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New Jersey – Gastroenterology – Pathology Diagnoses Polyp Removed During Colonoscopy As Adenocarcinoma
A payment of $775,000 had been made on the gastroenterologist’s behalf to settle a civil malpractice action brought against him by a patient.
It was alleged the gastroenterologist failed to follow-up on pathology results that revealed cancer after he had performed a colonoscopy on the patient, which led to a delay in the diagnosis of colorectal cancer.
On 8/12/2009, a 55-year-old woman presented to a gastroenterologist with complaints of abdominal pain and rectal bleeding. The patient’s medical history revealed a family history of colon cancer. The gastroenterologist recommended that the patient have a diagnostic colonoscopy to evaluate her persistent rectal symptoms.
On 9/17/2009, the gastroenterologist performed a colonoscopy on the patient. During the procedure, the gastroenterologist identified internal hemorrhoids associated with a sessile polyp in the mid-rectum. The gastroenterologist removed the polyp and submitted the specimen for pathologic analysis. The patient was discharged from the hospital on 9/17/2009.
On 9/18/2009, pathology diagnosed the polyp to be a moderately differentiated adenocarcinoma arising within a tubular adenoma. On 10/6/2009, the gastroenterologist entered a progress note in the patient’s hospital chart directly documenting the finding of adenocarcinoma made in the pathology report. Despite entering that chart note, the gastroenterologist never advised the patient of the finding of adenocarcinoma that had been made.
The gastroenterologist thereafter had no further contact with the patient until he saw her in his office on 8/23/2010, approximately eleven months after the colonoscopy had been performed. At that visit, the gastroenterologist diagnosed the patient with hemorrhoids and prescribed steroid suppositories; however, he once again failed to inform her of the finding of cancer that had been made following the September 2009 colonoscopy. Additionally, the gastroenterologist did not then recommend that the patient schedule a repeat colonoscopy.
The patient ultimately had a repeat colonoscopy performed by another physician on 4/27/2011. Following that procedure, she was found to have an invasive carcinoma of the mid-rectum, and she commenced receiving treatment for colon cancer.
When appearing before the panel, the gastroenterologist testified that he was aware of the pathology findings that had been made following the colonoscopy but did not specifically advise the patient of those findings because he considered the pathology findings to be “benign.” The gastroenterologist further testified that he was confident that he had removed the entirety of the rectal polyp at the time of the colonoscopy. The gastroenterologist maintains that, after completing the colonoscopy, he advised the patient that she would need to see him again in “about” a year, but there is no documentation in either the gastroenterologist’s medical record or the hospital chart which memorializes respondent’s having advised the patient to have a repeat colonoscopy within one year. Further, although the gastroenterologist entered a note in the patient’s hospital chart on 10/6/2009 documenting the pathology findings, he failed to record the pathology findings in his office medical record, and he failed to obtain and/or maintain a copy of the pathology report in his office record.
The Board judged the gastroenterologist’s conduct to have fallen below the standard of care given failure to document that he advised the patient to have a repeat colonoscopy performed within one year of the date on which the original colonoscopy was performed and failure to have documented the pathology findings of adenocarcinoma in his office record.
The Board assessed a fine against the gastroenterologist with stipulations to complete courses in medical record keeping and medical ethics.
State: New Jersey
Date: March 3017
Specialty: Gastroenterology
Symptom: Blood in Stool, Abdominal Pain
Diagnosis: Colon Cancer
Medical Error: Failure to follow up, Failure of communication with patient or patient relations, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Gynecology – CBC Tests Show Neutropenia And Leukopenia At An Annual Gynecological Exam
On 8/15/2013, a 34-year-old female presented to a gynecologist for an annual gynecological exam. At the exam, the patient expressed concerns about infertility. The gynecologist and the patient discussed various tests that may be used to address infertility and the gynecologist began ordering tests.
On 2/23/2015, the patient gave blood for a complete blood count (“CBC”) test that was ordered by the gynecologist.
On 3/5/2015, the gynecologist received and signed for the results of the CBC test. The CBC test indicated the patient had an abnormal white blood cell count, marked leukopenia, and severe neutropenia.
The gynecologist failed to notify the patient of the abnormal results of the CBC test.
The gynecologist failed to ensure that the patient had otherwise established a plan of care to address the abnormal results of the CBC test.
On 5/28/2015, the patient presented to the gynecologist for an annual gynecological exam. At the exam, it was determined that the patient was pregnant, and the gynecologist ordered blood tests for the patient. The gynecologist failed to order a repeat CBC test.
On 7/17/2015, the gynecologist received and signed for the results of the repeat CBC test. The repeat CBC test indicated that the patient’s white blood cell count had decreased further, the neutropenia had worsened, and she now had pancytopenia with a drop in the red blood cell and platelet count.
On 7/30/2015, the gynecologist notified the patient of the results of her repeat CBC test and referred her to a hematologist.
On 8/8/2015, the patient experienced a massive intracranial hemorrhage with herniation, as well as severe pancytopenia.
On 8/12/2015, the patient expired in the hospital. The fetus was also lost at that point.
The Medical Board of Florida judged the gynecologists conduct to be below the minimal standard of competence given that she failed to ensure that the patient had been notified of the abnormal results of the CBC test. The gynecologist failed to ensure that the patient had otherwise established, a plan of care to address the abnormal results of the CBC test. The gynecologist failed to order a repeat CBC test at the patient’s May exam.
The Medical Board of Florida issued a letter of concern against the gynecologist’s license. The Medical Board of Florida ordered that the gynecologist pay a fine of $8,500 against her license and pay reimbursement costs for the case at a minimum of $3,126.31 and not to exceed $5,126.31. The Medical Board of Florida ordered that the gynecologist complete five hours of continuing medical education in “risk management.”
State: Florida
Date: December 2017
Specialty: Gynecology, Obstetrics
Symptom: N/A
Diagnosis: Hematological Disease, Intracranial Hemorrhage
Medical Error: Failure to follow up, Delay in proper treatment, Failure of communication with patient or patient relations
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF
Florida – Family Medicine – Diagnosis Of Deep Cellular Fibrous Histiocytoma With A Differential Diagnosis Of Myofibroblastic Sarcoma
On 3/28/2014, a patient presented to a family practitioner with complaints of a right forearm mass.
On 4/4/2014, the family practitioner excised a 3-4 cm mass from the patient’s right forearm. The family practitioner sent the specimen out for review by a pathologist.
On 4/15/2014, the pathologist via a pathology report listed a diagnosis of deep cellular fibrous histiocytoma with a differential diagnosis of low grade myofibroblastic sarcoma. The pathology report further stated that re-excision was ‘“strongly recommended.”
On 4/16/2014, at a follow-up appointment, the family practitioner informed the patient that the mass was benign. He informed the patient that a wait-and-see approach would be appropriate, and, if the mass returned, further excision would be recommended. The family practitioner did not inform the patient of the differential diagnosis listed on the pathology report. He also did not advise the patient that a re-excision was strongly recommended by the pathologist.
On 1/30/2015, the mass on the patient’s forearm returned and was larger.
On 3/5/2015, a general surgeon performed a second excision on the patient.
On 3/11/2015, the pathology report of the second excision stated a diagnosis of high grade myxofibrosarcoma.
The Board judged the family practitioners conduct to be below the minimum standard of competence given that he failed to fully inform the patient of the pathology report findings and advise the patient that re-excision wass strongly recommended.
It was requested that the Board order one or more of the following penalties for the family practitioner: 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: November 2017
Specialty: Family Medicine
Symptom: Mass (Breast Mass, Lump, etc.)
Diagnosis: Cancer
Medical Error: Underestimation of likelihood or severity, Failure of communication with patient or patient relations
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Internal Medicine – Failure To Justify Suboxone Prescribing Practices
From 7/8/2011 to 8/13/2015, an internist treated a 37-year-old female with an opioid dependency for seven years with Suboxone therapy. During the treatment period, the internist prescribed the controlled substance Suboxone to the patient on one or more occasions. During the treatment period, the internist failed to substantiate, by test or positive exam, the patient’s history of opiate use to justify the use of Suboxone.
During the treatment period, the internist did not obtain a history of substance abuse, including illicit substances, or a complete medical history from the patient’s prior healthcare provider to support his diagnosis of opioid dependence and opiate withdrawal.
During the treatment period, the internist inappropriately diagnosed the patient, as his physical examination of the patient failed to indicate clinical opiate withdrawal symptoms, to help support his diagnosis of continuous opioid dependence and opiate withdrawal.
During the treatment period, the internist failed to perform tests, including screening for hepatitis B and C, complete metabolic panel, and complete blood count, to completely assess the patient’s condition.
During the treatment period, the internist failed to completely and accurately maintain medical records that justify Suboxone therapy as a proper course of treatment.
During the treatment period, the internist failed to document a clear treatment plan and time frame for detoxification, and/or thoroughly educate the patient about additional recovery.
During the treatment period, the internist failed to perform and/or maintain records of frequent urine toxicology for the patient to prevent noncompliance, dependence, addition, or diversion of controlled substances.
During the treatment period, the internist failed to document, incorporate in the medical records, or comment on all urine toxicology screens performed on the patient on one or more occasions.
During the treatment period, the internist failed to include all logs of prescriptions within his electronic medical record (“EMR”).
During the treatment period, the internist did not pursue, or document pursuing, psychological counseling, prescription drug monitoring (“PDMP”) and follow-up urine toxicology screens to guide optimal therapy.
It was requested that the Board order one or more of the following penalties for the internist: permanent revocation or suspension of his license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Board deemed appropriate.
State: Florida
Date: October 2017
Specialty: Internal Medicine
Symptom: N/A
Diagnosis: Drug Overdose, Side Effects, or Withdrawal
Medical Error: Failure to properly monitor patient, Failure to order appropriate diagnostic test, Failure of communication with patient or patient relations, Improper medication management, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
Florida – Ophthalmology – Lack Of Diagnostic And Preoperative Testing To Assess An Epiretinal Membrane
From 8/12/2015 to 4/1/2016, (“treatment period”) a 69-year-old male presented to an ophthalmologist with complaints of blurred vision in his eyes.
During the treatment period, the ophthalmologist diagnosed the patient with a mature cataract in his right eye, and complicated cataract, proliferative diabetic retinopathy, and epiretinal membrane (“ERM”) in his left eye.
During the treatment period, the ophthalmologist did not perform or document performing the appropriate objective preoperative diagnostic testing, such as an Optical Coherence Tomography (“OCT”), of the retina to adequately assess the ERM in the patient’s left eye.
During the treatment period, the ophthalmologist did not thoroughly examine or document a thorough examination of the patient’s eyes by performing objective preoperative testing and imaging, such as fundus photos documenting the ERM, an Amsier grid showing distortion of the patient’s vision, an Amsier grid on either eye, or showing the patient’s retina and irregularities in the retina to support the epiretinal membrane peel in the patient’s left eye.
During the treatment period, the medical records maintained by the ophthalmologist did not clearly document any indication of the ERM on the patient’s left eye preoperatively.
During the treatment period, the ophthalmologist did not perform or document performing, objective preoperative testing and imaging studies, such as an OCT of the retina, an Amsier grid showing distortion or metamorphopsia, taking fundus photos, or a fluorescein angiogram to justify his course of treatment in the patient’s left eye.
During the treatment period, the ophthalmologist did not thoroughly discuss with the patient or document thoroughly discussing with the patient the option of cataract surgery alone versus cataract surgery with the ERM.
On 8/27/2015, the ophthalmologist performed a cataract removal and intraocular lens implantation on the patient’s right eye.
On 10/8/2015, the ophthalmologist performed a cataract removal and epiretinal membrane peel on the patient’s left eye.
During the treatment period, the ophthalmologist did not maintain medical records that justified an appropriate plan or treatment for the patient’s condition.
The Board judged the ophthalmologist’s conduct to be below the minimal standard of competence given that he failed to perform and document appropriate diagnostic and preoperative testing. The ophthalmologist also failed to discuss with the patient the option of cataract surgery alone versus cataract surgery with the ERM.
It was requested that the Board order one or more of the following penalties for the ophthalmologist: 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: Ophthalmology
Symptom: Vision Problems
Diagnosis: Ocular Disease
Medical Error: Failure to order appropriate diagnostic test, Failure to examine or evaluate patient properly, Failure of communication with patient or patient relations, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 2
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 – 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
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
Florida – Gynecology – Hormone Replacement Therapy, A History Of Heart Disease, And Elevated Glucose Levels
On 5/16/2014, a 47-year-old female presented to a gynecologist for a routine gynecological exam. The patient had a significant history of heart disease, including a quadruple bypass surgery in 2009.
The patient had complaints of hot flashes, inability to lose weight, insomnia, night sweats, irritability, and mild bladder leakage. The gynecologist diagnosed the patient as menopausal. The gynecologist recommended hormone replacement therapy. He ordered hormone and thyroid level lab work. He did not order tests for cholesterol levels or basic metabolic status, despite the patient’s metabolic lab result, dated 2/6/2012, indicating an abnormally high glucose level.
On 6/11/2014, the patient presented to the gynecologist for follow-up. The gynecologist prescribed compounded creams containing the hormones estrogen, progesterone, and testosterone. He also prescribed Armour Thyroid, a thyroid hormone replacement drug containing the hormones T3 and T4.
At all times material to this complaint, the prevailing standard of care dictated that a physician prescribing hormone replacement therapy to a patient with a significant history of heart disease obtain appropriate medical clearance prior to prescribing such therapies.
The gynecologist did not obtain medical clearance prior to prescribing hormone replacement therapy to the patient, despite a significant history of heart disease.
The prevailing standard of care dictated that a physician prescribing hormone replacement therapy to a patient with a prior abnormal glucose value order or obtain sufficient blood work prior to prescribing hormone replacement therapy.
The gynecologist did not obtain sufficient blood work prior to prescribing hormone replacement therapy to the patient, despite the patient’s prior abnormal glucose value.
At all times material to this complaint, the prevailing standard of care dictated that a physician discuss the full risks and benefits of hormone replacement therapy with the patient prior to initiating the treatment. The gynecologist failed to discuss, or did not create or maintain adequate, legible documentation of discussing the full risks and benefits of hormone replacement therapy with the patient.
The Board issued a letter of concern against the gynecologist’s license. The Board ordered that the gynecologist pay a fine of $5,000 against his license and pay reimbursement costs for the case for a minimum of $7,244.87 and not to exceed $9,244.87. Also, the Board ordered that gynecologist complete ten hours of continuing medical education in “hormone replacement therapy” and five hours of continuing medical education in “risk management.”
State: Florida
Date: July 2017
Specialty: Gynecology
Symptom: Urinary Problems
Diagnosis: N/A
Medical Error: Failure to order appropriate diagnostic test, Failure of communication with patient or patient relations, Improper medication management
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
Florida – Gynecology – MRI Reveals Two Adjacent Large Intraperitoneal Complex Cystic Masses With Plan For Removal
On 11/19/2013, a 44-year-old female presented to a gynecologist for abdominal/pelvic discomfort.
The gynecologist performed an ultrasound and reported a “large ovarian cyst 14 cm in greatest extent… simple in nature.” The gynecologist ordered additional imaging of the patient’s abdomen and pelvis to further evaluate the cyst.
The patient was scheduled for surgical removal of the cyst to be performed by the gynecologist on 11/27/2013.
On 11/22/2013, an MRI of the patient’s pelvis was performed, which indicated the presence of “two adjacent large intraperitoneal complex cystic masses.”
On 11/27/2013, preoperatively, the gynecologist indicated that he read the history and physical and examined the patient and that there were “no changes.”
After receiving and reviewing the MRI report, the gynecologist failed to further evaluate, or alternatively, did not create, keep, or maintain adequate legible documentation of evaluating, whether a malignancy was present.
Prior to the surgery on 11/27/2013, the gynecologist failed to discuss, or alternatively, did not create, keep, or maintain adequate legible documentation of discussing, with the patient her desired plan-of-care in the event that the cysts contained malignant cells.
The gynecologist attempted to remove the cysts laparoscopically, by intentionally puncturing and aspirating the cysts. Prior to intentionally puncturing the cysts, the gynecologist did not place the cysts into a specimen bag to prevent contamination in the event that the cysts contained malignant cells. During the procedure, the contents of the cysts spilled into the patient’s abdominal cavity.
Intraoperatively, the procedure was converted to a laparotomy and the gynecologist removed the patient’s left ovary in its entirety and sent it to pathology. The pathology report indicated that the specimen was “of at least low malignant potential” indicating possible higher grade abnormality.
Accordingly, the gynecologist performed a total abdominal hysterectomy and removal of the right ovary.
The Board judged the gynecologist’s conduct to be below the minimal standard of competence given that he failed to further evaluate, preoperatively, to determine whether a malignancy was present, proceed with the correct surgical approach on 11/27/2013, by performing a laparotomy and removing the cysts intact, or by placing a specimen bag around the cysts prior to intentionally puncturing and aspirating the cysts, and discussing with the patient, preoperatively, to determine the patient’s desired plan-of-care for the possibility of malignancy.
It was requested that the Board order one or more of the following penalties for the gynecologist: 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: Gynecology
Symptom: Abdominal Pain, Mass (Breast Mass, Lump, etc.)
Diagnosis: Gynecological (Endometrial, Ovarian, Cervical) Cancer
Medical Error: Underestimation of likelihood or severity, Failure of communication with patient or patient relations, Procedural error
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF