Found 74 Results Sorted by Case Date
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Florida – Emergency Medicine – Patient With Intussusception Involving Loop Of Small Bowel Discharged Home With Magnesium Citrate



At 1:45 a.m. on 7/26/2014, a 46-year-old female presented to the emergency department with complaints of severe abdominal pain.  Upon arrival at the emergency department, the patient was evaluated by the ED physician.

The patient complained of severe abdominal pain and stated the pain was “10 out of 10.”  The patient then underwent laboratory studies and a CT scan of the abdomen/pelvis with intravenous and oral contrast.

A radiologist reviewed the CT scan at some time before 4:16 a.m., when he read and signed the preliminary report.  Upon review of the CT scan results the radiologist recorded in the preliminary report “intussusception involving loop of small bowel in the left lower quadrant with involved loops appearing edematous.”  The radiologist relayed the results of the CT scan to the ED physician via teleradiology.

The ED physician recorded the results of the CT scan in the patient’s emergency provider report and noted “thickened loop of small bowel in the left lower quadrant, [m]ay be intussuception [sic].”

At 4:32 a.m. the ED physician discharged the patient to her home with a magnesium citrate prescription and no additional discharge instructions.

At 8:28 a.m. a physician signed the final radiology report and noted “[i]ntussesception involving loop of small bowel in the left lower quadrant” and “preliminary report related to referring physician teleradiology at the time of the exam by the radiologist.”

Later that day, the patient developed worsening pain, and presented to another emergency department, and underwent an emergency surgery for resection of necrotic bowel.

The Board judged the ED physician’s conduct to be below the minimum standard of competence given his failure obtain emergent surgical consultation for further evaluation and treatment and continue hospitalization for operative intervention or ongoing evaluation of abdominal pain.

The Board ordered the ED physician to pay an administrative fine in the amount of $8,000.  Also, the Board ordered the ED physician to complete five hours of continuing medical education in the area of emergency medicine.

State: Florida


Date: December 2017


Specialty: Emergency Medicine


Symptom: Abdominal Pain


Diagnosis: Acute Abdomen


Medical Error: Improper treatment, Referral failure to hospital or specialist


Significant Outcome: Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Internal Medicine – Patient With Worsening Chronic Kidney Disease Presents With Arm Pain, Numbness, And Shortness Of Breath



From 2009 until 2014, an internist served as the patient’s primary care physician.

In 2009, the internist referred the patient to Cardiologist A for a cardiology evaluation.  The results of the 2009 cardiology evaluation revealed that the patient’s electrocardiogram and stress test were both abnormal.

At this time, Cardiologist A recommended that the internist increase the patient’s medication as needed in order to get the patient’s cholesterol to below seventy.

The patient was evaluated by Cardiologist A again in June 2010.

The June 2010 cardiac evaluation revealed that the patient had shortness of breath on exertion at times, possibly related to hypertension and subclinical congestive heart failure.

On 7/17/2013, the patient underwent lab work, the results which showed that his glomerular filtration rate (GFR) was thirty-four.  The internist staged the patient’s chronic kidney disease (CKD) at a stage III/IV.

The patient’s next set of lab work was conducted on 11/18/2013, the results of which showed that his GFR was twenty-two.  The internist wrote in a progress note that the patient’s CKD was a stage III/IV.

On 1/13/2014, the patient had lab work done again, the results which showed that his GFR was twenty-six.  In his progress note he wrote that the patient’s CKD was now a stage IV.

Despite a dramatic decline in the patient’s GFR levels indicative of worsening CKD, the internist did not refer the patient to a nephrologist.

On 1/13/2014, the patient presented to the internist complaining of left arm pain, numbness radiating to both hands, and shortness of breath.  The internist ordered an EKG, chest x-ray, and lab work.  His assessment of the patient at this time was dyspnea on exertion, questionable coronary artery disease, questionable pulmonary disease, and questionable anxiety.

On 1/14/2014, the patient returned to the office for an echocardiogram.  After the echocardiogram, the internist referred the patient to Cardiologist B for a consult.  The patient could not obtain an appointment with Cardiologist B until 2/3/2014.

The internist ordered that a stress test be conducted prior to the patient’s visit with Cardiologist B, and advised that the patient bring the results of the stress test to his appointment with Cardiologist B.

On 1/23/2014, the stress test was performed and the results were abnormal.

The Medical Board of Florida judged that the internist failed to adequately evaluate the patient’s symptoms and recognize the patient’s worsening coronary artery disease, development of congestive heart failure, and worsening chronic kidney disease.  He failed to refer the patient to a nephrologist for further evaluation upon seeing a dramatic decline in the patient’s GFR levels.  He also failed to send the patient to the emergency department for treatment when the patient presented to him with exhibiting cardiac symptoms and had a known history of heart disease.

The Medical Board of Florida issued a letter of concern against the internist’s license.  The Medical Board of Florida ordered that the internist pay a fine of $2,500 against his license and pay reimbursement costs for the case at a minimum of $5,756.36 and not to exceed $7,756.36.  The Medical Board of Florida also ordered that the internist complete five hours of continuing medical education in the treatment of patients with chronic kidney disease and chronic heart disease.

State: Florida


Date: December 2017


Specialty: Internal Medicine


Symptom: Extremity Pain, Numbness, Shortness of Breath


Diagnosis: Heart Failure, Cardiovascular Disease, Renal Disease


Medical Error: Failure to examine or evaluate patient properly, Referral failure to hospital or specialist


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Internal Medicine – Worsening Chronic Kidney Disease, Abnormal Stress Test, And Cardiac Symptoms



From 2009 until 2014, an internist served as a patient’s primary care physician.

In 2009, the internist referred the patient to Cardiologist A for a cardiology evaluation.  The results of the 2009 cardiology evaluation revealed that the patient’s electrocardiogram and stress test were both abnormal.  At this time Cardiologist A recommended that the internist increase the patient’s medication as needed in order to get the patient’s LDL cholesterol below seventy.

The patient was evaluated by Cardiologist A again in June 2010.  The June 2010 cardiac evaluation revealed that the patient had shortness of breath on exertion at times, possibly related to hypertension and subclinical congestive heart failure.

On 7/17/2013, the patient underwent lab work, the results which showed that his glomerular filtration rate (“GFR”) was thirty-four.  The internist stated the patient’s chronic kidney disease (“CKD”) as stage III/IV.

The patient’s next set of lab work was conducted on 11/18/2013, the results of which showed that his GFR was twenty-two.  The internist wrote in a progress note that the patient’s CKD was stage III/IV.

The patient had lab work done again on 1/13/2014, the results of which showed that his GFR was twenty-six.  In a progress noted created on 1/13/2014, the internist wrote that the patient’s CKD was now at stage IV.

Despite the dramatic decline in the patient’s GFR levels indicative of worsening CKD, the internist did not refer the patient to a nephrologist.

On 1/13/2014, the patient presented to the internist complaining of left arm pain, numbness radiating to both hands, and shortness of breath.  The internist ordered an EKG, chest x-ray, and lab work.  The internist’s assessment of the patient at this time was dyspnea on exertion, questionable coronary artery disease, questionable pulmonary issue, and questionable anxiety.

The internist had the patient return to the office on 1/14/2014 for an echocardiogram.  After the echocardiogram, the internist referred the patient to Cardiologist B for a consult.

The patient could not obtain an appointment with Cardiologist B until 2/3/2014.

The internist ordered that a stress test be conducted prior to the patient’s visit to Cardiologist B, and advised that the patient bring the results of the stress test to his appointment with Cardiologist B.  The stress test was performed on 1/23/2014, and the results were abnormal.

The Board judged the internist’s conduct to be below the minimum standard of competence given that the internist failed to adequately evaluate the patient’s symptoms and recognize the patient’s worsening coronary artery disease, development of congestive heart failure, and worsening of chronic kidney disease.  The internist should have referred the patient to a nephrologist for further evaluation upon seeing a dramatic decline in the patient’s GFR levels. When the patient, with a known history of cardiac disease, presented with cardiac symptoms, the internist should have should have sent the patient to an emergency department for treatment.

The Board ordered that the internist pay a fine of $2,000 imposed against his license.  The Board also ordered that the internist pay reimbursement costs of a minimum of $5,756.36 and not to exceed $7,756.36.  The internist was ordered to complete five hours of continuing medical education in the treatment of patients with chronic kidney disease and five hours of continuing medical education in the treatment of patients with chronic heart disease.

State: Florida


Date: December 2017


Specialty: Internal Medicine


Symptom: Extremity Pain, Numbness, Shortness of Breath


Diagnosis: Renal Disease, Cardiovascular Disease


Medical Error: Referral failure to hospital or specialist


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Emergency Medicine – Sharp Chest Pain After Intercourse



On 4/4/2015, a 47-year-old male presented to the emergency department with sharp chest pain after intercourse.

The RN on duty noted taking the patient’s vitals and performing an EKG, chest radiograph, and labs.

In his physician note, the ED physician documented the following: the patient did not take his medication for hypertension or dyslipidemia despite having a history of hypertension and homelessness;  the patient reported a history of coronary artery disease and possible coronary artery stent placement; and the patient reported chest discomfort and dyspnea for the week prior to presentation as well as a history of tobacco use.

The ED physician recorded a differential diagnosis including acute myocardial infarction, non-ST segment elevation myocardial infarction (“NSTEMI”), angina, and acute coronary syndrome.

The ED physician did not diagnose the patient with possible cardiac etiology of chest discomfort.  He also did not contact the on-call cardiologist.  The ED physician did not perform provocative testing or cardiac catheterization.  He also did not admit the patient for hospitalization and cardiology consultation.  The ED physician discharged the patient without requiring any further evaluation/treatment or serial EKG/troponin.  He did not arrange for close outpatient follow-up prior to discharge.

The Board issued a letter of concern against the ED physician’s license and ordered that he pay a fine, reimburse costs for the proceedings, and complete 5 hours of continuing education in risk management.

State: Florida


Date: November 2017


Specialty: Emergency Medicine


Symptom: Chest Pain


Diagnosis: Cardiovascular Disease


Medical Error: Failure to order appropriate diagnostic test, Referral failure to hospital or specialist, Failure to follow up


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Family Medicine – Recurrent Chest Pain Diagnosed As Esophageal Spasm



On 8/27/2012 a 47-year-old female presented with complaints of hypertension, possible hyperlipidemia, and pain in her foot.  A family practitioner assessed the patient and diagnosed her with poor control of her hypertension and reinforced medical advice for the patient to increase her lisinopril.  Additionally, the family practitioner waited for the results of the previous laboratory work and recommended conservative management and stretching for the foot and ankle.

On 4/1/2013, the patient again presented to the family practitioner to address difficulties with concurrent chest pain.  The patient stated the chest pains were very severe and “stopped her in her tracks at times.”  The patient stated that she felt she was having a heart attack, although she reportedly realized that that was not the case.  The family practitioner deemed the chest pain was likely an esophageal spasm, for which he prescribed the patient Librax (chlordiazepoxide/clidinium) and recommended that she see a gastroenterologist for an endoscopy if the medication failed to provide relief.  The family practitioner also assessed the patient for hypertension and instructed the patient to stop taking hydrochlorothiazide.  The family practitioner provided the patient with a trial of Dyrenium (triamterene).

On 4/12/2013, the patient complained of chest pain and suffered a cardiac arrest.  Upon EMS arrival, the patient was unstable and unresponsive.  The patient was transported to a hospital where she was later pronounced deceased.

The Board judged the family practitioners conduct to be below the minimal standard of competence given that he failed to conduct an adequate history, which included a risk factor assessment for a patient complaining of chest pain, to order or perform an EKG on a patient complaining of chest pain, and send a patient complaining of chest pain to an emergency room or an expedited outpatient facility for a chest pain evaluation.

The Board ordered that the family practitioner pay a fine of $5,000 against his license and pay reimbursement costs for a minimum of $2,122.00 and not to exceed $4,122.00.  The Board also ordered that the family practitioner complete ten hours of continuing medical education in diagnosis in cardiology and five hours of continuing medical education in “Risk Management.”

State: Florida


Date: November 2017


Specialty: Family Medicine


Symptom: Chest Pain, Extremity Pain


Diagnosis: Cardiovascular Disease


Medical Error: Diagnostic error, Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Referral failure to hospital or specialist


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Ophthalmology – Persistent Pain And Inflammation In The Right Eye Following Cataract Surgery



On 12/4/2013, a 78-year-old female presented to an ophthalmologist for phacoemulsification with posterior chamber implant (“cataract surgery”) on her right eye.

During the cataract surgery, the patient experienced a posterior capsule tear, a known complication and an accepted risk associated with cataract surgeries.

On 2/3/2014, the patient presented to the ophthalmologist for an examination, and the ophthalmologist noted inflammation in the patient’s operative eye.

On 3/27/2014, the patient presented to the ophthalmologist for an examination, and the ophthalmologist noted inflammation in the patient’s operative eye.

On 4/8/2014, the patient presented to the ophthalmologist for an examination, and the ophthalmologist noted that the patient experienced post-operative chronic iritis in her operative eye.

On 5/6/2014, the patient presented to the ophthalmologist for a follow-up examination of her operative eye.

On 8/14/2014, the patient presented to the ophthalmologist for a follow-up examination of her operative eye.

On 9/18/2014, the patient presented to the ophthalmologist and reported throbbing pain in her operative eye.

Despite knowing that the patient experienced a complicated cataract surgery, followed by persistent inflammation in her operative eye, the ophthalmologist did not perform a dilated examination until 9/18/2014.

Despite knowing the patient experienced a complicated cataract surgery, followed by persistent inflammation in her operative eye, the ophthalmologist did not refer her to a retina specialist.

The Board judged the ophthalmologist’s conduct to be below the minimum standard of competence given his failure to perform a dilated examination on the patient’s operative eye to investigate the causes of persistent post-operative inflammation within a reasonable time after the cataract surgery.  The ophthalmologist also failed to refer the patient to a retina specialist to investigate the causes of persistent post-operative inflammation within a reasonable time after cataract surgery.

The Board ordered that the ophthalmologist pay a fine of $2,500 against his license and that the ophthalmologist pay reimbursement costs for the case for a minimum of $4,634.56 but not to exceed $6.634.56.  The Board also ordered that the ophthalmologist complete five hours of continuing medical education in post-operative care and complete one hour of continuing medical education in “Risk Management.”

State: Florida


Date: November 2017


Specialty: Ophthalmology


Symptom: Head/Neck Pain, Swelling


Diagnosis: Post-operative/Operative Complication, Ocular Disease


Medical Error: Failure to examine or evaluate patient properly, Referral failure to hospital or specialist


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Family Practice – Unnecessary Excisions Performed For Multiple Lesions



On 6/15/2012, a 47-year-old female presented to a family practitioner with multiple lesions on her back, chest, and arms.

The family practitioner informed the patient that the lesions on her left humerus, right upper abdomen, mid upper back, left anterior mid chest, lower back, right lower back, and/or right upper anterior chest were malignant and/or potentially malignant.

On 7/6/2012, the family practitioner documented that the patient had a history of keloid formation after surgical excision.

On 6/15/2012, the family practitioner excised a lesion on the patient’s left humerus.  The lesion excised from the patient’s left humerus measured approximately 3 mm by 3 mm.  The family practitioner made an excision 4 cm by 4 cm or sixteen square centimeters to excise the lesion on the patient’s left humerus.

On 6/19/2012, a dermatopathology report determined that the excision taken from the patient’s left humerus was not malignant or premalignant.

On 6/27/2012, the family practitioner excised a lesion on the patient’s right upper abdomen.  The lesion on the patient’s right upper abdomen measured 3 mm.   The family practitioner made an excision 7 cm by 6 cm, or forty-two square centimeters to excise the lesion on the patient’s right upper abdomen.

On 6/29/2012, a dermatopathology report determined that the excision taken from the patient’s right upper abdomen was not malignant or premalignant.

On 7/6/2012, the family practitioner excised a lesion the patient’s mid upper back.  The lesion on the patient’s back measured approximately 3 mm.   The family practitioner made an excision 5 cm by 7 cm, or thirty-five square centimeters to excise the lesion on the patient’s mid upper back.

On 7/13/2012, the family practitioner excised a lesion on the patient’s left anterior mid chest.  The lesion on the patient’s left anterior mid chest measured approximately 4 mm by 4 mm.
The family practitioner made an excision 8 cm by 6 cm or forty-eight square centimeters to excise the lesion on the patient’s left anterior mid chest. He referred the patient for radiation treatment to prevent keloid formation.

On 7/20/2012, a dermatopathology report determined that the excision taken from the patient’s left anterior mid chest was not malignant or premalignant.

On 8/3/2012, the family practitioner excised a lesion the patient’s left lower back.  The lesion on the patient’s left lower back measured 5 mm by 4 mm.  The family practitioner made an excision 9 cm by 7 cm or sixty-three square centimeters to excise the lesion on the patient’s left lower back.

On 8/7/2012, a dermatopathology report determined that the excision taken from the patient’s left lower back was not malignant or premalignant.

On 8/10/2012, the family practitioner excised a lesion on the patient’s right lower back.  The lesion on the patient’s right lower back measured 4 mm by 4 mm.  The family practitioner made an excision 9 cm by 8 cm or seventy-two square centimeters to excise the lesion on the patient’s right lower back.

On 8/14/2012, a dermatopathology report determined that the excision taken from the patient’s right lower back was not malignant or premalignant.

On 8/27/2012, the family practitioner excised a lesion on the patient’s right upper anterior chest.  The lesion on the patient’s right upper anterior chest measured 2 mm by 2 mm.   He made an excision 10 cm by 7 cm, or seventy square centimeters to excise the lesion on the patient’s right upper anterior chest.

On 8/29/2012 a dermatopathology report determined that the excision taken from the patient’s right upper anterior chest was not malignant or premalignant.

The Board judged that the family medicine practitioners conduct to be below the minimal standard of competence given that he failed to perform a complete and comprehensive physical examination of the patient’s lesions; adequately consider the characteristics of the lesions, including the size, color, regularity, and degree of pigmentation; refer the patient for consultation with a dermatologist; refrain from diagnosing the patient with malignant and/or potentially malignant lesions without having adequate justification; accurately and appropriately diagnose the patient’s condition; confirm that each of the lesions on the patient was malignant or premalignant prior to excising the lesion; perform a shave biopsy, punch biopsy, or limited excisional biopsy with 1 mm margins on each of the lesions on the patient to determine whether the lesion was malignant or premalignant; make an excision with margins no greater than 5 mm to excise each of the lesion on the patient; refrain from making an excision on the patient without having adequate justification; avoid potential keloid formation on the patient, by making the fewest and/or smallest excisions appropriate and/or justifiable.

The family practitioner agreed to voluntarily cease practicing medicine and agreed to never reapply for licensure as a medical doctor in the state of Florida.

State: Florida


Date: August 2017


Specialty: Family Medicine, Dermatology


Symptom: Dermatological Abnormality


Diagnosis: Dermatological Issues


Medical Error: Unnecessary or excessive treatment or surgery, Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Referral failure to hospital or specialist, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Cardiothoracic Surgery – Failure To Follow Up After Pathology Report Shows Abnormal Lymphadenopathy



On 1/25/2013, a 65-year-old male, underwent an artery bypass grafting procedure on his right leg by a cardiothoracic surgeon at a medical center.

During the course of the procedure, the cardiothoracic surgeon took a biopsy of the patient’s right groin lymph node, which was sent off to pathology for analysis.

The patient was never notified by the cardiothoracic surgeon that a biopsy of the right groin lymph node was taken during the procedure.

The cardiothoracic surgeon should have documented the right groin lymph node biopsy as part of the procedure in the operative report for the procedure but failed to do so.

On 1/29/2013, the pathology report for the biopsied tissue revealed a pathologic diagnosis of mantle cell lymphoma.  The pathology report was sent via facsimile to the cardiothoracic surgeon’s office.  The cardiothoracic surgeon should have listed “abnormal lymphadenopathy” as the post-operative diagnosis and failed to do so.

On 1/30/2013, the patient was discharged from the medical center.

The Board judged the cardiothoracic surgeons conduct to be below the minimal standard of competence given that he should have notified the patient of the pathology results and failed to do so.  He also should have obtained oncologic consultation for the patient and failed to do so.  The cardiothoracic surgeon should have provided the patient’s primary care physician and the referring physician with a copy of the pathology report and failed to do so.

The Board issued a letter of concern against the cardiothoracic surgeon’s license.  The Board ordered that the cardiothoracic surgeon pay a fine of $5,000 against his license and pay reimbursement costs for the case for a minimum of $5,063.26 but not to exceed $7,063.26.  The Board ordered that the cardiothoracic surgeon complete a board approved medical records course and complete five hours of continuing medical education in “risk management.”

State: Florida


Date: August 2017


Specialty: Cardiothoracic Surgery, Oncology


Symptom: N/A


Diagnosis: Cancer


Medical Error: Failure to follow up, Failure of communication with other providers, Referral failure to hospital or specialist, Failure of communication with patient or patient relations, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



Florida – Family Medicine – Improper Prescribing Of Controlled Substances To A Patient With Drug Seeking Behavior, Dependence, and Withdrawals



On 7/13/2006 through 8/6/2013, a family practitioner treated a 37-year-old female for chronic neck and back pain.  The patient presented to the family practitioner with a history of hypertension, depression, anxiety, and back pain from a 2004 motor vehicle accident.

The patient’s medical records from her previous treating physicians indicated that the patient was addicted to Xanax, had attempted suicide via overdose of alcohol and Tylenol in 2004, and was a high-risk patient with regards to controlled substances.

Throughout the course of the treatment, the family practitioner prescribed controlled substances to the patient including Nucynta, Percocet, Xanax, Klonopin, Vicodin, and Soma.

On 10/7/2008, the family practitioner noted that the patient exhibited drug seeking behavior, had undergone physical withdrawals, and was having psychological dependence.  The family practitioner documented “no further controlled substances after this.”

On 10/7/2008, the family practitioner referred the patient to a pain management specialist.

From 10/17/2008 to 5/6/2010, the patient presented to a pain management specialist for her chronic pain.

Beginning on 5/17/2010, the patient discontinued treatment with the pain management specialist and resumed her treatment with the family practitioner for her chronic pain.

From 9/2/2011 through 8/6/2013, the patient presented to the family practitioner approximately every three months.  Despite the patient only presenting every three months, the family practitioner prescribed monthly refills of controlled substances for the patient.  The family practitioner prescribed Nucynta, Percocet, Xanax, Klonopin, Vicodin, and Soma to the patient in various combinations and amounts.

The prevailing standard of care requires that a physician treating a patient for chronic pain prescribe controlled substances appropriately.  The quantity and/or combination of controlled substances the family practitioner prescribed to the patient on one or more occasions from 9/2/2011 through 8/6/2013 were inappropriate.

The prevailing standard of care requires that a physician treating a high-risk patient for chronic pain create and implement an appropriate treatment plan.

The family practitioner did not create or implement, or did not document creating or implementing, an appropriate treatment plan for the patient.  The prevailing standard of care requires that a physician treating a high-risk patient for chronic pain evaluate the patient prior to refilling prescriptions for controlled substances.  On one or more occasions, the family practitioner prescribed multiple refills of controlled substances for the patient at a single office visit.

The prevailing standard of care required that a family physician treating a high-risk patient for chronic pain refer the patient to a chronic pain specialist.  The family practitioner did not refer, or did not document referring, the patient to a chronic pain specialist on or after 9/2/2011.

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: August 2017


Specialty: Family Medicine


Symptom: Head/Neck Pain, Back Pain, Psychiatric Symptoms


Diagnosis: Drug Overdose, Side Effects, or Withdrawal


Medical Error: Improper medication management, Referral failure to hospital or specialist, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Pediatrics – Deep Laceration Of The Right Knee Treated With Debridement, Irrigation, And Suturing



On 12/7/2011, an 8-year-old male presented to a medical emergency department with a deep laceration to his right knee.  The laceration was a full thickness cut with visualization of the capsule.  An x-ray revealed air in the knee joint.

A pediatrician examined the patient’s knee and performed debridement, cleaning by irrigation, and suturing of the laceration.  Bacitracin and dressing were applied to the patient’s knee.

On 12/10/2011, the patient returned to the emergency department with complaints of right knee swelling, redness, and pain.  The patient was admitted to the pediatric floor.

Further examination revealed septic arthritis in the patient’s right knee, which required two operations and the introduction of a PICC line for long-term antibiotic therapy.  The patient sustained cartilage damage as a result of the septic arthritis and suffered from significant knee pain.

The Board judged the pediatrician’s conduct to be below the minimal standard of competence given that he failed to refer the patient to an orthopedic surgeon and to fully wash out the patient’s joint by performing an open debridement under anesthesia.

The Board issued a letter of concern against the pediatrician’s license.  The Board ordered the pediatrician to pay a fine of $10,000 against his license and pay reimbursement costs at a minimum of $5,496.59 and not to exceed $7,496.59.  The Board also ordered that the pediatrician complete ten hours continuing medical education in pediatric orthopedic diagnosis and treatment and complete five hours of continuing medical education in “risk management.”

State: Florida


Date: June 2017


Specialty: Pediatrics, Orthopedic Surgery


Symptom: Joint Pain, Swelling


Diagnosis: Trauma Injury, Septic Arthritis


Medical Error: Improper treatment, Referral failure to hospital or specialist


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 4


Link to Original Case File: Download PDF



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