Found 272 Results Sorted by Case Date
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California – Interventional Radiology – Pain And Cold Foot After Arteriogram, Angioplasty, And Atherectomy



On 6/26/2015, a patient presented to an interventional radiologist’s outpatient clinic for a left lower extremity arteriogram and intervention for a thrombosed left lower extremity bypass graft, originally placed in 2007.  The patient had an extensive medical history including a renal transplant, diabetes, right leg amputation, and multiple revascularization procedures, including prior thrombectomies of the left lower extremity graft.

The patient reportedly had pain both at rest and with activity, and had a cold left leg prior to and immediately before the procedure.  In order to improve blood flow in the patient’s left leg, the interventional radiologist performed an arteriogram, angioplasty, tPA administration, atherectomy, and stent placement within the left lower extremity, including an attempt to revascularize the native superficial femoral artery.

Images show an initially thrombosed femoral artery to popliteal bypass graft and deep femoral artery.  Further images show balloons inflated in various parts of the graft and native arteries.  Final images show flow through a patent common femoral artery (CFA), bypass graft, and peroneal and anterior tibial arteries.  The deep femoral artery appeared occluded shortly beyond its origin.

After the procedure, a nurse noted the patient’s foot was cold.  The interventional radiologist also assessed the patient post-procedure and found the foot to be cold, both two (2) and four (4) hours post-procedure.  The interventional radiologist recommended to the patient that she travel to the emergency department of a university hospital.

The patient was then driven by her companion two hours to the emergency department, where she was assessed by an ED physician and a vascular surgeon.  She was taken to the operating room where she underwent surgery, which included a left leg above-the-knee amputation and a deep femoral artery thrombectomy.

The Board stated that the standard of care for an interventional radiologist when performing an intervention is to recognize complications and to take appropriate steps to manage them.  Although the patient’s foot was reportedly cold and painful immediately post-procedure, it can take some time for the foot to warm, and pain could be caused by reperfusion.  However, it is clear that two to four hours after the procedure, the interventional radiologist recognized that the patient’s leg had not improved and was worsening and that further care was needed.  Thus, when it became clear to the interventional radiologist that the foot was not improving, he recommended that the patient seek more treatment.

The records of the interventional radiologist’s care of the patient were inadequate in that they do not state whether the patient’s clinical status post-procedure was worse than before the procedure.  A post-procedure pulse examination was lacking which would have helped in determining the patient’s clinical status.

The patient reported to the ED physician that the pain began after the procedure and steadily worsened, which indicates that the patient rethrombosed her bypass graft and deep femoral artery (source of collateral flow) immediately.  This event should have been recognized by the interventional radiologist.

However, the interventional radiologist’s documentation for this patient was inadequate and sparse.  The medical records lacked documentation of the change in the patient’s status post-procedure, the discussion with the patient leading up to the discharge from his center, and the patient’s disposition.  The interventional radiologist discharged the patient to her own care directly from his clinic instead of calling Emergency Medical Services (EMS), which indicates that the interventional radiologist failed to recognize the gravity of what was occurring.

His conduct did not ensure that the patient would be attended continuously until definitive treatment was given.  The patient arrived at the emergency department at approximately 8:00 p.m., two hours after the patient was discharged from the interventional radiologist’s clinic.

Had the process of discharge and transfer occurred earlier, it is possible that the outcome could have been different.  The interventional radiologist failed to communicate with the ED physician ahead of the patient’s arrival.  The interventional radiologist gave the patient a CD of the procedure, a copy of the medical records, and his phone number, as an attempt of communicating with the emergency department personnel regarding the events that occurred at the interventional radiologist’s clinic.

However, the interventional radiologist failed to telephone the ED physicians at the emergency department to give a verbal report on the patient and to provide a more informative transition and preparation for continued care.  In expecting the practitioners at the emergency department to call the interventional radiologist to gain more information, the interventional radiologist improperly sought to shift his responsibility to provide needed information about the patient to the staff at the emergency department.

The interventional radiologist failed to maintain documentation regarding the change in the patient’s status post-procedure, the discussion leading up to the discharge from his center, and the patient’s disposition.  He stated that he was not sure if he documented these events, and if he did, he sent them with the patient.  Documentation sent with the patient has since been lost.  Documentation of a change in the patient’s clinical status was lacking.  The medical records lacked documentation of what was discussed regarding the patient’s disposition and where she was told to go for further care.

The Board judged the interventional radiologist’s conduct to have fallen below the standard of care for the following reasons:

1) The interventional radiologist failed to offer to transport the patient by ambulance or EMS services to ensure that she would be attended continuously until definitive treatment was given. His failure to do so indicates that he failed to understand the gravity of the situation which was occurring.

2) The interventional radiologist failed to adequately communicate with the emergency department, to call ahead of time to inform them that the patient was in transit, and to inform them of the circumstances.

3) The interventional radiologist failed to maintain adequate and accurate records.

The Board issued a public reprimand.

State: California


Date: December 2017


Specialty: Interventional Radiology, Vascular Surgery


Symptom: Extremity Pain


Diagnosis: Acute Ischemic Limb, Post-operative/Operative Complication


Medical Error: Diagnostic error, Delay in proper treatment, Underestimation of likelihood or severity, Failure of communication with other providers, Lack of proper documentation


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Anesthesiology – Proceeding With A Colonoscopy With A Non-Functioning End Tidal CO2 Monitor



A 59-year-old female presented to an anesthesiologist during her colonoscopy.  The anesthesiologist conducted a pre-operative anesthesia assessment of the patient.  She was then transported to the procedure room where a certified registered nurse anesthetist (“CRNA”) was to provide total intravenous anesthesia to the patient.

The end-tidal CO2 monitor (“ETCO2 monitor”) located in the scheduled procedure room was non-functional on the day before the surgery and a functioning ETCO2 monitor had not been received on the day of the surgery.

The anesthesiologist instructed the CRNA to proceed with the anesthesia without the ETCO2 monitor.  The anesthesiologist did not delay the procedure or postpone it for another date to allow time to obtain a functioning ETCO2 monitor.  The anesthesiologist did not transfer the patient to another procedure room that had a functioning ETCO2 monitor.  The anesthesiologist did not implement additional precautionary measures by closely monitoring the patient with his presence since he elected to proceed without an ETCO2 monitor as recommended by the ASA (American Society of Anesthesiologists).  The anesthesiologist was not present in the procedure room during the procedure.

The CRNA experienced difficulties with the patient’s airway soon after the induction of anesthesia.  The oral airway was inserted to assist the patient’s breathing, and the amount of oxygen flow was increased to help with the falling oxygen saturation.  Despite the increase in the amount of oxygen flow, the CRNS reported transient desaturations and reported repositioning the pulse oximeter numerous times throughout the procedure.

The patient developed bradycardia, which culminated to intubation and cardiac arrest, and the anesthesiologist’s presence was requested in the procedure room.  The anesthesiologist started chest compressions and resuscitated the patient.

The Board judged the anesthesiologist’s conduct to be below the minimum standard of competence given that he should have delayed the procedure, or postponed it for another date to allow time to obtain a functioning ETCO2 monitor.  He should also have transferred the patient to another procedure room that had a functioning ETCO2 monitor and implemented additional precautionary measures by closely monitoring the patient with since he elected to proceed without an ETCO2 monitor.

The Board ordered that the anesthesiologist pay a fine of $5,000 against his license and pay reimbursement costs for the case for a minimum of $6,841.07 and not to exceed $8,841.07.  The Board also ordered that the anesthesiologist complete five hours of continuing medical education in general anesthesia and complete five hours of continuing medical education in “Risk Management.”

State: Florida


Date: November 2017


Specialty: Anesthesiology


Symptom: N/A


Diagnosis: Post-operative/Operative Complication


Medical Error: Failure to properly monitor patient


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Ophthalmology – Persistent Pain And Inflammation In The Right Eye Following Cataract Surgery



On 12/4/2013, a 78-year-old female presented to an ophthalmologist for phacoemulsification with posterior chamber implant (“cataract surgery”) on her right eye.

During the cataract surgery, the patient experienced a posterior capsule tear, a known complication and an accepted risk associated with cataract surgeries.

On 2/3/2014, the patient presented to the ophthalmologist for an examination, and the ophthalmologist noted inflammation in the patient’s operative eye.

On 3/27/2014, the patient presented to the ophthalmologist for an examination, and the ophthalmologist noted inflammation in the patient’s operative eye.

On 4/8/2014, the patient presented to the ophthalmologist for an examination, and the ophthalmologist noted that the patient experienced post-operative chronic iritis in her operative eye.

On 5/6/2014, the patient presented to the ophthalmologist for a follow-up examination of her operative eye.

On 8/14/2014, the patient presented to the ophthalmologist for a follow-up examination of her operative eye.

On 9/18/2014, the patient presented to the ophthalmologist and reported throbbing pain in her operative eye.

Despite knowing that the patient experienced a complicated cataract surgery, followed by persistent inflammation in her operative eye, the ophthalmologist did not perform a dilated examination until 9/18/2014.

Despite knowing the patient experienced a complicated cataract surgery, followed by persistent inflammation in her operative eye, the ophthalmologist did not refer her to a retina specialist.

The Board judged the ophthalmologist’s conduct to be below the minimum standard of competence given his failure to perform a dilated examination on the patient’s operative eye to investigate the causes of persistent post-operative inflammation within a reasonable time after the cataract surgery.  The ophthalmologist also failed to refer the patient to a retina specialist to investigate the causes of persistent post-operative inflammation within a reasonable time after cataract surgery.

The Board ordered that the ophthalmologist pay a fine of $2,500 against his license and that the ophthalmologist pay reimbursement costs for the case for a minimum of $4,634.56 but not to exceed $6.634.56.  The Board also ordered that the ophthalmologist complete five hours of continuing medical education in post-operative care and complete one hour of continuing medical education in “Risk Management.”

State: Florida


Date: November 2017


Specialty: Ophthalmology


Symptom: Head/Neck Pain, Swelling


Diagnosis: Post-operative/Operative Complication, Ocular Disease


Medical Error: Failure to examine or evaluate patient properly, Referral failure to hospital or specialist


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



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



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

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

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

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

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

State: Florida


Date: November 2017


Specialty: Interventional Radiology


Symptom: Abdominal Pain


Diagnosis: Post-operative/Operative Complication, Acute Abdomen


Medical Error: Retained foreign body after surgery


Significant Outcome: Hospital Bounce Back


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Orthopedic Surgery – Damage To Inferior Vena Cava And Other Complications After Guidewire Improperly Placed In Disk Space



On 12/24/2014, a 59-year-old female was admitted to a medical center for a Microscopic Extraforaminal Lumbar Discectomy of L4-L5.  An orthopedic surgeon was assigned to perform the patient’s procedure.  He began the procedure by utilizing image intensification to use a guidewire for initial placement of dilators in the patient’s spine.

After removal of the guidewire, the orthopedic surgeon noted that he felt the guidewire had gone into the disk space slightly.

After sixty percent of the procedure was completed, the orthopedic surgeon was advised by the anesthesiologist that there was a decrease in the patient’s CO2.  It was subsequently noted that the patient’s blood pressure began to drop.

The orthopedic surgeon then placed an OpSite over the patient’s incision, turned the patient to a supine position, and called for assistance from a vascular surgeon.

On 12/24/2014, after becoming hypotensive and then experiencing pulseless electrical activity during the lumbar discectomy, the patient underwent an exploratory laparotomy with repair of inferior vena cava injury.

During the exploratory laparotomy, after approximately one hour of cardiopulmonary resuscitation and advanced cardiac life support protocol, the patient expired on the operating table.

At all times relevant to this case, the prevailing professional standard of care requires that when dealing with patients such as this one, a physician should place instruments into a patient’s body in a manner to do the least possible harm.

The Board judged the orthopedic surgeons conduct to be below the minimal standard of competence given that he allowed an instrument to pass into the patient’s cavity in such a way that injured underlying structures and by failing to recognize the penetration of the guidewire at the time of placement of the initial dilator, which lead to the injury of the patient’s inferior vena cava.

It was requested that the Board order one or more of the following penalties for the orthopedic surgeon: 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: Orthopedic Surgery


Symptom: N/A


Diagnosis: Post-operative/Operative Complication, Spinal Injury Or Disorder


Medical Error: Procedural error


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Florida – Plastic Surgery – Excessive Use Of Lidocaine During SmartLipo Results In Severe Complications



On 11/2/2012, a 39-year-old female presented to an internist for skin tightening intervention in the lower abdomen under local anesthesia with mild oral and intramuscular sedation, a procedure commonly known as “smart lipo.”

The patient was given 700 to 800 ml of an IV of various medicines, including lidocaine, and then three injections of 1% lidocaine.

Shortly after administration of the IV of various medicines and the lidocaine shots, the patient began to have a grand mal seizure.  The internist treated the patient with IV fluids and Narcan.

The patient reportedly had normal vital signs at the time, but then had another seizure fifteen minutes later.

According to the internist, ten minutes later, on the third seizure, the internist requested an ambulance.

The internist indicated that the patient, upon the third seizure, lost all pulse and respiration.

According to the EMS staff, the internist did not recognize that the patient was in cardiac arrest upon EMS arrival and was not assisting the patient.

The patient was taken to the emergency room in full cardiac arrest, where she died.

The medical examiner listed the patient’s cause of death as acute lidocaine toxicity due to use of lidocaine in a medical procedure.

The internist failed to adequately prepare or maintain medical records in this case in a way that allowed any medical professionals to adequately know the amount of lidocaine administered to the patient.

The Medical Board of Florida judged the internist’s conduct to be below the minimal standard of competence given that he failed to recognize a lack of blood pressure and administer cardiac support (CPR) upon recognition of a lack of blood pressure.  The internist also administered excess lidocaine that caused the patient’s death due to lidocaine toxicity.

The Medical Board of Florida issued a reprimand against the internist’s license.  The Medical Board of Florida ordered that the internist pay of $5,000 for his license and pay reimbursement costs for the case at a minimum of $10,683.65 and not to exceed $12,683.65.  The Medical Board of Florida ordered that the internist complete a records course, complete ten hours of continuing medical education in liposuction procedures and complete five hours of continuing medical education in “risk management.”

State: Florida


Date: August 2017


Specialty: Plastic Surgery, Internal Medicine


Symptom: N/A


Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Post-operative/Operative Complication


Medical Error: Improper medication management, Underestimation of likelihood or severity, Lack of proper documentation


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Florida – Anesthesiology – Multiple Procedural Errors While Performing Cervical Epidural Steroid Injections



On 4/6/2016, a 69-year-old female with a prior history significant for pulmonary tuberculosis, essential hypertension, paroxysmal supraventricular tachycardia, osteoporosis, menopause, hypothyroidism, arthritis, chronic asthmatic bronchitis, and a former smoker, presented to a medical clinic.

An anesthesiologist initially diagnosed the patient with cervicalgia and cervical radiculopathy due to degenerative chronic cervical spondylosis.  The patient was also hearing and speech impaired and used an interpreter and tablet for communication during all preoperative meetings.

The patient presented to the anesthesiologist in the surgery room for a signed consent of cervical transforaminal epidural steroid injection at right C4 and C5.  The anesthesiologist instead performed a cervical epidural steroid injection (“CESI”) above C6-C7 without obtaining consent from the patient.

The anesthesiologist failed to have an interpreter in the surgery room during the patient’s evaluation and treatment so that he could effectively communicate with her.

The patient was positioned in the prone position on the table and the anesthesiologist administered Versed 2 mg IV and Fentanyl 100 mcg for IV conscious sedation.

The anesthesiologist failed to administer local anesthesia to numb the patient’s skin, while she was awake and alert, prior to injecting the first epidural steroid injection at C5-C6.  The patient, unaware that she was receiving an injection and unable to clearly communicate her discomfort, responded to the initial puncture to her skin by a sudden jumping movement.

The anesthesiologist withdrew the needle and targeted lower interspace, C7-T1, using fluoroscopy.  He used a seventeen gauge Tuohy needle under intermittent fluoroscopic guidance for entry into the epidural space at C7-T1 for the second attempt to perform the CESI.  The anesthesiologist then injected the medication between C4 and C5 neural foramen.

The anesthesiologist documented one or more times prior to the 4/6/2016 procedure that he was performing a TFESI on the right at C4 and C5;  however, he instead performed a cervical interlaminar epidural steroid injection (“ILESI”) at C5-C6, and additionally at C7-T1, without obtaining consent from the patient.  He inappropriately elected to perform a CESI above C6-C7.  The anesthesiologist did not create or maintain fluoroscopic images of his initial attempt to inject at C5-C6.

After the procedure, the patient was taken to the recovery room, where an interpreter and tablet was present for communication.  The patient was no longer able to move her arm to communicate using the tablet and she experienced right upper extremity weakness and some right sided facial numbness.

The patient was transferred out of the medical center as a “Stroke alert” to a hospital, where she received a CAT or MRI scan, and again transferred to another hospital which did not have a neurosurgeon on staff.

After the CESI, the patient was diagnosed with iatrogenic cervical nerve root injury.

It was requested that the Board order one or more of the following penalties for the anesthesiologist: 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: August 2017


Specialty: Anesthesiology


Symptom: Weakness/Fatigue, Numbness


Diagnosis: Spinal Injury Or Disorder, Post-operative/Operative Complication


Medical Error: Wrong site procedure, Ethics violation, Failure of communication with patient or patient relations, Procedural error


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 3


Link to Original Case File: Download PDF



North Carolina – Vascular Surgery – Abdominal Aortic Aneurysm 8.3 cm In Size With Large Type I Endoleak



On 3/31/12, a 76-year-old male with a history of heart disease, chronic obstructive pulmonary disease (COPD), prior endovascular repair of a large abdominal aortic aneurysm (AAA) in 2010 at an outside hospital (OSH) presented to the VA Medical Center emergency department with complaints of back, flank, and hip pain.

On 4/1/12 in the early morning, the patient had a CT scan with contrast which revealed an 8.3 cm AAA with large Type I endoleak.  There was retroperitoneal stranding consistent with an aneurysm rupture.  At 7:45 a.m., these findings were communicated to the emergency department physician.

At 8:00 a.m., the patient was evaluated by a vascular surgeon.  Based on the vascular surgeon’s interpretation of the CT films and the patient’s clinical presentation, the vascular surgeon recommended admission for observation with a follow-up consultation with orthopedic surgery and interventional radiology.

The patient was admitted to the medical ward for the next three days during which he continued to have severe ongoing pain that was managed with pain medications.

On 4/4/12, the patient had a precipitous decline in his clinical status with severe hemodynamic compromise.  A repeat CT scan demonstrated a ruptured AAA with aortocaval fistula.  The patient was taken to the operation room where the vascular surgeon performed an open repair of the aortocaval fistula and ruptured AAA.  However, the patient suffered extensive operative blood loss, perioperative myocardial infarction, and neurological injury.

The patient survived the procedure but remained critically ill.  Over the next several days, the patient improved to a certain degree, but it was felt that the patient had suffered brain injury with little chance for meaningful recovery.

On 4/9/12, supportive measures were withdrawn, and the patient died.

In January 2017, the Board received information regarding a medical malpractice lawsuit settlement payment related to the care provided by the vascular surgeon to the patient.

The Board obtained the patient’s records and sent them to a qualified independent medical expert for review.  The independent medical expert judged the vascular surgeon’s conduct to be below the minimum standard of competence given failure to adequately diagnose and aggressively treat the patient’s symptomatic, ruptured AAA despite evidence of the patient’s life-threatening condition.

The vascular surgeon was reprimanded.

The Board reported the Consent Order to the Federation of State Medical Boards.and the National Practitioner Data Bank.

State: North Carolina


Date: July 2017


Specialty: Vascular Surgery, Emergency Medicine


Symptom: Back Pain, Pelvic/Groin Pain


Diagnosis: Aneurysm, Post-operative/Operative Complication


Medical Error: Delay in proper treatment


Significant Outcome: Death


Case Rating: 4


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



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



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