Found 61 Results Sorted by Case Date
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Florida – General Surgery – Right Colectomy Of The Patient’s Ascending Colon Instead Of A Left Colectomy Of The Descending Colon



A 49-year-old female presented to a general surgeon for a colonoscopy.  During the colonoscopy the general surgeon documented a 25mm polyp in the patient’s descending colon.  Due to its size, the general surgeon was only able to partially resect the polyp.  He placed a hemostatic clip to prevent bleeding and tattooed the area.

The patient was subsequently referred to the general surgeon for surgical resection of the left colon.

On 7/15/2015, the patient presented to the general surgeon for a preoperative history and physical.  On 7/15/2015, the general surgeon documented that a doctor incompletely resected a polyp in the patient’s colon, and identified the planned procedure as a right colectomy.

On 7/20/2016, the patient presented to the general surgeon at a community hospital.  On 7/20/2016, the general surgeon performed a right colectomy of the patient’s ascending colon.

The Board judged that the general surgeon’s conduct to be below the minimum standard of competence given that he performed a wrong-site procedure when he performed a right colectomy of the patient’s ascending colon instead of a left colectomy of her descending colon.

The Board ordered the general surgeon to pay a fine of $4,015.23.  The general surgeon was ordered to complete five hours of continuing medical education in “Risk Management.”  Also, the Board ordered that the general surgeon present a one hour lecture/seminar on wrong site and/or wrong procedures to medical staff at an approved medical facility.

State: Florida


Date: December 2017


Specialty: General Surgery


Symptom: N/A


Diagnosis: Gastrointestinal Disease


Medical Error: Wrong site procedure


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Orthopedic Surgery – Documentation Error Of Laceration Of Flexor Pollicis Longus Leads To Wrong Site Surgery



On 5/16/2014, a patient presented to an orthopedic outpatient surgery center with a left-hand work-related injury.  During the visit, an orthopedic surgeon properly diagnosed the patient with a flexor pollicis longus (FPL) tendon laceration of her left thumb.

The FPL tendon laceration was confirmed by the MRI scan performed on the patient on 7/3/2014.

On 8/7/2014, during the follow-up visit, the orthopedic surgeon wrongly documented the patient’s injury as an extensor pollicis longus (EPL) tendon laceration in the patient’s medical records

Consequently, on 9/10/2014, the patient presented to the orthopedic surgeon at the center, for an EPL tendon surgery (the wrong site, and/or medically unnecessary procedure) of her left thumb.  During the EPL tendon surgery, the orthopedic surgeon realized that the FPL tendon laceration repair should have been performed on the patient instead.  On 10/10/2014, the orthopedic surgeon performed the FPL tendon laceration repair on the patient’s left thumb.

The Board ordered the orthopedic surgeon pay a fine of $3,000 to the Board. Also, the Board ordered the orthopedic surgeon pay a reimbursement cost of $4,670.40.  The Board ordered that the orthopedic surgeon complete five hours of continuing medical education in “Risk Management.”  The Board ordered that the orthopedic surgeon complete one hour of lecture on wrong site procedure.

State: Florida


Date: December 2017


Specialty: Orthopedic Surgery


Symptom: N/A


Diagnosis: Musculoskeletal Disease, Trauma Injury


Medical Error: Wrong site procedure, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Anesthesiology – Wrong Site Procedure For A Transforaminal Epidural Steroid Injection



On 4/28/2015 an 80-year-old female, presented to an anesthesiologist for an initial consultation for possible epidural steroid injections.  On 4/28/2015, the patient had a history of left sided lower back pain and left lower extremity pain.

On 4/28/2015, the anesthesiologist scheduled the patient for a left transforaminal epidural steroid injection (TFESI) to be performed on 4/29/2015.

On 4/29/2015, the patient presented to the anesthesiologist at outpatient surgery and laser center for the planned left TFESI.  On 4/29/2015, the patient and anesthesiologist signed a consent form for a left TFESI.  After the patient was prepped for the procedure, the anesthesiologist performed a TFESI on the patient’s right side (the wrong site).  While the patient was still in the procedure room, the anesthesiologist was informed that he performed the TFESI on the incorrect side.  The anesthesiologist then performed a TFESI on the patient’s left side (the correct site).

The anesthesiologist’s procedure report on 4/29/2015 procedures did not accurately document the anesthesiologist’s performance of TFESI procedures on two different sides of the patient.

The Board ordered the anesthesiologist to pay a fine of $5,000 against his license.  Also, the Board ordered that the anesthesiologist pay reimbursement costs of $5,857.63.  The Board ordered that the anesthesiologist complete a medical records course.  The Board ordered that the anesthesiologist complete five hours of continuing medical education on “Risk Management.”  Also, the Board ordered the anesthesiologist to complete a one hour lecture on wrong site surgeries to medical staff at an approved site.

State: Florida


Date: December 2017


Specialty: Anesthesiology, Neurology


Symptom: Pain


Diagnosis: Spinal Injury Or Disorder


Medical Error: Wrong site procedure, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Neurosurgery – Wrong Site Procedure When Performing Surgery On A Subdural Hematoma



On 11/6/2016, a 61-year-old female presented to the emergency department, suffering from confusion and weakness after a fall.  A CT scan revealed that the patient had a large, left-sided subdural hematoma.

That same day, a neurosurgeon was asked to evaluate the patient.  The neurosurgeon correctly documented that the patient was suffering from a left-sided subdural hematoma.  The neurosurgeon further documented his intention to remove a blood clot from the left side of the patient’s subdural space.

Shortly thereafter, the patient was brought to the operating room and preparations were begun for a left-sided craniotomy.  However, at some point during the preparation process, the patient’s head was turned and the neurosurgeon began to operate on the right side.

After the neurosurgeon made an incision through the skin, he removed a bone flap and punctured the dura mater on the right side of the patient’s brain.  The neurosurgeon realized that he was operating on the incorrect side.  The neurosurgeon closed the operating site and proceeded to perform the correct procedure.

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


Specialty: Neurosurgery


Symptom: Confusion, Weakness/Fatigue


Diagnosis: Intracranial Hemorrhage, Trauma Injury


Medical Error: Wrong site procedure


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Neurosurgery – Cervical Microdiscectomy At Levels C5/7 And C6/7 Instead Of Levels C4/5 And C5/6



On 11/17/2014, a patient presented to a neurosurgeon for an anterior cervical microdiscectomy for decompression with allograft fusion at cervical levels C4/5 and C5/6.  During the procedure, it was discovered that the initial localization x-ray was misinterpreted and that the neurosurgeon performed the fusion at cervical levels C5/7 and C6/7 instead of cervical levels C4/5 and C5/6.  After the neurosurgeon discovered the error, he proceeded to perform the fusion at the correct cervical levels, C4/5 and C5/6.

The Board judged the neurosurgeons conduct to be below the minimum standard of competence given that he performed the procedure on the wrong site.

The Board ordered that the neurosurgeon pay a fine of $5,000 against his license and pay reimbursement costs of a minimum of $1,859.22 but not to exceed $3,859.22.  The Board also ordered that the neurosurgeon complete five hours of continuing medical education in “Risk Management” and complete a one hour lecture/seminar on wrong site surgeries.

State: Florida


Date: November 2017


Specialty: Neurosurgery


Symptom: N/A


Diagnosis: Spinal Injury Or Disorder


Medical Error: Wrong site procedure


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Vascular Surgery – Arteriogram Performed On A Patient’s Right Leg Instead Of The Left Leg



On 8/15/2016, a patient presented to a vascular surgeon with peripheral vascular disease, a non-healing ulcer on his left third toe tip, and diminished arterial blood flow in both legs.

Based on his initial evaluation, the vascular surgeon determined that a left leg arteriogram was necessary.

On 8/18/2016, the patient’s family consented to a left leg arteriogram and the vascular surgeon pre-operatively marked the patient’s left and correctly performed a timeout.

After the vascular surgeon performed the timeout, he performed a right leg arteriogram instead of the planned left leg arteriogram.

The Board judged the vascular surgeon’s conduct to be below the minimal standard of competence given that he performed a wrong-site procedure by performing an arteriogram on the patient’s right leg (wrong site) instead of the patient’s left leg (correct site).

It was requested that the Board order one or more of the following penalties for the vascular surgeon: 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: Vascular Surgery


Symptom: N/A


Diagnosis: Cardiovascular Disease


Medical Error: Wrong site procedure


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Neurosurgery – Laminectomy Performed On The Patient’s L3-L4 Level Instead of L4-L5 Level



In March 2016, a 72-year-old male sought treatment from a neurosurgeon for low back pain.  The neurosurgeon diagnosed the patient with lumbar spondylosis and lumbar spinal stenosis.

Informed consent was obtained from the patient for an L4-L5 laminoforaminotomy for the decompression of the spinal cord and partial medial facetectomy.

On 3/23/2016, the neurosurgeon performed a laminectomy at the patient’s L3-L4 level (wrong site) rather than at the L4-L5 level (correct site).

Approximately three months after the surgery, the patient saw his primary care physician because his back pain had returned.  The patient’s primary care physician obtained an MRI on 7/6/2016.  The MRI results revealed spinal stenosis at the patient’s L4-L5 level and post-operative changes at the L3-L4 level.

After reviewing the patient’s post-surgery MRI, the neurosurgeon realized that she performed the procedure at the L3-L4 level.

It was requested that the Board order one or more of the following penalties for the neurosurgeon: 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: Neurosurgery, Orthopedic Surgery


Symptom: Back Pain


Diagnosis: Spinal Injury Or Disorder


Medical Error: Wrong site procedure


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Anesthesiology – Multiple Procedural Errors While Performing Cervical Epidural Steroid Injections



On 4/6/2016, a 69-year-old female with a prior history significant for pulmonary tuberculosis, essential hypertension, paroxysmal supraventricular tachycardia, osteoporosis, menopause, hypothyroidism, arthritis, chronic asthmatic bronchitis, and a former smoker, presented to a medical clinic.

An anesthesiologist initially diagnosed the patient with cervicalgia and cervical radiculopathy due to degenerative chronic cervical spondylosis.  The patient was also hearing and speech impaired and used an interpreter and tablet for communication during all preoperative meetings.

The patient presented to the anesthesiologist in the surgery room for a signed consent of cervical transforaminal epidural steroid injection at right C4 and C5.  The anesthesiologist instead performed a cervical epidural steroid injection (“CESI”) above C6-C7 without obtaining consent from the patient.

The anesthesiologist failed to have an interpreter in the surgery room during the patient’s evaluation and treatment so that he could effectively communicate with her.

The patient was positioned in the prone position on the table and the anesthesiologist administered Versed 2 mg IV and Fentanyl 100 mcg for IV conscious sedation.

The anesthesiologist failed to administer local anesthesia to numb the patient’s skin, while she was awake and alert, prior to injecting the first epidural steroid injection at C5-C6.  The patient, unaware that she was receiving an injection and unable to clearly communicate her discomfort, responded to the initial puncture to her skin by a sudden jumping movement.

The anesthesiologist withdrew the needle and targeted lower interspace, C7-T1, using fluoroscopy.  He used a seventeen gauge Tuohy needle under intermittent fluoroscopic guidance for entry into the epidural space at C7-T1 for the second attempt to perform the CESI.  The anesthesiologist then injected the medication between C4 and C5 neural foramen.

The anesthesiologist documented one or more times prior to the 4/6/2016 procedure that he was performing a TFESI on the right at C4 and C5;  however, he instead performed a cervical interlaminar epidural steroid injection (“ILESI”) at C5-C6, and additionally at C7-T1, without obtaining consent from the patient.  He inappropriately elected to perform a CESI above C6-C7.  The anesthesiologist did not create or maintain fluoroscopic images of his initial attempt to inject at C5-C6.

After the procedure, the patient was taken to the recovery room, where an interpreter and tablet was present for communication.  The patient was no longer able to move her arm to communicate using the tablet and she experienced right upper extremity weakness and some right sided facial numbness.

The patient was transferred out of the medical center as a “Stroke alert” to a hospital, where she received a CAT or MRI scan, and again transferred to another hospital which did not have a neurosurgeon on staff.

After the CESI, the patient was diagnosed with iatrogenic cervical nerve root injury.

It was requested that the Board order one or more of the following penalties for the anesthesiologist: 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: Anesthesiology


Symptom: Weakness/Fatigue, Numbness


Diagnosis: Spinal Injury Or Disorder, Post-operative/Operative Complication


Medical Error: Wrong site procedure, Ethics violation, Failure of communication with patient or patient relations, Procedural error


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Urology – Stent Placed For Kidney Stone Placed In Wrong Ureter



On 7/16/2016, a 50-year-old male presented to the medical center emergency department with abdominal pain.

The patient was diagnosed with renal kidney stones and admitted to the hospital.

The patient was taken to the operating room for a planned cystoscopy, right ureteroscopy, and placement of right ureteral stent.

Informed consent was obtained from the patient for the placement of the right ureteral stent.

On 7/20/2016, a urologist placed a stent in the patient’s left ureter (wrong site), rather than the right ureter (correct site).  The patient was then discharged home.

On 7/25/2016, the patient returned to the hospital with complaints of abdominal pain.

A CT scan of the patient’s abdomen and pelvis revealed right distal ureteral stones with moderate right hydronephrosis.  The CT scan also revealed a left ureteral without left hydronephrosis.

On 7/26/2016, the patient was informed by the Chief Medical Officer of the hospital that the surgery was performed on the wrong side.

On 7/26/2016, the patient underwent a second procedure to remove the foreign body (left stent) and right ureteroscopy with laser lithotripsy and placement of right ureteral stent.

The second surgery was performed without incident and the patient was discharged home on 7/27/2016.

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: August 2017


Specialty: Urology


Symptom: Abdominal Pain


Diagnosis: Renal Disease


Medical Error: Wrong site procedure


Significant Outcome: Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Neurosurgery – Laminotomy And Foraminotomy Performed At One Level Lower Than Intended



On 12/9/2015, a patient presented to a neurosurgeon at the Laser Spine Institute with complaints of lower back pain and bilateral lower leg pain.

The neurosurgeon reviewed a previous MRI result for the patient which indicated that the patient had a lumbarized sacrum, foraminal stenosis at L5-S1 bilaterally, and L4-5 facet hypertrophy.

The neurosurgeon also reviewed previous nerve root block results, which indicated 20% relief at L5 and 80% relief when performed at L4-5.

The neurosurgeon recommended that the patient undergo a right laminotomy and foraminotomy at the L4-5 level.

On 12/11/2015, the patient returned for the recommended procedure.  The neurosurgeon performed a right laminotomy and foraminotomy on the patient at what he thought was the L4-5 previously identified at the 12/9/2015 visit.

The neurosurgeon relied on intraoperative imaging to find the operative level.

Due to the patient’s vertebral anatomy, on 12/11/2015, the neurosurgeon actually performed the procedure one level below the level he previously identified on the 12/9/2015 visit.  The level the neurosurgeon performed the procedure was the incorrect site and was not the site the neurosurgeon identified as the operative level at the 12/9/2015 visit.

On 2/24/2016, the neurosurgeon performed a second right laminotomy and foraminotomy on the patient, this time at the correct site, which was one level above the surgery he performed on 12/11/2015, and the same level he identified at the 12/9/2015 visit.

It was requested that the Board order one or more of the following penalties for the neurosurgeon: 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: Neurosurgery, Orthopedic Surgery


Symptom: Back Pain, Extremity Pain


Diagnosis: Spinal Injury Or Disorder


Medical Error: Wrong site procedure


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



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