Found 90 Results Sorted by Case Date
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Florida – Gynecology – Unnecessary Biopsies Performed When Lumps Are Noted on A Patient’s Breasts



Between December 2010 and August 2013, a patient presented to her gynecologist.

On 5/19/2011, the gynecologist found small, smooth, mobile lumps in the patient’s left and right breasts.

On 6/17/2011, the gynecologist performed a right breast biopsy on the patient.  The gynecologist noted that the right breast lump was likely a fibroadenoma.  The biopsied right breast tissue was found to be benign.

On 7/5/2011, the gynecologist performed a left breast biopsy on the  patient.  The gynecologist noted that the left breast lump was likely a fibroadenoma.  The biopsided left breast tissue was found to be benign.

At all times, the patient was at a low risk for having breast cancer.

The Board judged the gynecologist’s conduct to be below the minimum standard of practice given that the prevailing professional standard of care required that the gynecologist medically manage the patient’s left and right breast lumps with breast exams, breast sonographies, and/or mammograms.  The obstetrician’s performance of left and right breast biopsies on the patient was medically unnecessary.

The Board ordered that the gynecologist pay a fine of $16,000 against his license. Also, the Board ordered that the case fine be set at $9,486.57.  The Board ordered that the gynecologist complete five hours of continuing medical education in “Risk Management.”

State: Florida


Date: December 2017


Specialty: Gynecology, Gynecology


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


Diagnosis: N/A


Medical Error: Failure to order appropriate diagnostic test, Unnecessary or excessive treatment or surgery


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Virginia – Neurosurgery – All-Terrain Vehicle Rollover Accident Causes L1 Compression Fracture



On 1/19/2008, a 32-year-old man suffered an L1 compression fracture following an all-terrain vehicle rollover accident.  He saw a neurosurgeon who placed him in a rigid back brace and prescribed pain medications.  The patient’s fracture appeared to be clinically stable and appeared to be improving.  The Board deemed the long-term risk of developing a kyphotic deformity low in this patient.

On 3/7/2008,  the neurosurgeon performed a kyphoplasty of the spine the patient.  During the kyphoplasty, the vertebral body was too dense to accept the cement.  As a consequence, the cement extruded out of the fracture plans into the epidural space.

The neurosurgeon addressed this complication by performing a posterior laminectomy and decompression of the thecal sac.  The Board stated that the laminectomy procedure subjected the patient to a far greater risk for development of kyphosis than had existed prior to the kyphoplasty.

The Board considered the surgery unwarranted and issued a reprimand.  The neurosurgeon was ordered to complete 10 hours of continuing medical education in the subject of patient selection for spinal surgery.

State: Virginia


Date: November 2017


Specialty: Neurosurgery


Symptom: Back Pain


Diagnosis: Spinal Injury Or Disorder, Fracture(s)


Medical Error: Unnecessary or excessive treatment or surgery, Procedural error


Significant Outcome: N/A


Case Rating: 5


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 – Ophthalmology – Failure To Utilize Optical Coherence Tomography To Evaluate A Patient For Macular Conditions



An ophthalmologist treated a 90-year-old female from 1/26/2012 to 3/12/2014.  The patient presented to the ophthalmologist on 1/26/2012 with complaints of decreased vision and a prior history of Avastin injections.

The ophthalmologist diagnosed the patient with wet macular degeneration, vitreous membranes, posterior vitreous detachments, dry eyes, and previous cataract surgery with intraocular lenses.

The ophthalmologist performed fluorescein and indocyanine angiographies and ultrasonography.  The ophthalmologist performed a Lucentis injection in the right eye.

Over the course of his treatment of the patient, the ophthalmologist performed focal laser treatments in the patient’s left eye six times and in his right eye seven times;  intravitreal Lucentis injections in the patient’s left eye twenty-one times and the patient’s right eye twenty-two times;  intravitreal Avastin injections in both of the patient’s eyes four times;  fundus photos, fluorescein angiography and indocyanine green angiography over forty times, and ultrasounds on both of the patient’s eyes eight times.

The ophthalmologist failed to utilize, or did not create, keep, or maintain adequate, legible documentation of utilizing optical coherence tomography to evaluate the patient.

At all times material to this complaint, the prevailing standard of care dictates that a physician:  perform testing and/or treatment that are medically justified; provide medical justification for the testing and treatment provided to the patient;  utilize optical coherence tomography to evaluate a patient for macular conditions;  and record the lot number and/or other identifying information from used vials of Lucentis.

The ophthalmologist performed focal laser treatment on both of the patient’s eyes excessively and/or without medical justification on one or more occasions.  He also performed fluorescein and indocyanine angiography on the patient’s eyes excessively and/or without medical justification on one or more occasions.  The ophthalmologist performed ultrasounds on both of the patient’s eyes without medical justification on one or more occasions.  He did not document, or did not create, keep, or maintain adequate, legible documentation of the lot number of any other identifying information from any of the vials of Lucentis used during the course of treatment in the patient.  The ophthalmologist did not document, or did not create, keep, or maintain adequate, legible documentation of the patient’s conditions, any changes in the patient’s conditions, and/or medical indications for the testing and treatment.

It was requested that the Board order one or more of the following penalties for the ophthalmologist: 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: Ophthalmology


Symptom: Vision Problems


Diagnosis: Ocular Disease


Medical Error: Unnecessary or excessive treatment or surgery, Failure to order appropriate diagnostic test, Unnecessary or excessive diagnostic tests, Lack of proper documentation


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



California – Gynecologist – Complications After A Laparoscopic Assisted Vaginal Hysterectomy For Irregular Bleeding And Abdominal Pain



Sometime prior to 2011, a gynecologist began treating a patient with a history of a prior myomectomy in 2011, pre-diabetes, and fibromyalgia.

On 3/8/2011, the patient presented to the gynecologist with complaints of irregular vaginal bleeding with some pain in her right lower quadrant that worsened when she was on her period.  The patient informed the gynecologist that she was “ready for a hysterectomy.”  Medical records for this visit do not document the extent of the bleeding, whether or not the bleeding contributed to any other symptoms, the patient’s level of pain, or whether or not the pain interfered with the patient’s lifestyle.  At the conclusion of this visit, the gynecologist referred the patient for a pelvic ultrasound with plans to follow up after the ultrasound.

On 4/5/2011, the patient had a pelvic ultrasound which showed the uterus was oriented anteverted and located midline.  A fibroid was visualized in the right lateral aspect of the uterus that measured 5.3 by 4.2 by 5.3 centimeters.  The endometrial stripe measured 12 millimeters.  No other fibroids were seen.  The left and right ovary were normal.  There was no fluid in the cul-de-sac.  The fibroid had increased in size compared to a prior ultrasound in 2010.

On 4/11/2011, the patient presented to the gynecologist for a follow-up.  The gynecologist went over the results from the ultrasound and discussed possible treatment options.  The gynecologist did not recommend or perform an endometrial biopsy to determine the reason for endometrial thickening or repeat the ultrasound to watch this condition.  The gynecologist did not consider or document that the irregular bleeding could be caused by endometrial thickening, endometrial hyperplasia, or endometrial polyp.  She did not recommend a dilation and curettage.  At the conclusion of this visit, a decision was made for the patient to undergo a hysterectomy, which was scheduled to occur on 6/27/2011.  The patient indicated that she wanted a bilateral salpingo-oophorectomy, but the gynecologist advised her to leave in the ovaries.

On 6/24/2011, the patient presented to the gynecologist for a preoperative evaluation.  The gynecologist offered the patient medical and surgical options and the patient chose a hysterectomy.  The gynecologist explained various surgical options, including risk factors and complications.  During the physical examination of the patient, the gynecologist noted the patient’s uterus was bulky and that it did not descend well.  The gynecologist did not document any observable vaginal bleeding or any pelvic pain with palpation of the pelvic organs.  At the conclusion of this visit, the gynecologist had formed a surgical plan to include a total vaginal hysterectomy and depending on whether the uterus was mobile in the operation room, possible laparoscopic assisted vaginal hysterectomy, possible exploratory laparotomy, and possible cystoscopy.

On 6/27/2011, the gynecologist performed a laparoscopic assisted vaginal hysterectomy, bilateral salpingo-oophorectomy, cystoscopy, and lysis of adhesions on the patient.  The medical records do not document a specific clinical reason for this choice in surgical technique versus a laparotomy approach.

During the surgery, the gynecologist encountered a web of filmy adhesions that were abundant along the back of both ovaries and continued along the back of the uterus.  The adhesions connected the bowel to the uterus and ovaries.

There were also adhesions from the ovaries to the side walls.  The gynecologist considered converting to an open procedure but opted to continue with laparoscopic dissection.  After dissection of all of the adhesions, the gynecologist obtained a general surgery consultation as a precaution to review the small bowel, which had been adherent, especially near the right ovary.  After observation through the monitor only, neither the surgeon nor the gynecologist noted any bowel injuries.

The gynecologist then proceeded with the vaginal hysterectomy portion of the surgery, which progressed “a bit more difficult than average but not remarkably so.”

Upon completion of the vaginal portion of the surgery, the gynecologist returned to the abdominal cavity.  Upon doing so, she noted a slight oozing from the round ligament on the left, which she cauterized.  The gynecologist then irrigated the pelvis and looked for any bleeding or injury but found none.

Prior to closing, the gynecologist requested a urology consultation.  After cystoscopy and examination revealed no injury to the bladder or ureter, the gynecologist completed the procedure.  The gynecologist’s detailed operative report does not specifically document the difficulties or complexities she encountered during the over eight-hour operation.

During the first three post-operative days, the patient experienced complications from the surgery that began to worsen.  The patient’s symptoms included abdominal pain, distention, lack of appetite, bowel dysfunction, fever, tachycardia, weakness, emesis, and anemia.

After attempting to treat the patient with antibiotics and observation, on 7/5/2011, the patient was taken in for an exploratory laparotomy.

During the surgery, several liters of feces were found in the patient’s abdomen, which were suctioned out.  Then, the abdomen was irrigated.  Further into the surgery, a 1-centimeter tear in the distal sigmoid and another 3-centimeter tear in the proximal rectum were identified, repaired, and treated with a colostomy.

From 7/5/2011 to 8/1/2011, the patient remained hospitalized and experienced complications including but not limited to nausea, vomiting, fatigue, fever, tachycardia, wound infection, anemia, and significant leukocytosis.  During this time period, the patient had to undergo radiological drainage of intraabdominal collections and was on several courses of antibiotics.  The patient was discharged from the hospital on 8/1/2011, approximately thirty-five days after her total hysterectomy.

Per the Board, the gynecologist committed gross negligence in her care and treatment of the patient by continuing with a long and complicated abdominal and pelvic surgery through laparoscopy without converting to laparotomy to prevent multiple intraoperative injuries.

In addition, the Board judged the gynecologist’s conduct to be below the minimum level of competence given the performance of a total abdominal hysterectomy and bilateral salpingo-oophorectomy without definitive clinical indication and without consideration of alternative treatments, prior to consideration of a major surgery, and given failure to maintain adequate and accurate records relating to her care and treatment of the patient.

The Board issued a public reprimand with stipulations to complete a medical record keeping course.

State: California


Date: July 2017


Specialty: Gynecology, General Surgery


Symptom: Abdominal Pain, Fever, Gynecological Symptoms, Nausea Or Vomiting, Weakness/Fatigue


Diagnosis: Post-operative/Operative Complication, Gynecological Disease


Medical Error: Procedural error, Unnecessary or excessive treatment or surgery, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Nebraska – Family Medicine – Excessive X-Rays And Antibiotics For Sinus Infection And Pneumonia



A family practitioner treated a 32-year-old female, for approximately 10 years.  The patient had a mechanical mitral valve and was on Coumadin therapy.  The family practitioner diagnosed her with sinus infections and pneumonia repeatedly.  He ordered nine sinus x-rays, eight chest x-rays, and 29 prothrombin time tests, the majority of which were subtherapeutic, during a one-year period.  The patient was a chronic smoker, and there was nothing in the chart to indicate smoking cessation counseling was tried.  The patient was treated with Biaxin (from one to four weeks at a time), 13 Rocephin injections, Levaquin for three weeks, Bactrim for one month, Keflex for two days and 10 days and Diflucan, Levaquin and Rocephin treatments simultaneously.

The family practitioner’s use of repeated sinus x-rays for the patient, which have questionable medical value under these circumstances, constituted substandard medical care.

Also, the family practitioner’s use of antibiotic therapy for the patient, there being no evidence that such therapy has a recognized medical benefit under the circumstances, constituted substandard medical care.

Finally, the family practitioner’s failure to refer the patient for pulmonary evaluations, after repeated visits with the same symptoms, constituted substandard of medical care.

For these allegations and others, the Board judged that the family practitioner’s methodology of practice overall and the specific negligent acts of his practice constituted negligence.  The Board ordered that the family practitioner have his license censured, have a practice monitor to review his practice on a quarterly basis for one year, pay a fine, and complete review courses on the following subjects: Eye, Nose, and Throat practice and referral, Endocrinology, Immunology and Immune Systems, indications for the need of radiographs and the appropriate use of radiology consultations.

State: Nebraska


Date: July 2017


Specialty: Family Medicine


Symptom: N/A


Diagnosis: Pneumonia, Infectious Disease


Medical Error: Improper medication management, Unnecessary or excessive diagnostic tests, Failure of communication with other providers, Unnecessary or excessive treatment or surgery


Significant Outcome: N/A


Case Rating: 2


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



Iowa – Pathology – Sclerosing Lesion Misdiagnosed As Breast Cancer



A 56-year-old woman’s annual mammogram showed a lesion in her right breast.  A needle core biopsy of the lesion was obtained on 4/28/2014.  A general pathologist reviewed the patient’s slides and diagnosed the patient with an invasive well-differentiated ductal carcinoma of the right breast.  Based on his diagnosis, the general pathologist ordered immunohistochemical stains for estrogen and progesterone receptors and other tests.  A surgical follow up was recommended.

The patient was referred to a surgeon who informed her she would undergo an immediate lumpectomy.  The patient sought further consultation from a general surgeon and plastic surgeon for evaluation and treatment of the cancer and reconstructive surgery.  The patient met with both on 5/6/2014, at which time she elected to proceed with a bilateral mastectomy, followed by breast reconstructive surgery. The general surgeon’s records show he ordered a consultation with the John Stoddard Cancer Tumor Board for another opinion. The general surgeon contacted the general pathologist and informed him of the findings.  On that same day, the general pathologist sent the slides to Mayo Clinic to be re-read.  The general pathologist also scheduled the case to be discussed at the Marshalltown Medical and Surgical Center’s Tumor Board on 5/19/2014.

The Mayo Clinic issued its report on 5/20/2014, diagnosing a complex sclerosing lesion with unusual ductal hyperplasia and microcalcifications.  On that same date, the general pathologist authored an addendum to his pathology report amending the diagnosis to conform with that of the Mayo Clinic and adding the following comment:

“The case is reviewed for tumor board.  After reviewing the case, the case was sent to Mayo Clinic for a second opinion and the [sic] diagnosis is changed from invasive ductal cell carcinoma to complex sclerosing lesion.  The changes in the diagnosis are communicated with the general surgeon.  Results of the correct report will be discussed with the patient by the general surgeon”.

The patient underwent a lumpectomy performed by the general surgeon on 5/22/2014.  Iowa Pathology Associates reviewed the slides from the lumpectomy and issued a histopathology report confirming the diagnosis of a complex sclerosing lesion.  The report stated, “there is no evidence of atypicality or malignancy.”

An audio recording made by the patient’s husband of a discussion he and the patient had with the general pathologist regarding the misdiagnosis was admitted into evidence.  In response to an inquiry regarding why the second opinion was not obtained prior to making an initial diagnosis, the general pathologist cited to the cost of a consultation.

A senior pathologist at the Iowa clinic reviewed the patient’s slides at the Board’s request and, in contrast to the general pathologist’s carcinoma diagnosis, arrived at a diagnosis of “radial scar” which term is often used interchangeably with “complex sclerosing lesion”.  The senior pathologist testified that she found the diagnosis to be an easy one and that an “average pathologist” would have been able to make it.  However, in her written report the senior pathologist relied on a textbook, which contained the following passage: “The importance of recognizing various patterns of adenosis and sclerosing lesions, and the reason why they are considered together in this chapter, is that they may be mistaken for invasive carcinoma…”  The senior pathologist noted that the condition she diagnosed is benign, although complete excision of the lesion is generally recommended if the diagnosis has been made on a needle biopsy because of the risk of associated malignancy which can be identified only after surgical excision.

The senior pathologist also questioned the general pathologist’s use of special stains in this case.  She explained that myoepithelial cells are not present in invasive cancers and, therefore, stains can be used to look for those cells.  If a stain is used and it shows that myoepithelial cells are present, the sample would not be consistent with invasive cancer.  The senior pathologist emphasized that had the general pathologist ordered the appropriate stains, such as P63, to confirm or rule out cancer in the patient’s case, he might not have misdiagnosed cancer.  On the other hand, the senior pathologist argued that the stains the general pathologist ordered were for breast cancer receptors (estrogen and progesterone) and for human epidermal growth factor receptor 2 (“HER2”) status and that the HER2 was sent for fluorescent in-situ hybridization (“FISH”) analysis, all of which were unnecessary because the patient did not have breast cancer.  The senior pathologist noted that these unnecessary steps added substantial costs to the patient’s care.

The senior pathologist emphasized that this patient might have undergone an unnecessary lumpectomy or mastectomy had her case not been reviewed further.  The senior pathologist found that the general pathologist failed to meet the standard of care when he misdiagnosed the patient because of a substantial lack of knowledge or ability to discharge the professional obligations within the scope of pathology practice.  She also determined that the general pathologist’s actions, in this case, showed a failure to possess and exercise the degree of skill, learning, and care expected of a reasonable, prudent physician acting in the same or similar circumstances.

In response to the Board’s inquiry regarding this patient, the general pathologist admitted his initial diagnosis was incorrect.  He stated, however, that he read the patient’s slides a few days later while preparing to present the case at a Tumor Board and began to have second thoughts about the diagnosis.  According to the general pathologist, he “mentally” amended the diagnosis at that time to being “suspicious of cancer”.  The general pathologist stressed that he discussed the case with the patient’s clinician and also sent it to the Mayo Clinic for a second opinion.  He explained that complex sclerosing lesions are very difficult to evaluate and are subject to misdiagnosis.  The general pathologist testified that when he received the pathology report from the Mayo Clinic on 5/20/2014, he authored a correction to his original report, amending the diagnosis to complex sclerosing lesion with unusual ductal hyperplasia and microcalcifications.

The general pathologist further testified at a hearing that the HER2 test and FISH analysis were requested by the patient’s clinician and were obtained due to that request.

The general pathologist emphasized that he learned from his error in this case and now requests additional immunostains and/or second opinions in these types of cases.

Another pathologist reviewed the case and while agreeing that the general pathologist reached an incorrect diagnosis at the outset, disagreed with the senior pathologist’s determinations that the misdiagnosis and use of stains demonstrated any lack of professional knowledge or a deviation from the standard of care from the general pathologist’s part.  He opined that this type of lesion can be difficult to evaluate, especially when the general pathologist has only a small amount of tissue provided by a needle core biopsy as opposed to a completely excised lesion.  The reviewing pathologist also emphasized that, while the senior pathologist opined the general pathologist ordered unnecessary stains, the pathologists at Mayo Clinic ordered additional stains when they re-read the slides involved.

The other reviewing pathologist offered his opinion that the general pathologist did not display professional incompetence or any behavior harmful or detrimental to the public in his review of the patient’s case.

For this allegation and others, the Board judged the general pathologist’s conduct to be below the minimum standard of competence given (his/her) lack of professional competency and practice that was harmful or detrimental to the public.  The general pathologist was warned that such practice in the future may result in further disciplinary action against his medical license.

For this allegation and others, the Board ordered the general pathologist to arrange in the auditing of 5% of his cases by outside pathology laboratory approved by the Board and ensure that the auditing entity submits a report to the Board on a quarterly basis.  He was also ordered to obtain consultation with a board-certified dermatopathologist in all suspected melanoma cases and author a paper discussing the diagnostic criteria for well-differentiated squamous cell carcinoma and keratoacanthoma in vulvar tissue.

State: Iowa


Date: June 2017


Specialty: Pathology


Symptom: N/A


Diagnosis: Dermatological Issues


Medical Error: Diagnostic error, Unnecessary or excessive treatment or surgery


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



Florida – Physician Assistant – Cardiac Catheterization Ordered In The Wrong Patient



On 10/11/2015, Patient A, an 89-year-old male presented to the emergency department with complaints of chest congestion, weakness, and chest pressure.

Lab results revealed that Patient A had elevated troponin levels, and he was admitted and referred for a cardiology consultation.

On 10/11/2015, the patient saw a cardiologist for the cardiology consultation.  The cardiologist documented that the patient had an upper respiratory infection and recommended that the patient continue antibiotics, gentle diuresis, and outpatient medical therapy.

At around the same time, on the same date, the cardiologist saw Patient B for a cardiology consultation.  Sometime after the cardiac consultations of Patient A and Patient B, the cardiologist contacted a physician assistant and instructed him to order a cardiac catheterization for Patient B.

The physician assistant placed an entry in Patient A’s medical chart instead of Patient B’s chart, ordering the cardiac catheterization.  The physician assistant failed to review Patient A’s available medical records, including labs, notes, and imaging studies, before placing the cardiac catheterization order in his chart.

The following morning, cardiac catheterization was unnecessarily performed on Patient A.

The Board judged the physician assistant’s conduct to be below the minimal standard of competence given that he failed to review the patient’s available medical records, including labs, notes, and images studies, before placing the cardiac catheterization order in his chart.

The Board issued a letter of concern against the physician assistant’s license.  The Board ordered that the physician assistant pay a fine of $2,000 against his license and pay reimbursement costs for the case at a minimum of $2,611.86 and not to exceed $3,111.86.  The Board also ordered that the physician assistant complete five hours of continuing medical education in “risk management.”

State: Florida


Date: June 2017


Specialty: Physician Assistant, Cardiology


Symptom: Weakness/Fatigue


Diagnosis: Infectious Disease


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


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



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