Found 14 Results Sorted by Case Date
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California – Neurology – Three EEGs Ordered Without Indication And Diagnosis Of Epilepsy



A 9-year-old girl was referred by her pediatrician to a child neurologist for headaches.  The child neurologist first saw the patient on 9/10/2009. The patient’s mother stated that the patient’s headaches started in 7/20/2009.  The patient had no episodes of loss of consciousness of any type. The child neurologist’s review of systems revealed headaches, neck pain, and back pain.  The child neurologist noted headaches following a viral infection in July 2009 described as constant tension and pressure with nausea, photophobia, and difficulty concentration.  The child neurologist’s diagnosis was childhood migraine and prescribed 10 mg amitriptyline. The child neurologist ordered an MRI to rule out neoplasm and aneurysms. The child neurologist also ordered an EEG, which was not indicated for headaches.

On 9/18/2009, the EEG was performed.  The technician described the EEG with “sharp and slow waves.” On 9/30/2009, the child neurologist saw the patient for an office visit.  The child neurologist read the EEG as showing “generalized polyspike and wave which was synchronous bilaterally over both hemispheres which is highly suggestive of a generalized seizure disorder.”  The child neurologist stopped the amitriptyline 10 mg she prescribed at the last visit because of “seizures on EEG.” She ordered a neurosurgery consult and planned a separate meeting with the mother.

The child neurologist next saw the patient on 11/4/2009.  The child neurologist prescribed Depakote at 250 b.i.d. The patient’s Depakote level was at 72.  The patient reported no seizures or auras, but the child neurologist in her diagnosis documented “seizures, breakthrough.”  The child neurologist ordered a second video EEG with computer analysis without medical indication. The EEG was performed on 11/25/2009.  The technician report showed no abnormality. The child neurologist’s report was of generalized polyspike and slow waves bilaterally, “highly suggestive of generalized epilepsy,” with localized slowing in the left temporal area.

On 2/11/2010, the child neurologist saw the patient for a follow-up visit.  The chief complaint was learning difficulty. The Depakote level was 53. The patient denied experiencing any auras and/or any seizures.  On the next visit, on 5/11/2010, the patient still did not report any auras or seizures. The child neurologist’s diagnoses were generalized epilepsy, childhood headaches, adverse effect of medication, and learning disability.  The child neurologist ordered a third video EEG with computer analysis to rule out seizures and BAER (brainstem auditory evoked response) to rule out hearing loss, despite no medical indication. The video EEG was performed on 6/28/2010 and was normal.  On 7/12/2010, the child neurologist saw the patient for a follow-up visit. The patient denied having headaches and seizures. The child neurologist ordered a 72-hour ambulatory EEG despite the normal EEG.

The child neurologist next saw the patient on 1/19/2011 for a follow-up visit.  The patient’s mother complained that the patient’s math and history test results were still low.  The patient had no witnessed seizures and was tolerating Keppra well. Despite the negative findings, the child neurologist diagnosed “seizures, breakthrough, rule out.”  The child neurologist ordered another video EEG. At this point in time, the 72-hour video EEG she previous ordered on 7/12/2010 had not been performed.

On 2/18/2011, a 72-hour ambulatory EEG was performed.  The child neurologist’s last visit with the patient was on 3/14/2011.  On the last visit, the child neurologist noted that the 72-hour ambulatory EEG was normal.  She discontinued Keppra. She diagnosed the patient with “arachnoid cyst, middle cranial fossa; generalized epilepsy; learning disability; and adverse effect of medication given correctly.”

The Medical Board of California judged that the child neurologist’s conduct departed from the standard of care because she ordered 3 video EEGs and an ambulatory EEG without medical indication, ordered a BAER with no medical indication, misdiagnosed epilepsy on a patient with no medical history of seizures of any type, and made diagnoses of breaththrough seizures with no basis, contrary to her own findings that were no auras or seizures reported.

The Medical Board of California placed the child neurologist on probation and ordered the child neurologist to complete a medical record keeping course, a professionalism program (ethics course), an education course (at least 40 hours per year for each year of probation), and a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.  The child neurologist was assigned a practice monitor and was prohibited from supervising physician assistants and advanced practice nurses.

State: California


Date: January 2018


Specialty: Neurology, Pediatrics


Symptom: Headache, Nausea Or Vomiting, Back Pain, Head/Neck Pain


Diagnosis: N/A


Medical Error: Unnecessary or excessive diagnostic tests, False positive


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Interventional Radiology – Assigning A Diagnosis To The Wrong Patient Leads To Cardiac Catheterization Performed On The Wrong Patient



On 1/28/2015, Patient A, a 47-year-old male, presented to the hospital with chest pain and was admitted for treatment.  A radiological technician was ordered to complete a CT angiogram of the heart for Patient A.

On 1/29/2015, a radiologist received Patient A’s angiogram images to review, as well as heart images for another Patient B.  The radiologist assigned a diagnosis of sixty to seventy percent stenosis to Patient A.

The diagnosis of sixty to seventy percent stenosis was intended for Patient B, not Patient A, who did not have any noticeable blockage or stenosis.

On 1/29/2015, subsequent to the radiologist assigning the diagnosis of sixty to seventy percent stenosis to Patient A, Patient A underwent an unnecessary cardiac catheterization without further incident.

On 1/30/2015, the radiologist conducted a corrected review and diagnosis of Patient A’s angiogram.

On 2/3/2015, the radiologist informed Patient A of the error.

The Board judged the radiologist’s conduct to be below the minimal standard of competence given that he assigned a diagnosis to the wrong patient, which resulted in the patient undergoing a medically unnecessary procedure, a cardiac catheterization.

It was requested that the Board order one or more of the following penalties for the radiologist: 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: Interventional Radiology


Symptom: Chest Pain


Diagnosis: Cardiovascular Disease


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


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Urology – Unnecessary Laparoscopic Radical Prostatectomy With Bilateral Pelvic Lymph Node Dissection Performed



On 2/1/2016, a 66-year-old male presented to a urologist for a prostate biopsy.  The urologist or his agents sent the specimens from the patient’s biopsy to pathology.

On 2/10/2016, a pathology report diagnosing the patient with adenocarcinoma of the prostate was issued.

On 2/16/2016 and 2/29/2016, the patient presented to the urologist to review the prostate biopsy pathology.

On 3/16/2016, the urologist performed a robotic assisted laparoscopic radical prostatectomy with bilateral pelvic lymph node dissection on the patient.  The urologist or his agents sent the specimens from the patient’s surgical procedure to pathology.

On 3/25/2016, a pathology report indicating the specimens were “negative for malignancy” was issued.

On 3/25/2016, the urologist or his agents swabbed the patient to obtain a DNA sample to cross-check the DNA profile of the biopsied specimens (from the 2/1/2016 appointment) with the patient’s known DNA sample.

On 4/5/2016, a DNA report was issued, confirming that the DNA profile from the biopsied specimens (from the 2/1/2016 appointment) did not match the DNA profile of the patient.

On 3/16/2016, the urologist performed health care services that were medically unnecessary when he performed the surgical procedure on the patient.

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: N/A


Diagnosis: N/A


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


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Pathology – Gallbladder Malignancy Confirmed In Wrong Patient



On 5/4/2015, Patient A underwent a laparoscopic gallbladder removal.  Following the procedure, a pathologist reviewed what she thought was the patient’s gallbladder specimen for malignancy.

The gallbladder specimen the pathologist reviewed actually belonged to a different patient, Patient B.

The pathologist determined that the specimen for Patient B was malignant.

The pathologist erroneously reported that Patient A’s gallbladder specimen was cancerous.  The pathologist did not confirm that the specimen belonged to Patient A prior to reporting her diagnosis.

Following the pathologist’s erroneous diagnosis, in July 2015, Patient A underwent two chemotherapy treatments.

On 8/14/2015, the pathologist reviewed Patient A’s actual gallbladder specimen to confirm her prior diagnosis.  At that time the pathologist discovered her error and correctly reported that Patient A’s gallbladder specimen was benign.

The Board judged the pathologist’s conduct to be below the minimum standard of competence given that she failed to confirm that Patient A’s identify matched the gallbladder specimen she reviewed prior to reporting that Patient A’s gallbladder was cancerous.

It was requested that the Board order one or more of the following penalties for the pathologist: 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: July 2017


Specialty: Pathology


Symptom: N/A


Diagnosis: Cancer


Medical Error: Accidental error, False positive


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



Florida – Pathology – Pathologist Concludes Invasive Ductal Carcinoma Present On Specimen Leading To Double Mastectomy



On 6/11/2012, a 47-year-old female presented to a pathology clinic for a right breast core biopsy.

On 6/12/2012, a pathologist reviewed the specimen obtained from the biopsy and dictated his interpretation as “invasive ductal carcinoma, NOS, Nottingham grade 1” on a surgical pathology report.

On 9/6/2012, the patient underwent a double mastectomy to remove breast tissue from both breasts.

In October 2012, the patient was notified that the specimen from her biopsy was erroneously diagnosed and that she never had breast cancer.

On 12/12/2012, the pathologist amended the patient’s surgical pathology report, indicating that the specimen was obtained from a benign adenosis tumor.

The Medical Board of Florida judged the pathologists conduct to be below the minimal standard of competence given that he failed to make a correct pathological interpretation of the specimen obtained from the biopsy.

The Medical Board of Florida issued a letter of concern against the pathologist’s license.  The Medical Board of Florida ordered that the pathologist pay a fine of $8,000 against his license and pay reimbursement costs for the case at a minimum of $3,726.76 and not to exceed $5,726.76.  The Medical Board of Florida also ordered that the pathologist complete ten hours of continuing medical education in identification and diagnosis of malignancies with a focus on the interpretation of pathological reports and complete five hours of continuing medical education in “risk management.”

State: Florida


Date: June 2017


Specialty: Pathology


Symptom: N/A


Diagnosis: Breast Cancer


Medical Error: False positive


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Gastroenterology – Patient And Provider Not Notified Of Amended Pathology Biopsy Results From Colonoscopy



On 5/6/2013, a 55-year-old female presented to a digestive health center for a colonoscopy with biopsy.  During the colonoscopy, a gastroenterologist found a mass in the patient’s rectosigmoid region.  He obtained multiple biopsies of the mass and sent the specimens for in-house pathologic evaluation.  The colonoscopy was completed without complication and the patient was brought to recovery in stable condition.

On 5/7/2013, an in-house pathologist rendered a preliminary gastrointestinal pathology report which reported that the specimen was highly suspicious for a signet ring adenocarcinoma.  The initial pathology report indicated that the case was sent to a second pathologist for another opinion.

The gastroenterologist received and reviewed the initial pathology report.  He referred the patient to a colorectal surgeon for surgical intervention.

On 5/8/2013, the second pathologist issued a pathology report which stated that the specimen was negative for signet cells and adenocarcinoma and recommended a re-biopsy to completely rule out malignancy.  The gastroenterologist received and reviewed the copy of the report by the second pathologist.

On 5/16/2013, the in-house pathologist issued an amended gastrointestinal pathology report which stated that the specimen was negative for signet ring cells.  The gastroenterologist received and reviewed the amended pathology report.

Despite receiving and reviewing the pathology report from both the pathologists, the gastroenterologist failed to notify the patient of the change in the reading of the specimen.  The gastroenterologist also failed to ensure that the colorectal surgeon was notified of the change in the reading of the specimen.

On 6/11/2013, the patient underwent a low anterior resection, mobilization of splenic flexure, and diverting loop ileostomy with colonic J pouch.

The Board judged the gastroenterologists conduct to be below the minimal standard of competence given that he failed to notify the patient of the change in the reading of the specimen and ensure that the colorectal surgeon was notified of the change in the reading of the specimen.

The Board issued a letter of concern against the gastroenterologist’s license.  The Board ordered that the gastroenterologist pay a fine of $10,000 against his license and pay reimbursement costs of a minimum of $3,008.71 and not to exceed $5,008.71.  The Board also ordered that the gastroenterologist complete five hours of continuing medical education in “risk management.”

State: Florida


Date: June 2017


Specialty: Gastroenterology


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


Diagnosis: Cancer


Medical Error: Failure of communication with patient or patient relations, False positive, Failure of communication with other providers


Significant Outcome: N/A


Case Rating: 5


Link to Original Case File: Download PDF



California – Neurology – Diagnostic Errors When Evaluating Neck Pain, Back Pain, And Headaches After A Motor Vehicle Accident



On 2/28/2012, a 27-year-old male presented to a neurologist with chief complaints of neck, lower back, and headache following a motor vehicle accident that occurred approximately 3 weeks earlier.  The patient denied any loss of consciousness in the accident and gave no history of suffering a head trauma. The patient’s neurological examination was normal except for mild reflex asymmetry in the upper and lower extremities and a slow gait.  The neurologist noted moderate tenderness on palpation of the cervical paraspinal musculature with full range of motion, but no neck stiffness. The neurologist listed his diagnoses of the patient as: post-concussive headache/migraine syndrome; status post MVA and head injury; cervical spasm; lumbar spasm; and the neurologist wanted to rule out cervical and lumbar radiculopathy.

On this initial visit, the neurologist performed an in-office EEG for the patient’s headaches and “head injury,” but the patient never reported suffering a head injury in the accident, or any loss of consciousness or any seizure activity that would justify this study at this time.  The EEG was normal. The neurologist also performed an in-office EMG and NCV of both bilateral upper and lower extremities, testing 68 muscles, which the neurologist stated took approximately 1 hour. During the study, the neurologist obtained no response of bilateral tibial H-Reflexes.  The neurologist’s impression of the NCV was that the patient suffered from “right sided mild carpal tunnel syndrome” in the “bilateral upper extremities.” The test results, however, did not support the neurologist’s impression as the patient did not have the electrophysiological features for carpal tunnel syndrome.  The neurologist’s further impression was that the patient “possible S1 radiculopathy,” however, the test results did not establish a diagnosis of S1 radiculopathy.

The neurologist also ordered an MRI of the patient’s brain, cervical spine, and lumbar spine.  The neurologist also advised the patient to obtain physical therapy/occupational therapy or chiropractic treatment, but the neurologist failed to write a prescription for physical or occupational therapy and failed to refer the patient to a facility where he could obtain such treatments.

On this visit, the neurologist billed $550 for the office visit, $4,320 for the NCV, $380 for he H-Reflex amp study, $640 for the needle EMG, and $1,125 for the EEG, for a total single visit charge of $7,015.

On 3/6/2012, the patient returned for a follow-up visit complaining of increased neck, shoulder, and low back pain.  The neurologist’s list of diagnoses remained the same as the previous visit and appeared to be cut and pasted into the new chart note.  During this visit, the neurologist performed “Cervical and Lumbar trigger points” injections, but there was no report documenting this procedure in the certified chart, and the neurologist’s billing summary did not reflect a charge for this procedure on this date.

On 4/19/2012, the patient underwent an MRI of his brain and lumbar spine at an outside facility, which were interpreted as normal.  The cervical MRI, however, revealed a 3 to 4 mm left paramedian disc protrusion at C7-T1, degenerative changes at C2 to C6, and a 13 mm x 6 mm lesion in the left lobe of the thyroid gland consistent with thyroid adenoma or colloid cyst.

On 4/30/2012, the patient returned for a follow-up visit complaining of neck and shoulder pain.  The neurologist noted moderate tenderness on palpation of the cervical paraspinal musculature at C6 to C7, but the patient’s range of movement was within normal limits.  The neurologist’s diagnoses were post-concussive headache syndrome, status post MVA, and cervical and lumbar spasm.

The neurologist performed “Cervical Trigger point” injections at 6 different points, but there was no report documenting this procedure in the certified chart.  The neurologist also had the patient undergo an in-office carotid artery duplex scan even though the patient had no carotid bruits on examination, had no clinical evidence or history of vascular pathology involving the anterior circulation, nor any evidence or history of transient ischemic attack or other similar medical conditions, which would justify the scan.  The scan was completely normals. The neurologist charted that he asked the patient to go to “intense physical therapy” and told the patient that his symptoms were mostly due to spasm due to “cervical acute disc herniation.” The patient, however, did not have a herniated cervical disc.

On this visit, the neurologist billed $1,350 for the in-office carotid artery duplex scan, $950 for the trigger point injections with ultrasound guidance (for which there was no procedure report), $415 for interpreting the outside MRI of the spinal canal, and $415 for interpreting the MRI of the brain, which had been reported by the outside facility to be normal.

On 5/2/2012, the patient returned for another follow-up visit complaining of pain with spasm in his neck and shoulder area.  The neurologist charted that the patient stated the injections from 2 days earlier and the new medication helped relieve his pain, but it returned last night.  The neurologist noted neck pain and spasm in the midscapular area with “back pain/spasm but less.” The neurologist, however, did not explain how the patient’s back pain was less since on the prior visit, 2 days earlier, the patient had no back complaints.  The neurologist’s list of diagnoses were identical to those listed on the patient’s initial visit on 2/28/2012, including the status post “head injury” and ruling out “cervical and lumbar Radiculopathy,” which appeared to be copied and pasted from the February note.

On 5/18/2012, the patient returned for another follow-up visit complaining of severe neck pain.  The neurologist noted moderate tenderness in the cervical paraspinal muscles at C4 to C7, and moderate tenderness in the paraspinal muscles at L2 to S1, but the patient had no back complaints on this visit.  The neurologist’s list of “current” diagnoses were identical to those listed on the patient’s initial visit on 2/28/2012, including the status post “head injury,” “lumbar spasm,” and ruling out of “lumbar Radiculopathy,” which appeared to be cut and pasted from the initial visit in February.  In his unsigned cervical injection procedure report, the neurologist listed the patient’s diagnoses as cervical radiculopathy, cervical spinal stenosis, intractable migraine, post concussion headache, and cervical muscle spasm, but here was no evidence in the certified chart that the patient suffered from all these conditions.

On 5/30/2012, the patient returned for a further follow-up visit complaining of neck pain radiating into his left shoulder.  The neurologist’s review of systems was identical to that of the previous visit, including the misspelling, and appeared to have been copied and pasted from the prior note.  The neurologist noted back pain and spasms even though the patient had no back complaints on this visit and no tenderness was found upon examination.

The neurologist performed another NCV/EMG of the patient’s bilateral upper extremities, but there had been no significant change in the patient’s condition to justify repeating this test.  The neurologist’s impression was that the patient had bilateral cervical radiculopathy at C5-C7, inter alia, but the test results did not support the neurologist’s impression for radiculopathy.

For all the previous appointments, the neurologist’s plan was to order physical therapy for the patient, but there as no prescription or order found in the certified chart indicating that the neurologist ordered or prescribed physical therapy on this visit.

On 6/13/2012, the patient returned for another follow-up visit complaining of increased neck pain radiating into his left shoulder.  The neurologist’s review of systems was identical to the previous visit, including the misspelling, and noted back pain and spasms even though the patient had no back complaints on this visit.  In his unsigned procedure note, the neurologist performed a cervical thoracic facet steroid injection, under ultrasound guidance, but the corresponding ultrasound images listed a date of 6/14/2012.  The consent for the procedure was not signed by the patient, and there was no explanation in the certified chart indicating why someone else signed the consent for the patient, who was alert and talking with the neurologist during the visit.  On this visit, the neurologist wrote a prescription for the patient to receive physical or occupational therapy.

On 6/27/2012, the patient returned for another follow-up visit with improved neck pain, but now complained of back pain and spasm.  The neurologist’s review of systems was identical to the previous visit, including the misspelling, and it appeared to have been copied and pasted from the prior note.  The neurologist noted moderate tenderness in the paraspinal musculature at L2-S1, but the patient’s range of motion was normal. The neurologist also recorded ankle jerks upon examination.  The neurologist performed another NCV/EMG of the patient’s bilateral extremities, which the neurologist interpreted as showing bilateral radiculopathy at L5 and S1, but the test results did not support a diagnosis of radiculopathy.  The neurologist again obtained no responses of the bilateral tibial II-Reflexes, demonstrating improper placement of the electrodes or that these areas were not tested.

Throughout these appointments, the neurologist failed to order additional tests or studies concerning the thyroid lesion identified on the cervical MRI, and failed to refer the patient to an endocrinologist or other appropriate specialist for further evaluation and treatment of the thyroid lesion.

The patient ordered a repeat MRI of the patient’s lumbar spine and continued physical therapy, but there was no documentation in the certified chart that the patient was actually receiving physical therapy at this time.  This appeared to be the last time the patient saw the neurologist, but there was a LabCorp lab request form in the certified chart indicating that labs were collected on 6/13/2014 at 3:48 p.m., but there was no corresponding chart notes reflecting a patient visit on this date

The Medical Board of California judged that the neurologist’s conduct departed from the standard of care because he failed to accurately analyze and interpret the repeat in-office EMG/NCV studies performed, appropriately evaluate the large lesion identified on the cervical MRI and/or refer the patient to an endocrinologist or other appropriate professional for its evaluation and treatment, fully evaluate and initially treat the patient’s neck and back pain and headaches with conservative care and non-interventional treatment, initially order physical therapy for the patient while repeatedly performing invasive treatments, and overall fully, properly, and appropriately evaluate and treat the patient’s complaints.

For this case and others, the Medical Board of California revoked the neurologist’s license.

State: California


Date: June 2017


Specialty: Neurology


Symptom: Head/Neck Pain, Headache, Back Pain, Joint Pain


Diagnosis: Spinal Injury Or Disorder


Medical Error: Unnecessary or excessive diagnostic tests, Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, False positive, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Neurology – Headache Presentation And Unsupported Radiculopathy Diagnosis



On 12/16/2011, a 44-year-old female first presented to a neurologist with a chief complaint of headaches on the left side of her head only and rated her pain as a 4 out of 10.  The neurologist noted moderate tenderness in the paraspinal musculature of the cervical spine at C4-C7 with some limited range of motion, but the neurologist failed to specify how, and in what manner, the patient’s range was limited.

The neurologist ordered an MRI of the patient’s brain and cervical spine and performed an in-office NCV/EMG of the patient’s bilateral upper extremities.  The neurologist’s impression was that the patient had moderate radiculopathy at C5 and C6 of the left, mild radiculopathy on the right, and mild carpal tunnel syndrome on the right.  The test results, however, did not support the neurologist’s impressions of radiculopathy or carpal tunnel syndrome. Also, the patient had no clinical examination findings for radiculopathy, making the need for this test, along with its findings, questionable.  The neurologist also misinterpreted the normal findings of the median motor and sensory distal latency and amplitude responses in diagnosing carpal tunnel syndrome.

The neurologist billed $350 for the office visit, $2,160 for the NCV, $380 for the H-Reflex amp study, and $50 for venipuncture, a charge which was not supported by the certified records, for a total charge for this single visit of $2,940.

On 1/11/2012, the patient had the MRI of her brain performed and interpreted by an outside facility, which showed no significant abnormalities or evidence of acute disease.  On 1/16/2012, the patient returned for a follow-up visit and complained of continued headaches, now a 7 out of 10, and stated they were worse at night, and she was unable to lay on her left side.  The neurologist noted moderate tenderness of the cervical paraspinal musculature at C4-C7 with limited range of motion bilaterally. The neurologist performed an occipital block and cervical trigger point injection under ultrasound guidance, but there was no report documenting this procedure in the patient’s certified chart.

The neurologist billed $450 for the office visit, $1,250 for the trigger point and nerve injection using ultrasound guidance (for which there was no procedure report), $415 to interpret the essentially normal MRI scan of the patient’s brain performed and interpreted by the outside facility, and $50 for xylocaine, for a total billing of $2,165.  This appeared to be the patient’s last visit with the neurologist.

The Medical Board of California judged that the obstetrician’s conduct departed from the standard of care because he failed to accurately analyze and interpret the NCV/EMG, provide appropriate evaluation and treatment of the patient’s headaches, and refer the patient to physical therapy.  The neurologist also billed for a venipuncture that was not performed or supported by the chart, an H-Reflex study, which was either not obtained or performed, and interpreting an essentially normal MRI of the patient’s brain performed, which was interpreted by an outside facility as showing no significant abnormalities or evidence of acute disease.

For this case and others, the Medical Board of California revoked the neurologist’s license.

State: California


Date: June 2017


Specialty: Neurology


Symptom: Headache


Diagnosis: N/A


Medical Error: Failure to examine or evaluate patient properly, False positive, Referral failure to hospital or specialist, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Otolaryngologist – Endoscopic Sinus Surgery For Right-sided Ear Pain, Hearing Loss, And Drainage



On 6/14/2011, a patient presented to an otolaryngologist on referral from another physician for evaluation of right-side ear pain, hearing loss, and drainage.  The otolaryngologist diagnosed a large right-sided tympanic membrane perforation, chronic sinusitis, and hearing loss secondary to chronic sinusitis and tympanic membrane perforation.

On 7/25/2011, the otolaryngologist ordered a CT scan and requested copies of the patient’s most recent hearing examination.  On 8/19/2011, the patient underwent a CT scan that did not show any significant sinus disease.  The otolaryngologist documented that the CT scan revealed chronic sinusitis and recommended endoscopic sinus surgery.  On 7/18/2012, the otolaryngologist performed endoscopic sinus surgery on the patient, which was complicated by right-sided CSF leak.  The otolaryngologist repaired the leak intra-operatively.

The Medical Board of California judged that the otolaryngologist committed gross negligence in his care and treatment of the patient given that he failed to appropriately diagnose chronic sinusitis and performed endoscopic sinus surgery on a patient without an appropriate medical indication.  The otolaryngologist also failed to order audiological testing for the patient, consider tympanoplasty surgery, and admit the patient to the hospital after she suffered a right-sided CSF leak during endoscopic surgery.

For allegations in this case and others, the Medical Board of California requested a hearing be held for the otolaryngologist and issue a decision on: permanent revocation or suspension of his license, revoking or denying approval of his authority to supervise physician assistants, placing him on probation, or taking other and further action as deemed necessary and proper.

State: California


Date: December 2016


Specialty: Otolaryngology


Symptom: Hearing Problems, Head/Neck Pain, Wound Drainage


Diagnosis: Ear, Nose, or Throat Disease, Post-operative/Operative Complication


Medical Error: Unnecessary or excessive treatment or surgery, Failure to order appropriate diagnostic test, False positive, Referral failure to hospital or specialist, Improper treatment


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Otolaryngologist – Complications During Submucous Resection Septoplasty And Endoscopic Sinus Surgery



On 1/30/2013, a patient saw Otolaryngologist A for an evaluation of decreased hearing in the right ear.  Otolaryngologist A diagnosed the patient with right-sided sensorineural “deafness” and chronic sinusitis and recommended a follow-up appointment in one month, hypertonic saline and Afrin spray for the sinusitis, and an MRI to rule out hearing loss caused by a schwannoma.  On 3/5/2013, the patient underwent a CT scan because the attending radiologist felt that the patient’s ventriculoperitoneal shunt from a previous intracranial aneurysm surgery was a contraindication for an MRI.  The CT indicated that the patient had normal sinuses and no deviation of the patient’s nasal septum.

On 3/7/2013, Otolaryngologist A saw the patient and documented that the cause of the patient’s right-sided deafness had not been delineated and that she continued to have nasal congestion and post-nasal drip.  Otolaryngologist A ordered an audiogram and recommended continued use of saline spray and a follow-up appointment in one month.  On 3/18/2012, the patient underwent diagnostic audiological testing that revealed the patient’s hearing was symmetrical and normal.

On 4/18/2012, Otolaryngologist A saw the patient and documented that all of the patient’s symptoms had resolved with nasal saline and Afrin sprays.  Otolaryngologist A diagnosed the patient with chronic sinusitis despite the fact that the patient’s previous CT scan was negative for sinusitis.  On 7/2/2013, the patient returned to Otolaryngologist A with sinus complaints and indicated the nasal saline and Afrin sprays were no longer helping.  Otolaryngologist A reviewed the previous CT scan and documented that the patient’s sinuses were normal, diagnosed chronic sinusitis, and scheduled the patient for endoscopic sinus surgery with possible submucous resection septoplasty.  On 7/7/2013, Otolaryngologist A performed a pre-operative history and physical on the patient that did not document a finding that the patient had a deviated septum.  On 8/21/2013, Otolaryngologist A documented a pre-operative history and physical on the patient that noted gross swelling of the turbinates, but he never offered any medical or surgical intervention for this condition other than nasal saline and Afrin sprays.

On 8/21/2013, Otolaryngologist A performed a submucous resection septoplasty surgery on the patient and then started endoscopic sinus surgery on the patient’s left-side sinuses by removing the uncinate process and the middle turbinates.  The otolaryngologist then resected the ethmoid sinuses and proceeded with the enlargement of the left maxillary sinus window.  At that point in the procedure, the patient suffered rapid bleeding and blood loss.  Otolaryngologist A decided to pack the patient’s left nose with numerous Codman pledgets to control the bleeding and then performed endoscopic sinus surgery on the ethmoid, maxillary, and sphenoid sinuses on the right side.  After completing the surgery on the right side, Otolaryngologist A decided not to remove the Codman pledgets and to leave the patient intubated for transfer to the hospital’s emergency department for evaluation and admission to the ICU and for possible blood transfusions.  Otolaryngologist A noted in his operative notes that he would determine the cause of the bleeding after the patient received blood transfusions.

On 8/22/2013, the patient was seen by another otolaryngologist.  Otolaryngologist B ordered an angiogram that revealed a pseudoaneurysm of the distal internal maxillary artery, which appeared to be the source of the patient’s bleeding.  On 8/24/2013, Otolaryngologist B performed surgery on the patient, removed the Codman pledgets from the patient’s right and left sinuses, and identified and treated two left maxillary sinusotomies that he believed to be the source of the patient’s bleeding.  On 8/25/2013, the patient was transferred out of the ICU. On 8/29/2013, the patient was discharged from the hospital.  On 9/16/2013, the patient saw Otolaryngologist A for a clinical visit.  Otolaryngologist A documented that the patient was not performing adequate post-operative care of her sinuses and recommended daily saline rinses and Afrin use every other day.  On 10/14/2013, the patient saw Otolaryngologist A. Otolaryngologist A recommended hypertonic saline rinses 6-8 times per day for the next 6 months.

The Medical Board of California judged that Otolaryngologist A committed gross negligence in his care and treatment of the patient given that he failed to formulate and/or implement a plan to address the patient’s intraoperative bleeding and obtain appropriate consultation to determine the source of the patient’s bleeding.  Otolaryngologist A also performed a septoplasty on the patient without medical indication, used an inappropriately large number of Codman pledgets during the patient’s surgery, left the Codman pledgets in place postoperatively, and recommended chronic use of Afrin spray.  Otolaryngologist A was also negligent when he removed the patient’s middle turbinates without medical indication, failed to appropriately treat the patient’s inferior turbinate hypertrophy, and failed to order a timely angiogram to assess the patient’s reported hearing loss.

For allegations in this case and others, the Medical Board of California requested a hearing be held for the otolaryngologist and issue a decision on permanent revocation or suspension of his license, revoking or denying approval of his authority to supervise physician assistants, placing him on probation, or taking other and further action as deemed necessary and proper.

State: California


Date: December 2016


Specialty: Otolaryngology


Symptom: Hearing Problems, Bleeding


Diagnosis: Ear, Nose, or Throat Disease, Post-operative/Operative Complication


Medical Error: Unnecessary or excessive treatment or surgery, Failure to order appropriate diagnostic test, False positive, Referral failure to hospital or specialist, Improper treatment, Improper medication management, Procedural error


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



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