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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 – Obstetrics – Lack Of Maternal Serum Alpha-Fetoprotein Testing With Pregnancy Complications
On 2/24/2014, a 36-year-old female presented to an obstetrician for fatigue, breast tenderness, and absence of menstruation. At the aforementioned visit, the obstetrician diagnosed the patient with amenorrhea and sent her to have blood work.
On 2/25/2014, the patient was notified of her positive pregnancy test.
On 3/10/2014, 3/17/2014, 3/24/2014. 4/24/2014, 8/7/2014, and 9/25/2015, the obstetrician ordered obstetrical ultrasounds and/or sonograms for the patient.
On 4/23/2014 and 8/20/2014, the patient presented to the obstetrician with thick vaginal fluid and blood discharge, morning sickness, nausea, chills, fever, and back pain.
On 5/23/2014, 6/20/2014, 7/16/2014, 8/15/2014, 9/12/2014, 10/13/2014, 10/20/2014, and 10/27/2014, the patient presented to the obstetrician for follow-up visits.
On 11/2/2014, the patient gave birth to her son, who was born with spina bifida/myelomeningocele.
The obstetrician failed to diagnose neural tube defect on imaging studies.
The obstetrician failed to order a maternal serum alpha-fetoprotein (MSAFP) test and did not maintain adequate legible documentation of ordering an MSAFP test.
The obstetrician failed to order an anatomical survey sonogram.
The Board ordered that the obstetrician pay a fine of $7000 against his license. The Board ordered that the obstetrician pay reimbursements costs of a minimum of $3,786.18 and not to exceed $5,786.18. The Board also ordered that the obstetrician complete a course on “Quality Medical Record Keeping for Health Care Professionals” and that he complete five hours of continuing medical education on “Risk Management.”
State: Florida
Date: December 2017
Specialty: Obstetrics
Symptom: Fever, Bleeding, Nausea Or Vomiting, Back Pain
Diagnosis: Obstetrical Complication, Spinal Injury Or Disorder
Medical Error: Failure to order appropriate diagnostic test, Failure to follow up, 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 – Three Patients Seen At Once Without Proper Examination and Documentation
On 9/21/2012, Patient A, Patient B, and Patient C presented to a geriatric practitioner at the same time in his office. The geriatric practitioner saw the patients for less than nine minutes total. At no time were the patients separated for individual assessments. The patients were an undercover detective and two informants, using pseudonyms. The appointment was audiotaped and videotaped.
The geriatric practitioner failed to perform a physical examination on any of the three patients. The geriatric practitioner failed to create a treatment plan for any of the three patients. He also sent the three patients for x-rays without a physical examination. Per the geriatric practitioner’s instructions, all three patients presented for x-rays; however, only Patient A and Patient C actually had x-rays performed. The geriatric practitioner failed to create or maintain documentation of referring the three patients for x-rays.
On 10/30/2012, the three patients presented to the geriatric practitioner for a follow-up visit. At that time, the geriatric practitioner failed to review readily available medical records from the patients’ first visit, failed to inquire about x-ray results, failed to review physical therapy results, failed to perform physical examinations and/or failed to create treatment plans for all three patients.
The Board judged the geriatric practitioner’s actions to be below the minimum standard of competence given his failure to perform a physical examination, perform a complete individual physical examination for each patient prior to referral for x-rays, other diagnostic testing, or further treatment. Also, the geriatric practitioner failed to review any medical records or results at a follow-up visit, including x-rays, from prior visits, and/or procedures and review and analyze the physical therapy progress of the patients, and create treatments plans for each patient.
The Board ordered that the geriatric practitioner pay a fine of $12,000 against his license and pay reimbursement costs for the case for a minimum of $37,421.80 and not to exceed $39,421.80. The Board also ordered that the geriatric practitioner complete a medical records course and complete five hours of continuing medical education on “Risk Management.” The Board put the geriatric practitioner’s license on probation and required that he have indirect supervision to practice by a Board-approved physician.
State: Florida
Date: November 2017
Specialty: Family Medicine
Symptom: N/A
Diagnosis: N/A
Medical Error: Failure to examine or evaluate patient properly, Ethics violation, Failure to follow up, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 1
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
Washington – Internal Medicine – Proper Monitoring Of Thyroid Dysfunction And High Blood Pressure
Beginning in June 2014, a physician began treating Patients A and B for thyroid dysfunction and Patient C for high blood pressure. The physician communicated with Patient A and B through phone consultation and met Patient C in social situations and during at least two office visits. The physician reviewed previous lab work on thyroid functions for Patients A and B. The physician based Patient C’s treatment upon his physical observation of her conditions, two Zytoscans (device that measures electrical currents in the skin), and taking her blood pressure. Patient A and B’s lab work indicated both patients having lower than normal thyroid function. The physician started both Patients A and B on a thyroid hormone supplement. He prescribed medication commonly used for treating high blood pressure for Patient C based upon his observations, oral reports of Patient C, and the Zytoscans. The physician failed to do lab work, took minimal chart notes, and did not schedule follow-up examinations for Patients A, B, or C.
For several months, the physician continued prescribing for Patients A, B, and C without ever seeing the patients in person for further work up. The physician’s interactions with Patients A and B were solely over the phone, while the physician notes state that he had two office visits with Patient C. The physician did not order thyroid stimulating hormone (TSH) testing to further verify if continuing the thyroid hormone supplement would be appropriate in managing Patient A and B’s conditions.
In June 2015, Patient A presented to another provider with concerns of heart palpitations. Patient A told the provider he noticed the palpitations reduced when he reduced his thyroid hormone supplement dosage. During this consultation, Patient A disclosed his treatment with the physician which alerted the provider to have Patient A’s TSH levels checked. Patient A’s lower than normal TSH result prompted the provider to immediately begin weaning Patient A off of his thyroid hormone supplement.
Patient B also presented to the same provider in June 2015. At her visit, Patient B presented with a rash on her chest which she had for over a month. The new provider assessed the rash being unrelated to her treatment with the physician; however, due to her receiving similar treatment as Patient A, the provider had Patient B’s TSH level tested. Patient B’s results indicated her TSH level was below the normal range.
On 8/26/2015, the physician saw Patient C for what he thought was a urinary tract infection. The physician first prescribed Keflex but changed it to ciprofloxacin based upon the results of a Zytoscan. Caution is required when giving ciprofloxacin to patients with hypokalemia.
On or about 9/9/2015, Patient C presented to the hospital emergency department where she was diagnosed with significant hypokalemia (lowered levels of potassium in the blood) and hyponatremia (lowered levels of sodium in the blood) which caused Patient C to suffer fatigue and heart palpitations. Patient C went immediately from the emergency department to a new care provider. After an oral interview with Patient C, the new care provider learned that Patient C was taking a number of medications prescribed by the physician. The new care provider attempted to contact the physician a number of times to obtain the physician’s chart notes, lab studies, and other medical records for Patient C but was unsuccessful. Patient C told her new care provider that the physician had been giving her medications for a number of years. She stated, “I tell him what I need.” In the physician’s response to the Commission, he stated that “if [Patient C] called me to have a prescription filled, I would do that for her.”
The Commission stipulated the physician reimburse costs to the Commission and write and submit a paper of at least 2000 words, with references and annotated bibliography, regarding Washington State rules for physicians forming and maintaining patient/physician relationships, the differential diagnosis of hyperthyroidism and hypothyroidism, the proper monitoring of electrolyte levels for patients with high blood pressure, and the importance of complying with Commission sanctions.
State: Washington
Date: November 2017
Specialty: Internal Medicine, Family Medicine
Symptom: Palpitations, Rash
Diagnosis: Endocrine Disease
Medical Error: Failure to follow up, Failure to properly monitor patient, Improper medication management
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
Florida – Obstetrics – Missed Indicators Of A Neural Tube Defect
On 2/24/2014, a 36-year-old female presented to an obstetrician for fatigue, breast tenderness, and absence of menstruation. At the aforementioned visit, the obstetrician diagnosed the patient with amenorrhea and sent her to have blood work.
On 2/25/2014, the patient was notified of her positive pregnancy test.
On 3/20/2014, 3/17/2014, 3/24/2014, 4/24/2014, 8/7/2014, and 9/25/2015, the obstetrician ordered obstetrical ultrasounds and/or sonograms on the patient.
On 4/23/2014 and 8/20/2014, the patient presented to the obstetrician with thick vaginal fluid and bloody discharge and/or morning sickness, nausea, chills, fever, and back pain.
On 5/23/2014, 6/20/2014, 7/16/2014, 8/15/2014, 9/12/2014, 10/13/2014, 10/20/2014, and 10/27/2014, the patient presented to the obstetrician for follow-up visits.
On 11/2/2014, the patient gave birth to her son. The child was born with a neural tube defect called spina bifida/myelomeningocele.
The obstetrician failed to observe on imaging studies, and follow-up on, known indicators that the patient’s child may have had a neural tube defect, or alternatively, did not create, keep, or maintain adequate legible documentation of observing on imaging studies, and following up on known indicators that the patient’s child may have had a neural tube defect.
The obstetrician failed to order maternal serum alpha-fetoprotein (MSAFP) test, or alternatively, did not create, keep, or maintain adequate legible documentation of ordering a MSAFP test.
The obstetrician failed to order an anatomical survey sonogram, or alternatively, did not create, keep, or maintain adequate legible documentation of ordering an anatomical survey sonogram.
It was requested that the Board order one or more of the following penalties for the obstetrician: 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: Obstetrics
Symptom: Weakness/Fatigue, Bleeding, Abnormal Vaginal Discharge, Back Pain
Diagnosis: Neurological Disease
Medical Error: Failure to order appropriate diagnostic test, Failure to follow up, Lack of proper documentation
Significant Outcome: Permanent Loss Of Functional Status Or Organ
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 – 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
Virginia – Pulmonology – Progression Of Interstitial Lung Disease And Pulmonary Nodules
In 2005, a 71-year-old male was diagnosed with pulmonary fibrosis.
In 2010, the patient began seeing a pulmonologist for follow-up and treatment of interstitial fibrosis with marked progression of interstitial lung disease.
On 5/11/2010, CT imaging identified nodules in the upper and lower left lung and consolidative process in the left lung base.
On 8/5/2010 and 8/302010, follow-up imaging noted significant and progressive increase in the size of the nodule in the left upper lobe, highly suspicious for malignancy. There was also a slight increase in the density in the left lower lobe, concerning for malignancy.
On 10/15/2010, a CT guided lung biopsy was performed, which was complicated by pneumothorax. The biopsy revealed atypical bronchial cells and multinucleated giant cells. The pulmonologist did not follow-up with repeat imaging.
On 9/12/2011, repeat imaging study showed growth of the left lower lobe mass.
On 12/15/2011, follow-up PET scan showed a large hypermetabolic focus in the left lower lobe.
On 4/11/2012, the patient presented to the emergency room with progressive shortness of breath, increasing abdominal distention, and poor appetite.
On 4/16/2012, the patient was diagnosed with stage 4 adenocarcinoma with metastasis to the abdomen, pleural effusion positive for metastatic carcinoma, and possible post-obstructive pneumonia.
In his statement dated 6/8/2016, the pulmonologist stated that the failure to follow up with repeat imaging after the patient’s biopsy on 10/15/2010 was a breach of patient care.
The Board issued the pulmonologist a reprimand.
State: Virginia
Date: June 2017
Specialty: Pulmonology
Symptom: N/A
Diagnosis: Lung Cancer
Medical Error: Failure to follow up
Significant Outcome: N/A
Case Rating: 4
Link to Original Case File: Download PDF