Found 58 Results Sorted by Case Date
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Florida – Orthopedic Surgery – Documentation Error Of Laceration Of Flexor Pollicis Longus Leads To Wrong Site Surgery



On 5/16/2014, a patient presented to an orthopedic outpatient surgery center with a left-hand work-related injury.  During the visit, an orthopedic surgeon properly diagnosed the patient with a flexor pollicis longus (FPL) tendon laceration of her left thumb.

The FPL tendon laceration was confirmed by the MRI scan performed on the patient on 7/3/2014.

On 8/7/2014, during the follow-up visit, the orthopedic surgeon wrongly documented the patient’s injury as an extensor pollicis longus (EPL) tendon laceration in the patient’s medical records

Consequently, on 9/10/2014, the patient presented to the orthopedic surgeon at the center, for an EPL tendon surgery (the wrong site, and/or medically unnecessary procedure) of her left thumb.  During the EPL tendon surgery, the orthopedic surgeon realized that the FPL tendon laceration repair should have been performed on the patient instead.  On 10/10/2014, the orthopedic surgeon performed the FPL tendon laceration repair on the patient’s left thumb.

The Board ordered the orthopedic surgeon pay a fine of $3,000 to the Board. Also, the Board ordered the orthopedic surgeon pay a reimbursement cost of $4,670.40.  The Board ordered that the orthopedic surgeon complete five hours of continuing medical education in “Risk Management.”  The Board ordered that the orthopedic surgeon complete one hour of lecture on wrong site procedure.

State: Florida


Date: December 2017


Specialty: Orthopedic Surgery


Symptom: N/A


Diagnosis: Musculoskeletal Disease, Trauma Injury


Medical Error: Wrong site procedure, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Neurosurgery – Wrong Site Procedure When Performing Surgery On A Subdural Hematoma



On 11/6/2016, a 61-year-old female presented to the emergency department, suffering from confusion and weakness after a fall.  A CT scan revealed that the patient had a large, left-sided subdural hematoma.

That same day, a neurosurgeon was asked to evaluate the patient.  The neurosurgeon correctly documented that the patient was suffering from a left-sided subdural hematoma.  The neurosurgeon further documented his intention to remove a blood clot from the left side of the patient’s subdural space.

Shortly thereafter, the patient was brought to the operating room and preparations were begun for a left-sided craniotomy.  However, at some point during the preparation process, the patient’s head was turned and the neurosurgeon began to operate on the right side.

After the neurosurgeon made an incision through the skin, he removed a bone flap and punctured the dura mater on the right side of the patient’s brain.  The neurosurgeon realized that he was operating on the incorrect side.  The neurosurgeon closed the operating site and proceeded to perform the correct procedure.

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


Specialty: Neurosurgery


Symptom: Confusion, Weakness/Fatigue


Diagnosis: Intracranial Hemorrhage, Trauma Injury


Medical Error: Wrong site procedure


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Virginia – Neurosurgery – All-Terrain Vehicle Rollover Accident Causes L1 Compression Fracture



On 1/19/2008, a 32-year-old man suffered an L1 compression fracture following an all-terrain vehicle rollover accident.  He saw a neurosurgeon who placed him in a rigid back brace and prescribed pain medications.  The patient’s fracture appeared to be clinically stable and appeared to be improving.  The Board deemed the long-term risk of developing a kyphotic deformity low in this patient.

On 3/7/2008,  the neurosurgeon performed a kyphoplasty of the spine the patient.  During the kyphoplasty, the vertebral body was too dense to accept the cement.  As a consequence, the cement extruded out of the fracture plans into the epidural space.

The neurosurgeon addressed this complication by performing a posterior laminectomy and decompression of the thecal sac.  The Board stated that the laminectomy procedure subjected the patient to a far greater risk for development of kyphosis than had existed prior to the kyphoplasty.

The Board considered the surgery unwarranted and issued a reprimand.  The neurosurgeon was ordered to complete 10 hours of continuing medical education in the subject of patient selection for spinal surgery.

State: Virginia


Date: November 2017


Specialty: Neurosurgery


Symptom: Back Pain


Diagnosis: Spinal Injury Or Disorder, Fracture(s)


Medical Error: Unnecessary or excessive treatment or surgery, Procedural error


Significant Outcome: N/A


Case Rating: 5


Link to Original Case File: Download PDF



Florida – Physician Assistant – Patient With Animal Bite Wound Treated With Sutures Only



On 7/13/2011, a 47-year-old female presented to a physician assistant with an animal bite wound.  The physician assistant treated the patient’s animal bite wound with sutures.

The physician assistant discussed this wound with an orthopedic specialist, who recommended IV antibiotics and an antibiotic prescription for home.

The physician assistant did not order or administer antibiotics to the patient while the patient was in the hospital.  The physician assistant did not order or administer antibiotics to the patient at the time of discharge.

The Board judged the physician assistant’s conduct to be below the minimal standard of competence given that she failed to prescribe antibiotics when assessing and/or treating a patient with the following presentation.

The Board issued a letter of concern against the physician assistant’s license. The Board ordered that the physician assistant pay a fine of $2,000 against her license and pay reimbursement costs for the case at a minimum of $3,867.71 but not to exceed $5,867.71.  The Board also ordered that the physician assistant complete five hours of continuing medical education in diagnosing and/or treating patients with wounds and five hours of continuing medical education in “risk management.”

State: Florida


Date: July 2017


Specialty: Physician Assistant


Symptom: N/A


Diagnosis: Trauma Injury, Infectious Disease


Medical Error: Improper treatment


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Internal Medicine – Daily Dose Of 1200 Milligrams Of Gabapentin For Patient With End Stage Renal Disease



On 5/8/2014, a 74-year-old female presented to an internist for the purpose of establishing care.  The patient had multiple medical problems, including diabetes, end-stage renal disease, and recurrent C. difficile infections.

At all times pertinent to this complaint, the patient was undergoing chronic hemodialysis treatment.

On 6/10/2014, the patient presented to the internist for a follow-up visit.  The internist prescribed 600 mg tablets of gabapentin to the patient to treat her diabetic neuropathy.  The patient’s prescription directed her to take the 600 mg of gabapentin twice daily, totalling 1200 mg of gabapentin per day.

On 6/14/2014, after taking her prescribed dosage of gabapentin, the patient lost control of her leg muscles and fell, resulting in a fracture of the T12 vertebrae in her back.

The prevailing professional standard of care required the internist to prescribe the patient a dosage of gabapentin not to exceed 150 mg per day, due to her end-stage renal disease.  The internist prescribed the patient an inappropriate and/or excessive dosage of gabapentin.

According to the internist, he verbally instructed the patient and/or her family members to modify the gabapentin prescription.

The internist failed to document and/or accurately document the alleged verbal instruction to the patient and/or her family members to modify the patient’s gabapentin prescription.

The Board issued a letter of concern against the internist’s license.  The Board ordered that the internist pay a fine of $5,000 against his license and pay reimbursement costs for the case at a minimum of $30,433.57 and not to exceed $32,433.57.  The Board also ordered that the internist complete a medical records course and complete five hours of continuing medical education in clinical pharmacology and drug dosing.

State: Florida


Date: June 2017


Specialty: Internal Medicine, Nephrology


Symptom: Weakness/Fatigue


Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Diabetes, Neurological Disease, Spinal Injury Or Disorder, Renal Disease, Fracture(s)


Medical Error: Improper medication management, Accidental Medication Error, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Pediatrics – Deep Laceration Of The Right Knee Treated With Debridement, Irrigation, And Suturing



On 12/7/2011, an 8-year-old male presented to a medical emergency department with a deep laceration to his right knee.  The laceration was a full thickness cut with visualization of the capsule.  An x-ray revealed air in the knee joint.

A pediatrician examined the patient’s knee and performed debridement, cleaning by irrigation, and suturing of the laceration.  Bacitracin and dressing were applied to the patient’s knee.

On 12/10/2011, the patient returned to the emergency department with complaints of right knee swelling, redness, and pain.  The patient was admitted to the pediatric floor.

Further examination revealed septic arthritis in the patient’s right knee, which required two operations and the introduction of a PICC line for long-term antibiotic therapy.  The patient sustained cartilage damage as a result of the septic arthritis and suffered from significant knee pain.

The Board judged the pediatrician’s conduct to be below the minimal standard of competence given that he failed to refer the patient to an orthopedic surgeon and to fully wash out the patient’s joint by performing an open debridement under anesthesia.

The Board issued a letter of concern against the pediatrician’s license.  The Board ordered the pediatrician to pay a fine of $10,000 against his license and pay reimbursement costs at a minimum of $5,496.59 and not to exceed $7,496.59.  The Board also ordered that the pediatrician complete ten hours continuing medical education in pediatric orthopedic diagnosis and treatment and complete five hours of continuing medical education in “risk management.”

State: Florida


Date: June 2017


Specialty: Pediatrics, Orthopedic Surgery


Symptom: Joint Pain, Swelling


Diagnosis: Trauma Injury, Septic Arthritis


Medical Error: Improper treatment, Referral failure to hospital or specialist


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 4


Link to Original Case File: Download PDF



Florida – Radiology – Motor Vehicle Accident With Missed Diagnosis After Review Of The CT Scan



On 8/14/2013, a 63-year-old female patient presented to a hospital with trauma sustained in a car accident.

X-rays of the patient’s chest and ankle were performed.  CT scans of the patient’s head, face, cervical spine, chest, abdomen, and pelvis were performed.  A radiologist read the x-rays and CT scans performed on the patient.  The radiologist recognized several transverse process fractures in the patient’s lumbar spine.  The radiologist failed to diagnose an L4 vertebral body fracture that was present on one or more CT images.  The radiologist failed to order further CT or MRI scans of the patient’s lumbar spine.

The Board judged the radiologist’s standard of care to be below the minimum standard of competence given his failure to recognize and diagnose the L4 vertebral body fracture present on one or more CT images for the patient and order further CT or MRI scans of the lumbar spine.

The Board ordered that the radiologist pay a fine of $7,500 against his license and that the radiologist pay reimbursement costs from a minimum of $3,004.65 to a maximum of $5,004.65.  The Board also ordered that the radiologist complete six hours of continuing medical education in radiological studies/interpretation.

State: Florida


Date: June 2017


Specialty: Radiology


Symptom: N/A


Diagnosis: Fracture(s), Spinal Injury Or Disorder


Medical Error: Diagnostic error, Failure to order appropriate diagnostic test


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Emergency Medicine – Delayed Response In Spine Immobilization And Ordering X-Rays And CT Scan In Patient With Lumbar Spine Fractures



On 6/22/2012 at 12:30 a.m., a patient was an unrestrained back seat passenger of a taxicab when it was involved in a motor vehicle accident.  The patient was intoxicated at the time of the accident.

EMT-Paramedics were dispatched to the scene of the accident and documented that the patient was moving all extremities and had a pulse, motor, and sensation in all four extremities.  The EMT-Paramedics transported the patient to the emergency department without back-board or spinal immobilization precautions.

At 12:58 a.m., the patient arrived at the hospital.

At 1:32 a.m., an ED physician performed an exam of the patient’s back and documented equivocal lumbar back tenderness.  The ED physician performed an exam of the patient’s pelvis and documented equivocal pelvic tenderness.  He also performed a neurologic exam and documented no movement of the patient’s toes or leg muscles.  The ED physician performed a rectal exam and documented that the patient exhibited an absence of anal sphincter tone.

AT 1:48 a.m., the ED physician ordered x-rays of the patient’s lumbosacral spine and pelvis.  The lumbosacral spine x-ray results showed a comminuted fracture dislocation at T12-L1.

At 2:58 a.m., the ED physician ordered a computed tomography scan of the patient’s lumbar spine.  The CT scan of the patient’s lumbar spine also showed a comminuted fracture dislocation at T12-L1.

At 3:17 a.m., the ED physician ordered that the patient be placed on a backboard.

At 4:20 a.m., the patient was transferred by ambulance to a level 1 Trauma Center.

The patient was ultimately diagnosed with paraplegia.  A medical malpractice lawsuit was filed against the physician.

The Board judged the ED physician’s conduct to be below the minimal standard of competence given that he failed to immediately perform a full trauma evaluation, immediately immobilize the patient’s spine, immediately order an x-ray of the patient’s chest, immediately order a CT scan of the patient’s abdomen, and immediately order a CT scan of the patient’s pelvis.

The Board issued a letter of concern against the ED physician’s license.  The Board ordered that the ED physician pay a fine of $5,000 against his license and pay reimbursement costs for the case at a minimum of $6,452.58 and not to exceed $8,452.58.  The Board also ordered that the ED physician complete five hours of continuing medical education of emergency medicine and five hours of continuing medical education in “risk management.”

State: Florida


Date: June 2017


Specialty: Emergency Medicine, Trauma Surgery


Symptom: N/A


Diagnosis: Fracture(s), Spinal Injury Or Disorder


Medical Error: Failure to examine or evaluate patient properly, Delay in proper treatment


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 4


Link to Original Case File: Download PDF



Florida – Interventional Radiology – Kyphoplasty Performed On T11 Instead Of T12 Site For T12 Fracture After A Fall



On 10/13/2015, a 70-year-old male was transported to the emergency department after a fall from a hammock when the rope broke.

A CT scan of the lumbar spine was done and a 20% anterior wedge compression fracture on the T12 section was found.  An MRI of the lumbar spine, on the same day, showed an acute T12 compression fracture.  An MRI of the thoracic spine was done, on the same day, and showed an acute T12 compression fracture with bone marrow edema.

The patient was admitted to the hospital and recommended for T12 kyphoplasty.

On 10/14/2015, an interventional radiologist performed a kyphoplasty on the patient’s T11 vertebrae (wrong site), instead of the T12 vertebrae.

The patient was discharged on 10/19/2015 and began having progressively more pain.

On 10/22/2015, the patient was readmitted to the hospital by ambulance with progressively worsening pain.

On 10/23/2015, a two-view x-ray of the lumbar spine revealed that a T12 compression fracture had remained unchanged despite the 10/12/2015 surgery, and that the T11 vertebrae had been unnecessarily operated upon.

The patient was discharged to a rehabilitation center for two weeks to recover.

The Board issued a letter of concern against the interventional radiologist’s license.  The Board ordered that the interventional radiologist pay a fine of $4,000 against his license and pay reimbursement costs for the case at a minimum of $2,009.04 and not to exceed $4,009.04.  The Board also ordered that the interventional radiologist complete five hours of continuing medical education in “risk management” and complete a one-hour lecture/seminar on wrong site surgeries.

State: Florida


Date: June 2017


Specialty: Interventional Radiology


Symptom: Pain


Diagnosis: Fracture(s), Spinal Injury Or Disorder


Medical Error: Wrong site procedure


Significant Outcome: Hospital Bounce Back


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Radiology – Failure To Diagnose Subdural Hematoma From Radiology Report



On 10/27/2015, a patient presented to the emergency department after suffering a fall.

An emergency department physician ordered a computerized tomography (CT) scan of the patient’s head.

Radiologist A reviewed the CT scan.  Radiologist A failed to recognize or failed to report the presence of a significant subdural hematoma.  Radiologist A erroneously reported that the CT scan showed no acute intracranial abnormalities.

The patient’s wounds from the fall were treated, and the patient was discharged home.  That night, the patient became unresponsive at home and was transported back to the hospital.

A second CT scan was performed and was reviewed by Radiologist B.  Radiologist B compared the second CT scan to the first CT scan performed earlier that day.

Radiologist B noted that the first CT scan showed a 6 mm hematoma.  He reported that the second CT scan showed that the hematoma had markedly increased in size to 28 mm since the first scan taken approximately six hours before.

The patient expired the morning of 10/28/2015, due to complications from an acute subdural hematoma.

The Board judged Radiologist A’s conduct to be below the minimal standard of competence given that she failed to recognize and report any significant abnormalities present on a patient’s CT scan.

It was requested that the Board order one or more of the following penalties for Radiologist A: permanent revocation or suspension of her 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: June 2017


Specialty: Radiology


Symptom: N/A


Diagnosis: Intracranial Hemorrhage, Trauma Injury


Medical Error: False negative


Significant Outcome: Death, Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



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