Found 121 Results Sorted by Case Date
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California – Neurology – Three EEGs Ordered Without Indication And Diagnosis Of Epilepsy



A 9-year-old girl was referred by her pediatrician to a child neurologist for headaches.  The child neurologist first saw the patient on 9/10/2009. The patient’s mother stated that the patient’s headaches started in 7/20/2009.  The patient had no episodes of loss of consciousness of any type. The child neurologist’s review of systems revealed headaches, neck pain, and back pain.  The child neurologist noted headaches following a viral infection in July 2009 described as constant tension and pressure with nausea, photophobia, and difficulty concentration.  The child neurologist’s diagnosis was childhood migraine and prescribed 10 mg amitriptyline. The child neurologist ordered an MRI to rule out neoplasm and aneurysms. The child neurologist also ordered an EEG, which was not indicated for headaches.

On 9/18/2009, the EEG was performed.  The technician described the EEG with “sharp and slow waves.” On 9/30/2009, the child neurologist saw the patient for an office visit.  The child neurologist read the EEG as showing “generalized polyspike and wave which was synchronous bilaterally over both hemispheres which is highly suggestive of a generalized seizure disorder.”  The child neurologist stopped the amitriptyline 10 mg she prescribed at the last visit because of “seizures on EEG.” She ordered a neurosurgery consult and planned a separate meeting with the mother.

The child neurologist next saw the patient on 11/4/2009.  The child neurologist prescribed Depakote at 250 b.i.d. The patient’s Depakote level was at 72.  The patient reported no seizures or auras, but the child neurologist in her diagnosis documented “seizures, breakthrough.”  The child neurologist ordered a second video EEG with computer analysis without medical indication. The EEG was performed on 11/25/2009.  The technician report showed no abnormality. The child neurologist’s report was of generalized polyspike and slow waves bilaterally, “highly suggestive of generalized epilepsy,” with localized slowing in the left temporal area.

On 2/11/2010, the child neurologist saw the patient for a follow-up visit.  The chief complaint was learning difficulty. The Depakote level was 53. The patient denied experiencing any auras and/or any seizures.  On the next visit, on 5/11/2010, the patient still did not report any auras or seizures. The child neurologist’s diagnoses were generalized epilepsy, childhood headaches, adverse effect of medication, and learning disability.  The child neurologist ordered a third video EEG with computer analysis to rule out seizures and BAER (brainstem auditory evoked response) to rule out hearing loss, despite no medical indication. The video EEG was performed on 6/28/2010 and was normal.  On 7/12/2010, the child neurologist saw the patient for a follow-up visit. The patient denied having headaches and seizures. The child neurologist ordered a 72-hour ambulatory EEG despite the normal EEG.

The child neurologist next saw the patient on 1/19/2011 for a follow-up visit.  The patient’s mother complained that the patient’s math and history test results were still low.  The patient had no witnessed seizures and was tolerating Keppra well. Despite the negative findings, the child neurologist diagnosed “seizures, breakthrough, rule out.”  The child neurologist ordered another video EEG. At this point in time, the 72-hour video EEG she previous ordered on 7/12/2010 had not been performed.

On 2/18/2011, a 72-hour ambulatory EEG was performed.  The child neurologist’s last visit with the patient was on 3/14/2011.  On the last visit, the child neurologist noted that the 72-hour ambulatory EEG was normal.  She discontinued Keppra. She diagnosed the patient with “arachnoid cyst, middle cranial fossa; generalized epilepsy; learning disability; and adverse effect of medication given correctly.”

The Medical Board of California judged that the child neurologist’s conduct departed from the standard of care because she ordered 3 video EEGs and an ambulatory EEG without medical indication, ordered a BAER with no medical indication, misdiagnosed epilepsy on a patient with no medical history of seizures of any type, and made diagnoses of breaththrough seizures with no basis, contrary to her own findings that were no auras or seizures reported.

The Medical Board of California placed the child neurologist on probation and ordered the child neurologist to complete a medical record keeping course, a professionalism program (ethics course), an education course (at least 40 hours per year for each 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 child neurologist was assigned a practice monitor and was prohibited from supervising physician assistants and advanced practice nurses.

State: California


Date: January 2018


Specialty: Neurology, Pediatrics


Symptom: Headache, Nausea Or Vomiting, Back Pain, Head/Neck Pain


Diagnosis: N/A


Medical Error: Unnecessary or excessive diagnostic tests, False positive


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Gynecology – Unnecessary Biopsies Performed When Lumps Are Noted on A Patient’s Breasts



Between December 2010 and August 2013, a patient presented to her gynecologist.

On 5/19/2011, the gynecologist found small, smooth, mobile lumps in the patient’s left and right breasts.

On 6/17/2011, the gynecologist performed a right breast biopsy on the patient.  The gynecologist noted that the right breast lump was likely a fibroadenoma.  The biopsied right breast tissue was found to be benign.

On 7/5/2011, the gynecologist performed a left breast biopsy on the  patient.  The gynecologist noted that the left breast lump was likely a fibroadenoma.  The biopsided left breast tissue was found to be benign.

At all times, the patient was at a low risk for having breast cancer.

The Board judged the gynecologist’s conduct to be below the minimum standard of practice given that the prevailing professional standard of care required that the gynecologist medically manage the patient’s left and right breast lumps with breast exams, breast sonographies, and/or mammograms.  The obstetrician’s performance of left and right breast biopsies on the patient was medically unnecessary.

The Board ordered that the gynecologist pay a fine of $16,000 against his license. Also, the Board ordered that the case fine be set at $9,486.57.  The Board ordered that the gynecologist complete five hours of continuing medical education in “Risk Management.”

State: Florida


Date: December 2017


Specialty: Gynecology, Gynecology


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


Diagnosis: N/A


Medical Error: Failure to order appropriate diagnostic test, Unnecessary or excessive treatment or surgery


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Family Medicine – Three Patients Seen At Once Without Proper Examination and Documentation



On 9/21/2012, Patient A, Patient B, and Patient C presented to a geriatric practitioner at the same time in his office.  The geriatric practitioner saw the patients for less than nine minutes total.  At no time were the patients separated for individual assessments.  The patients were an undercover detective and two informants, using pseudonyms.  The appointment was audiotaped and videotaped.

The geriatric practitioner failed to perform a physical examination on any of the three patients.  The geriatric practitioner failed to create a treatment plan for any of the three patients.  He also sent the three patients for x-rays without a physical examination.  Per the geriatric practitioner’s instructions, all three patients presented for x-rays;  however, only Patient A and Patient C actually had x-rays performed.  The geriatric practitioner failed to create or maintain documentation of referring the three patients for x-rays.

On 10/30/2012, the three patients presented to the geriatric practitioner for a follow-up visit.  At that time, the geriatric practitioner failed to review readily available medical records from the patients’ first visit, failed to inquire about x-ray results, failed to review physical therapy results, failed to perform physical examinations and/or failed to create treatment plans for all three patients.

The Board judged the geriatric practitioner’s actions to be below the minimum standard of competence given his failure to perform a physical examination, perform a complete individual physical examination for each patient prior to referral for x-rays, other diagnostic testing, or further treatment.  Also, the geriatric practitioner failed to review any medical records or results at a follow-up visit, including x-rays, from prior visits, and/or procedures and review and analyze the physical therapy progress of the patients, and create treatments plans for each patient.

The Board ordered that the geriatric practitioner pay a fine of $12,000 against his license and pay reimbursement costs for the case for a minimum of $37,421.80 and not to exceed $39,421.80.  The Board also ordered that the geriatric practitioner complete a medical records course and complete five hours of continuing medical education on “Risk Management.”  The Board put the geriatric practitioner’s license on probation and required that he have indirect supervision to practice by a Board-approved physician.

State: Florida


Date: November 2017


Specialty: Family Medicine


Symptom: N/A


Diagnosis: N/A


Medical Error: Failure to examine or evaluate patient properly, Ethics violation, Failure to follow up, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Obstetrics – Excessive And Unindicated Antepartum Testing Performed Over the Course Of A Pregnancy



Between May 2011 and December 2011, an obstetrician provided obstetric services to a 16-year-old female and followed the course of her pregnancy.

The patient had an estimated delivery date of 12/1/2011 and ultimately delivered her baby on 12/1/2011.

On 5/5/2011 and 5/19/2011, the obstetrician performed first-trimester ultrasounds on the patient to monitor the patient’s fetus.

On 6/17/2011, the obstetrician performed a second-trimester ultrasound on the patient to monitor the patient’s fetus.

On 10/11/2011, the obstetrician performed a third-trimester ultrasound on the patient to monitor the patient’s fetus.  The patient’s fetus was in the 29th percentile for growth, which was normal.

On 10/20/2011, the obstetrician performed a third-trimester ultrasound on the patient to monitor the patient’s fetus.  The patient’s fetus was in the 44th percentile for growth, which was normal.

There was no indication for the third-trimester ultrasound that the obstetrician performed on the patient on 10/20/2011.

On 10/28/2011, the obstetrician performed a biophysical profile with ultrasound on the patient and her fetus in order to monitor the patient’s fetus.

The indications documented for the biophysical profile with ultrasound that the obstetrician performed for the patient and her fetus on 10/28/2011 were intrauterine growth restriction and “size less than dates.”  Both intrauterine growth restriction and “size less than dates” were ruled out by the ultrasound conducted on 10/11/2011 and 10/20/2011.

There was no indication for the biophysical profile with ultrasound that the obstetrician performed on the patient and her fetus on 10/28/2011.

On 11/4/2011, the obstetrician performed a biophysical profile with ultrasound on the patient and her fetus in order to monitor the patient’s fetus.  The indications documented for the biophysical profile with ultrasound that the obstetrician performed on the patient and her fetus on were intrauterine growth restriction and “size less than dates.”

Both intrauterine growth restriction and “size less than dates” were ruled out by the ultrasound conducted on 10/11/2011 and 10/20/2011, and the biophysical profile performed on 10/28/2011.

There was no indication for the biophysical profile with ultrasound that the obstetrician performed on the patient and her fetus on 11/4/2011.

On 11/11/2011, the obstetrician performed a third-trimester ultrasound on the patient to monitor the patient’s fetus.  The patient’s fetus was in the 34th percentile for growth, which was normal.  There was no indication for the third-trimester ultrasound the obstetrician performed on the patient on 11/11/2011.

On 11/18/2011, the obstetrician performed a third-trimester ultrasound on the patient to monitor the patient’s fetus.  The patient’s fetus was in the 68th percentile for growth, which was normal.  There was no indication for the third-trimester ultrasound that the obstetrician performed.

The standard of care required that the obstetrician adequately manage the patient’s pregnancy through the use of only indicated antepartum testing and to refrain from performing excessive and unindicated antepartum testing.

It was requested that the Board order one or more of the following penalties for the internist: 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 Board deemed appropriate.

State: Florida


Date: October 2017


Specialty: Obstetrics


Symptom: N/A


Diagnosis: N/A


Medical Error: Unnecessary or excessive diagnostic tests


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Radiology – Two Patients With The Same First Name, Last Name, And Year Of Birth



On 12/23/2014, Patient A and Patient B, both 89-year-old females, presented to the radiology department.  Patient A presented for a carotid ultrasound while Patient B presented for a PICC line insertion.  Both patients had the same first name and last name and were born the same year, but were born on different dates.

After undergoing a carotid ultrasound, Patient A was erroneously transported to the special procedures unit for a PICC line insertion.  A radiologist injected the patient with lidocaine in preparation of performing the PICC line insertion.

The radiologist began to insert the PICC line guidewire but stopped when the accompanying nurse recognized that Patient A was not the correct patient.

The radiologist did not create or maintain documentation of properly performing a timeout procedure.

The Medical Board of Florida issued a letter of concern against the radiologist’s license.  Also, the Medical Board of Florida ordered that the radiologist pay a fine of $2,500 against his license and pay reimbursement costs for the case at a minimum of $2,276.31 and not to exceed $4,276.31.  The Medical Board of Florida ordered that the radiologist complete five hours of continuing medical education in “risk management” and complete a one hour lecture on “wrong site surgeries” including information on “wrong patient procedures.”

State: Florida


Date: August 2017


Specialty: Radiology


Symptom: N/A


Diagnosis: N/A


Medical Error: Accidental error, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Plastic Surgery – Failure To Manage Hypertension And Hypoxia Perioperatively



In 2013, Plastic Surgeon B was an independent contractor providing facial cosmetic surgery services two days a week for a clinic in California.  A 57-year-old male made an appointment at the clinic for 9/7/2013.  The patient was interested in improving the appearance of his lower face and eyes.

The patient filled out a medical history form, on which he checked, “Yes” to the question, “Are you currently undergoing radiation therapy or chemotherapy for cancer?”  There was no additional explanation.  He did not list the name of the primary care physician (PCP) on the form but indicated that his PCP could be contacted for questions.  He indicated that he was taking no medications and had no allergies.  He listed no prior surgeries.

On 9/13/2013, the patient met with Plastic Surgeon A for a pre-operative visit.  Plastic Surgeon A performed a history and physical examination and wrote prescriptions for diazepam 5 mg #20 tablets, Tylenol with oxycodone 10/325 mg #30, and Keflex 500 mg.  Plastic Surgeon A indicated that the patient had hypertension but was not on any medication.  The patient’s blood pressure was noted to be 152/97.  The patient signed informed consent forms for a face and neck-firming procedure as well as blepharoplasty.  Plastic Surgeon A did not co-sign the forms (which are used to indicate that the plastic surgeon had personally reviewed the risks, benefits, and alternatives of the procedures with the patient and answered all questions).  Plastic Surgeon A noted his surgical plan as “Face & neck.  Upper lids skin only.  Possible fat transfer to cheeks.  Fast absorbing suture.”  Plastic Surgeon A did not sign his surgical plan.

Plastic Surgeon A left his position at the clinic, and the patient’s care was transferred to Plastic Surgeon B.  Surgery was rescheduled for 9/26/2013 with Plastic Surgeon B, and a “Meet the Doctor” date of 9/19/2013 was scheduled.  On 9/16/2013, Plastic Surgeon B filled out and signed a History and Physician Examination form on the patient.  The form documented only the facial examination and surgical plan, including lower lid laser.  There is no documentation of vital signs, particularly no blood pressure reading.  The patient signed new informed consent forms for face and neck firming surgery and blepharoplasty by Plastic Surgeon B.  Plastic Surgeon B did not co-sign the informed consent forms indicating that he had personally reviewed the risks, benefits, and alternatives of the procedures with the patient and answered all questions.  There is no consent form for laser resurfacing.

On 9/25/2013, the patient saw Plastic Surgeon B, and Plastic Surgeon B’s notes indicate “Famvir” and “take BP today.”  There is no documentation in the chart that a prescription for Famvir was written or that the drug was dispensed or used by the patient.  There is also no documentation that the patient’s blood pressure was taken.

The patient presented for surgery on 9/26/2013.  Vital signs were taken, and his blood pressure was documented as 177/116 right and 160/95 left.  At 11:30 a.m., the patient was in the surgical suite and was given oral sedation consisting of diazepam 30 mg; lorazepam 1 mg; acetaminophen with hydrocodone 5/325 mg; promethazine 25 mg; clonidine 0.1 mg; and diphenhydramine 25 mg.  Local anesthesia was infiltrated into the facial skin and subcutaneous tissues one hour and fifteen minutes later at 12:45 p.m.  This consisted of 1% lidocaine with 1:100,000 epinephrine (75 ml); 0.25% bupivacaine with 1:200,000 epinephrine (30 ml); normal saline (60 ml); and approximately 1:150,000 epinephrine with the total being approximately 200 ml of local anesthesia infiltrated.

Surgery commenced sometime after 1:00 p.m. on 9/26/2013.  The patient’s pulse rate, oxygen saturation, and blood pressure were monitored automatically throughout the procedure.  The patient remained hypertensive throughout the procedure, and no additional medications were provided for blood pressure control.  The procedure began with the patient’s oxygen saturation at 98%.  At 1:32 p.m., the oxygen saturation dropped to 58% and remained in the 60-70% range until approximately 3:15 p.m., when it returned to the 90% range.  Additional sedating drugs were given between 4:05 p.m. and 4:30 p.m., and oxygen readings fell again into the 50-70% range until the end of the procedure with only occasional readings in the normal range.

Although not documented in the record, Plastic Surgeon B indicated that sometime after 3:00 p.m., he was called upon to attend a post-operative patient who had presented with incisions on her face that had opened, an emergency.  Plastic Surgeon B left the patient in the surgical suite and, after 20 to 30 minutes attending to the emergency patient, Plastic Surgeon B returned to the surgical suite to complete the patient’s surgery.  Neither his departure from the OR nor the names and qualifications of those attending the patient in his absence are documented in the operative note.  Upon Plastic Surgeon B’s return, the patient was given additional oral sedation, as well as more local anesthesia.  The time of injection of an additional 44 ml of local anesthesia was not documented on the Patient Surgery Information Sheet.  The certified surgical technician administered the anesthesia under Plastic Surgeon B’s supervision and assisted in the procedure; Plastic Surgeon B indicated at his subject interview with the Board on 7/30/2015 that a nurse was also present, but this is not documented in the record.  Surgery was completed at approximately 6:00 p.m.  The patient’s final blood pressure was 186/116.  The patient was discharged home at 6:25 p.m.

The operative report on the patient signed by Plastic Surgeon B is a template document that provided no personal detail on the procedure.  For example, the template stated that skin openings were left behind the patient’s ears for expressing fluid, but the post-operative notes stated that the patient had drainage tubes placed bilaterally.  The operative report stated that a lower lid blepharoplasty was performed, but no such procedure was performed on the patient.

Post-operative photographs of the patient were taken on 9/27/2013, but there is no progress note for this visit.  A note for a visit on 9/28/2013 was signed by a technician and noted that the drainage tubes were being left in place; the patient was apparently not seen by a physician on this visit.  On 9/30/2013, the patient was examined by Plastic Surgeon B (although he did not sign the progress note); at this time, the remaining drainage tube was removed; the patient’s blood pressure was recorded as 187/113; advice given to the patient was to rest and relax.  On 10/2/2013, the patient was seen by staff, and his eyelid sutures were removed; the patient’s blood pressure was recorded as 154/94.  On 10/5/2013, the patient’s blood pressure was recorded as 162/105; there is no progress note for this visit, except that an unsigned addendum to the 10/2/2013 visit indicates that the facelift sutures were removed on 10/5/2013.  Post-operative photographs were taken on 10/21/2013, but there is no accompanying progress note.

The patient was dissatisfied with the results of the procedure and the care he received from Plastic Surgeon B.  The patient filed a consumer complaint, which the Board received on 6/23/2014.

The Board judged Plastic Surgeon B’s conduct to be below the minimum level of competence given failure to address the patient’s hypertension, failure to sufficiently address the patient’s episodes of hypoxia during the procedure, and failure to accurately document his encounters with the patient.

The Board notes that performing surgery on a hypertensive patient adds additional risk to the procedure for excessive bleeding, hematoma formation, and stroke.  Such a risk should be mitigated prior to the initiation of any elective procedure.  Per the Board, if a patient becomes hypertensive during a surgical procedure, medications should be provided to the patient to stabilize the blood pressure.

The Board also notes that if a patient becomes hypoxic during a procedure, it is required to assure the oxygen saturation probe is working correctly and to provide exogenous oxygen for the patient to breathe and return his oxygen saturation to the normal range.  There is no documentation that Plastic Surgeon B responded to the patient’s low oxygen saturation.

The Board expressed concern that the patient’s medical record contained numerous instances of unsigned, incomplete, and absent notes.  Vital signs were at times not documented.  A prescription for Famvir was administered but not documented.  There was no documentation of Plastic Surgeon B’s absence from the surgical suite and no indication of personnel that was left in charge of the patient while Plastic Surgeon B addressed another patient’s emergency.  Operative notes were inadequate and inaccurate.

The Board issued a public reprimand with stipulations that Plastic Surgeon B a medical record keeping course and a continuing medical education course in pre-operative patient evaluation, informed consent, and management of intra-operative hypertension and hypoxia.

State: California


Date: August 2017


Specialty: Plastic Surgery


Symptom: N/A


Diagnosis: N/A


Medical Error: Improper treatment, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



New York – Physician Assistant – Lack Of Lab Work For Routine Visit For A 37-Year-Old Female



On 11/3/2008, a 37-year-old female presented to a physician assistant for a physical and PAP smear.  During the examination, the physician assistant performed a pelvic examination and found normal female genitalia without lesion or discharge.  A PAP smear was obtained without incident.  The physician assistant’s examination of the patient’s abdomen revealed the abdomen was soft and nontender.  The physician assistant’s plan was to reassess the patient in three months unless otherwise indicated.

The physician assistant did not order the patient to undergo any lab work, such as an hCG test.

On 11/12/2008, the patient presented to the hospital with a full-term pregnancy and delivered a baby on the same date.

The Board judged that the physician assistant’s medical care of the patient deviated from accepted standards of care given failure to recognize signs of pregnancy.

State: New York


Date: July 2017


Specialty: Physician Assistant, Family Medicine, Internal Medicine, Obstetrics


Symptom: N/A


Diagnosis: N/A


Medical Error: Failure to order appropriate diagnostic test, Failure to examine or evaluate patient properly


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



New York – Physician Assistant – History Of Bipolar Disorder With Concern For Irregular Menses



On 8/13/2007, a 21-year-old female presented to a physician assistant for follow up treatment of bipolar disorder and concern for irregular menses.

During the examination, the patient advised the physician assistant that her most recent period was the prior November and that she had not had a gynecological examination in ten years. The physician assistant examined the patient’s abdomen, which he found to be benign.  In regard to the patient’s complaints of irregular menses, the physician assistant ordered a variety of blood work and stated that he would follow up with the patient in three months, unless otherwise indicated.  The blood work that he ordered did not include a hCG test.

On 8/16/2007, the patient arrived at the emergency department with a full-term pregnancy and delivered her baby on that same day.

The Board judged that the physician assistant’s medical care deviated from accepted standards of care given failure to perform an adequate physical examination, given failure to order a hCG test, and given failure to recognize signs of pregnancy.

State: New York


Date: July 2017


Specialty: Physician Assistant, Family Medicine, Internal Medicine


Symptom: Gynecological Symptoms


Diagnosis: N/A


Medical Error: Failure to order appropriate diagnostic test, Failure to examine or evaluate patient properly


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Gynecology – Hormone Replacement Therapy, A History Of Heart Disease, And Elevated Glucose Levels



On 5/16/2014, a 47-year-old female presented to a gynecologist for a routine gynecological exam.  The patient had a significant history of heart disease, including a quadruple bypass surgery in 2009.

The patient had complaints of hot flashes, inability to lose weight, insomnia, night sweats, irritability, and mild bladder leakage.  The gynecologist diagnosed the patient as menopausal.  The gynecologist recommended hormone replacement therapy.  He ordered hormone and thyroid level lab work.  He did not order tests for cholesterol levels or basic metabolic status, despite the patient’s metabolic lab result, dated 2/6/2012, indicating an abnormally high glucose level.

On 6/11/2014, the patient presented to the gynecologist for follow-up.  The gynecologist prescribed compounded creams containing the hormones estrogen, progesterone, and testosterone.  He also prescribed Armour Thyroid, a thyroid hormone replacement drug containing the hormones T3 and T4.

At all times material to this complaint, the prevailing standard of care dictated that a physician prescribing hormone replacement therapy to a patient with a significant history of heart disease obtain appropriate medical clearance prior to prescribing such therapies.

The gynecologist did not obtain medical clearance prior to prescribing hormone replacement therapy to the patient, despite a significant history of heart disease.

The prevailing standard of care dictated that a physician prescribing hormone replacement therapy to a patient with a prior abnormal glucose value order or obtain sufficient blood work prior to prescribing hormone replacement therapy.

The gynecologist did not obtain sufficient blood work prior to prescribing hormone replacement therapy to the patient, despite the patient’s prior abnormal glucose value.

At all times material to this complaint, the prevailing standard of care dictated that a physician discuss the full risks and benefits of hormone replacement therapy with the patient prior to initiating the treatment.  The gynecologist failed to discuss, or did not create or maintain adequate, legible documentation of discussing the full risks and benefits of hormone replacement therapy with the patient.

The Board issued a letter of concern against the gynecologist’s license.  The Board ordered that the gynecologist pay a fine of $5,000 against his license and pay reimbursement costs for the case for a minimum of $7,244.87 and not to exceed $9,244.87.  Also, the Board ordered that gynecologist complete ten hours of continuing medical education in “hormone replacement therapy” and five hours of continuing medical education in “risk management.”

State: Florida


Date: July 2017


Specialty: Gynecology


Symptom: Urinary Problems


Diagnosis: N/A


Medical Error: Failure to order appropriate diagnostic test, Failure of communication with patient or patient relations, Improper medication management


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Urology – Unnecessary Laparoscopic Radical Prostatectomy With Bilateral Pelvic Lymph Node Dissection Performed



On 2/1/2016, a 66-year-old male presented to a urologist for a prostate biopsy.  The urologist or his agents sent the specimens from the patient’s biopsy to pathology.

On 2/10/2016, a pathology report diagnosing the patient with adenocarcinoma of the prostate was issued.

On 2/16/2016 and 2/29/2016, the patient presented to the urologist to review the prostate biopsy pathology.

On 3/16/2016, the urologist performed a robotic assisted laparoscopic radical prostatectomy with bilateral pelvic lymph node dissection on the patient.  The urologist or his agents sent the specimens from the patient’s surgical procedure to pathology.

On 3/25/2016, a pathology report indicating the specimens were “negative for malignancy” was issued.

On 3/25/2016, the urologist or his agents swabbed the patient to obtain a DNA sample to cross-check the DNA profile of the biopsied specimens (from the 2/1/2016 appointment) with the patient’s known DNA sample.

On 4/5/2016, a DNA report was issued, confirming that the DNA profile from the biopsied specimens (from the 2/1/2016 appointment) did not match the DNA profile of the patient.

On 3/16/2016, the urologist performed health care services that were medically unnecessary when he performed the surgical procedure on the patient.

It was requested that the Board order one or more of the following penalties for the urologist: 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 Board deemed appropriate.

State: Florida


Date: July 2017


Specialty: Urology


Symptom: N/A


Diagnosis: N/A


Medical Error: Unnecessary or excessive treatment or surgery, False positive


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 2


Link to Original Case File: Download PDF



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