Found 55 Results Sorted by Case Date
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Florida – Radiology – Gastrografin GI Series Performed to Ascertain GI Leak But No Leak Reported By Radiologist



On 6/23/2014, a 66-year-old male presented to the Physicians Regional Medical Center for gastric bypass surgery.

Following the gastric bypass procedure, on 6/24/2014, a radiologist performed a Gastrografin upper GI series on the patient to ascertain whether there was a leak or obstruction in the patient’s digestive tract.  A leak of contrast material was visible on radiographic images obtained by the radiologist during the procedure;  however, the radiologist failed to detect the leak in the patient’s digestive tract and reported a negative GI series.  The patient was subsequently discharged from the hospital.

Approximately thirty hours after his discharge, the patient returned to the hospital suffering from abdominal pain and sepsis.  It was discovered that the patient had a perforation in his digestive tract.  During surgery to repair this perforation, the patient suffered cardiac arrest and anoxic brain injury.  The patient ultimately expired as a result of these complications on 7/10/2014

The Board judged the radiologist’s conduct to be below the minimum standard of competence given his failure to detect a leak in the patient’s digestive tract during the performance of a Gastrografin upper GI series.

State: Florida


Date: December 2017


Specialty: Radiology


Symptom: N/A


Diagnosis: Acute Abdomen


Medical Error: False negative


Significant Outcome: Death, Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Radiology – Mammogram And Ultrasound Of Breast Mass Interpreted As A Cyst



On 6/30/2011, a 50-year-old female presented to a breast center for a bilateral digital diagnostic mammogram with computer-aided detection and right breast ultrasound (“mammogram and ultrasound”) for a palpable abnormality (“mass”).

On 6/30/2011, a radiologist interpreted the mammogram and ultrasound in her final report as follows: “[T]here has been no interval change in the appearance of the breasts with no evidence for malignancy.  At the 7 o’clock position, 7 cm away from the nipple, correlating to the [mass] is a simple cyst….”

The radiologist recommended “[M]ammography and yearly physical examination per ACS guidelines, supplemented with monthly self-examination,  If clinically indicated, the cyst could be aspirated.”  At no time did the radiologist recommend a biopsy of the mass.

The radiologist rated the mammogram as a BI-RADS Category II, “[B]enign.”  A correct interpretation of the mass would have indicated that it had lobular and angular margins, and increased through transmission.  The mammogram should have been rated BI-RADS category V, “[H]ighly suspicious: [A]ppropriate action should be taken.”  The radiologist should have recommended a biopsy of the mass.

On 1/23/2012, the patient was advised by a subsequent treating physician that she had invasive ductal carcinoma, Stage III.

The Board judged the radiologist’s conduct to be below the minimum standard of competence given her failure to correctly interpret the mammogram and ultrasound and recommend a biopsy of the mass.

The Board ordered that the radiologist pay a fine of $6,500 against her license and that the radiologist pay a reimbursement cost to the case of a minimum of $2,924.06 but not to exceed $4,924.06.  The Board ordered that the radiologist complete ten hours of continuing medical education in identification and diagnosis of malignancies with a focus on interpretation of breast imaging studies.

State: Florida


Date: November 2017


Specialty: Radiology


Symptom: N/A


Diagnosis: Breast Cancer


Medical Error: False negative, Failure to order appropriate diagnostic test


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Radiology – Back Pain With Subsequent MRI And Missed Incidental Finding



In 2009, a patient with a history of smoking developed back pain.  Her primary care physician sent her to a hospital for two MRIs of her spine: one on 3/9/2009 and another on 4/13/2009.  Radiologist A at the hospital obtained the MRI images and sent them to a teleradiology company for review.  Radiologist B at the teleradiology company reviewed the MRIs.  Neither of his reports mentioned any lung abnormalities.

In 2010, the patient developed a cough and was sent to the hospital for a chest x-ray.  Radiologist A reviewed the x-ray and reported that he found no significant pathology.

After suffering from continued bouts of coughing, the patient was sent to the hospital for another chest x-ray in 2012.  Radiologist A reviewed the x-ray and reported that he found no significant pathology.

In 2013, Radiologist A received a chest x-ray for asthma.  Radiologist A reviewed the x-ray and found a mass on the patient’s right lung.  Radiologist A recommended that the patient undergo a computed tomography (CT) scan.  The CT scan revealed a 4.8 by 2.5 centimeter mass, which was subsequently identified as cancerous.  The patient was diagnosed with unresectable Stage IIIA non-small cell lung cancer metastatic to the lymph nodes.  The patient underwent 33 radiation treatments and multiple rounds of chemotherapy.

In January 2014, the patient filed a complaint against Radiologist A and Radiologist B asserting medical malpractice.  She claimed that her lung cancer diagnosis was delayed by four years given failure to detect the mass when they reviewed her MRIs and chest x-rays.

In November 2015, prior to the start of the trial, the patient began to have breathing issues, balance problems, dizziness, and difficulty with memory.  On 11/3/2015, her primary care physician ordered a CT scan, which revealed that the cancer had metastasized to her brain.

On 11/13/2015, the jury returned a verdict in favor of the patient with liability spread equally among Radiologist A and Radiologist B.  The jury awarded the patient a total of $3 million.

The California Board issued a public reprimand against Radiologist B given his failure to report the medical malpractice case to the Hawaiian Board.

State: California


Date: October 2017


Specialty: Radiology


Symptom: Cough, Back Pain


Diagnosis: Lung Cancer


Medical Error: False negative


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



North Carolina – Internal Medicine – Three Emergency Department Visits With Persistent Severe Headache And A Negative CT Head Scan



The Board was notified of a professional liability payment paid on 3/8/16.

A 48-year-old female presented to the emergency department three times over the course of two days with complaints of severe headache.

During the 7/28/12 visit, she had a non-contrast CT head, which was reported as normal.  The patient’s headache was treated as an acute migraine attack.  She was discharged with anti-migraine, anti-nausea, and anti-anxiety medications.

On 7/29/12, the patient returned with persistent symptoms, was treated symptomatically, and discharged.  Later that day, the patient again returned to the emergency department with continuing headache and persistent nausea and vomiting.

The patient was admitted to the hospital under the care of an internist.  The patient was started on maintenance IV fluids to treat dehydration and was treated for the underlying migraine with analgesics and antiemetic.

During the internist’s care of the patient, the internist did not order a spinal tap or additional CT scan, instead relying on the 7/28/12 emergency department CT scan.

On hospitalization day three, the patient was discharged with anti-migraine and anti-nausea medications, and was advised to follow up with her primary care physician or neurologist within a week.

On 8/2/12, the day after discharge, the patient returned to the emergency department with a continuing headache and a CT scan of her head showed intracranial hemorrhage in the right temporal lobe.

The patient was then airlifted to a tertiary care center and had clipping of a brain aneurysm/hematoma removal and ventriculoperitoneal shunt placement.

The Board obtained the patient’s records and sent them to a qualified independent medical expert for review.

The independent medical expert judged the internist’s conduct to be below the minimum standard of competence given failure to provide adequate care for severe persistent headache with normal neurological exam.  The medical expert found that the internist failed to perform a lumbar puncture and repeat imaging or seek neurology input.

The Board issued a public letter of concern, which was reported to the Federation of State Medical Boards.  It was not reported to the National Practitioner Data Bank.

State: North Carolina


Date: July 2017


Specialty: Internal Medicine, Hospitalist


Symptom: Headache, Nausea Or Vomiting


Diagnosis: Intracranial Hemorrhage


Medical Error: False negative, Delay in proper treatment, Failure to order appropriate diagnostic test, Underestimation of likelihood or severity


Significant Outcome: Permanent Loss Of Functional Status Or Organ, Hospital Bounce Back


Case Rating: 4


Link to Original Case File: Download PDF



California – Radiology – Epidural Injection With Subsequent Lower Extremity Pain And Sensory And Motor Function Loss



On 1/15/2010, a 61-year-old female underwent an epidural injection.  Following the procedure, she complained of sharp pain in the lower extremities, followed by sensory and motor function loss below the T10 and T11 level.  The patient was transferred by ambulance to the emergency department.

A thoracic and lumbar MRI was performed and interpreted by a radiologist.  The final report for the lumbar spine states “Mild desiccation and degenerative changes of the disc but no disc bulge or herniation is noted.”  His final report of the thoracic spine demonstrates “normal MRI of the thoracic spine…A repeat study of the thoracolumbar spine is recommended without contrast infusion in both projections to better evaluate this area as this is on the edge of the study on the current images both lumbar and thoracic is not well delineated.”  Although the images were suboptimal, the epidural hematoma of the lower thoracic spine was evident in the axial images.

On 1/19/2010, a repeat MRI was performed.  The radiologist interpreted the MRI stating there is “abnormal signal focus demonstrated in the spinal canal from approximately the T10-T11 disc space inferiorly through the T12-L1 disc space located mostly in the posterior and posterolateral aspect of the spinal canal displacing the cords slightly anteriorly and causing a slight mass effect on the cord and subarachnoid sac.  This is consistent with a subdural or epidural hematoma.”

The Board judged the radiologist’s conduct as having fallen below the standard of care given failure to observe and document all pertinent findings on diagnostic imaging studies, failure to discuss findings requiring urgent treatment with the referring physician, failure to diagnose the abnormality found on MRI, and failure to document his discussion with the referring physician regarding the abnormality on MRI.

A public reprimand was issued against the radiologist.

State: California


Date: June 2017


Specialty: Radiology, Emergency Medicine


Symptom: Extremity Pain, Numbness, Weakness/Fatigue


Diagnosis: Spinal Injury Or Disorder


Medical Error: False negative, Failure of communication with other providers, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



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



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

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

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

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

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

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

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

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

It was requested that the Board order one or more of the following penalties for Radiologist A: permanent revocation or suspension of her license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Board deemed appropriate.

State: Florida


Date: June 2017


Specialty: Radiology


Symptom: N/A


Diagnosis: Intracranial Hemorrhage, Trauma Injury


Medical Error: False negative


Significant Outcome: Death, Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



Rhode Island – Radiology – CT Scan After A Laparoscopic Cholecystectomy



In 2013, a patient underwent a laparoscopic cholecystectomy.  A CT scan was ordered.  The radiologist did not detect a bowel perforation that was present on the CT scan.

The Board issued a reprimand with stipulations to pay a fine and complete 8 hours of continuing medical education.

State: Rhode Island


Date: April 2017


Specialty: Radiology


Symptom: N/A


Diagnosis: Acute Abdomen


Medical Error: False negative


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Virginia – Pathology – Excised Tissue Determined As “Changes Consistent With Tonsillitis”



On 8/1/2013, Pathologist A examined excised tissue from a 55-year-old male and diagnosed “changes consistent with tonsillitis.”

In September 2014, the patient discovered a palpable nodule in the right submandibular region of his throat, which was aspirated on 10/20/2014, and determined to be squamous cell carcinoma.

In December 2014, Pathologist B reexamined the original pathology tissue, determined that Pathologist A’s diagnosis had been incorrect, and found that the specimen showed “squamous cell carcinoma poorly differentiated.”

Histologic evidence showed that the poor differentiation of the malignant cells clearly distinguished them from the surrounding benign lymphocytes, and the tumor was present in approximately 80% of the excised tissue.

Pathologist A’s erroneous diagnosis resulted in a fourteen-month delay in the diagnosis and treatment of the patient’s cancer.

The Board issued a Reprimand.

State: Virginia


Date: February 2017


Specialty: Pathology, Otolaryngology


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


Diagnosis: Cancer


Medical Error: False negative


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Gynecology – Breast Biopsy Specimen A Malignant, Specimen B Benign



In 2012, a female was followed for routine gynecologic care by a gynecologist.  The patient’s history was significant for a laparoscopic tubal ligation although nulliparous.  The history included that in about 2007, the patient required a right breast biopsy and possibly an aspiration for benign findings.  She subsequently underwent a bilateral breast reduction.  She began menopause and she received hormone replacement therapy in the form of the Combipatch (50/140), which she continued for more than two years.  She had ongoing vulvar lichen sclerosis, treated with steroid cream.  The patient’s mother had pancreatic cancer and passed away in 2010.  The patient’s physical exam was otherwise noteworthy for mild hypertension.

On 8/1/2012, the patient presented for her routine annual exam.  She had been weaning herself from the estrogen hormone patch by cutting them in half.  She had no complaints.  Her physical, including a breast exam, was essentially negative.  Pap testing was deferred.  A mammogram was ordered, but not performed.  The fact that the patient failed to comply with the request was not known to the gynecologist’s office.

In November of 2012, when the patient identified 2 lumps in her right breast, she went for a mammogram.  On 11/16/2012, the mammogram was performed.  Suspicious findings warranted a follow-up ultrasound of the right breast.  The gynecologist’s office also authorized an ultrasound.  Radiology performed directed needle biopsies on an expedited basis.  On 11/20/2012, a radiologist performed 2 needle biopsies.  He noted that the gynecologist’s office was “telephoned with this information,” referring to the expedited biopsy.  This intervention was not noted in the gynecologist’s records.

On 11/26/2012, the patient returned to the gynecologist’s office.  She complained of vaginal irritation and requested the results of her biopsies, which had been performed the previous week.  The patient was diagnosed with recurrent lichen sclerosis and was advised that the pathology results on the breast were not yet available.

On 11/27/2012, the patient called the gynecologist’s office for the test results.  On the same day, Los Alamitos pathology produced a report.  They documented sending copies to the radiologist and the gynecologist at that time.  In that path report, page 1 documented that specimen A was an invasive ductal carcinoma.  This finding was reiterated in the body of the text on page 2, labeled “microscopic description.”  The gynecologist noted review of page 2 of the path report but did not note the diagnosis.

On 11/28/2012, the gynecologist called the patient back and advised her that the biopsy was benign.  The gynecologist advised the patient of the benign biopsy based on the text she referred to regarding the specimen B.  In fact, this was an error by the gynecologist.  The gynecologist claims that this mistake was caused by a transmission error.  There were actually two specimens noted in the report.  Although page 2 details benign findings for specimen B, the report states: “A) Specimen…Histology type: INVASIVE DUCTAL CARCINOMA.”

The gynecologist admitted in a subject interview before the Board that she erred by not reviewing page 1 of the same path report which also identified an “invasive ductal carcinoma, high grade, poorly differentiated” from specimen A.

The patient did not return until 2/12/2013 when she complained of pelvic pressure and back pain.  As an aside, she asked for an opinion of what she thought to be a hematoma at the biopsy site in her right breast.  Examination revealed a firm mass.  The patient was immediately sent to a surgeon for further treatment.  As the gynecologist transferred the records she noted that she had misinterpreted the biopsy results of November and had falsely reassured the patient at that time.  This is documented in the chart on 2/26/2013 as a “breast follow-up,” dictated 2/12/2013.  The patient went on to receive her care from a surgeon and several oncologists for metastatic right breast cancer (Stage III).

The Board expressed concern that the gynecologist was grossly negligent in failing to follow up on important findings of those tests.  She was unaware that the radiology had performed multiple biopsies.

She failed to establish procedures to ensure adequate communication of information between radiology and her office.

There was also concern over a lack of documentation regarding her exam of the breast on 2/12/2013.  There was no mention of a follow-up of the previous breast biopsy or documentation of the exam of the breast on 2/12/2013.  This information was provided in a 2/26/2013 addendum.  Lab work was not routinely “signed-off” and dated with an indication of appropriate analysis.

The Board issued a public reprimand.  She was ordered to take a medical record-keeping course offered by the Physician Assessment and Clinical Education (“PACE”) Program at the University of California San Diego School of Medicine.  She was also ordered to enroll in a professionalism program.

State: California


Date: February 2017


Specialty: Gynecology


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


Diagnosis: Breast Cancer


Medical Error: Accidental error, False negative, Failure of communication with other providers, 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



California – Cardiology – Decreased LV Systolic Function Misinterpreted As Normal



A pediatric cardiologist followed a patient after surgery for a congenital heart defect with poor LV systolic function.  The patient underwent an echocardiogram on 1/15/2010, 2/12/2010, 3/12/2010, 3/17/2010, and 4/9/2010. The narrative in the pediatric cardiologist’s reports stated “normal LV systolic motion” and/or “normal LV systolic and diastolic function.”  The reported quantitative function was anywhere between 10% and 24%, which should have been stated as decreased rather than normal.

The Medical Board of California judged that the pediatric cardiologist’s conduct departed from the standard of care because he misinterpreted the echocardiograms as normal rather than decreased LV systolic function.

The Medical Board of California ordered the pediatric cardiologist to surrender his license.

State: California


Date: January 2017


Specialty: Cardiology, Pediatrics


Symptom: N/A


Diagnosis: Cardiovascular Disease


Medical Error: False negative


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



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