Found 120 Results Sorted by Case Date
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California – Gynecology – Laparotomy And Bilateral Cystectomy For Removal Of Benign Cysts With Subsequent Complication



During February and March of 2010, a patient was seen by her primary care nurse practitioner and was directed to conduct blood work to evaluate various physical symptoms.  On 3/24/2010, the patient was seen by her nurse practitioner for evaluation of lab results. During the appointment, the nurse practitioner reviewed blood work results and ordered a pelvic ultrasound.  The ultrasound revealed that the patient had very large cysts on both ovaries, measuring approximately 13 cm and 17 cm. The patient was referred to Gynecologist A for treatment of the large cysts and pelvic pain.

On 4/7/2010, the patient emailed Gynecologist A to inform her of the ultrasound results and seek treatment as needed.  Gynecologist A recommended surgery to remove the cysts. The surgery was scheduled to take place on 6/2/2010. During a pre-operative appointment with Gynecologist A on 5/19/2010, the patient provided consent for the surgical procedure.  The consent form indicated that the patient consented to a bilateral cystectomy, possibly by laparotomy, and the possible need for an oophorectomy. The patient was informed of risks of surgery, including the risk of damage to nearby organs.

On 5/23/2010, the patient presented to the emergency department with acute pelvic pain.  She was seen the next day by Gynecologist B, who was aware that the patient’s Gynecologist A was in the operating room that day performing procedures.  Gynecologist B telephoned Gynecologist A in the operating room to determine if the patient could be added to the surgical schedule on that day. The patient reported to the emergency department for evaluation and possible surgery.

On the same day, 5/24/2010, Gynecologist A performed surgery on the patient.  Gynecologist A performed a laparotomy and a bilateral cystectomy. Gynecologist A sent two specimens of excised tissue to the laboratory for analysis and pathology report.  On 5/25/2010, Gynecologist A reported that she conducted an examination under anesthesia, a bilateral ovarian cystectomy, and exploratory laparotomy. Gynecologist A described making a midline incision and removing large cysts from both ovaries.  Gynecologist A described the ovaries, fallopian tubes, and uterus as unremarkable.

On 5/26/2010, two days later, a pathologist filed a report of the two specimens Gynecologist A obtained during the surgery.  It showed that the first specimen comprised a right ovarian cyst with a fallopian tube densely adherent to the cyst, and the second specimen comprised a left ovarian cyst with a fallopian tube densely adherent to the cyst.  The report further indicated all samples were found to be benign.

On 6/7/2010, the patient saw Gynecologist A for a post-operative appointment.  Gynecologist A charted and informed the patient that the pathology report and laboratory findings showed that the cysts removed during the surgery had been benign.  Gynecologist A did not inform the patient of the pathology report findings that portions of both fallopian tubes had been removed during the surgery.

On 5/14/2013, the patient was seen by a nurse practitioner in the Department of Obstetrics and Gynecology for complaints of pelvic pain and for a referral for infertility evaluation.  During this appointment, the nurse practitioner reviewed the reports from the 5/25/2010 surgery and noticed that the surgical specimens obtained during surgery contained the fimbriated ends of both fallopian tubes, likely rendering the patient infertile.

On 6/13/2013, the patient underwent a hysterosalpingogram, which confirmed that her fallopian tubes were abnormal.  On 6/25/2013, the nurse practitioner explained to the patient the results of the abnormal hysterosalpingogram, and the laboratory findings that her fallopian tubes had been removed during the 5/24/2010 surgery, which had not been previously disclosed to her.

The Medical Board of California judged that Gynecologist A’s conduct departed from the standard of care because she failed to adequately review and communicate the results of the pathology report showing the patient’s fallopian tubes had been removed during surgery.

The Medical Board of California placed Gynecologist A on probation for 35 months and ordered Gynecologist A to complete a medical record-keeping course, a professionalism program (ethics course), and an education course.

State: California


Date: November 2016


Specialty: Gynecology


Symptom: Pelvic/Groin Pain


Diagnosis: Gynecological Disease


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


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 3


Link to Original Case File: Download PDF



California – Orthopedic Surgery – Total Replacement And Excision Of Lateral Mass Of The Left Knee Results In Foot Drop



On 6/7/2010, a 67-year-old patient presented to an orthopedic surgeon for a consultation regarding his knees.  The orthopedic surgeon noted that the patient had bilateral knee pain for years, right worse than left.  The examination of both knees was described but did not include any reference to a mass.  The diagnosis was “severe degenerative joint disease in the medial compartment of the left knee.  Probable tear of the medial meniscus of the right knee.”  An MRI of the right knee was performed on 6/22/2010 showing a “complex tear in the posterior horn of the medial meniscus.”  There were also degenerative changes noted in the patellofemoral joint, grade III lateral patellar facet, and grade II medial and lateral compartments with an intra-articular loose body.

On 11/10/2010, the patient presented to the orthopedic surgeon who noted that the patient was in for a recheck but both knees remained painful.  The physical examination was as follows: “There is tenderness in the anterior knees and medial and lateral joint lines.  He walks with an antalgic gait.  He has difficulty climbing a step.  There is a 3-inch mass around the head of the left fibula.”  His diagnoses were “1. Status post arthroscopy with early to moderate degenerative joint disease in the right knee.  2.  Severe degenerative joint disease in the left knee with huge mass laterally.”  He ordered an MRI of the left knee to evaluate the mass and recommended a left total knee replacement.  There was no further discussion as to the diagnosis of a mass, pending the MRI scan.  The tumor had been present behind the patient’s leg for about five years.  It was the patient’s understanding that it was a “fatty tumor” and that “it wouldn’t be a problem removing it.”

On 11/29/2010, preoperatively, the MRI identified a soft tissue mass behind the head of the fibula and the report clearly diagnosed this mass as most likely a neurofibroma, and not a lipoma.  The study did show the degenerative changes of the joint as expected.  The important passage regarding the mass is as follows: “There is a soft tissue mass behind the head of the fibula measuring 4.9 x 2.3 cm in size.  This could represent a neurofibroma or less likely, a complicated popliteal cyst.  In this patient, additional image with intravenous contrast media may be helpful for a better evaluation.”

On 12/22/2010, the orthopedic surgeon noted that the patient had neurologic complaints in the peroneal nerve distribution: “Complains of numbness dorsum foot and lateral two toes.  Mass has been getting larger the last five years.  Exam 5 cm mass, soft, overlying head of fibula.  Positive Tinel’s, normal ankle dorsiflexion, but able to heel walk.”  These clinical findings suggested that the mass was either in the nerve or directly affecting the nerve, as indicated by the MRI scan, but the orthopedic surgeon’s differential diagnosis did not include a primary nerve lesion nor was it referenced in the treatment plan or the informed consent.

The 12/22/2010 informed consent was a standard typed report with the only custom portions being that the diagnosis, other than degenerative joint disease, was “mass lateral posterior knee with peroneal nerve entrapment” and the procedure included “excision mass, left lateral knee.”

On 12/28/2010, the orthopedic surgeon took the patient to surgery and performed a left total knee replacement and excision of mass.  The pathology identified the mass to be consistent with a schwannoma.  No malignancy was identified.  The tumor appeared to be completely excised and there were no nerve elements in the specimen.  The operative report on 12/28/2010 documented a standard total knee replacement procedure.  The portion addressing the mass excision stated: “The mass was dissected free and no branches of the peroneal nerve were encountered, as they were retracted posteriorly.  The mass was hard.  It was sitting on the muscle belly of the anterolateral compartment.  It was removable with no obvious area of infiltration, and it was completely encapsulated.”  The patient recalled the orthopedic surgeon after the surgery “…coming in and telling me that the knee replacement went well and he removed the tumor, and it was much larger than he expected; but he did not severe the nerve.”

The following day, the patient had a foot drop, which was a known complication of the procedure.  The orthopedic surgeon did appropriately recommend treatment with a drop foot brace.  This note suggests that he was still of the opinion that the peroneal nerve was intact, and the foot drop was merely a postoperative neuropraxia.  The patient underwent nerve conduction studies and x-rays of the peroneal nerve.

On 1/10/2011, the first follow-up note after the surgical procedure is made.  This was one week, six days postop and the patient had very little pain.  The examination showed the incision was benign and there was “no active ankle dorsiflexion.”  The impression was “status post left total knee replacement.”  The orthopedic surgeon advised physical therapy and to continue with a drop foot brace.

On 1/24/2011, the diagnosis remained “status post left total knee replacement.”  There was still no diagnosis of any type of a neurologic problem, but the orthopedic surgeon did recommend an electromyography of the peroneal nerve.  The patient underwent two electrodiagnostic tests, both of which suggested that the peroneal nerve was not functioning, but the surgeon did not seem to consider a disruption of the nerve requiring exploration.

On 2/8/2011, electrodiagnostics by another physician showed no peroneal nerve function.  This was one of two consecutive studies that showed that there was no peroneal function, either motor or sensory.

On 3/7/2011, it was noted the patient still had decreased sensation in the first web space, no muscle dorsiflexion, and again, no diagnosis was made other than knee replacement and the recommendation was for repeat nerve conduction testing in four weeks.

On 3/22/2011, a second electrodiagnostic study showed no sensory or motor function, with no change.

On 4/4/2011, the orthopedic surgeon requested physiatry and neurosurgery consults.

On 6/8/2011, the neurosurgical consultation noted a complete foot drop with no improvement over six months.  His plan was “peroneal nerve explored, decompressed, mobilized to identify what exactly is going on.”  While the orthopedic surgeon’s operative report indicated that the he had identified and retracted the peroneal nerve away from the mass, the neurosurgeon found there was a surgical severance of the nerve during the original procedure and the lesion was part of the nerve.  He surgically repaired the nerve.

By 7/20/2012, the patient’s symptoms were unchanged despite repair of the nerve.  Based on the neurosurgical’s clinical impression, the mass was determined to be a schwannoma involving the peroneal nerve, and the original procedure was complicated by surgical severance of the peroneal nerve.

The Board judged the orthopedic surgeon’s conduct as having fallen below the minimum level of competence given that the orthopedic surgeon failed to acknowledge the presence of the nerve tumor that was in the preoperative MRI scan of the patient and given that he severed the patient’s peroneal nerve during surgery but failed to recognize the complication during surgery or postoperatively.

The Board ordered the orthopedic surgeon to be placed on probation for four years with stipulations to complete 40 hours annually in any areas of deficient practice, to complete a medical record keeping course, to enroll in a clinical training program equivalent to the Physician Assessment and Clinical Education Program, and to undergo clinical monitoring.

State: California


Date: October 2016


Specialty: Orthopedic Surgery, Neurosurgery


Symptom: Weakness/Fatigue, Extremity Pain


Diagnosis: Post-operative/Operative Complication, Neurological Disease


Medical Error: Procedural error, Underestimation of likelihood or severity


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 3


Link to Original Case File: Download PDF



Arizona – Anesthesiology – Phenol-induced Myelopathy With Paraplegia



The Board received notice of a malpractice settlement regarding an anesthesiologist’s care of a 67-year-old man.

In 2007, a patient presented to an anesthesiologist.  Over the first 13 months of treatment, the anesthesiologist performed eleven spine related procedures, including 3 lumbar epidural steroid injections, 2 lumbar radiofrequency ablations (6 months apart), 3 right multilevel cervical radiofrequency ablation procedures (at 6 month intervals), and 3 left multilevel cervical radiofrequency ablation procedures (at 6 months intervals).  Six of the RFA procedures were accompanied by phenol injections (two lumbar, four cervical).  Around this time, the anesthesiologist performed physical examinations on two occasions and noted tenderness to palpation of the back.  There was no evidence that he had performed any cervical or lumbar neurologic examination.  During the 13 month interval and despite the frequent interventional procedures, the narcotic dose was increased from 60 mg morphine equivalent daily (“MED”) to 135 mg MED.

He was seen by other practitioners within the anesthesiologist’s group who performed other procedures and increased the narcotic dose to 240 mg MED.

In October 2009, the anesthesiologist resumed care of the patient and increased the narcotic dosage from 240 to 330 mg MED.  This dose was continued for 18 months until the patient’s final visit on 03/24/2011.

During this eighteen month time period, the anesthesiologist performed 20 spine related procedures, including 5 lumbar epidural steroid injections, 2 cervical epidural steroid injections, 2 right multilevel cervical RFAs, 2 left multilevel cervical RFAs, 2 right multilevel lumbar RFAs, 2 left multilevel lumbar RFAs, 2 occasions of bilateral multilevel thoracic facet joint injections, and 2 occasions of bilateral multilevel lumbar face injections.  On 5 occasions, a 6% phenol injection was performed at the same time as RFAs (2 cervical, 3 lumbar).

On 03/24/2011, the anesthesiologist testified that the patient had complained of significant worsening pain.  The anesthesiologist performed multilevel cervical radiofrequency ablation with injection of phenol.  The patient’s record noted that the pain level was unchanged.  The anesthesiologist did not record a physical examination for the persistent pain.

On 03/26/2011, the patient presented with increased neck pain, weakness, difficulty walking, and difficulty standing.  A cervical MRI revealed the interval appearance of diffusely abnormal central spinal cord signal with edema since the MRI on 06/18/2007.  The radiologist reported that the findings likely represented an acute inflammatory process.  The patient was transferred to another hospital.

The Board judged the anesthesiologist’s conduct to be below the minimum standard of competence given failure to perform an appropriate evaluation, examination, and work-up prior to performing injections, failure to address persistent symptoms, and failure to sign medical records in a timely fashion.  The patient experienced phenol-induced myelopathy with paraplegia.

During testimony, the anesthesiologist reported that he no longer used intercostal radiofrequency ablation.  He also testified that his practice has since adopted an electronic medical record system with voice recognition software.  He also testified that he has been given an assistant to assist with documentation.

The Board ordered the anesthesiologist be reprimanded.

State: Arizona


Date: October 2016


Specialty: Anesthesiology


Symptom: Back Pain


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


Medical Error: Procedural error, Failure to examine or evaluate patient properly, Improper medication management, Lack of proper documentation


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 2


Link to Original Case File: Download PDF



Wisconsin – General Surgery – Colorectal Mass, Bleeding, And Abdominal Discomfort With Subsequent Abdominal Perineal Resection And Colonoscopy



On 8/24/2009, a 39-year-old woman was referred to Surgeon A for a colorectal mass, bleeding, and abdominal discomfort.  A rectal exam was not documented.  The plan stated: “I will try to get the report from [Physician A] about the colonoscopic examination.  In the meantime, we will go ahead and order a CT of the abdomen and pelvis.”

On 8/25/2009, after obtaining CT and colonoscopy pathology results, the following noted: “CT rectal mass, etiology?  She needs biopsy before doing surgery.  I will talk to [Physician A] … Pathology report at Columbia St. Mary.”

“It is adenocarcinoma, the lesion is very low, and needs abdominoperineal resection and permanent colostomy.  The procedure is explained to her.  She is willing to have surgery.”

On 8/26/2009, a consent form was signed and the surgeon performed an abdominal perineal resection with permanent colostomy.  On 8/29/2009, the patient saw an oncologist, and on 9/4/2009, she saw a radiation oncologist.  Subsequently, adjuvant therapies of chemotherapy and radiation were recommended and performed.

On 2/1/2009, the patient underwent revision of colostomy performed by Surgeon B.

Surgeon A was deemed to have fallen below the standard of minimal competence given that he failed to determine the exact location of the tumor within the rectum and did not perform a sphincter sparing surgery, which should have avoided the needed for a permanent colostomy.  Surgeon A failed to offer Patient A the option of preoperative radiation and chemotherapy.  He failed to recommend an oncology consultation prior to the initial surgery.

State: Wisconsin


Date: October 2016


Specialty: General Surgery, Gastroenterology, Oncology


Symptom: Abdominal Pain, Bleeding, Mass (Breast Mass, Lump, etc.)


Diagnosis: Colon Cancer


Medical Error: Unnecessary or excessive treatment or surgery, Diagnostic error, Failure of communication with other providers, Failure of communication with patient or patient relations


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 2


Link to Original Case File: Download PDF



Virginia – Emergency Medicine – Fall Results In Right-Handed Numbness And Paracervical Tenderness



On 8/4/2013, a 66-year-old female arrived in the emergency room after falling down stairs and was seen by an ED physician.

The patient complained of neck pain and new onset right-handed numbness.  On exam, she had paracervical tenderness.

The ED physician discharged her home with a diagnosis of shoulder contusion.

Approximately 11 hours after the ED physician had discharged the patient, she was re-admitted to the hospital via ambulance complaining of being unable to move her limbs.  Imaging revealed several cervical fractures and a subluxation at C6-C7 with cord compression.  She was transferred to another facility via med flight where she underwent two separate surgeries to repair the cervical fractures, stabilize her spine, and alleviate pressure on her spinal cord.  The patient subsequently underwent four months of inpatient rehabilitation in a skilled nursing facility, followed by seven additional months of outpatient physical and occupational therapy.

In a written statement, the ED physician explained that when he first examined the patient, she complained of right-handed numbness and exhibited left-sided neck stiffness with paracervical tenderness.  He diagnosed her with a neck contusion, ordered imaging of both shoulders and elbows, but did not order any imaging of her neck “based on [his] thorough examination of the affected areas.”  The ED physician also stated that he determined imaging of the patient’s spine was not indicated and noted in the patient’s medical record that he “did not observe any signs of neurological deficit.”  The ED physician further stated that in the future, out of an abundance of caution, he would do neck imaging in similar circumstances.

The Board issued a reprimand.

State: Virginia


Date: September 2016


Specialty: Emergency Medicine


Symptom: Head/Neck Pain, Numbness


Diagnosis: Spinal Injury Or Disorder


Medical Error: Underestimation of likelihood or severity


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


Case Rating: 3


Link to Original Case File: Download PDF



California – General Surgery – Appendix Removed As Appendicitis Considered For Bowel Obstruction



On 10/30/2013, a general surgeon treated a 22-year-old male who was admitted to the hospital via the emergency department the prior day.  The patient complained of “constipation and crampy lower abdominal pains.” He also complained of vomiting and lower right quadrant pain. His WBC count was 7000.  CT scans revealed distended small bowel loops and a stool-filled structure in the right lower quadrant and pelvis. The appendix was not visualized. The general surgeon noted that a diagnosis of small bowel obstruction was suspected.  The plan was documented for a “Laparoscopic appendectomy, possible relief of obstruction, not a laparoscopic cholecystectomy, possible laparotomy.”

On 10/30/2013, the patient was taken to the operating room for exploratory surgery.  The surgery took 2 hours 10 minutes. The general surgeon performed a laparoscopy, a lysis of adhesions, and removed the patient’s normal appendix.  In an interview with the Board, the general surgeon acknowledged that appendicitis seemed unlikely at that point as the cause of the bowel obstruction.  The general surgeon failed to convert the laparoscopy to a laparotomy procedure. Postoperatively, the patient became gravely ill. He developed septic shock with obvious peritonitis.

On 10/31/2013, the general surgeon performed a laparotomy procedure.  He found that the cecum was necrotic and perforated. He performed an ileocolectomy.  The anastomosis was redone intraoperatively to assure adequate perfusion.

The Medical Board of California judged that the general surgeon’s conduct departed from the standard of care because he failed to timely convert the laparoscopy to a laparotomy to adequately diagnose cecal volvulus secondary to congenital malrotation and lack of retroperitoneal attachments in this area.

The Medical Board of California ordered the general surgeon to surrender his license.

State: California


Date: September 2016


Specialty: General Surgery


Symptom: Abdominal Pain, Constipation, Nausea Or Vomiting


Diagnosis: Acute Abdomen, Sepsis, Post-operative/Operative Complication


Medical Error: Delay in diagnosis


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 4


Link to Original Case File: Download PDF



California – General Surgery – Alternative Approach To Middle Fossa Surgery In Removing Acoustic Neuroma



A 43-year-old patient, living in Maryland, lost all hearing in his right ear at an early age due to mumps.  In mid-2005, he noticed that he was losing hearing in his left ear. An MRI performed in Maryland on 2/7/2006 revealed a 3 mm x 6 mm acoustic neuroma growing on nerve bundles connected to the patient’s inner ear and filling the distal end of his left (IAC) internal auditory canal.

The patient’s Maryland physician proposed removing the tumor by utilizing the middle fossa surgical approach, accessing the tumor by entering through the side of the patient’s skull.  Such an operation could potentially involve a 1-2 week hospital stay and 4-8 weeks of recovery at home. The physician also told the patient that the approach was not guaranteed to preserve the patient’s hearing.

The patient’s wife researched the patient’s condition on the internet and found a website for the Skull Base Institute, owned by a general surgeon, in Southern California.  The website claimed that the neurosurgeon removed acoustic neuromas using a minimally invasive procedure that would require a briefer surgery, minimal hospitalization, and minimal recovery time.  The website did not disclose that the general surgeon was not a neurosurgeon. By telephone, the general surgeon or his staff told the patient’s wife that the general surgeon proposed to remove the patient’s tumor by guiding an endoscope through the base of his skull under his ear and that this approach would result in briefer hospitalization and less recovery time than the middle fossa approach.  The general surgeon promised a 98% chance of preserving the patient’s hearing. Based on the general surgeon’s representations, the patient and his wife chose the general surgeon to perform the removal of the tumor. The patient then had his medical records and an initial payment of $600 sent to the general surgeon for a consultation.

On 2/16/2006, the general surgeon evaluated the patient by telephone.  After the telephone conversation, the general surgeon dictated a consultation note wherein he documented that the patient “was seen” in a surgical consultation to decide whether he was a candidate for endoscopic resection of his tumor.  The general surgeon also documented detailed neurological and physical examinations of the patient, all using the date of 2/16/2006, when the general surgeon talked to the patient on the telephone. The general surgeon testified that the physical examination information came from documents the patient obtained from his Maryland physicians on 2/22/2006.  The general surgeon testified that his practice at the time was to add entries to his notes but not to date each additional entry. He now uses an electronic medical record system that dates each entry.

During the consultation, the general surgeon claimed he discussed non-interventional observation to the patient, but he did not document it as an option in his consultation note.  The general surgeon did not offer an independent consultation with a radiation oncologist regarding management of the patient’s lesion. The general surgeon documented that he told the patient and his wife that using an alternative procedure, gamma knife radiation, to treat the tumor “will burn the tumor and cause it to shrink in size, but the tumor will continue to grow,” an inaccurate description of the procedure.  The general surgeon told the patient that the fully endoscopic approach that he was recommending involved “no manipulation or retraction of brain tissue,” which was not accurate, as a post-operative MRI revealed a retraction injury to the patient’s cerebellum.

The patient and his wife traveled to California and met the general surgeon on 2/28/2006.  The general surgeon did not conduct and did not document a systemic physical examination of the patient on that date.  The general surgeon did conduct an examination of the patient’s head but made no record of this examination for that date.  The patient told the general surgeon that his first priority was to preserve his hearing. A surgical technician worked as the general surgeon’s office manager and operating room technician in 2003-2007, and had contact with the patients when they called the general surgeon for consultations.  The general surgeon’s Skull Base Institute website at the time of the patient’s surgery referred to the surgical technician as a registered nurse. She was not a registered nurse and was not licensed by any state as a nurse. The surgical technician denied ever informing patients of the risks and benefits of any procedure the general surgeon would perform.  The evidence showed, however, that the surgical technician, in a discussion with the patient’s wife, referred to the middle fossa approach to acoustic neuroma surgery, an approach not used by the general surgeon, as “barbaric.”

On 3/1/2006, the general surgeon performed surgery on the patient using a 0-degree endoscope.  The general surgeon did not involve any collaborating specialist, but performed the procedure alone.   During the procedure, the general surgeon observed and excised what he thought to be the patient’s acoustic neuroma, even though the location of the lesion he excised was not consistent with the location of the acoustic neuroma on the MRI imaging available to him at the time.  The material the general surgeon excised was sent to pathology in a container labeled “left acoustic neuroma.” In his operative note, the general surgeon did not document that a specimen was sent to pathology or how it was labeled.

At the administrative hearing, the general surgeon explained his approach to the patient’s treatment.  He understood that the patient had an acoustic neuroma, based on the February 2006 MRI images and on the 2/7/2006 MRI report.  The general surgeon believed the tumor was in the lateral portion of the IAC. The average IAC is 8 mm x 10 mm long, so the general surgeon thought he would have to drill up to 6 mm into the IAC to reach the tumor while avoiding the cochlea, which was distal to the IAC.  Damaging the cochlea would render the patient completely deaf in his left ear.

The general surgeon made a 1 inch incision behind the patient’s left ear, accessed the intradural space, and drained CSF to relax the brain and provide more space for the endoscope.  Then the general surgeon introduced the endoscope into the posterior fossa and advanced it into the area of the IAC. The general surgeon opened the bony IAC 1 or 2 mm with a diamond drill and then used a shear tip to open the IAC another 1 mm.  He saw a 3 mm x 4 mm brown lesion on the ⅞ nerve, and a 3 mm x 3 mm lesion on the fifth cranial nerve. The general surgeon then opened the IAC another 3 mm. The general surgeon dissected the brown lesion off of the 7th/8th nerve, 6 mm into the IAC.  The general surgeon then removed another 1 mm or 1.5 mm of the IAC and tapped on the fundus at the lateral end of the IAC. By the conclusion of the operation, the general surgeon had opened the patient’s IAC to a distance of 7.5 mm. He incorrectly believed the tumor he removed from within the IAC was the tumor revealed in the February MRI.  In fact, the general surgeon had completely missed the tumor.

Immediately after completing the operation, the general surgeon told the patient’s wife that he had successfully removed the entire tumor.  Shortly afterward, the patient’s wife told the general surgeon that the patient was experiencing very painful headaches, and that she was concerned there might be intracranial bleeding.  The general surgeon believed the danger of bleeding by that time was minimal but ordered a post-operative MRI. The weight of the evidence indicated that, although an MRI taken so close in time after the surgery would show swelling and other artifacts of surgery, the areas of enhancement on the intracanalicular portion of the left ⅞ nerve complex, as seen in the preoperative MRI, remained in the post-operative MRI.  This would be consistent with a failure to remove the tumor. The radiologist believed that the tumor remained, but the general surgeon maintained that the MRI, taken so soon after the surgery, revealed only post surgical scarring and artifacts and that the operation was successful.

On 3/7/2006, the pathology department sent the general surgeon’s office a pathology report stating that there was no tumor tissue in the sample the general surgeon had removed from the patient during surgery.  The general surgeon, after the surgery and after reviewing the surgical pathology report and the post-operative MRI, intentionally misrepresented to the patient and his wife that he had successfully removed the tumor.  He then intentionally sent or directed someone to send to the patient and his wife a falsified, third version of the pathology report, showing the tumor had been removed when, in fact, it had not been removed.

Accepting the general surgeon’s assurances that all was well, the patient and his wife returned to Maryland after the surgical wound had sufficiently healed.  The patient continued to experience headaches and hearing loss. On 3/25/2006, in response to a request to the general surgeon for his records, the patient received two separate envelopes in the mail.  The two envelopes sent or caused to be sent by the general surgeon contained different versions of the pathology report from the patient’s operation. The two versions of the pathology report recorded diametrically opposite results.  One report stated that the pathologist had detected no tumor tissue – the operative language being “no features of acoustic neuroma are seen: in the material the general surgeon took from the patient’s skull, meaning the general surgeon had not removed the tumor.  This pathology report concluded: “No tumor seen.” The other pathology report was an altered copy of the original report, with the words “no” and “no tumor seen” redacted to change the report’s significant language to suggest that the general surgeon had removed the patient’s tumor.

The patient’s primary care physician ordered another MRI of the patient.  The new MRI showed that the patient still had a tumor in his IAC. It appeared to be identical to the image in the preoperative MRI.  The Maryland doctors proposed a middle fossa approach, from under the temporal lobe, to remove the tumor. Most patients with this approach would have up to a 60% chance of retaining hearing.  The several nerves passing through the IAC control facial muscles, balance, and hearing. The danger of hearing loss arises from operating so close to the cochlear nerve.

On 5/25/2006, a surgeon and co-surgeon operated on the patient and successfully removed the tumor.  As a result of the surgery, the patient lost all hearing in his left ear and was rendered completely deaf.  The 5/25/2006 operative report identified the preoperative diagnosis as “Left intracanalicular acoustic neuroma.”  The post-operative diagnosis was identical. The report described the operative procedure as a “middle fossa skull-based approach” and “resection of tumor.”  The report did not characterize the tumor as a cochlear schwannoma, but as an acoustic neuroma that penetrated the cochlea. The general surgeon maintained, however, that the patient’s tumor was unequivocally a cochlear schwannoma, a rare form of acoustic neuroma outside the IAC.

Due to the general surgeon’s unsuccessful surgery, the patient was harmed in the sense that he travelled across the country and made partial payment for a fruitless operation.  He risked experiencing swelling, possible hearing loss, infection, and meningitis. He was led to believe that the operation was successful when it was, in fact, a failure, raising and then destroying his hopes that he could retain his hearing.

For this allegation, the State Board of California revoked the general surgeon’s license.

State: California


Date: September 2016


Specialty: General Surgery, Neurosurgery


Symptom: Hearing Problems, Headache


Diagnosis: Post-operative/Operative Complication, Neurological Disease


Medical Error: Wrong site procedure, Failure to examine or evaluate patient properly, Ethics violation, Failure of communication with patient or patient relations, Lack of proper documentation


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 4


Link to Original Case File: Download PDF



Arizona – Gynecology – Ablation Performed Without Consent



On 07/15/2013, a 44-year-old woman presented to a gynecologist with a complaint of abnormal bleeding.  An ultrasound and endometrial biopsy were carried out.  The patient noted that she was unable to tolerate over-the-counter pain medications.  She expressed a desire for pregnancy.  A history and physical examination was performed, and no abnormalities were noted.  The patient was then scheduled for a dilation and curettage (D&C) and a hysteroscopy.

On 07/19/2013, the gynecologist performed a D&C and a hysteroscopy along with a Novasure ablation.  After the procedure, the patient was informed by nursing staff that an ablation had been included.  The patient became upset as she had not consented to an ablation procedure.  A permit request from the gynecologist’s office as well as a consent form signed at the hospital only mention the D&C and hysteroscopy procedures.

On 07/25/2013, the patient was seen for a post-operative follow-up and no complications were noted.

The Board judged the gynecologist’s conduct to be below the minimum standard of competence given failure to obtain informed consent.  An ablation can increase the risk of miscarriage and pregnancy complications.

The Board ordered the gynecologist be reprimanded.

State: Arizona


Date: August 2016


Specialty: Gynecology


Symptom: Gynecological Symptoms


Diagnosis: N/A


Medical Error: Ethics violation, Failure of communication with patient or patient relations


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 2


Link to Original Case File: Download PDF



Arizona – Obstetrics/Gynecology – Retained Products Of Conception Leads To Complications



A 29-year-old woman was giving delivery to a newborn.  The Ob/Gyn Physician noted that the patient’s hemoglobin was 13.1.  After the patient progressed to complete dilation, the Ob/Gyn Physician noted on fetal monitoring bradycardic episodes with pushing.  According to the Ob/Gyn Physician, he obtained verbal patient consent for a vacuum-assisted delivery.  With vacuum assistance, the patient delivered after two contractions.  The placenta was delivered; however, the Ob/Gyn Physician noted that a piece of the placenta was missing, and the patient continued to have bleeding.  The Ob/Gyn Physician diagnosed the patient with post-partum hemorrhage even though the notes indicated a normal amount of blood loss for a vaginal delivery.

According to the Ob/Gyn Physician, he obtained the patient’s verbal consent for a bedside curettage and subsequently, he attempted the procedure using hydromorphone and a Banjo curette (a sharp instrument).  The Ob/Gyn Physician reportedly removed a small portion of the placenta, and the patient’s bleeding subsequently subsided.  The patient’s hemoglobin was noted to be 11.  3 hours later, the patient reported feeling lightheaded and was given a bolus of IV fluid.  A subsequent hemoglobin was 9.1.

An ultrasound was then obtained, and the radiologist noted a concern for additional retained products of conception (POC).  The Ob/Gyn Physician reported that he offered the patient a second curettage under anesthesia, but this conversation was not documented in the chart.  A nurse called the Ob/Gyn Physician and requested an on-site assessment.  The Ob/Gyn Physician evaluated the patient and ordered no further therapy.

The patient’s subsequent hemoglobin was 6.6, and the Ob/Gyn Physician’s note stated that he felt the decrease in blood count was not from bleeding, but catch-up from the patient’s post-partum hemorrhage.  The Ob/Gyn Physician reported that he discussed options of intravenous iron or transfusion with the patient.  However, no such conversation was documented, and the patient was discharged on oral iron.

One month later, the patient called the office and reported heavy bleeding, and the Ob/Gyn Physician called in a prescription for misoprostol.  The patient continued to have heavy bleeding and went to the emergency department where an ultrasound showed findings concerning for retained products of conception.  The Ob/Gyn Physician performed a suction dilation and curettage.  The patient had continued bleeding, and the Ob/Gyn Physician used a sharp curette followed by another suctioning.

A large placenta fragment presented along with membrane-like strands, and the suctioning and curette were used again, with further suction curettage when bleeding continued.  The repeated suctioning and curettage were performed without ultrasound guidance or hysteroscopy.  When the patient became hypotensive immediately postoperatively, the Ob/Gyn Physician suspected a perforation and obtained an ultrasound.  Minimal fluid was noted in the peritoneal cavity.  The Ob/Gyn Physician concluded that no significant bleeding was present.

A pathology report was obtained two days after surgery with tube and ovary identified on the specimen.  Consequently, the patient was taken to the operating room for laparoscopy at which time significant damage was identified to both tubes and one ovary.  Surgery was carried out.  The patient was rendered unable to conceive without medical intervention.

The Board judged the Ob/Gyn physician conduct to be below the minimum standard of competence given failure to carry out manual exploration and ultrasound prior to uterine instrumentation when incomplete placental delivery is identified.  A large blunt instrument instead of a sharp instrument should be used for removal of tissue, if needed, with guidance by ultrasound to reduce the risk of perforation.  The Ob/Gyn physician failed to carry out curettage when a patient experiences secondary post-partum hemorrhage.  Use of concurrent ultrasound should be considered.  The Ob/Gyn Physician deviated from the standard of care by performing suction dilation and curettage blindly when the patient returned one month later with bleeding.

The physical failed to promptly evaluate for perforation with hysteroscopy and/or laparoscopy/laparotomy despite continued bleeding and hypotension.

Given these complications, the patient is unable to conceive without medical intervention.  The retained products of conception can cause infection.  Numerous curettages can lead to Asherman’s syndrome.  The finding of calcified products of conception in the dilation and curettage done by the patient’s subsequent physician suggests the patient is at increased risk for miscarriage or placenta accreta.

The Board ordered the Ob/Gyn physician be reprimanded.  He was ordered to register for a competency evaluation at a facility approved by the board.  If the board recommends practice monitoring, the physician should submit the name of an Arizona licensed physician that could provide practice monitoring with periodic chart reviews.

State: Arizona


Date: June 2016


Specialty: Obstetrics


Symptom: Bleeding


Diagnosis: Obstetrical Hemorrhage


Medical Error: Procedural error


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 3


Link to Original Case File: Download PDF



Washington – Family Practice – Accidental Fall With Pain In Hands, Twitching In Extremities, And Muscle Spasms In Legs Months Later



On 2/15/2012, a woman in her late forties met with her family practitioner to address pain in her right knee two days after slipping on the kitchen floor.  The patient reported her knee hurt when bearing weight on it and when turning to the right.  Upon examining the patient’s knee, the family practitioner instructed the patient to wait over the next month for the inflammation to subside and to see if she was able to function as she did before the fall.

On 3/6/2012, the patient sent the family practitioner a secure message requesting a massage prescription, as she had been receiving intermittent massage treatment for many years and felt it helped her with her shoulder pain.  The patient clearly stated the pain was caused by bruxism and caused or increased her tinnitus.  A referral was placed that afternoon by a physician covering for the family practitioner.  The patient responded on 3/12/2012 requesting a prescription, instead of a referral, for insurance purposes.  On 3/13/2012, the family practitioner issued the requested document.  In a subsequent correspondence, the patient also brought up feeling tension in her shoulders when she went down the stairs, feeling nerve pain in her hands and elbows when she sneezed, and walking with numbness in her hands.  The family practitioner did not comment on the patient’s newer symptoms and did not ask her to make an appointment to be seen by the family practitioner.  The family practitioner failed to appreciate the significance of hand numbness and sneeze-induced pain described by the patient.

In May 2012, the patient saw an orthopedic surgeon to further examine her knee.  The orthopedic surgeon’s formal assessment was patellofemoral syndrome.  After the appointment, the patient wrote to the orthopedic surgeon seeking a clear answer regarding the muscle spasms in her legs she was experiencing in about 10-20 times a day and sometimes in her arms.  The orthopedic surgeon told her this issue is not common for someone with her condition and could be a result of a number of things including electrolyte imbalances, dehydration, or neurologic causes and to talk to her primary care provider for further work up.  The orthopedic surgeon provided a report to the family practitioner.

On 6/27/2012, the family practitioner saw the patient to address concerns of increased pain in her hands and how she still felt she had not fully recovered from her fall earlier that year.  She also felt increased pain during exercise and twitching in her extremities.  The patient reported a history of carpal tunnel.  The family practitioner performed an examination of the patient’s wrists and found symptoms consistent with carpal tunnel in the patient’s left wrist.  The family practitioner also noted the patient gained 17 pounds in approximately a year and a half and discussed the long-term importance of staying active.  The family practitioner suspected the patient could be diabetic (as both her parents were diabetic, increasing her risk) and that her possibly having diabetes could be contributing to her neurologic symptoms.  The family practitioner ordered testing for diabetes.  Although diabetes may have been a concern, the symptoms and history are not compatible with a diagnosis of diabetic neuropathy.  Through a secure message two days after the appointment, the family practitioner told the patient that while not yet diabetic, her sugars were higher than before, and that she wanted her to find ways to increase her activity and reduce her weight, and offered to refer her to another provider for a steroid injection in her knee.

On 7/6/2012, the patient sent the family practitioner a secure message in which she described the pain in her hands as “incredible” and when she bent her head down, her left arm went numb.  This symptom is a clear sign of origin in the spinal cord and should have resulted in urgent patient evaluation and prompt referral to neurology or neurosurgery.  The patient reported she wanted to wait six to eight more weeks to see if the pain resolved.  The family practitioner said that six weeks is an appropriate time to wait, and if it was not improving, she would refer the patient for nerve conduction testing and a neurosurgery referral.

On 7/20/2012, after the patient’s pain did not resolve, the family practitioner referred the patient for nerve conduction studies and a neurosurgery referral.  In August 2012, the patient met with a neurologist who confirmed the patient had left-sided carpal tunnel as well as myelopathic symptoms.  Magnetic resonance imaging (MRI) revealed the patient had suffered damage to her spinal cord at C4-C5, C5-C6, and C6-C7 from her fall earlier that year and required surgery.  The patient underwent surgery in late September.

The family practitioner failed to provide an appropriate and timely referral to a specialist.  The patient experiences ongoing symptoms.

The Commission stipulated the family practitioner reimburse costs to the Commission, complete 6 hours of continuing education in the areas of diagnosis and management of spinal cord and nerve root injuries and long-term complications of glucose intolerance and diabetes mellitus, and write and submit a paper of at least 1000 words on the subjects of her continuing education courses and the ways her practice will change based on the experience.

State: Washington


Date: June 2016


Specialty: Family Medicine, Internal Medicine, Neurology


Symptom: Extremity Pain, Numbness


Diagnosis: Spinal Injury Or Disorder


Medical Error: Delay in proper treatment


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 4


Link to Original Case File: Download PDF



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