Found 128 Results Sorted by Case Date
Page 13 of 13

Wisconsin – Emergency Medicine – Pediatric Patient With Fever, Cough, And Shortness Of Breath



At 2:41 p.m. on 5/12/02, a 4-year-old female with a cough and fever was taken by her parents to the emergency department.  The patient’s parents reported to the ED physician that the patient had had a cold with a runny nose for the preceding 10 days, but had developed a cough the day prior to the emergency department visit and a fever of 103 F on the morning of the emergency department visit.  The ED physician examined the patient and recorded a heart rate of 160, respirations of 24, and a temperature of 102.1 F.  The ED physician’s physical examination of the patient’s ears, eyes, neck and abdomen were essentially within normal limits.  The patient’s lungs were clear to auscultation, bilaterally, her oxygen saturation was normal and she did not appear to have any difficulty breathing.  The patient did not appear to be in any acute distress at the time.  The ED physician made a diagnosis of bronchiolitis/croup and discharged the patient from the emergency department to return home.  The ED physician recommended to the patient’s parents that the patient return to the emergency department if her condition became worse.

At 9:10 p.m. on 5/12/02, the patient’s mother contacted the emergency department by telephone and requested to talk with the ED physician.  The ED physician returned the call and the patient’s mother reported that for the preceding hour the patient had been coughing and had been experiencing some trouble breathing.  The patient’s mother reported that the patient was better when she was sitting in an upright position.  The ED physician was of the opinion that the patient’s symptoms did not warrant another trip to the emergency department at that time.  The ED physician recommended that the parents keep the patient in a sitting position and call back in 30 minutes if the patient continued to have problems.  The ED physician did not advise the parents at that time to return the patient to the emergency department for further evaluation and treatment.

The patient’s parents did not contact the ED physician after 30 minutes following the termination of their telephone conversation, but later that evening the patient developed extreme respiratory distress followed by respiratory arrest.  The patient’s parents contacted 911 at 10:47 p.m., the patient was administered CPR and was transported to the emergency department.  When the patient arrived at the emergency department at 11:08 p.m., the patient was in respiratory and cardiac arrest.  The ED physician attended to the patient in the emergency department but efforts to resuscitate the patient were unsuccessful.  The autopsy disclosed the presence of Haemophilus influenzae sepsis.

The Board judged the ED physician’s conduct to be below the minimum standard of competence given his failure to recommend to the patient’s parents during the telephone call at 9:10 p.m. on 5/12/02 that the patient be returned to the emergency department immediately for further evaluation and treatment.

The ED physician’s conduct created the unacceptable risks that the patient’s medical condition, including the patient’s respiratory status, would continue to worsen and that appropriate treatment would be delayed or denied.  A minimally competent physician, to avoid or minimize the unacceptable risks to the patient, would have recommended that the patient’s parents immediately transport the patient to the emergency department for further evaluation and treatment.

The Board ordered that the ED physician pay the costs of the proceeding and complete 12 hours of continuing education in pediatric respiratory infections and emergencies.

State: Wisconsin


Date: December 2006


Specialty: Emergency Medicine, Pediatrics


Symptom: Fever, Cough, Shortness of Breath


Diagnosis: Sepsis


Medical Error: Delay in proper treatment, Diagnostic error


Significant Outcome: Death, Hospital Bounce Back


Case Rating: 4


Link to Original Case File: Download PDF



Virginia – Obstetrics – 37 Weeks With Proteinuria, Hypertension, And Edema



On 1/10/2002, a 25-year-old female at thirty-seven weeks gestation presented to an obstetrician with a blood pressure of 145/85, proteinuria 4+, edema 1+ in hands and legs, and fetal heart rate of 174.

The obstetrician sent the patient home for bed rest and ordered lab work.

On 1/14/2002, the patient presented with no detectable fetal heart tones and was admitted to the hospital for labor and delivery of a stillborn infant.

The obstetrician reported that he changed his evaluation and management of patients by adopting a more proactive approach that includes hospitalization of patients who demonstrate signs of preeclampsia.

The Board issued a reprimand.

State: Virginia


Date: September 2006


Specialty: Obstetrics


Symptom: Swelling


Diagnosis: Preeclampsia


Medical Error: Delay in proper treatment


Significant Outcome: Death, Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



Wisconsin – Emergency Medicine – Cysts In The Perirectal Area



At approximately 4:00 p.m. on 11/14/1998, an obese 41-year-old man presented to the emergency department complaining of pain.  He was first seen by an RN:

1) The patient stated he had a cyst in the right groin area about 3” by 7” in size. He said he first noticed it about 3 days earlier.  He also said he had the same thing 6 years ago, which was treated with medication.

2) The patient said he had taken aspirin for the pain and he was not eating.

3) The RN took the patient’s vital signs and recorded his temperature as 99.5°, his blood pressure as 124/81, his pulse as 107, and his respirations as 16.

4) When asked by the RN to assess his pain on a scale of 0-10, the patient said “12.”

5) The patient was then seen by the ED physician in the emergency department.

The ED physician noted that the patient reported the following:

1) Complaints of a cyst localized to the right perirectal area, which had been present for three or four days.

2) Pain then localized to the rectal area.

3) A similar appearing lesion present a few years earlier which was resolved by treatment with oral antibiotics.

4) Decreased appetite and energy, fevers and chills.

The ED physician recorded that the patient was in no acute distress and noted the results of his examination as: “[E]xam of the perirectal area reveals there is a hard well encapsulated non-mobile markedly tender erythematous lesion noted right at the perirectal area.  The raised area measures approximately around 4 cm in diameter.  Skin is intact.  No areas of drainage.”  The ED physician recorded his assessment of the patient’s condition as a perirectal cyst.  Although not recorded, the ED physician recognized that the lesion was infected.

The ED physician then conducted the following:

1) Gave the patient a prescription for 20 units of Cipro 500 mg, to be taken one tablet twice a day for 10 days.

2) Gave the patient a prescription for 12 units of Tylenol #3, to be taken 1 tablet every 4-6 hours as needed.

3) Provided the patient with an intramuscular injection of 60 mg Toradol.

4) Instructed the patient to soak in baths with Epsom Salt.

5) Instructed the patient to follow up with his primary care practitioner for a possible incision and drainage, if symptoms did not improve in three or four days.

6) Discharged the patient from the emergency department.

The ED physician’s conduct in providing care to the patient fell below the minimal level of competence for a physician in that the ED physician:

1) Failed to order a complete blood count (CBC), which would have provided him with additional information about the seriousness of the infection.

2) Failed to recognize the lesion as an abscess based on the symptoms.

3) Failed to perform a needle aspiration or incision and drainage to determine if fluid was present, which would rule out cellulitis and confirm the condition as an abscess.

4) Failed to perform, or seek a consultation so another physician could perform, an incision and drainage of the abscess to remove the infected fluid.

The ED physician’s failures subjected the patient to the additional risks of harm that the infection would become worse, involve more tissue, and become septicemia.

At approximately 9:30 p.m. the next day, the patient returned to the emergency department and was seen by the same RN and a different physician.  The patient reported the following:

1) His pain on a scale of 0-10, as “13.”

2) Progressive pain and swelling in the area of the perineum since the previous visit.

3) Marked pain and swelling in the scrotum.

4) Some discomfort in both inguinal areas and in the suprapubic area.

5) Intermittent diaphoresis.

6) Intermittent chills and fever in the 101 to 104 range.

7) Nausea and vomiting several times.

The physician reported his exam of the area as: “The scrotum is markedly swollen to the point where it is very tense.  The scrotal skin is erythematous, somewhat edematous, indurated and markedly tender to palpation. The perineal area shows marked induration and tenderness without obvious drainage fluctuance, or crepitance.”  Laboratory results: White blood cell count of 24.5 with 78 segs, 6 bands. Hct of 46.9. Glucose 123. BUN 15. Creatinine 1.2. Sodium 134. Potassium 3.6. Chloride 99. AST 13. Alkaline phosphatase 89. Bilirubin 2.4.

The patient was immediately transferred to another hospital for evaluation and treatment.  The patient was taken to the operating room for incision and drainage of the abscess and removal of necrotic tissue.  It was then discovered that the entire perineal area was involved and the patient was diagnosed with Fournier’s gangrene, subsequently resulting in the loss of his right testicle.

The Board ordered that the ED physician pay the costs of the proceeding, be reprimanded, and complete 12 hours of continuing education in the assessment, diagnosis, and treatment of infectious processes or other conditions in the perirectal or perineal areas.

State: Wisconsin


Date: September 2006


Specialty: Emergency Medicine, Internal Medicine


Symptom: Pelvic/Groin Pain, Fever, Nausea Or Vomiting


Diagnosis: Necrotizing Fasciitis


Medical Error: Diagnostic error


Significant Outcome: Permanent Loss Of Functional Status Or Organ, Hospital Bounce Back


Case Rating: 4


Link to Original Case File: Download PDF



Wisconsin – Emergency Medicine – Fever, Elevated WBC, And Abdominal Pain Diagnosed As Possible Mittelschmerz



On 7/8/1999, a 13-year-old patient presented to an urgent care clinic at a hospital complaining of back pain, right lower quadrant abdominal pain, and with a fever of 101 degrees.  The patient was five feet tall and weighed 265 pounds.  The nurse’s examination notes state that the patient’s abdomen was round and firm, and that it was soft.  A family practitioner assessed the patient’s abdomen as soft with positive bowel sounds and lower right quadrant tenderness.  The family practitioner noted in the patient’s chart that her pulse rate was 120 per minute, and that her respirations were 32 per minute.

The family practitioner ordered laboratory analysis of a blood sample.  In his documentation, the family practitioner stated “[w]hite count is bizarre with a 5700 white count, 24 neutrophils, 32 bands.  Reactive lymphs are increased.”  The family practitioner ordered two radiographs, a flat plate, and an upright, which he read as “basically unremarkable”.  Three radiographs were taken of the patient. The family practitioner did not learn that the third x-ray film had been taken until sometime after that day.

The x-ray films taken of the patient were read the next day by a radiologist, who noted free air in the abdomen.  The radiologist noted the following in his report: “Impression: Findings consistent with free air under both diaphragms with several associated slightly distended loops of small bowel.  These findings were called immediately to the Treatment Center and discussed with [a physician].”

The family practitioner prescribed Toradol 60 mg IM, for pain, and assessed the patient’s condition as “Probable Mittelschmerz.”  Mittelschmerz is a condition of pain on ovulation; it lasts approximately six to eight hours, and is not accompanied by any notable fever, or by rapid pulse or respirations, or an increase in immature white blood cells in circulation.  The patient’s temperature, band count, pulse rate, and respiration rate were all significantly elevated.  An internal pelvic examination, pelvic ultrasound, or CAT scan was not performed when the patient presented at urgent care.

Prior to releasing the patient to go home, the family practitioner consulted with a surgeon regarding the patient’s symptoms and health status.  The family practitioner did not determine that the patient had free air in her abdomen and, therefore, did not inform the surgeon of its presence.  The family practitioner did not ask surgeon to come to the hospital to examine the patient, or to come to the hospital to examine the radiographs of the patient.  A minimally competent family practice physician would call a surgeon to the hospital to examine the patient and keep the patient in the hospital under close observation when free air is observed in an abdominal radiograph.

The family practitioner released the patient to go home with her mother, with instructions to contact the surgeon if her condition got worse overnight; finish taking her Macrobid; to consume “clear liquids tonight only”; to return to the clinic the following morning to undergo another complete blood count (CBC), and, if not better, to see the surgeon the following day.  The family practitioner also prescribed Naprosyn 500 bid for pain.

The family practitioner’s decision to send the patient home with a diagnosis of Mittelschmerz exposed her to the grave risk of an untreated surgical emergency, when the minimally competent physician would have begun prompt medical intervention and preparations for surgery.

The family practitioner noted the following in the patient’s chart:

SUBJECTIVE: This is a 13-year-old white female, very heavy 265 pounds with temperature 101 today.  Seen and put on Microbid and Pyridium Saturday for UTI.  Continues to have back pain and fever, right lower quadrant pain today, mucousy stool, usually is soft, a little harder today.

OBJECTIVE: Temperature 101, went down with Tylenol.  Pulse 120, respiratory rate 32.  Head: Normocephalic, atraumatic.  Eyes: PERRLA.  Tympanic membranes intact. Abdomen is soft.  Positive bowel sounds.  Right lower quadrant tenderness. She is two weeks post-period.  White count is bizarre with a 5700 white count, 24 neutrophils, 32 bands.  Reactive lymphs are increased.  Flat plate and upright are basically unremarkable.

ASSESSMENT: Probable mittelschmerz. She got excellent relief with Toradol in the treatment center and was able to hold down some Sprite.

PLAN: Naprosyn 500 bid, finish her Macrobid.  Clear liquids tonight only.  If any worsening tomorrow, mom is a nurse on 2 South, she will see [the surgeon] in the morning. I discussed the case with him and he said to watch it tonight and he will deal with it tomorrow if there is any increase in pain.

While at home, the patient vomited throughout the night and aspirated.  She was brought to the urgent care clinic the next morning, with cold and mottled skin, shallow panting respirations, and mental confusion.  She required resuscitation in the urgent care, and was taken directly to the operating room. The surgeon’s impression was: “septic shock, probably due to perforated viscus”.

The operation disclosed a tubo-ovarian abscess with large quantities of pus in the intraperitoneal cavity. The patient suffered two cardiac arrests during the operation, from which she was resuscitated, and two episodes of bradycardia, with resuscitation. She was taken to the intensive care unit with adult respiratory distress syndrome, renal failure, hemodynamic instability, and died early the next morning from cardiac arrest with ventricular fibrillation that could not be corrected.

The patient’s discharge summary report dictated after the operation stated the following regarding the patient’s diagnosis: Preoperative diagnosis: ABD Pain.  Final Diagnosis: 1) marked chronic salpingitis with fibrosis; 2) ovarian abscesses with acute fibrinopurulent peritonitis change.

The Board ordered the family practitioner pay the costs of the proceeding, be reprimanded, and complete 24 hours of continuing education in abdominal diagnosis, evaluation and management, including pediatric or adolescent patients.

State: Wisconsin


Date: August 2005


Specialty: Emergency Medicine, Family Medicine, Gynecology, Internal Medicine, Pediatrics


Symptom: Fever, Nausea Or Vomiting, Abdominal Pain, Back Pain


Diagnosis: Acute Abdomen, Sepsis


Medical Error: Diagnostic error


Significant Outcome: Death, Hospital Bounce Back


Case Rating: 5


Link to Original Case File: Download PDF



Wisconsin – Emergency Medicine – Swollen And Red Scrotal Area With Diagnosis Chicken Pox 3 Days Previously In Pediatric Patient



A 7-year-old patient presented to the emergency department on 4/21/2000 with pain in his left leg, a swollen scrotal area, and redness in the scrotal area and left inner thigh.  The patient had been diagnosed with chickenpox 3 days previously.  The ED physician examined the patient.  Laboratory studies demonstrated a high white blood count.  A testicular ultrasound revealed blood flow to the testicles but a significant amount of surrounding fluid typical of a hydrocele.  The examination also disclosed a thickened scrotal wall consistent with an inflammatory process.  The ED physician diagnosed a swollen scrotum secondary to chickenpox.  The ED physician discharged the patient from the emergency department with recommendations to apply ice to the scrotum, administered Tylenol for pain, and follow up with the patient’s regular physician on 4/24/2000.

The patient returned to the emergency department on 4/23/2000 with increased scrotal swelling and increased redness into the abdominal area and inner thighs, bilaterally, bubbles on the scrotum, a swollen penis, and increased pain.  The ED physician examined the patient and diagnosed cellulitis and a bacterial infection secondary to the chicken pox.  The ED physician had the patient transferred to Children’s Hospital where the patient was diagnosed with necrotizing fasciitis secondary to Group A strep, a complication of chickenpox.  The complaint alleged that the ED physician failed to appropriately evaluate, diagnose, and treat a developing infection when he examined the patient in the emergency department on 4/21/2000.

The ED physician has since retired from the practice of medicine and surgery.  The Board ordered that the ED physician surrender his current registration and license to practice medicine and surgery and not reapply for a license.

State: Wisconsin


Date: July 2005


Specialty: Emergency Medicine, Pediatrics


Symptom: Extremity Pain, Swelling


Diagnosis: Necrotizing Fasciitis


Medical Error: Diagnostic error


Significant Outcome: Hospital Bounce Back


Case Rating: 4


Link to Original Case File: Download PDF



Wisconsin – Emergency Medicine – Urinary Retention After Exploratory Laparoscopy During Which A Right Ovarian Cyst Was Drained And Biopsied



In December 1998, a 40-year-old female presented with complaints of menometrorrhagia and was diagnosed with a right adnexal mass.

On 12/10/1998, the patient underwent an outpatient dilation and curettage (D and C) and an exploratory laparoscopy during which a cyst on the right ovary was drained and biopsied.

On 12/11/1998, at 12:05 a.m., the patient presented to the emergency department with complaints of abdominal pain.  Vital signs on admission were a temperature of 97.8, a pulse of 88, respirations of 22, and blood pressure of 130/70.  She had a recent history of the outpatient D and C and exploratory laparoscopy and not urinating since the procedure until vomiting induced urination.

An ED physician examined the patient at 12:25 a.m. and ordered placement of a Foley catheter which returned clear urine with no relief of pain.  At 12:35 a.m., the ED physician ordered pain medications with IV normal saline.  Administration occurred at 12:47 a.m. and shortly thereafter the patient reported the pain was gone, and she was sleepy.  At 2:30 a.m., the ED physician discharged the patient.  The ED physician performed no diagnostic testing, including CT and radiographs, to determine the cause of the patient’s symptoms during the course of admission.  The ED physician did not notify the physician who performed the surgery on the previous day of the patient’s subsequent admission to the emergency department with complaints of pain in the area of the previous surgery.

On 12/11/1998, the patient returned to the hospital at 6:00 p.m. with complaints of severe abdominal pain.  Examination revealed diffuse tenderness on percussion with involuntary guarding.  Exploratory surgery revealed diffuse peritonitis and a small ileal enterotomy.  Segmental small bowel resection was performed and the patient developed respiratory failure, renal insufficiency, and clinical indicators of sepsis.  The patient eventually fully recovered.

The Board judged the ED physician’s conduct to be below the minimum standard of competence given failure to properly evaluate a recent post-surgical patient with complaints of abdominal pain, including the failure to perform appropriate diagnostic testing, and the ED physician’s failure to notify the physician who performed the surgical procedure on the previous day.

The Board ordered that the ED Physician pay the costs of the proceeding, be reprimanded, and complete 12 hours of continuing education in the evaluation and treatment of abdominal pain, with an emphasis on post-surgical presentations.

State: Wisconsin


Date: May 2005


Specialty: Emergency Medicine


Symptom: Abdominal Pain, Urinary Problems


Diagnosis: Procedural Site Infection


Medical Error: Failure to order appropriate diagnostic test, Failure to examine or evaluate patient properly, Failure of communication with other providers


Significant Outcome: Hospital Bounce Back


Case Rating: 4


Link to Original Case File: Download PDF



California – Family Practice – Home Visit Evaluation Of Stomach Cramps, Nausea, Vomiting, And Diarrhea Diagnosed As Pulled Muscle



On 12/26/1997, a patient became ill with stomach cramps, nausea, and subsequent abdominal pain, vomiting, and diarrhea.  On 12/30/1997, the family practitioner went to see the patient at her home.  In his examination of the patient, the family practitioner pressed on the patient’s stomach and took a urine sample.  The family practitioner told the patient that there was no blood in her urine.  He also told the patient that her pain was caused by a muscle pulled during coughing.

In the patient’s chart note for that visit, there was no indication that the family practitioner took the patient’s temperature or that he performed a history and physical.  The chart note indicates that the patient had abdominal muscle pain with acute gastroenteritis.

On 1/1/1998, the patient presented to an emergency department.  The record prepared by the emergency department physician indicated that the patient presented with complaints of abdominal cramps, nausea, vomiting, and diarrhea for the prior three days.  The ED physician’s assessment of the patient indicated abdominal pain etiology to be determined, questionable early appendicitis versus other intra-abdominal pathology, dehydration, electrolyte imbalance, hyponatremia, and hypokalemia.  In the records, the ED physician further noted that the family practitioner was aware of the patient’s condition, and the ED physician had fully discussed the case and the patient’s disposition with the family practitioner.  The ED physician ordered x-rays and laboratory tests.  Laboratory tests reviewed a WBC of 15.2 with a marked left shift (24% bands and 69% polymorphonuclear cells).  The patient was discharged.

On 1/2/1998, the patient’s husband contacted the family practitioner with complaints from the patient of black stools.  The family practitioner advised the husband to bring in the patient’s stool specimen.  The stool sample was tested and found to be negative for occult blood.  The family practitioner did not ask the husband to bring in the patient.  The family practitioner did not re-examine the patient.  The family practitioner did not obtain any of the patient’s emergency department records.

On 1/8/1998, the patient’s husband telephoned the family practitioner.  On 1/10/1998, the family practitioner returned the telephone call.  The patient’s husband told the family practitioner that the patient was taking the medication clarithromycin, an antibiotic which had been prescribed for a family member.  The patient requested this medication be refilled for herself since it seemed to be helping her.  The family practitioner agreed to fill a prescription for clarithromycin for her.  The family practitioner was informed that, at this time, which was day 14 of the patient’s illness, the patient was still very sick and could hardly get out of bed.

On 1/14/1998, the patient was admitted to the hospital by another physician.  The patient had continuing complaints of fever, nonproductive cough, and abdominal pains.  The physician’s assessment of the patient was a probable appendiceal abscess, history of mild asthma, and history of urethral stricture status post dilation.

On 1/15/1998, surgery was performed. The surgery revealed that the patient had a perforated appendix with multiple pelvic abscesses.  Surgeons removed the terminal ileum, cecum, and ascending colon with side-to-side anastomoses of the ileum and transverse colon.

The patient continues to suffer profound debility, bowel urgency, and diarrhea secondary to short colon.  The patient has required monthly vitamin B-12 injections secondary to removal of the terminal ileum.

The Board judged the family practitioner’s conduct as having fallen  below the standard of care given the following reasons:

1) When the family practitioner made a house call in 12/1997, he failed to perform an adequate physical examination of the patient.

2) He failed to take the patient’s temperature and failed to perform a pelvic and rectal examination.

3) He failed to prepare adequate chart notes of his examination of the patient.

4) He failed to order laboratory tests.

5) He failed to obtain and review the patient’s medical records from her visit to the emergency department on 1/1/1998.

6) He failed to recognize the significance of the laboratory tests obtained in the emergency department.

7) At the request of the patient, the family practitioner refilled clarithromycin for the patient despite his initial diagnosis of “gastroenteritis.”

8) The family practitioner failed to recognize that 14 days of illness was too long for gastroenteritis and failed to consider alternative diagnoses.

9) He failed to diagnose and timely treat appendicitis.

10) He failed to understand that appendicitis can present in a variety of ways.

11) He failed to recognize that retrocecal appendicitis may present with diarrhea.

12) He failed to consider further examination when he was informed of the patient’s significant debility and worsening condition.

The Board deemed the family practitioner’s conduct as having fallen below the standard of care and placed the family practitioner on probation for two years.  Stipulations included enrolling in the Physician Assessment and Clinical Education Program at the University of California, San Diego School of Medicine (“PACE Program”), completing a medical record keeping course, completing 16 hours of continuing medical education in the area of deficiency, submitting quarterly reports, and paying a fine.

State: California


Date: June 2002


Specialty: Family Medicine, Emergency Medicine, Hospitalist, Internal Medicine


Symptom: Abdominal Pain, Diarrhea, Nausea Or Vomiting


Diagnosis: Acute Abdomen


Medical Error: Failure to examine or evaluate patient properly, Underestimation of likelihood or severity, Lack of proper documentation


Significant Outcome: Permanent Loss Of Functional Status Or Organ, Hospital Bounce Back


Case Rating: 4


Link to Original Case File: Download PDF



Florida – Plastic Surgery – Intra-operative Anemia During Blepharoplasty And Lipoplasty



On 02/06/1997, a 33-year-old woman presented to a plastic surgeon to discuss blepharoplasty and lipoplasty.  The patient was scheduled for a pre-operative autologous blood donation, but cancelled the donation appointment.

On 02/21/1997, the plastic surgeon performed blepharoplasty and lipoplasty of the thighs, buttocks, and abdomen, extracting around 6,300 ml of material.  The estimated blood loss was 500 ml.  The patient received no blood transfusion before and during the procedure.  The plastic surgeon did not perform pre-operative blood tests to determine the patient’s blood clotting status, hemoglobin level, and hematocrit.

The plastic surgeon performed an intra-operative test which revealed the patient’s hemoglobin level to be 8.2 and hematocrit to be 23.6.  Despite these findings, the plastic surgeon continued with surgery.

During her overnight postoperative stay, the patient had two episodes of hypotension.  The plastic surgeon did not order or perform any post-operative laboratory tests.  The patient received no blood and was discharged the following morning on 02/22/1997.

On 02/25/1997, the patient presented to an emergency department with weakness and swollen knees.  She was diagnosed with a blood loss of approximately 3,000 ml as a result of the prior surgery.  Her hemoglobin/hematocrit was noted to be critically low at 3.7/11.  She underwent blood transfusions to treat her acute anemia.

The Board judged that the plastic surgeon’s conduct fell below the minimum standard of competence by failing to order blood clotting factors, hemoglobin, and hematocrit prior to surgery, failing to stop the surgery upon discovering her anemia during surgery, failing to perform the surgery in a hospital as opposed to in an office setting, failing to perform follow up lab studies given the anemia found during surgery, and failing to adequately document the patient’s post-operative recovery.

The Board ordered that the plastic surgeon complete 30 hours of continuing medical education in the relevant field of pre-operative and post-operative testing.  The Board ordered that the license be placed on probation for one year and six months.  During probation, the plastic surgeon was to be monitored to ensure he is practicing competently.  Surgical restrictions included that the plastic surgeon should obtain pre-operative blood work-up, including hemoglobin, hematocrit, basic metabolic panel, and urinalysis on every prospective surgical patient who is to undergo anesthesia as well as ordering a hemoglobin and hematocrit post-operatively.  The plastic surgeon was ordered to take a Special Purpose Examination (SPEX) if recommended by the evaluator within six months of the Final Order.

State: Florida


Date: August 1998


Specialty: Plastic Surgery


Symptom: Swelling, Weakness/Fatigue


Diagnosis: Post-operative/Operative Complication


Medical Error: Improper treatment, Failure to order appropriate diagnostic test


Significant Outcome: Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



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