Found 20 Results Sorted by Case Date
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Florida – Urology – Fluorescence In Situ Hybridization Ordered For A Patient With Incomplete Bladder Emptying And Renal Cysts



From 4/25/2012 to 1/29/2014, a 66-year-old female was treated by a urologist for incomplete bladder emptying and renal cysts.

On 4/25/2012 and 1/15/2014, the patient underwent urinalysis tests which returned negative for blood in the urine.

On 1/15/2014, the patient underwent fluorescence in situ hybridization (FISH) ordered by the urologist, which returned negative.

At all times material to this complaint, the patient displayed no indications to receive FISH testing.

The Board judged the urologist’s conduct to be below the minimal standard of competence given that he failed to document his plan to order FISH testing in the patient’s medical records and that the urologist’s ordering of FISH testing for the patient was medically unnecessary.

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: Urinary Problems


Diagnosis: Urological Disease


Medical Error: Unnecessary or excessive diagnostic tests, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Urology – Failure to Follow-Up On Chest X-Rays Ordered In A Patient With Micro Hematuria And Stone Disease



A urologist treated a patient from 2/3/2011 to 3/4/2011.

On 2/3/2011, the patient first presented to the urologist with micro hematuria and stone disease.

On 2/9/2011, the urologist ordered pre-operative blood work and chest x-rays for the patient.

The radiology report of the chest x-ray dated 2/9/2011 revealed a “newly developed 2.5 cm irregular contoured nodule located in the right lower lobe” that was “suspicious for potential malignancy and chest CT correlation [was] recommended…”

The urologist did not review the 2/9/2011 chest x-ray or radiology report and subsequently did not notify the patient and the patient’s primary care physician of the radiology findings.

On July 2012, the patient’s primary care physician ordered a chest x-ray, which demonstrated a 5 cm mass with metastasis.

A medical malpractice lawsuit was filed against the urologist.

The Board judged the urologist conduct to be below the minimal standard of competence given that he failed to review the chest x-ray and radiology report that were ordered by his staff and inform the patient and the patient’s primary care physician of the findings of the chest x-ray.

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: Urinary Problems


Diagnosis: Urological Disease, Cancer, Renal Disease


Medical Error: Failure to follow up


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



Washington – Physician Assistant – Groin Rash, Swelling, And Hard Left Testicle Found On Infant



On 1/3/2015, a seven-month-old patient was brought to an urgent care facility where he was seen by a physician assistant.  His history included over several months of groin rash that was being treated with steroid cream.  The patient’s mother reported that the patient’s left testicle was hard.  Over the past two days, his symptoms had worsened.  The physician assistant examined the patient and found a rash and swelling at the scrotum only.  He diagnosed the patient with a diaper rash.

On 1/4/2015, the patient’s grandparents brought the patient to the emergency department, where he was examined by a second provider.  The patient’s grandparents reported that the patient seemed uncomfortable and that his left scrotum appeared red, swollen, and firm.  An ultrasound found the patient’s left testicle with decreased blood flow.  The patient was transferred to another facility and testicular torsion was confirmed.  The patient underwent emergency surgery where his testicle was found nonviable and removed.

The physician assistant did not consider testicular torsion in the differential diagnosis and failed to order an ultrasound to rule out this condition.

The Commission stipulated the physician assistant reimburse costs to the Commission, complete a continuing medical education course in assessment and diagnosis of acute scrotal conditions, and submit a paper of no less than one thousand words, with references, on the subject of acute scrotal conditions.

State: Washington


Date: April 2017


Specialty: Physician Assistant, Pediatrics, Urology


Symptom: Rash, Swelling


Diagnosis: Testicular Torsion


Medical Error: Failure to order appropriate diagnostic test


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Internal Medicine – Undiagnosed Fever, Urinary Retention, And Hematuria Results In Death



On 12/23/2013, a 63-year-old male presented to a medical center with complaints of fever, insomnia, urinary retention, and hematuria, lasting the past six days.

Upon admission to the medical center, the patient was examined by an internist, and the internist diagnosed the patient with a urinary tract infection and urinary retention.

Based on this diagnosis, the internist ordered the administration of ceftriaxone, the placement of a Foley catheter, a urinalysis work-up, and a consultation with a urologist.

The patient’s urinalysis came back negative, and the Foley catheter enabled the patient’s bladder to void.

While a consultation with a urologist was ordered, it was never actually completed.

There was no documentation in the patient’s medical records that indicated the underlying causes of the patient’s urinary retention, hematuria, fever, and pain.

The internist failed to perform and failed to document performing an examination of the patient’s abdomen, lower back, kidneys, and genitourinary system that was sufficiently detailed enough to confirm or rule out the possible underlying causes of the patient’s urinary retention, hematuria, fever, and pain.

The internist failed to order and failed to document ordering additional laboratory and imaging testing of the patient’s abdomen, lower back, kidneys, and genitourinary system, after the patient’s urinalysis came back negative.

The internist failed to follow up on and failed to document following up on the urology consultation and the urology consultation results ordered for the patient.

The internist stated in his discharge summary that the patient “was seen by urology and workup was negative.”

On 12/25/2013, the patient was discharged from the hospital with instructions to follow up with his primary care physician and an outpatient urology practice.

On 12/28/2013, the patient’s condition deteriorated and he expired in his home as a result of undiagnosed peritonitis.

The Medical Board of Florida judged the internist’s conduct to be below the minimal standard of competence given that he failed to perform an examination of the patient’s abdomen, lower back, kidneys, and genitourinary system that was sufficiently detailed enough to confirm or rule out the possible underlying causes of the patient’s urinary retention, hematuria, fever, and pain.  The internist also failed to follow up on additional laboratory and imaging testing of the patient’s abdomen, lower back, kidneys, and genitourinary system until the underlying causes of the patient’s urinary retention, hematuria, fever, and pain was determined.  The internist failed to follow up on the urology consultation and/or results of the urology consultation that was ordered for the patient.  Also, the internist failed to reevaluate and reassess the patient’s condition prior to his discharge from the hospital.

The Medical Board of Florida issued a letter of concern against the internist’s license. Also, the Medical Board of Florida ordered that the internist pay a fine of $8,000 against his license and pay reimbursement costs for the case at a minimum of 3,462.89 and not to exceed $5,462.89.  The Medical Board of Florida ordered that the internist complete five hours of continuing medical education in the “diagnosis and treatment of urinary retention and hyponatremia” and complete five hours of continuing medical education in “risk management.”

State: Florida


Date: November 2016


Specialty: Internal Medicine, Urology


Symptom: Fever, Bleeding, Pain, Urinary Problems


Diagnosis: Infectious Disease, Urological Disease


Medical Error: Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Failure of communication with other providers, Failure to follow up, Lack of proper documentation


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



Washington – Urology – Challenges Placing Suprapubic Catheter With Subsequent Retention Of Foreign Body



A urologist provided care for a patient who suffered urinary retention, along with several other non-related health issues.  The patient had been on a urethral Foley catheter that caused ongoing problems with irritation and inflammation.  After discussions with the patient, a decision was made for placement of a suprapubic catheter to try to eliminate some of the issues and discomfort caused by the Foley catheter.

On 1/22/2009, the urologist attempted to place a suprapubic catheter into the patient.  After two unsuccessful attempts, the urologist elected to abandon the suprapubic procedure and replace the urethral Foley catheter, with a plan to try again at a later date.

Unbeknownst to the urologist, a sheath from a needle used in the procedure remained in the abdomen.  The instrument count was reported as correct.  On 2/9/2009, the sheath was successfully removed without further complications.

The Commission stipulated the urologist reimburse costs to the Commission and write and submit a paper of at least 1000 words, with references, on the subject of retained foreign body objects.  In his analysis, the urologist will discuss patient selection for the procedure, choice of procedure, and how to account for non-countable items.

State: Washington


Date: May 2016


Specialty: Urology


Symptom: Urinary Problems


Diagnosis: Urological Disease


Medical Error: Retained foreign body after surgery


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



North Carolina – Pediatrics – Testicular Pain, Tenderness, And Swelling With Ultrasound Scheduled In 2 Days



In June 2015, the Board received report of a malpractice settlement payment.

On 08/27/2011, a 14-year-old male presented with pain, tenderness, and swelling of the right testicle for two days.  The internist’s diagnosis was “testicular swelling, rule out hydrocele.”  He prescribed ibuprofen and Augmentin.

The internist scheduled an ultrasound for 08/29/2011, at which time the patient was diagnosed with testicular torsion.  The testicle had become necrotic and was surgically removed on that day.

The independent medical expert judged the internist’s  conduct to be below the minimum standard of competence given failure to order an ultrasound to be done immediately or failure to refer the patient to a urologist on an emergency basis and failure to document a suspicion for testicular torsion.

The Board ordered the internist to be reprimanded and pay a $1,000.00 disciplinary fine.

State: North Carolina


Date: March 2016


Specialty: Pediatrics, Internal Medicine


Symptom: Pelvic/Groin Pain


Diagnosis: Testicular Torsion


Medical Error: Delay in proper treatment, Diagnostic error


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Colorado – Urology – Testosterone Pellets And Testosterone Level Monitoring



In September 2013, a 56-year-old male was evaluated by a urologist for decreased testosterone level and urinary symptoms.  The urologist documented a low normal testosterone level, androgen deficiency, and other symptoms.  Afterwards, the urologist implanted testosterone pellets on four separate occasions.  The patient developed a 1 cm abscess at the third implantation visit, which was drained and resolved.  The urologist ordered labs prior to the fourth testosterone implantation which indicated the patient’s testosterone level was 1,058 (normal listed as 250-1100) with an elevated free testosterone of 212.4 (normal listed as 35-155) and estrogen level of 425 (normal listed as 130 or less).

The Board judged urologist’s care to be below the minimum standard of competence given failure to review the follow up lab tests prior to performing a fourth testosterone implantation.

State: Colorado


Date: March 2016


Specialty: Urology


Symptom: Urinary Problems


Diagnosis: Urological Disease


Medical Error: Failure to follow up


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Urology – Left Testicular Mass And Swelling After Left Inguinal Hernia Repair



On 12/8/2011, a general surgeon performed a left inguinal hernia repair on a patient, a then 78-year-old male.  In the weeks following the surgery, the patient experienced swelling of his left testicle.

On 1/5/2012, the patient presented to the general surgeon for a follow-up.  The patient complained of no pain, and although the swelling had decreased, his left testicle remained swollen.  The general surgeon then referred the patient for an ultrasound of the scrotum.

On 1/10/2012, an ultrasound of the patient’s scrotum revealed a solid mass in the left testicle approximately 2.6×2 cm.

On 1/18/2012, the patient’s left testicle remained swollen, and the general surgeon referred the patient to a urologist.

On 1/18/2012, the patient presented to the urologist for treatment of the left testicular mass.  Following a physical examination, review of the ultrasound, and subsequent lab work, the urologist diagnosed the patient with a neoplasm of uncertain behavior of the testis and recommended an immediate left radical orchiectomy.  The urologist did not consider further diagnostic study and did not order or review the records from the general surgeon prior to scheduling the surgery.

On 1/20/2012, a urologist performed a left radical orchiectomy and another repair of the hernia on the patient.  The pathology report revealed testicle orchiectomy with partial infarction, vascular congestion, thrombosis, fibrosis, and hemosiderin deposition.  No cancer was found.

The Board expressed concern that the urologist failed to adequately consider the differential diagnosis for the patient’s left testis mass before operating so quickly on a post-operative complication of the patient’s hernia repair.

The Board expressed concern that the urologist practiced at a level below the standard of care by not considering less aggressive options such as a partial nephrectomy in a very elderly man with comorbidities.

The Board issued a reprimand and ordered continuing medical education of 40 hours.  It was also recommended that the urologist enrolls in the Physician Assessment and Clinical Education Program offered at the University of California – San Diego School of Medicine.

State: California


Date: March 2016


Specialty: Urology


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


Diagnosis: Post-operative/Operative Complication, Urological Disease


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


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 2


Link to Original Case File: Download PDF



California – Urology – Fever, Hypotension, Tachycardia, And Darkening Urine Develops During Kidney Stone Removal Operation



On 11/14/2012 at 6:30 a.m., a 60-year-old female presented to the emergency department with a five-day history of intermittent abdominal pain located in the right lower quadrant, which was severe at time of presentation.  She also presented with chills without fever.  Two days prior, the patient had developed nausea and vomiting, which eventually became blood-streaked.  The patient was placed on morphine for the pain, and the pain eased.  The patient was prophylactically placed on intravenous antibiotics for suspected infection.  A CT scan of the abdomen and pelvis revealed a 5 mm kidney stone at the right ureterovesical junction (UVJ) with moderate hydronephrosis above it.  A urologist was called in on consult, and the patient was admitted to the hospital.

The urologist read the emergency department records and laboratory results and scan, examined the patient, and affirmed that she had a 5 mm obstructive UVJ ureteral stone, which was symptomatic with hydronephrosis and creatinine and glomerular filtration rate dysfunction.  After discussing his findings and recommendations with the patient and obtaining consent, the urologist schedule the patient for a right ureteroscopy, possible stone basketing or laser lithotripsy of the stone, and insertion of a right double-J ureteral stent for the evening of 11/14/2012.

The patient entered the operating room at 5:40 p.m. on 11/14/2012.  The operative procedure with the patient under general anesthesia commenced at 6:20 p.m. and concluded at 8:50 p.m.  The urologist commenced the cystoscopy and ureteroscopy and had difficulty inserting the Glidewire to place surgical implements due to fluid retention and edema in the kidney.  The placement of the initial Glidewire took 45 minutes.  Once the catheter and other implements were in place, an anesthesiologist reported to the urologist that the patient had developed a fever of 38.6 C (101.48 F) and that a large amount of darker urine was issuing from the right ureteral orifice.  The urologist elected to continue and complete the stone removal and stent placement.  Approximately 6 liters of IV fluid resuscitation were administered intraoperatively.  The patient’s temperature fell to near normal, but hypotension and tachycardia continued.  The urologist completed the ureteroscopy, stone retrieval, and placement of a right ureteral stent despite the development of signs of sepsis in the patient.  Postoperatively, the patient’s infection was diagnosed as sepsis, presumably urosepsis.  It required IV fluid boluses, IV antibiotics, pressors, and ICU admission for treatment of septic shock.

Ureteral stones can cause sepsis if there is an infection trapped behind a ureteral stone.  Many times, the urine culture is clear, despite having an infection building behind an impacted stone.  Any sign of infection, including an elevated white blood cell count, fever, blood pressure abnormality, tachycardia, or purulence behind the stone, should warn the urologist of impending infection and sepsis.  A patient with an impacted ureteral stone and infection should be treated with either percutaneous nephrostomy tube or ureteral stent placement, and the stone should be treated only after the infection has resolved.

The Medical Board of California judged that the urologist committed negligent acts in his care and treatment of the patient given that he completed the operative procedure, instead of aborting it or placing a stent only and treating the infection first, despite the presence of signs and symptoms of serious infection.

For this case and others, the Medical Board of California issued a public reprimand and ordered that the urologist complete a clinical training or educational program equivalent to the Physician Assessment and Clinical Education Program (PACE) offered at the University of California, San Diego School of Medicine (Program) within 60 calendar days.

State: California


Date: October 2015


Specialty: Urology, Nephrology


Symptom: Abdominal Pain, Bleeding, Fever, Nausea Or Vomiting


Diagnosis: Sepsis, Post-operative/Operative Complication, Urological Disease


Medical Error: Improper treatment, Procedural error


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Gynecology – Unsuccessful Treatment Of Stress Urinary Incontinence



On 12/18/2009, a gynecologist performed a procedure on a patient to place a Solyx sling for treatment of stress urinary incontinence.  The Solyx sling procedure was not successful at resolving the stress urinary incontinence, and following the surgery, the patient continued to have symptoms of incontinence.

On 1/27/2010, the patient was seen by the gynecologist for persistent symptoms of incontinence.  The gynecologist diagnosed stress urinary incontinence, uterine prolapse, cystocele, and rectocele.  The gynecologist recommended the patient undergo surgical repair of pelvic floor relaxation.

On 12/10/2010, the gynecologist performed pelvic surgery on the patient at a medical center. The surgery consisted of anterior colporrhaphy, with insertion of Suspend Tutoplast fascia lata graft, paravaginal repair, colpopexy, rectocele repair with insertion of Suspend Tutoplast fascia lata graft, and cystoscopy.

As the cystoscopy was performed, the gynecologist was not able to see jets of blue dyed urine from either of the ureteral orifices, although she was able to see flurries of liquid.

Following the surgery, the patient complained of pain in the lower left abdomen.  On 12/12/2010, the patient developed an elevated white blood cell count.  A CT scan of the patient’s abdomen and pelvis revealed an abnormality of the left ureter.  A nephrostomy tube was placed, and the patient was discharged on 12/15/2010 with instructions to return to have the ureter repaired once all signs of infection had cleared up.

On1/5/2011, the patient saw a urologist and underwent a nephrostogram showing complete obstruction of the left ureter.

On 1/18/2011, the urologist performed surgery on the patient to correct the ureteral injury.  He performed a cystoscopy, released the left ureter, placed a stent, and removed a foreign body. The urologist noted damage to the bladder, protrusion of mesh from the fascia lata graft, and several sutures within the bladder.  On 2/28/2011, the urologist removed the left ureteral stent.

Th patient continued to have stress urinary incontinence after the 12/10/2010 surgical procedure and corrective surgeries with the urologist.  The patient was subsequently treated for urinary stress incontinence at another medical center with good results.

Per the Board, throughout the course of the gynecologist’s treatment of the patient, the gynecologist failed to address the primary presenting issue of stress urinary incontinence.  The gynecologist performed invasive surgical procedures for a minimally symptomatic prolapse but failed to perform any procedure specifically for stress urinary incontinence.  The gynecologist’s failure to address the initial presenting complaint during the course of her treatment of the patient and instead performed procedures not indicated for stress urinary incontinence constituted an extreme departure from the standard of care.

The Board issued a public reprimand with stipulations to complete an education program focused on implantable gynecological device procedures.

State: California


Date: September 2015


Specialty: Gynecology, Urology


Symptom: Urinary Problems, Abdominal Pain


Diagnosis: Urological Disease, Post-operative/Operative Complication


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


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



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