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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 – Emergency Medicine – Patient With Intussusception Involving Loop Of Small Bowel Discharged Home With Magnesium Citrate
At 1:45 a.m. on 7/26/2014, a 46-year-old female presented to the emergency department with complaints of severe abdominal pain. Upon arrival at the emergency department, the patient was evaluated by the ED physician.
The patient complained of severe abdominal pain and stated the pain was “10 out of 10.” The patient then underwent laboratory studies and a CT scan of the abdomen/pelvis with intravenous and oral contrast.
A radiologist reviewed the CT scan at some time before 4:16 a.m., when he read and signed the preliminary report. Upon review of the CT scan results the radiologist recorded in the preliminary report “intussusception involving loop of small bowel in the left lower quadrant with involved loops appearing edematous.” The radiologist relayed the results of the CT scan to the ED physician via teleradiology.
The ED physician recorded the results of the CT scan in the patient’s emergency provider report and noted “thickened loop of small bowel in the left lower quadrant, [m]ay be intussuception [sic].”
At 4:32 a.m. the ED physician discharged the patient to her home with a magnesium citrate prescription and no additional discharge instructions.
At 8:28 a.m. a physician signed the final radiology report and noted “[i]ntussesception involving loop of small bowel in the left lower quadrant” and “preliminary report related to referring physician teleradiology at the time of the exam by the radiologist.”
Later that day, the patient developed worsening pain, and presented to another emergency department, and underwent an emergency surgery for resection of necrotic bowel.
The Board judged the ED physician’s conduct to be below the minimum standard of competence given his failure obtain emergent surgical consultation for further evaluation and treatment and continue hospitalization for operative intervention or ongoing evaluation of abdominal pain.
The Board ordered the ED physician to pay an administrative fine in the amount of $8,000. Also, the Board ordered the ED physician to complete five hours of continuing medical education in the area of emergency medicine.
State: Florida
Date: December 2017
Specialty: Emergency Medicine
Symptom: Abdominal Pain
Diagnosis: Acute Abdomen
Medical Error: Improper treatment, Referral failure to hospital or specialist
Significant Outcome: Hospital Bounce Back
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Internal Medicine – Patient With Worsening Chronic Kidney Disease Presents With Arm Pain, Numbness, And Shortness Of Breath
From 2009 until 2014, an internist served as the patient’s primary care physician.
In 2009, the internist referred the patient to Cardiologist A for a cardiology evaluation. The results of the 2009 cardiology evaluation revealed that the patient’s electrocardiogram and stress test were both abnormal.
At this time, Cardiologist A recommended that the internist increase the patient’s medication as needed in order to get the patient’s cholesterol to below seventy.
The patient was evaluated by Cardiologist A again in June 2010.
The June 2010 cardiac evaluation revealed that the patient had shortness of breath on exertion at times, possibly related to hypertension and subclinical congestive heart failure.
On 7/17/2013, the patient underwent lab work, the results which showed that his glomerular filtration rate (GFR) was thirty-four. The internist staged the patient’s chronic kidney disease (CKD) at a stage III/IV.
The patient’s next set of lab work was conducted on 11/18/2013, the results of which showed that his GFR was twenty-two. The internist wrote in a progress note that the patient’s CKD was a stage III/IV.
On 1/13/2014, the patient had lab work done again, the results which showed that his GFR was twenty-six. In his progress note he wrote that the patient’s CKD was now a stage IV.
Despite a dramatic decline in the patient’s GFR levels indicative of worsening CKD, the internist did not refer the patient to a nephrologist.
On 1/13/2014, the patient presented to the internist complaining of left arm pain, numbness radiating to both hands, and shortness of breath. The internist ordered an EKG, chest x-ray, and lab work. His assessment of the patient at this time was dyspnea on exertion, questionable coronary artery disease, questionable pulmonary disease, and questionable anxiety.
On 1/14/2014, the patient returned to the office for an echocardiogram. After the echocardiogram, the internist referred the patient to Cardiologist B for a consult. The patient could not obtain an appointment with Cardiologist B until 2/3/2014.
The internist ordered that a stress test be conducted prior to the patient’s visit with Cardiologist B, and advised that the patient bring the results of the stress test to his appointment with Cardiologist B.
On 1/23/2014, the stress test was performed and the results were abnormal.
The Medical Board of Florida judged that the internist failed to adequately evaluate the patient’s symptoms and recognize the patient’s worsening coronary artery disease, development of congestive heart failure, and worsening chronic kidney disease. He failed to refer the patient to a nephrologist for further evaluation upon seeing a dramatic decline in the patient’s GFR levels. He also failed to send the patient to the emergency department for treatment when the patient presented to him with exhibiting cardiac symptoms and had a known history of heart disease.
The Medical Board of Florida issued a letter of concern against the internist’s license. The Medical Board of Florida ordered that the internist pay a fine of $2,500 against his license and pay reimbursement costs for the case at a minimum of $5,756.36 and not to exceed $7,756.36. The Medical Board of Florida also ordered that the internist complete five hours of continuing medical education in the treatment of patients with chronic kidney disease and chronic heart disease.
State: Florida
Date: December 2017
Specialty: Internal Medicine
Symptom: Extremity Pain, Numbness, Shortness of Breath
Diagnosis: Heart Failure, Cardiovascular Disease, Renal 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 – Internal Medicine – Worsening Chronic Kidney Disease, Abnormal Stress Test, And Cardiac Symptoms
From 2009 until 2014, an internist served as a patient’s primary care physician.
In 2009, the internist referred the patient to Cardiologist A for a cardiology evaluation. The results of the 2009 cardiology evaluation revealed that the patient’s electrocardiogram and stress test were both abnormal. At this time Cardiologist A recommended that the internist increase the patient’s medication as needed in order to get the patient’s LDL cholesterol below seventy.
The patient was evaluated by Cardiologist A again in June 2010. The June 2010 cardiac evaluation revealed that the patient had shortness of breath on exertion at times, possibly related to hypertension and subclinical congestive heart failure.
On 7/17/2013, the patient underwent lab work, the results which showed that his glomerular filtration rate (“GFR”) was thirty-four. The internist stated the patient’s chronic kidney disease (“CKD”) as stage III/IV.
The patient’s next set of lab work was conducted on 11/18/2013, the results of which showed that his GFR was twenty-two. The internist wrote in a progress note that the patient’s CKD was stage III/IV.
The patient had lab work done again on 1/13/2014, the results of which showed that his GFR was twenty-six. In a progress noted created on 1/13/2014, the internist wrote that the patient’s CKD was now at stage IV.
Despite the dramatic decline in the patient’s GFR levels indicative of worsening CKD, the internist did not refer the patient to a nephrologist.
On 1/13/2014, the patient presented to the internist complaining of left arm pain, numbness radiating to both hands, and shortness of breath. The internist ordered an EKG, chest x-ray, and lab work. The internist’s assessment of the patient at this time was dyspnea on exertion, questionable coronary artery disease, questionable pulmonary issue, and questionable anxiety.
The internist had the patient return to the office on 1/14/2014 for an echocardiogram. After the echocardiogram, the internist referred the patient to Cardiologist B for a consult.
The patient could not obtain an appointment with Cardiologist B until 2/3/2014.
The internist ordered that a stress test be conducted prior to the patient’s visit to Cardiologist B, and advised that the patient bring the results of the stress test to his appointment with Cardiologist B. The stress test was performed on 1/23/2014, and the results were abnormal.
The Board judged the internist’s conduct to be below the minimum standard of competence given that the internist failed to adequately evaluate the patient’s symptoms and recognize the patient’s worsening coronary artery disease, development of congestive heart failure, and worsening of chronic kidney disease. The internist should have referred the patient to a nephrologist for further evaluation upon seeing a dramatic decline in the patient’s GFR levels. When the patient, with a known history of cardiac disease, presented with cardiac symptoms, the internist should have should have sent the patient to an emergency department for treatment.
The Board ordered that the internist pay a fine of $2,000 imposed against his license. The Board also ordered that the internist pay reimbursement costs of a minimum of $5,756.36 and not to exceed $7,756.36. The internist was ordered to complete five hours of continuing medical education in the treatment of patients with chronic kidney disease and five hours of continuing medical education in the treatment of patients with chronic heart disease.
State: Florida
Date: December 2017
Specialty: Internal Medicine
Symptom: Extremity Pain, Numbness, Shortness of Breath
Diagnosis: Renal Disease, Cardiovascular Disease
Medical Error: Referral failure to hospital or specialist
Significant Outcome: N/A
Case Rating: 2
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 – Emergency Medicine – Sharp Chest Pain After Intercourse
On 4/4/2015, a 47-year-old male presented to the emergency department with sharp chest pain after intercourse.
The RN on duty noted taking the patient’s vitals and performing an EKG, chest radiograph, and labs.
In his physician note, the ED physician documented the following: the patient did not take his medication for hypertension or dyslipidemia despite having a history of hypertension and homelessness; the patient reported a history of coronary artery disease and possible coronary artery stent placement; and the patient reported chest discomfort and dyspnea for the week prior to presentation as well as a history of tobacco use.
The ED physician recorded a differential diagnosis including acute myocardial infarction, non-ST segment elevation myocardial infarction (“NSTEMI”), angina, and acute coronary syndrome.
The ED physician did not diagnose the patient with possible cardiac etiology of chest discomfort. He also did not contact the on-call cardiologist. The ED physician did not perform provocative testing or cardiac catheterization. He also did not admit the patient for hospitalization and cardiology consultation. The ED physician discharged the patient without requiring any further evaluation/treatment or serial EKG/troponin. He did not arrange for close outpatient follow-up prior to discharge.
The Board issued a letter of concern against the ED physician’s license and ordered that he pay a fine, reimburse costs for the proceedings, and complete 5 hours of continuing education in risk management.
State: Florida
Date: November 2017
Specialty: Emergency Medicine
Symptom: Chest Pain
Diagnosis: Cardiovascular Disease
Medical Error: Failure to order appropriate diagnostic test, Referral failure to hospital or specialist, Failure to follow up
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
Florida – Family Medicine – Recurrent Chest Pain Diagnosed As Esophageal Spasm
On 8/27/2012 a 47-year-old female presented with complaints of hypertension, possible hyperlipidemia, and pain in her foot. A family practitioner assessed the patient and diagnosed her with poor control of her hypertension and reinforced medical advice for the patient to increase her lisinopril. Additionally, the family practitioner waited for the results of the previous laboratory work and recommended conservative management and stretching for the foot and ankle.
On 4/1/2013, the patient again presented to the family practitioner to address difficulties with concurrent chest pain. The patient stated the chest pains were very severe and “stopped her in her tracks at times.” The patient stated that she felt she was having a heart attack, although she reportedly realized that that was not the case. The family practitioner deemed the chest pain was likely an esophageal spasm, for which he prescribed the patient Librax (chlordiazepoxide/clidinium) and recommended that she see a gastroenterologist for an endoscopy if the medication failed to provide relief. The family practitioner also assessed the patient for hypertension and instructed the patient to stop taking hydrochlorothiazide. The family practitioner provided the patient with a trial of Dyrenium (triamterene).
On 4/12/2013, the patient complained of chest pain and suffered a cardiac arrest. Upon EMS arrival, the patient was unstable and unresponsive. The patient was transported to a hospital where she was later pronounced deceased.
The Board judged the family practitioners conduct to be below the minimal standard of competence given that he failed to conduct an adequate history, which included a risk factor assessment for a patient complaining of chest pain, to order or perform an EKG on a patient complaining of chest pain, and send a patient complaining of chest pain to an emergency room or an expedited outpatient facility for a chest pain evaluation.
The Board ordered that the family practitioner pay a fine of $5,000 against his license and pay reimbursement costs for a minimum of $2,122.00 and not to exceed $4,122.00. The Board also ordered that the family practitioner complete ten hours of continuing medical education in diagnosis in cardiology and five hours of continuing medical education in “Risk Management.”
State: Florida
Date: November 2017
Specialty: Family Medicine
Symptom: Chest Pain, Extremity Pain
Diagnosis: Cardiovascular Disease
Medical Error: Diagnostic error, Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Referral failure to hospital or specialist
Significant Outcome: Death
Case Rating: 3
Link to Original Case File: Download PDF
Vermont – Family Practice – Oversight In Anorexia Nervosa Monitoring
A patient was treated by a family practitioner from May 2012 to September 2012.
On the first office visit, the patient presented with symptoms and behaviors that met the DSM-IV criteria of anorexia nervosa, as well as the National Institute for Mental Health criteria of Pediatric Acute Neuropsychiatric Syndrome (PANS). The patient’s medical records from the patient’s prior primary care physician included a diagnosis of anorexia nervosa and a prior recommendation for inpatient mental health treatment for anorexia.
The family practitioner made the following diagnoses: systemic inflammatory syndrome with multi-systemic symptoms and marked neuropsychiatric dysfunction with probable underlying infectious triggers; PANS (Pediatric Acute Neuropsychiatric Syndrome); and probable PITANDs (Pediatric Infection-Triggered Autoimmune Neuropsychiatric Disorders). Anorexia nervosa was not documented as a primary or differential diagnosis. The family practitioner indicated that he considered the possibility of a purely behavioral syndrome like anorexia nervosa, but felt that the patient’s anorexia was “part of a more complex multi-system picture.”
The family practitioner based his diagnosis on the patient’s history and symptoms meeting the diagnostic criteria for PANS, testing positive to three infectious agents, and an initial response positive response to PITANDs treatment, in addition to a lack of positive response to anorexia nervosa focused management with the patient’s prior primary care physician and other consultants.
The family practitioner saw the patient on three occasions over a four month period, which the Board believes is inadequate for management of anorexia for an adolescent. The family practitioner relied on his nurse to call the patient on weekly updates and weight checks.
In addition to three office visits, the family practitioner’s treatment included ordering numerous blood tests, and the prescribing of medications, antibiotics, herbal supplements, and vitamins for the infection etiologies and the inflammatory conditions. However, he did not prescribe any medications for the treatment of anorexia nervosa. While the family practitioner believed that the patient was being treated by his primary care physician, this was not confirmed with any other provider, and the family practitioner did not communicate directly with any other provider beyond sending his initial office visit note and lab results to the patient’s primary care physician.
The Board judged the family practitioner’s medical records and communication with the patient’s primary care physician concerning his treatment of the patient were inadequate. The family practitioner’s office notes did not document past surgical and family history, temperature, height, BMI calculation, and growth curve charting.
Based on review of the family practitioner’s medical records concerning his treatment of the patient and the documentation of his communication with the patient’s parents, it appears that the family practitioner did not clearly explain his role in the patient’s care to the patient’s parents until the end of his treatment. Is it possible that the patient’s parents believed that the family practitioner had taken over the role as the primary care physician and was actively managing the patient’s care.
The family practitioner’s position was that he believed that he was participating in the care of the patient in the role as a consultant to his primary care physician and that the patient’s primary care physician was concurrently monitoring the patient. With the exception of the provision of his initial office note and lab results, the family practitioner did not communicate with the patient’s primary care provider during the course of his treatment. After sending his initial note and lab results, the family practitioner did not communicate with the patient’s primary care provider or any other medical professionals until the patient had an acute worsening of the condition on 9/13/2012.
The Board judged that the family practitioner failed to appropriately monitor, manage, and maintain comprehensive medical records on a juvenile patient with a severe eating disorder.
The Board ordered that the family practitioner be reprimanded, complete one hour of continuing medical education on cognitive bias, and that he shall only practice medicine in a structured, group setting for a period of three years.
State: Vermont
Date: September 2017
Specialty: Family Medicine, Psychiatry
Symptom: Weight Loss
Diagnosis: Psychiatric Disorder
Medical Error: Improper treatment, Failure of communication with other providers, Failure of communication with patient or patient relations, Failure to properly monitor patient, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
Florida – Family Practice – Unnecessary Excisions Performed For Multiple Lesions
On 6/15/2012, a 47-year-old female presented to a family practitioner with multiple lesions on her back, chest, and arms.
The family practitioner informed the patient that the lesions on her left humerus, right upper abdomen, mid upper back, left anterior mid chest, lower back, right lower back, and/or right upper anterior chest were malignant and/or potentially malignant.
On 7/6/2012, the family practitioner documented that the patient had a history of keloid formation after surgical excision.
On 6/15/2012, the family practitioner excised a lesion on the patient’s left humerus. The lesion excised from the patient’s left humerus measured approximately 3 mm by 3 mm. The family practitioner made an excision 4 cm by 4 cm or sixteen square centimeters to excise the lesion on the patient’s left humerus.
On 6/19/2012, a dermatopathology report determined that the excision taken from the patient’s left humerus was not malignant or premalignant.
On 6/27/2012, the family practitioner excised a lesion on the patient’s right upper abdomen. The lesion on the patient’s right upper abdomen measured 3 mm. The family practitioner made an excision 7 cm by 6 cm, or forty-two square centimeters to excise the lesion on the patient’s right upper abdomen.
On 6/29/2012, a dermatopathology report determined that the excision taken from the patient’s right upper abdomen was not malignant or premalignant.
On 7/6/2012, the family practitioner excised a lesion the patient’s mid upper back. The lesion on the patient’s back measured approximately 3 mm. The family practitioner made an excision 5 cm by 7 cm, or thirty-five square centimeters to excise the lesion on the patient’s mid upper back.
On 7/13/2012, the family practitioner excised a lesion on the patient’s left anterior mid chest. The lesion on the patient’s left anterior mid chest measured approximately 4 mm by 4 mm.
The family practitioner made an excision 8 cm by 6 cm or forty-eight square centimeters to excise the lesion on the patient’s left anterior mid chest. He referred the patient for radiation treatment to prevent keloid formation.
On 7/20/2012, a dermatopathology report determined that the excision taken from the patient’s left anterior mid chest was not malignant or premalignant.
On 8/3/2012, the family practitioner excised a lesion the patient’s left lower back. The lesion on the patient’s left lower back measured 5 mm by 4 mm. The family practitioner made an excision 9 cm by 7 cm or sixty-three square centimeters to excise the lesion on the patient’s left lower back.
On 8/7/2012, a dermatopathology report determined that the excision taken from the patient’s left lower back was not malignant or premalignant.
On 8/10/2012, the family practitioner excised a lesion on the patient’s right lower back. The lesion on the patient’s right lower back measured 4 mm by 4 mm. The family practitioner made an excision 9 cm by 8 cm or seventy-two square centimeters to excise the lesion on the patient’s right lower back.
On 8/14/2012, a dermatopathology report determined that the excision taken from the patient’s right lower back was not malignant or premalignant.
On 8/27/2012, the family practitioner excised a lesion on the patient’s right upper anterior chest. The lesion on the patient’s right upper anterior chest measured 2 mm by 2 mm. He made an excision 10 cm by 7 cm, or seventy square centimeters to excise the lesion on the patient’s right upper anterior chest.
On 8/29/2012 a dermatopathology report determined that the excision taken from the patient’s right upper anterior chest was not malignant or premalignant.
The Board judged that the family medicine practitioners conduct to be below the minimal standard of competence given that he failed to perform a complete and comprehensive physical examination of the patient’s lesions; adequately consider the characteristics of the lesions, including the size, color, regularity, and degree of pigmentation; refer the patient for consultation with a dermatologist; refrain from diagnosing the patient with malignant and/or potentially malignant lesions without having adequate justification; accurately and appropriately diagnose the patient’s condition; confirm that each of the lesions on the patient was malignant or premalignant prior to excising the lesion; perform a shave biopsy, punch biopsy, or limited excisional biopsy with 1 mm margins on each of the lesions on the patient to determine whether the lesion was malignant or premalignant; make an excision with margins no greater than 5 mm to excise each of the lesion on the patient; refrain from making an excision on the patient without having adequate justification; avoid potential keloid formation on the patient, by making the fewest and/or smallest excisions appropriate and/or justifiable.
The family practitioner agreed to voluntarily cease practicing medicine and agreed to never reapply for licensure as a medical doctor in the state of Florida.
State: Florida
Date: August 2017
Specialty: Family Medicine, Dermatology
Symptom: Dermatological Abnormality
Diagnosis: Dermatological Issues
Medical Error: Unnecessary or excessive treatment or surgery, Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Referral failure to hospital or specialist, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
Florida – Cardiothoracic Surgery – Failure To Follow Up After Pathology Report Shows Abnormal Lymphadenopathy
On 1/25/2013, a 65-year-old male, underwent an artery bypass grafting procedure on his right leg by a cardiothoracic surgeon at a medical center.
During the course of the procedure, the cardiothoracic surgeon took a biopsy of the patient’s right groin lymph node, which was sent off to pathology for analysis.
The patient was never notified by the cardiothoracic surgeon that a biopsy of the right groin lymph node was taken during the procedure.
The cardiothoracic surgeon should have documented the right groin lymph node biopsy as part of the procedure in the operative report for the procedure but failed to do so.
On 1/29/2013, the pathology report for the biopsied tissue revealed a pathologic diagnosis of mantle cell lymphoma. The pathology report was sent via facsimile to the cardiothoracic surgeon’s office. The cardiothoracic surgeon should have listed “abnormal lymphadenopathy” as the post-operative diagnosis and failed to do so.
On 1/30/2013, the patient was discharged from the medical center.
The Board judged the cardiothoracic surgeons conduct to be below the minimal standard of competence given that he should have notified the patient of the pathology results and failed to do so. He also should have obtained oncologic consultation for the patient and failed to do so. The cardiothoracic surgeon should have provided the patient’s primary care physician and the referring physician with a copy of the pathology report and failed to do so.
The Board issued a letter of concern against the cardiothoracic surgeon’s license. The Board ordered that the cardiothoracic surgeon pay a fine of $5,000 against his license and pay reimbursement costs for the case for a minimum of $5,063.26 but not to exceed $7,063.26. The Board ordered that the cardiothoracic surgeon complete a board approved medical records course and complete five hours of continuing medical education in “risk management.”
State: Florida
Date: August 2017
Specialty: Cardiothoracic Surgery, Oncology
Symptom: N/A
Diagnosis: Cancer
Medical Error: Failure to follow up, Failure of communication with other providers, Referral failure to hospital or specialist, Failure of communication with patient or patient relations, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 4
Link to Original Case File: Download PDF