicate that she was informed of the medical history along with the laboratory and imaging results.

At 7:31 a.m., the patient had significant bleeding from the head laceration and was treated by two other physicians.

At 8:46 a.m., another CBC was drawn given the amount of bleeding.  At 10:25 a.m., the internist signed the order.

The internist performed an admission history and physical exam.  At 10:43 a.m., she signed it.  The internist reviewed the patient’s medical record, including labs.  The results of the second CBC were not available.  The internist cleared the patient for surgery.  She stated that she believed the patient’s vital signs were stable, and her head laceration had been addressed.  Her treatment plan included “AM labs” and holding enoxaparin due to the patient’s “active bleed.”

The internist did not check the 8:46 a.m. lab results or conduct any other testing on the patient before or after the elective surgery.

The anesthesiologist examined the patient in the pre-operative holding area and reviewed the record and history in an effort to determine the appropriate method of anesthesia.  The anesthesiologist called the internist to obtain additional history and learn what hematological disorder the patient had.  The anesthesiologist’s note states that the internist replied that she was unaware.

On 3/5/2015 at 11:10 p.m., the patient was found unresponsive in her bed with a large amount of rectal bleeding, hypotension, and fixed pupils.  A CBC ordered by the hospital’s intensivist, the first since the 8:46 a.m. lab on 3/5/2015, revealed that the patient’s H/H had decreased to 4.8/16.4.

In her statement to the Board’s investigator, the internist said that there was no bleeding in the emergency department.  Neither the patient nor the daughter informed her of any rectal bleeding.  The patient’s vital signs and blood counts were within a reasonable range given the patient’s age.  The internist further stated that she cleared the patient for surgery given that the head laceration was addressed.  She would not have cleared the patient for surgery if she had been aware of rectal bleeding.  In addition, the internist also stated that the anesthesiologist called her prior to the surgery to ask about the patient’s blood work and wanted to know if it would be safe to administer epidural anesthesia.  Lastly, the internist explained that she did not check on the 8:46 a.m. lab results or initiate other treatment or follow-up for the patient because she relied on the consulting and treating physicians and hospital nurses to render appropriate treatment and to notify her of any change in the patient’s condition.

The Board issued the internist a reprimand.

State: Virginia


Date: July 2016


Specialty: Emergency Medicine, Internal Medicine


Symptom: Bleeding


Diagnosis: Hemorrhage


Medical Error: Failure to properly monitor patient, Failure to follow up


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Arizona – Emergency Medicine – Recent Cardiac Catheterization With Subsequent Presentation Of Right Groin Pain



The Board received notification of a malpractice settlement.

On 07/20/2011, a 66-year-old male presented to the emergency department.  He reported bleeding of his right groin status post cardiac catheterization performed 2 days prior.  The patient was evaluated by ED physician A, who noted that the bleeding had improved and that the right groin swelling had not gotten worse.  The patient reported taking enoxaparin and warfarin for his mechanical aortic valve.  The remainder of the examination was unremarkable with the exception of some noted bruising to the right groin.  The patient was discharged home after prolonged observation in the ED.

On 07/23/2011, the patient returned to the same ED and was evaluated by a resident.  The patient complained of right groin pain that radiated into the right lower back and was associated with numbness and tingling of his anterior right thigh.  ED physician B was supervising the resident.  The resident noted that the patient had developed a “knot” over the insertion site the night before, which was followed by increased pain into the right back.  At the time of the second ED visit, the patient reported that the pain was more persistent, and he was having difficulty walking.

The resident noted that the patient was taking blood thinners and that he “bruises/bleeds easily” secondary to the blood thinning medications.  Tenderness to palpation of the right groin was noted as well as a 3 x 6 cm oval area of ecchymosis with a small palpable round mass underneath and a 3 cm long longitudinal mass that was extremely tender.

There was no documentation of a back examination.  The neurologic portion of the examination was limited to the patient’s mental status.  A blood analysis and a CT scan were ordered.  The CT scan revealed a small to moderate retroperitoneal bleed on the right side consistent with right psoas hematoma as well as enhancement of the right common femoral artery and vein concerning for an aneurysm.

The reading radiologist recommended an ultrasound and the findings were discussed with the resident.  No ultrasound was available at that time.  The patient was subsequently discharged home with instructions to return with any worsening pain, fevers, chest pain, or shortness of breath, and to follow up with his cardiologist.  The ED physician submitted an addendum to the medical record noting that he examined the patient with the resident and agreed with the care plan.

Later that same day, the patient was taken to a different ED by ambulance complaining of shortness of breath.  The patient was noted to be in significant respiratory distress and was subsequently intubated for pending respiratory failure.  A blood analysis showed a hemoglobin of 4.2, creatinine of 3.4, potassium of 6.6, and an INR of 2.2.  The patient was severely anemic with hyperkalemia from acute renal failure.  When treatment was initiated to correct hyperkalemia, the patient went into cardiac arrest.

At 5:45 a.m. on 07/24/2011 and despite aggressive treatment efforts, the patient was pronounced dead.

An autopsy performed revealed the immediate cause of death was a massive right-sided retroperitoneal hematoma likely resulting from an intimal tear in the right femoral artery with dissection and adventitial hemorrhage.

The Board judged the ED physician’s conduct to be below the minimum standard of competence given failure to obtain an ultrasound to determine if an aneurysm was present.  He also failed to appreciate the risks of sending a patient home who has a bleed and who is on blood thinners.

The ED physician testified that the recommendation to obtain further ultrasound imaging was not communicated to him.  The ED physician expressed deep remorse for the error in judgment and stated that it would never be repeated.

The Board ordered the ED physician be reprimanded.

State: Arizona


Date: June 2016


Specialty: Emergency Medicine, Cardiology, Internal Medicine


Symptom: Bleeding, Numbness, Back Pain, Pelvic/Groin Pain, Swelling


Diagnosis: Hemorrhage


Medical Error: Failure to order appropriate diagnostic test, Underestimation of likelihood or severity, Failure of communication with other providers, Failure to follow up, Improper supervision


Significant Outcome: Death, Hospital Bounce Back


Case Rating: 5


Link to Original Case File: Download PDF



North Carolina – General Surgery – Leukocytosis, Drop In Hemoglobin, And Increasing Creatinine After Laparoscopic Colonic Resection



The Board was notified of a professional liability payment on 10/05/2015.

On 06/02/2010, a 49-year-old female underwent laparoscopic removal of part of her colon by another surgeon.  Post-operatively, the patient’s laboratory work included an elevated WBC of 18.5, hemoglobin falling from 15.7 g/dL pre-operative to 10.8 g/dL, and an elevated creatinine level.

On 06/03/2010, the patient was discharged from the hospital.

Several hours after discharge, the patient returned to the hospital with complaints of severe abdominal pain and distention, nausea, vomiting, inability to void, and dehydration.  A general surgeon was the on-call physician who admitted the patient to the hospital with a diagnosis of urinary retention, acute renal failure, and anemia.

At the time the general surgeon initially treated the patient, the patient’s WBC had increased to 20.3, and her hemoglobin had further decreased to 8 g/dL.  After the patient’s hospital admission, the general surgeon’s treatment included assisting the patient’s primary surgeon in two additional exploratory surgeries.  During the hospitalization, the patient required ventilatory support and renal dialysis.

On 06/18/2015, the patient was transferred to another hospital for further critical care.

The Board obtained the patient’s records and sent them to a qualified independent medical expert for review.  The independent medical expert opined that the general surgeon’s conduct may have been below the minimum standard of competence given failure to correctly diagnose the patient with post-operative intra-abdominal hemorrhage based on her presentation, which included an increasing WBC, decreasing hemoglobin, tachycardia, and abdominal distention.

The Board issued a public letter of concern, which was reported to the Federation of State Medical Boards.  It was not reported to the National Practitioner Data Bank.

State: North Carolina


Date: May 2016


Specialty: General Surgery


Symptom: Abdominal Pain, Nausea Or Vomiting, Urinary Problems


Diagnosis: Post-operative/Operative Complication, Hemorrhage


Medical Error: Diagnostic error


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



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