Found 17 Results Sorted by Case Date
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Florida – Interventional Radiology – Guidewire Found In Patient’s Abdomen Following CT-Guided Percutaneous Drainage



On 8/24/2015, a 63-year-old male presented to a medical center for a CT-guided percutaneous aspiration with possible drainage of an abdominal abscess.

During the course of the procedure, an interventional radiologist placed a guidewire into the operative field.  Once the procedure was completed the patient had stable vital signs and no immediate complications were known.

On 9/12/2015, the patient was re-admitted to the medical center with complaints of abdominal pain.  A subsequent CT scan revealed a foreign body on the left side of the patient’s abdomen.

On 9/15/2015, a general surgeon performed laparoscopic retrieval of the foreign body, at which time a portion of the guidewire, measuring 11.0 centimeters in length, was found and removed intact.

The Board ordered that the interventional radiologist pay a fine of $5,000 against his license and that the radiologist pay reimbursement costs for the case at a minimum of $4,737.16 and not to exceed $6,737.16.  The Board also ordered that the interventional radiologist complete five hours of continuing medical education in “Risk Management”  and that the interventional radiologist complete a one hour lecture/seminar on retained foreign body objects.

State: Florida


Date: November 2017


Specialty: Interventional Radiology


Symptom: Abdominal Pain


Diagnosis: Post-operative/Operative Complication, Acute Abdomen


Medical Error: Retained foreign body after surgery


Significant Outcome: Hospital Bounce Back


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Internal Medicine – Retained Guide Wire Found After Replacement Of Dialysis Catheter



On 3/19/2015, a patient presented to a hospital with complaints of chest pain, history of acute stent thrombosis, and renal failure.

On 3/21/2015, a physician referred the patient to an internist for replacement of temporary dialysis catheter to address her acute kidney failure.  The internist placed a double-lumen dialysis catheter in the patient’s left subclavian vein.

Due to the catheter not functioning properly, another physician performed a catheter exchange procedure on the patient on 3/23/2015.  After the procedure, the inspection of the catheter revealed that the guide wire remained in one of the lumens of the catheter.

Neither the internist nor his staff removed the guide wire from the catheter prior to the insertion of the catheter into the patient’s left subclavian vein.

The Board judged the internist’s conduct to be below the minimum standard of competence given that he left a foreign body in a patient.

The Board ordered that the internist pay a fine of $3,500 against his license and pay reimbursement costs for the case for a minimum of $3,419.35 and not to exceed $5,419.35.  The Board also ordered that the internist complete five hours of continuing education in “Risk Management” and complete a lecture/seminar on retained foreign body objects to medical staff.

State: Florida


Date: November 2017


Specialty: Internal Medicine, Nephrology


Symptom: Chest Pain


Diagnosis: Renal Disease


Medical Error: Retained foreign body after surgery


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Virginia – Orthopedic Surgery – Metal Fragment From Drill Bit Breaks Off During Total Knee Replacement



On 7/27/2009, while an orthopedic surgeon was performing a right total knee replacement on a patient, a metal fragment that was the tip of a drill bit or metal pin used to guide the drill, broke off below the surface of the bone and was left in place in the patient’s knee.  The orthopedic surgeon did not note the occurrence in his operative report or records of the patient’s follow-up treatment, other than in a note relating to a March 2014 right knee x-ray that he ordered and read.

The patient told the Board’s investigator that the orthopedic surgeon never told her about the drill bit or complications from the surgery during any of her follow-up visits and that she learned this information in April 2015 from another orthopedist who had viewed an x-ray of her knee.

The orthopedic surgeon stated that he expected hospital nursing staff present during the patient’s knee surgery would have reported the retained metal fragment as an “adverse event.”  He also stated that he believes he would have told the patient about the occurrence when she was in the hospital following surgery, although he acknowledged that no such conversation was documented in his records.

The orthopedic surgeon further stated that during surgery, he had opted to leave the fragment in place, as it was located within the bone and away from any vital structures, and the risk of damage from removing it outweighed any potential benefit to the patient.

The Board issued a reprimand.

State: Virginia


Date: January 2017


Specialty: Orthopedic Surgery


Symptom: N/A


Diagnosis: N/A


Medical Error: Retained foreign body after surgery, Failure of communication with patient or patient relations, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Florida – General Surgery – Endocatch Bag Left In Patient’s Abdomen During Bowel Resection And Not Added To Surgical Count



On 5/11/2015, a patient underwent a routine colonoscopy.  The colonoscopy revealed a small colon polyp; a subsequent biopsy of the polyp revealed it to be colon cancer.

On 5/18/2015, the patient presented to a hospital for bowel resection to be performed by a general surgeon.

During the course of the procedure, the general surgeon removed a portion of omentum and requested an endocatch bag, which was not added to the surgical count, to temporarily store the omentum.

The contents of the endocatch bag were too large to remove through the endocatch, and the general surgeon released the endocatch bag into the patient’s abdomen to be removed at the end of the procedure through the extraction site.

At the conclusion of the procedure the extraction site was closed and the endocatch bag was not removed from the patient’s body.

On 5/19/2015, the general surgeon verified with staff that the endocatch bag had not been removed and the patient was returned to surgery where the endocatch bag was successfully removed.

The general surgeon left a foreign body in a patient by leaving an endocatch bag inside the patient during a bowel resection procedure on 5/18/2015.

The Medical Board of Florida issued a letter of concern against the general surgeon’s license.  The Medical Board of Florida ordered that he pay a fine of $4,000 against his license and pay reimbursement costs for the case at a minimum of $1,563.30 and not to exceed $3,563.30.  The Medical Board of Florida also ordered that the general surgeon complete five hours of continuing medical education in “risk management” and complete a one-hour lecture/seminar on retained foreign body objects.

State: Florida


Date: December 2016


Specialty: General Surgery


Symptom: N/A


Diagnosis: Post-operative/Operative Complication, Colon Cancer


Medical Error: Retained foreign body after surgery


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Urology – Insertion Of Catheter Without Removing Protective Sheath During A Cystoscopy-Assisted Balloon Dilation And Stenting Procedure



On 9/15/2014, a patient presented to a urologist for a cystoscopy-assisted balloon dilation and stenting procedure to correct a stricture in his left ureter.

The urologist performed the cystoscopy-assisted balloon dilation and stenting of the patient’s left ureteral stricture.

The cystoscopy-assisted balloon dilation and stenting procedure required the urologist to utilize a catheter to move a balloon and stent into place in the patient’s left ureter.

The catheter utilized by the urologist for the patient’s procedure was equipped with a protective catheter sheath.  This sheath had to be removed prior to the insertion of the catheter into the patient’s ureter.

Neither the urologist nor his support staff removed the protective catheter sheath from the catheter prior to the insertion of the catheter into the patient’s ureter.

The urologist successfully placed the stent into the patient’s left ureter during the cystoscopy-assisted balloon dilation and stenting procedure, but following the procedure the patient experienced intense persistent pain with accompanying nausea.

On 12/11/2014, an exploratory ureteroscopy was performed on the patient’s left ureter.  This procedure revealed the presence of the protective catheter sheath from the cystoscopy-assisted balloon dilation and stenting procedure performed by the urologist on 9/15/2014.  The sheath was successfully removed the patient’s left ureter and the patient’s pain and nausea subsided.

The Medical Board of Florida judged the urologist’s conduct to be below the minimal standard of competence given that he left a foreign body in a patient.

It was requested that the Medical Board of Florida 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 Medical Board of Florida deemed appropriate.

State: Florida


Date: October 2016


Specialty: Urology


Symptom: Pain, Nausea Or Vomiting


Diagnosis: Post-operative/Operative Complication


Medical Error: Retained foreign body after surgery


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Washington – Urology – Challenges Placing Suprapubic Catheter With Subsequent Retention Of Foreign Body



A urologist provided care for a patient who suffered urinary retention, along with several other non-related health issues.  The patient had been on a urethral Foley catheter that caused ongoing problems with irritation and inflammation.  After discussions with the patient, a decision was made for placement of a suprapubic catheter to try to eliminate some of the issues and discomfort caused by the Foley catheter.

On 1/22/2009, the urologist attempted to place a suprapubic catheter into the patient.  After two unsuccessful attempts, the urologist elected to abandon the suprapubic procedure and replace the urethral Foley catheter, with a plan to try again at a later date.

Unbeknownst to the urologist, a sheath from a needle used in the procedure remained in the abdomen.  The instrument count was reported as correct.  On 2/9/2009, the sheath was successfully removed without further complications.

The Commission stipulated the urologist reimburse costs to the Commission and write and submit a paper of at least 1000 words, with references, on the subject of retained foreign body objects.  In his analysis, the urologist will discuss patient selection for the procedure, choice of procedure, and how to account for non-countable items.

State: Washington


Date: May 2016


Specialty: Urology


Symptom: Urinary Problems


Diagnosis: Urological Disease


Medical Error: Retained foreign body after surgery


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Wisconsin – General Surgery – Encountering Adhesions During Lap Band And Tubing Removal



In 2006, a 34-year-old woman had a lap band procedure done in Mexico.  She had complications that required additional procedures and that were performed in Mexico in June 2007 and May 2008.

In June 2009, she presented to General Surgeon A, who on 8/24/2009, performed laparoscopic surgery to remove the lap band and tubing.  The operative report indicates that a tag cap had been placed on the end of the tubing during the surgery in Mexico.  This tag cap was thought to have been causing a chronic infection.  The operative report indicated that there were a significant amount of adhesions making dissection difficult.  On 9/29/2009, she had a follow-up visit with General Surgeon A and reported doing well.  In October 2009, she reported having abdominal pain.  A CT scan revealed that a piece of the lap band had come off and had been left inside the patient.  On 2/10/2010, laparoscopic surgery was performed to remove the piece of the lap band.

On 5/31/2014, General Surgeon A was found by the court to be negligent in treating the patient.  General Surgeon A denied negligence.  He insisted that the lap band buckle had not been properly locked when the band was originally placed.  When removing the lap band, the buckle became loose.  He did not see the buckle fall.  The Board ordered a minimum of 10 hours education on gastric band removal, gastric band bariatric surgery, or related abdominal surgery.

State: Wisconsin


Date: August 2015


Specialty: General Surgery


Symptom: Abdominal Pain


Diagnosis: Post-operative/Operative Complication


Medical Error: Retained foreign body after surgery


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Vascular Surgery – Guidewire Tip Breaks When Attempting To Revascularize 1st And 2nd Right Foot Toes



On 7/9/2013, a 44-year-old male, with a past history of renal failure after a failed kidney transplant, insulin-dependent diabetes, coronary and peripheral vascular disease (PVD), and dry gangrene of the 1st and 2nd right foot toes presented to a dialysis center for a follow-up visit.  At that time, a vascular surgeon examined the patient and noted in the patient’s chart that it was ok to proceed with a “right 1st toe amputation.”  This notation, however, was subsequently crossed out by the vascular surgeon as an error.  The vascular surgeon ordered that the patient undergo a repeat arterial duplex scan of his right posterior tibial artery (PTA), peroneal artery (PA), anterior tibial artery (ATA), and a dorsalis pedis artery (DTA) as he had no improvement in the dry gangrene of 2 toes on his right foot.

On 7/11/2013, the patient presented for the arterial duplex scan, which showed improved blood flow in the PTA and PA, but the ATA and DPA were re-occluded.  As a result of these findings, the vascular surgeon recommended that another angiogram be performed with possible balloon angioplasty in an attempt to revascularize the occluded arteries.

On 7/26/2031, the vascular surgeon performed an arteriogram of the patient’s right lower extremity.  The PTA pulse was documented at +1 both pre and post-procedure. The images of the arteriogram showed widely patent circulation to the patient’s foot via the PTA, but the TA was occluded, and the DPA was not seen.  The vascular surgeon documented, in his procedure note, that he was unable to gain guide-wire access due to the occluded ATA. Upon removal of the guide-wire, it was discovered that the distal tip of the wire had broken off and remained in the occluded ATA.  The vascular surgeon, however, failed to document the retained tip of the wire in his operative report or procedure note, and he failed to notify the patient of the retained wire fragment. Another employee, who assisted during the procedure, filed an Incident Report concerning the retained wire fragment.

On 7/29/2013, the patient returned to the dialysis center for a mapping of the greater saphenous vein to see if the vein could be utilized for a bypass graft.  The vascular surgeon determined that the vein was viable for the bypass graft and scheduled the patient for a femoral distal bypass of the right lower extremity in an attempt to revascularize the lower leg and foot.  At that time, the vascular surgeon did not inform the patient of the retained wire from the arteriogram performed on 7/26/2013.

On 8/1/2013, the vascular surgeon performed the vein bypass surgery of the patient’s right lower extremity.  In his operative report, the vascular surgeon documented that there was a strong biphasic signal of the distal ATA at the completion of the procedure.  On this same date, the vascular surgeon dictated an addendum to his 7/26/2013 arteriogram operative report regarding the retained tip of the guide wire, but the vascular surgeon did not inform the patient of the retained wire tip.

On 8/6/2013, the patient returned to the dialysis center complaining of a lot of pain, and it was noted that the dry gangrene of his 2 right toes had progressed into wet gangrene.  Also, the vein bypass procedure, performed 5 days earlier, had failed to revascularize the patient’s lower right leg and foot. As a result of the failed vein bypass and the other previously failed endovascular attempts to revascularize the area, the vascular surgeon determined that the patient required the amputation of his right leg below the knee.  Had the patient’s 1st right toe been amputated as originally documented in the 7/9/2013 office visit, his right lower leg would have been salvaged.  On 8/20/2013, the vascular surgeon saw the patient, who was complaining of increased devitalization of his right foot and pain. At that time, the patient was scheduled for a below the knee amputation of his right leg.  At this visit, the vascular surgeon informed the patient that the distal tip of the guide wire had broke off during the 7/26/2013 procedure and was retained in the occluded section of his ATA. Thereafter, the patient had his right leg amputated below the knee.

The Medical Board of California judged that the vascular surgeon’s conduct departed from the standard of care because he failed to document the retained tip of the wire fragment in his operative report and procedure note on 7/26/2013 and failed to timely notify the patient.  He also made multiple failed attempts at lower extremity revascularization, which resulted in below the knee leg amputation of the patient’s right lower leg.

For this case and others, the Medical Board of California placed the vascular surgeon on probation for 1 year and ordered the vascular surgeon to complete an education course (at least 20 hours per year for each year of probation), a medical record keeping course, and a professionalism program (ethics course).  The vascular surgeon was also prohibited from supervising physician assistants.

State: California


Date: June 2015


Specialty: Vascular Surgery


Symptom: Extremity Pain


Diagnosis: Acute Ischemic Limb


Medical Error: Delay in proper treatment, Ethics violation, Failure of communication with patient or patient relations, Lack of proper documentation, Retained foreign body after surgery


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 3


Link to Original Case File: Download PDF



California – Vascular Surgery – Overinflating Balloon Ruptures During Angioplasty At The Level Of The Subclavian Vein



On 7/29/2013, a 34-year-old male on hemodialysis presented to a dialysis center with severe arm swelling of the upper left extremity.  At that time, dialysis was performed, and the patient was scheduled to return for a left upper extremity fistulogram.

On 8/5/2013, the patient presented for the fistulogram, which revealed significant venous stenosis.  A vascular surgeon then performed a balloon angioplasty at the level of the subclavian vein. During the procedure, the vascular surgeon overinflated the balloon, and it ruptured.  After the rupture, the vascular surgeon proceeded to remove the balloon, which tore, leaving a balloon fragment within the blood vessel. When the balloon was removed, it had 2 torn edges.  The vascular surgeon failed to attempt to remove the retained balloon fragment and failed to make any effort to secure the fragment in place to prevent distal migration and possible embolization in the future.  The vascular surgeon also failed to document the balloon rupture and the retained fragment in his operative report or in the procedural note. The vascular surgeon further failed to notify the patient of the retained balloon fragment.  Another employee, who assisted during the procedure, filed an Incident Report about the balloon rupture and retained fragment. This report resulted in an investigation, and the patient was contacted to return to the dialysis center.

As a result of the Incident Report, the vascular surgeon was requested to prepare an addendum to his operative report.  The vascular surgeon’s initial addendum stated that the distal 1/3 of the balloon had been ripped off the catheter, which “was not evident at the time of the procedure.”  This was incorrect. On 8/15/2013, the vascular surgeon signed and dated the addendum to his operative report, but had removed the language that the torn balloon “was not evident at the time of the procedure.”

On 8/19/2013, the patient returned to the dialysis center when he was finally informed about the balloon rupture and fragment.  The vascular surgeon told the patient that an x-ray evaluation was necessary to attempt to locate and possibly retrieve the retained balloon fragment.  The patient consented, and the evaluation was performed, but the balloon fragment was not located.

The Medical Board of California judged that the vascular surgeon’s conduct departed from the standard of care because he failed to make an effort to remove the retained balloon fragment in the blood vessel at the time of the initial procedure or to secure it in place to prevent it from migrating at that time, document the rupture and retained balloon fragment in his operative report or procedure note of 8/5/2013, and timely notify the patient.

For this case and others, the Medical Board of California placed the vascular surgeon on probation for 1 year and ordered the vascular surgeon to complete an education course (at least 20 hours per year for each year of probation), a medical record keeping course, and a professionalism program (ethics course).  The vascular surgeon was also prohibited from supervising physician assistants.

State: California


Date: June 2015


Specialty: Vascular Surgery


Symptom: Swelling


Diagnosis: N/A


Medical Error: Retained foreign body after surgery, Ethics violation, Failure of communication with patient or patient relations, Procedural error


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Washington – Gynecology – Morbidly Obese Patient With Extensive Abdominal Surgical History Undergoes Total Laparoscopic Hysterectomy With Resulting Complications



A 42-year-old morbidly obese female had a history of abdominal surgery that included a Cesarean section and tubal ligation in 2005, a laparoscopic cholecystectomy in December 2005, and a laparoscopic resection of endometriosis in November 2008.  Following the November 2008 procedure to remove endometriosis, the patient continued to experience pain, heavy bleeding with menses, and other symptoms.  The patient was informed of treatment options and chose to undergo total laparoscopic hysterectomy.

On 5/22/2012, a gynecologist began performing a laparoscopic total hysterectomy on the patient.  Before beginning the laparoscopic surgery, the gynecologist used a RUMI uterine manipulator to obtain better visualization and access during the laparoscopic procedure.  A uterine tip at the end of the RUMI device was advanced through the cervical canal, into the uterus, and secured into position with a balloon inflated with saline.  An attachment called a Koh cup was advanced along the RUMI device, into the vagina, and was seated at the opening of the cervix.

The gynecologist then began the laparoscopic surgery.  She made an incision at the umbilicus, and after lifting the abdomen in attempt to separate any potential adhesions from the abdominal  wall, she placed a blunt tissue dissecting trocar using a laparoscope for visualization.  It immediately became apparent that the laparoscope was in the lumen of the small bowel.  The gynecologist and the assisting surgeon decided to convert the procedure to an open procedure, so that they could repair the perforation in the small bowel.  The gynecologist removed the RUMI device, but did not remove the Koh cup.  The assisting surgeon repaired the small bowel, and the gynecologist completed the hysterectomy.  Shortly following the gynecologist’s completion of the hysterectomy, the patient began experiencing declining oxygen saturation, requiring attention from multiple anesthesiologists.  After the procedure was completed, the patient was immediately taken for CT imaging, where it was determined that she did not have a pulmonary embolism.  The patient was subsequently taken to the Critical Care Unit by order of the anesthesiologist for treatment of her continued oxygen saturation issues, which resolved the following day without discovery of the etiology.  The Koh cup remained in the patient.

In the month following surgery, the patient experienced a foul smelling vaginal discharge, and abdominal pain that may have been associated with other medical issues.  On 6/25/2012, the patient’s regular gynecologist did a vaginal exam and discovered the unintentionally retained Koh cup.  The Koh cup was removed two days later, with the patient under general anesthesia.

In response to this event, the gynecologist now uses a RUMI device that does not separate from the vaginal cup.  The gynecologist also now requires that the Koh cup be accounted for by including it in the surgical checklist.

In addition to the retained foreign body issues, it is the Commission’s position that because of the patient’s history of abdominal surgery, with the attendant likelihood of abdominal adhesions, the gynecologist did not appropriately visualize the peritoneum for adhesions to the bowel before inserting the trocar and laparoscope.  The gynecologist should have either correctly performed the direct entry visualization technique that she used, or alternatively used an open laparoscopic approach (Hasson technique) to avoid the bowel injury that occurred.  Although bowel injury during the course of a total laparoscopic hysterectomy is a known complication, this injury might have been avoided in this case with the correct performance of an appropriate approach.

For this allegation and another, the Commission stipulated that the gynecologist reimburse costs to the Commission, develop a written protocol designed to prevent unintended retention of foreign body objects, write and submit a paper of at least 1000 words, with bibliography, in which she provides root cause analysis of the factors leading to the retained surgical sponge, write and submit a paper of at least 1000 words, with bibliography, containing a discussion regarding the need for visualization of the lining of the peritoneum and the correct performance of an appropriate laparoscopic approach for patients with a history of abdominal surgery, and present these two surgical cases to a peer group at a facility where she performs surgery.

State: Washington


Date: May 2015


Specialty: Gynecology


Symptom: Abnormal Vaginal Discharge, Abdominal Pain


Diagnosis: Post-operative/Operative Complication


Medical Error: Retained foreign body after surgery, Procedural error


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



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