Found 17 Results Sorted by Case Date
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Florida – Family Practice – Unnecessary Excisions Performed For Multiple Lesions



On 6/15/2012, a 47-year-old female presented to a family practitioner with multiple lesions on her back, chest, and arms.

The family practitioner informed the patient that the lesions on her left humerus, right upper abdomen, mid upper back, left anterior mid chest, lower back, right lower back, and/or right upper anterior chest were malignant and/or potentially malignant.

On 7/6/2012, the family practitioner documented that the patient had a history of keloid formation after surgical excision.

On 6/15/2012, the family practitioner excised a lesion on the patient’s left humerus.  The lesion excised from the patient’s left humerus measured approximately 3 mm by 3 mm.  The family practitioner made an excision 4 cm by 4 cm or sixteen square centimeters to excise the lesion on the patient’s left humerus.

On 6/19/2012, a dermatopathology report determined that the excision taken from the patient’s left humerus was not malignant or premalignant.

On 6/27/2012, the family practitioner excised a lesion on the patient’s right upper abdomen.  The lesion on the patient’s right upper abdomen measured 3 mm.   The family practitioner made an excision 7 cm by 6 cm, or forty-two square centimeters to excise the lesion on the patient’s right upper abdomen.

On 6/29/2012, a dermatopathology report determined that the excision taken from the patient’s right upper abdomen was not malignant or premalignant.

On 7/6/2012, the family practitioner excised a lesion the patient’s mid upper back.  The lesion on the patient’s back measured approximately 3 mm.   The family practitioner made an excision 5 cm by 7 cm, or thirty-five square centimeters to excise the lesion on the patient’s mid upper back.

On 7/13/2012, the family practitioner excised a lesion on the patient’s left anterior mid chest.  The lesion on the patient’s left anterior mid chest measured approximately 4 mm by 4 mm.
The family practitioner made an excision 8 cm by 6 cm or forty-eight square centimeters to excise the lesion on the patient’s left anterior mid chest. He referred the patient for radiation treatment to prevent keloid formation.

On 7/20/2012, a dermatopathology report determined that the excision taken from the patient’s left anterior mid chest was not malignant or premalignant.

On 8/3/2012, the family practitioner excised a lesion the patient’s left lower back.  The lesion on the patient’s left lower back measured 5 mm by 4 mm.  The family practitioner made an excision 9 cm by 7 cm or sixty-three square centimeters to excise the lesion on the patient’s left lower back.

On 8/7/2012, a dermatopathology report determined that the excision taken from the patient’s left lower back was not malignant or premalignant.

On 8/10/2012, the family practitioner excised a lesion on the patient’s right lower back.  The lesion on the patient’s right lower back measured 4 mm by 4 mm.  The family practitioner made an excision 9 cm by 8 cm or seventy-two square centimeters to excise the lesion on the patient’s right lower back.

On 8/14/2012, a dermatopathology report determined that the excision taken from the patient’s right lower back was not malignant or premalignant.

On 8/27/2012, the family practitioner excised a lesion on the patient’s right upper anterior chest.  The lesion on the patient’s right upper anterior chest measured 2 mm by 2 mm.   He made an excision 10 cm by 7 cm, or seventy square centimeters to excise the lesion on the patient’s right upper anterior chest.

On 8/29/2012 a dermatopathology report determined that the excision taken from the patient’s right upper anterior chest was not malignant or premalignant.

The Board judged that the family medicine practitioners conduct to be below the minimal standard of competence given that he failed to perform a complete and comprehensive physical examination of the patient’s lesions; adequately consider the characteristics of the lesions, including the size, color, regularity, and degree of pigmentation; refer the patient for consultation with a dermatologist; refrain from diagnosing the patient with malignant and/or potentially malignant lesions without having adequate justification; accurately and appropriately diagnose the patient’s condition; confirm that each of the lesions on the patient was malignant or premalignant prior to excising the lesion; perform a shave biopsy, punch biopsy, or limited excisional biopsy with 1 mm margins on each of the lesions on the patient to determine whether the lesion was malignant or premalignant; make an excision with margins no greater than 5 mm to excise each of the lesion on the patient; refrain from making an excision on the patient without having adequate justification; avoid potential keloid formation on the patient, by making the fewest and/or smallest excisions appropriate and/or justifiable.

The family practitioner agreed to voluntarily cease practicing medicine and agreed to never reapply for licensure as a medical doctor in the state of Florida.

State: Florida


Date: August 2017


Specialty: Family Medicine, Dermatology


Symptom: Dermatological Abnormality


Diagnosis: Dermatological Issues


Medical Error: Unnecessary or excessive treatment or surgery, Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Referral failure to hospital or specialist, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Plastic Surgery – Laser Treatment For Lipoma At The Back Of The Head



On 9/6/2011, a 51-year-old male consulted with a family practitioner performing cosmetic procedures for the removal of a lipoma located at the back of his head.  The patient’s history included hyperthyroidism, for which he was seeing a physician, and atrial fibrillation, for which the patient chose not to take blood thinners.  The family practitioner’s assessment and plan was “LipoLite of lipoma of occiput.”  The patient signed a consent form.  However, there was no mention of the potential for a burn pertaining to the type of laser used by the family practitioner.  In addition, there was no verbal discussion of potential risks and complications.

On 9/9/2011, the patient returned to the family practitioner for LipoLite removal of the lipoma.  The only documentation in the medical record of the visit is a procedure note.  There are no vital signs recorded in the procedure note, no indication of the number of joules, or energy that was delivered, and no mention of temperature monitoring.  There are start and end times for the infiltration of lidocaine with epinephrine and a start and end time indicating a 15 minute treatment with LipoLite laser with 2.5 zones treated.  The family practitioner noted sloughing of the skin at the left upper part of the lipoma near an old scar and the epithelium is noted to have a slight blister formation.  The family practitioner monitored tissue temperature with his hand and by the patient’s reaction to various levels of pain.

On 9/14/2011, the family practitioner noted mild edema and erythema of the site and surrounding area.  On 9/19/2011, there was drainage from the wound and the family practitioner noted the central area with a dark firm scabbed layer with pink erythema at the lower left with no abscess or seroma and mild tenderness.  On 9/28/2011, the patient returned reporting that the wound had been leaking for approximately five days.  The patient was continued on wound care.

On 10/5/2011, the patient noted a hard scabbed area with a surrounding white area.  The family practitioner referred the patient to a wound care clinic.

The Board deemed the family practitioner’s conduct as having fallen below the standard of care for failing to perform a history and physical examination at the initial consultation, for failing to record vital signs before and during a surgical procedure, and for failing to obtain sufficient knowledge of the laser prior to use.  The Board noted a failure to recognize a blister during a laser procedure and a scab or eschar in the post-operative period as representing a possible full-thickness skin loss as well as failure to obtain cultures from a draining wound.

The Board issued a public reprimand against the physician.  Stipulations included 30 hours of continuing medical education in the area of cosmetic laser surgery and a continuing medical education course in medical record keeping.

State: California


Date: May 2017


Specialty: Plastic Surgery, Dermatology, Family Medicine


Symptom: Mass (Breast Mass, Lump, etc.), Dermatological Abnormality, Wound Drainage


Diagnosis: Post-operative/Operative Complication


Medical Error: Procedural error, Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Failure of communication with patient or patient relations, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Oncology – Wrong Area Excised When Attempting To Remove Melanoma Of The Posterior Upper Left Arm



On 5/1/2013, a patient presented to an oncologist for a sentinel lymph node biopsy and a radical excision of a melanoma on the posterior aspect of her left upper arm.

When attempting to excise the melanoma on the posterior aspect of the patient’s left upper arm, the oncologist performed the excision on the wrong area of the posterior aspect of the patient’s left upper arm.

Post-operatively, the oncologist sent a specimen from the patient’s left upper arm excision to pathology.

On 5/6/2013, a surgical pathology report was issued stating that the specimen from the left upper arm excision was negative for melanoma.

On 5/6/2013, the patient underwent a second surgical procedure, and the melanoma was excised from the correct area of the posterior aspect of the patient’s left upper arm.

The Medical Board of Florida judged the oncologist’s conduct to be below the minimal standard of competence given that the oncologist performed the wrong site procedure when he performed a surgical excision on the wrong area of the posterior aspect of the patient’s left upper arm.

It was requested that the Medical Board of Florida order one or more of the following penalties for the oncologist: permanent revocation or suspension of his license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Medical Board of Florida deemed appropriate.

State: Florida


Date: April 2017


Specialty: Oncology, Dermatology


Symptom: N/A


Diagnosis: Cancer


Medical Error: Wrong site procedure


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Arizona – Dermatology – Failure To Adequately Conduct Mohs Surgery



The Board received a complaint alleging failure to adequately conduct Mohs surgery.  During the Board’s investigation, the Medical Consultant reviewed the charts of three patients regarding the dermatologist’s performances of Mohs surgery for a patient with basal cell carcinoma of the left ear, a patient with squamous cell carcinoma of the left ear and preauricular face, and a patient with basal cell carcinoma of the right ear.  The Mohs histology slides prepared for each patient were reviewed.  The Medical Consultant concluded that in each case the dermatologist’s removal of either the basal cell carcinoma or squamous cell carcinoma was incomplete.  It was noted that there was insufficient tissue present on the histology slides to represent a complete margin of a 2 cm tumor of the ear.  The dermatologist’s Medical Consultants disagreed.

The Medical Consultants noted in that the patient with the basal cell carcinoma of the right ear, there was poor correlation with Mohs Map, the operative report, and the findings in the histology slides.  In addition, there was no documentation discussing adjuvant therapies, further staging work up, or the persistent tumor with the patient at the time of Mohs surgery.

These patients had documented recurrences of their skin cancers that required additional Mohs surgery and in some cases, lead to tissue loss, nerve damage, and the need for reconstruction.

The Board judged the dermatologist’s conduct to be below the minimum standard of competence given failure to completely remove the tumor for three patients.

The Board ordered dermatologist be reprimanded.

State: Arizona


Date: April 2017


Specialty: Dermatology


Symptom: Dermatological Abnormality


Diagnosis: Cancer, Dermatological Issues


Medical Error: No error found


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Dermatology – Pathologist Performs Botox And Radiesse Injections Resulting In Complications



On 6/20/2014, a pathologist performed Botox injection to a patient’s forehead and Radiesse injections to her cheeks in the pathologist’s home.

Three days later, on 6/23/2014, the patient complained of severe swelling and redness at the injection sites on her cheeks.

The pathologist advised the patient to use a cold compress, to apply hydrocortisone cream, to take Claritin and ibuprofen, and to return for follow up in two days.

Shortly thereafter, the patient began to experience more swelling and draining at the injection sites.

On 6/26/2014, the patient presented to the pathologist for a follow-up appointment.  The pathologist documented that the patient’s swelling had subsided and that her pain was mainly relieved.  The patient was instructed to continue to take Claritin and ibuprofen for two weeks.

On 7/10/2015, the patient presented to a physician with complaints of pain, swelling, and drainage at the injection sites.  The physician treated the patient for abscesses that had occurred at the injection sites.

The Medical Board of Florida judged the pathologists conduct to be below the minimal standard of competence given that the pathologist did not record the lot number of the Radiesse in the patient’s chart.  Also, the pathologist placed the injection too close to the patient’s eye area.  The pathologist placed the injections too superficially in the patient’s skin.  The pathologist incorrectly diagnosed the patient with a hypersensitivity reaction.

The Medical Board of Florida issued a letter of concern against the pathologist’s license.  The Medical Board of Florida ordered that the pathologist pay a fine of $5,000 against her license and pay reimbursement costs for the case at a minimum of $5,175.43 and not to exceed $7,175.43.  The Medical Board of Florida also ordered that the pathologist complete a records course within one year of the final order, complete ten hours of continuing medical education in cosmetic procedures, and complete five hours of continuing medical education in “risk management.”

State: Florida


Date: March 2017


Specialty: Dermatology, Pathology


Symptom: Dermatological Abnormality, Swelling, Wound Drainage


Diagnosis: Dermatological Issues


Medical Error: Diagnostic error, Lack of proper documentation, Procedural error


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Washington – Dermatology – Intense Pulsed Light Device Use In Cosmetic Treatments



A physician was the co-owner and medical director of a dermal spa.  A patient received hair removal, photofacial, and skin tightening treatments at the dermal spa from 8/4/2014 through 9/10/2014.  These treatments were performed using an intense pulsed light (IPL) device.  The use of IPL devices, among other devices, is regulated by WAC 246-919-605 – commonly referred to as the “laser rules,” though that title is under-inclusive.

Contrary to laser rules, prior to initiating treatment with the IPL device, the physician failed to document or perform a history and physical examination.  The physician performed and supervised the patient’s treatments without creating a sufficient medical record or ensuring that a sufficient medical record was created.  The physician failed to provide or document the provision of instructions for emergency and follow-up care, as required by the laser rules.

The informed consent document signed by the patient, prior to her treatment, did not record that the patient was informed that a non-physician may operate the IPL device, as required by the laser rules.  Contrary to laser rules, the physician failed to ensure the existence of a quality assurance program and failed to have written office protocols for supervised professional staff to follow before delegating the use of the IPL device.

The physician delegated the performance of the final three treatments to an esthetician.  Following the final treatment on 8/4/2015, the dermal spa records indicated that the patient developed slight burns on her chest and forearms.  The notes further indicated that the patient “said she had sun exposure before treatments.”  The physician indicated that patients are advised to avoid sun exposure prior to treatment and advised to inform the dermal spa staff if they are exposed to the sun before treatment so that adjustments can be made to the IPL device.  However, there was no further documentation regarding this potential complication, or regarding the physician’s involvement or availability to treat potential complications or provide consultation.

The Commission stipulated the physician write and submit a paper of at least 1000 words, with annotations, regarding the Washington State “Laser Rules” and her plan for ensuring that she is in compliance with the laser rules, write and implement a quality assurance program at the dermal spa, ensure that each patient receiving treatment with the IPL has a complete medical record, and reimburse costs to the Commission.

State: Washington


Date: January 2017


Specialty: Dermatology


Symptom: Dermatological Abnormality


Diagnosis: Post-operative/Operative Complication, Dermatological Issues


Medical Error: Procedural error, Failure to follow up, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Dermatology – Rosacea Treated With Intense Pulsed Light Treatment



On 5/5/2011, a patient presented to a cosmetic laser clinic.  At this initial appointment, a nurse recommended that the patient receive Intense Pulsed Light treatment (“IPL”) utilizing the Lumenis One machine to treat rosacea, redness, and discoloration on his neck and chest.  On 5/5/2011, a dermatologist approved the nurse’s treatment recommendations.  The proposed IPL treatments were to be administered over three clinical visits.  The patient was not informed of the potential risk of severe burn and significant scarring associated with IPL treatment.

On 5/16/2011, the patient underwent his first IPL treatment without any adverse outcome.

On 8/15/2011, the dermatologist performed the second IPL treatment on the patient’s neck and chest using the Lumenis One machine.  At the time that respondent performed the second IPL on the patient, she had not previously reviewed the clinic’s written IPL protocol.  The dermatologist did not adjust the settings on the Lumenis One machine and instead relied on the preset settings.  The patient complained of extreme pain during this administration of the IPL treatment.  The patient asked the dermatologist to stop the IPL treatment at least four times during the course of the treatment.  The dermatologist did not stop the treatment, but only hesitated momentarily to wait for the patient to regain his composure.

The dermatologist continually made comments to coax the patient to proceed with the IPL treatment.  The dermatologist did not adjust the settings on the Lumenis One machine during the course of the IPL treatment.

On 8/15/2011, following the IPL treatment, the patient observed two large purple spots with blistering on his chest.

On 8/19/2011, the patient returned to the clinic for an IPL follow-up appointment with the dermatologist.  During this visit, the dermatologist diagnosed the patient with post-IPL second-degree burns to the neck and chest area.

On 6/7/2012, the patient returned to the clinic for an IPL follow-up appointment with the dermatologist.  The dermatologist noted that the patient had hypopigmented rectangles on his chest.

The dermatologist failed to adequately inform the patient of the potential risks of IPL treatment including burns and scarring.  The dermatologist failed to read the protocol governing the Lumenis One machine prior to treating the patient and failed to adjust the machine to a lower energy prior to treating the patient.

The Board issued a reprimand to the dermatologist and ordered the dermatologist to enroll in a clinical in-service training provided by the vendor of the IPL medical device.

State: California


Date: October 2016


Specialty: Dermatology


Symptom: Dermatological Abnormality


Diagnosis: Dermatological Issues


Medical Error: Procedural error


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Family Medicine – Lack Of Proper Examination And Diagnosis Of 23-Year-Old Female With Rash, Cough, Fever, And Vomiting



In November 2009, California was near a second peak of the bimodal H1N1 influenza pandemic that began in Mexico in April 2009.  Rapid flu testing at this time was of limited value in detecting H1N1.  Healthcare facilities were inundated with patients complaining of influenza-like illnesses.

On 11/2/2009, a 23-year-old female with a history of current smoking, mild asthma, and allergic rhinitis was seen by a physician assistant at an urgent care clinic where a family practitioner worked.  She presented with headache, nausea, fatigue, and body aches for days.  She was afebrile and had no skin rash.  Rapid flu A&B testing was negative.  The patient was diagnosed with a viral syndrome and treated with fluids and rest.

On 11/16/2009, the patient returned to the urgent care clinic for a chief complaint of bug bites on her legs.  She was seen by the family practitioner.  She no longer complained of flu-like symptoms.  Insect bites were noted to have been present for one week.  The family practitioner documented that she was afebrile and had multiple maculopapules and pustules on the left lower extremity.

The family practitioner did not obtain a skin culture.  He diagnosed the patient with cellulitis of the leg and insect bites.  The family practitioner failed to document in the patient’s medical record the basis for his diagnosis of cellulitis.  The family practitioner started the patient on Bactrim DS twice daily for 10 days.

The patient was evaluated by a dermatologist on 11/17/2009 for multiple insect bites with swelling and itching.  She did not complain to the dermatologist of fever, chills, weakness, or muscle aches.  She was instructed to take Bactrim DS as prescribed by the family practitioner and was given Altabax and Lidex cream for topical wound care.

The patient returned to urgent care on 11/22/2009.  She was seen by a different physician with fever to 104, cough, malaise, body aches, and bug bites.  The patient had stopped taking Bactrim due to nausea but then resumed taking it after seeing the dermatologist.

On exam, an elevated temperature of 100.2 and tachycardia at 114 were noted, as were congested nares, red throat, and swollen neck lymph nodes.  The rash on the left lower extremity persisted, so a scab was removed from one of the lesions for a culture.  The culture result was negative when reported on 11/23/2009.  Rapid flu testing was also negative.  The treating physician suspected flu and prescribed Tamiflu, 75mg per day, and Phenergan for nausea.  The patient was continued on other treatments, per the dermatologist’s orders, for left lower extremity rash.

On 11/22/2009, the patient’s mother telephoned the urgent care clinic and reported that the patient had a rash all over her back.  A physician assistant advised the patient to stop Tamiflu and to replace Bactrim with Omnicef.  The patient’s mother was advised to return to the clinic or to go to the emergency department if the patient’s condition worsened.  On the morning of 11/23/2009, the patient’s mother telephoned the clinic again, reporting that the patient had a fever and was nauseated.  She was advised to bring the patient to the clinic.

On 11/23/2009, the family practitioner saw the patient with her mother present.  The patient presented with a history of continued fever, chills, cough, nausea, and vomiting.  The family practitioner was aware that the patient was told to stop using Tamiflu and that her Bactrim prescription was replaced with Omnicef.  The family practitioner did not perform and/or document a skin examination, even though one of the patient’s complaints was that she had a new rash.  On exam, the patient had a fever with a temperature at 101.2, tachycardia with heart rate at 118, and a normal blood pressure.

The family practitioner charted that she was “ill appearing but in no acute distress.”  HEENT, heart, lung and abdominal exams were negative.  The family practitioner’s assessment was “fever not otherwise specified, URI, and nausea with vomiting.”  The family practitioner’s medical record does not support a diagnosis of URI, as the only recorded symptom consistent with that diagnosis is a cough.  Other symptoms of URI, such as red throat, enlarged lymph nodes, and nasal congestion, which were documented by another doctor on 11/22/2009, were absent from the record of the patient’s visit on 11/23/2009.  The family practitioner later stated that on 11/23/2009, he was primarily concerned about the patient’s dehydration, though he failed to document this concern in the patient’s chart.  He ordered an intramuscular injection of Reglan 10 mg for nausea.  His plan was to continue with Onmicef for the URI, even though this medication was originally prescribed for a skin rash.

The family practitioner’s follow-up plan, in its entirety, is documented as follows: “ER worse.”  The family practitioner later claimed that this annotation meant that he wanted the patient to be referred to the emergency department and that he discussed this issue at length with the patient’s mother who declined this because of cost.

However, the family practitioner failed to document this discussion in the patient’s chart.  The family practitioner decided to continue treating the patient on an outpatient basis instead of hospitalizing her or referring her to the emergency department.  Despite the fact that this patient had developed a new rash, continued to have fevers and cough for a week, and continued to have two days of vomiting to the point where she could not keep medications down, the family practitioner failed to order laboratory or imaging studies and did not formulate or document a sufficiently detailed treatment plan.

In the early evening of 11/23/2009, the patient was unarousable at home and was taken to the hospital by paramedics.  Upon arrival at the hospital, she suffered generalized tonic-clonic seizures, which continued despite medication.  Despite aggressive treatment in the emergency department, her condition did not improve, and she was admitted to the intensive care unit, where she received consultations from multiple specialists.

On 11/24/2009, after the family practitioner found out that the patient was admitted to the intensive care unit, he made an addendum to the patient’s chart regarding the 11/23/2009 visit. The information added to the patient’s chart was a report of a neurologic examination.  In this addendum, the family practitioner charted that the patient was alert and oriented X3 with normal cognition, cranial nerves II-XII grossly intact, normal strength bilaterally, and normal gait.  At least a portion of this neurologic examination did not actually take place.

The patient was examined on 11/23/2009, with her mother present, and she claimed, and the family practitioner later admitted, that he did not perform a cranial nerve examination or motor strength bilaterally.  The remaining portions of the added neurological examination note were based on the family practitioner’s recollected observation of the patient on 11/23/2009 and were not a result of a purposeful neurological examination, as his note made it appear.

On 11/26/2009, after a second neurological consultation, the patient was declared brain dead.  On the basis of a subsequent autopsy, the cause of death was determined to be Reyes syndrome and viral encephalitis.

The family practitioner departed from the standard of care in his treatment of the patient as follows:

1) The family practitioner’s inadequate history and physical examination, including a failure to perform a skin examination of the patient on 11/23/2009 was a simple departure from the standard of care.

2) The family practitioner’s failure to perform and/or document a neurological examination of the patient on 11/23/2009 was a simple departure from the standard of care.

3) After deciding to continue treating the patient on an outpatient basis, family practitioner’s failure to order any laboratory or imaging studies on 11/23/2009 was a simple departure from the standard of care.

4) The family practitioner’s failure to formulate a treatment plan that addressed the patient’s symptoms on 11/23/2009 was a simple departure from the standard of care.

5) The family practitioner’s 11/24/2009 recording of elements of the neurological examination of A.C. that he did not actually perform was a simple departure from the standard of care.

The Board judged the family practitioner’s conduct to have fallen below the standard of care.  Stipulations included enrolling in the Physician Assessment and Clinical Education Program offered at the University of California – San Diego School of Medicine.  The Board issued a public letter of reprimand.

State: California


Date: March 2014


Specialty: Family Medicine, Dermatology, Emergency Medicine, Infectious Disease, Internal Medicine


Symptom: Dermatological Abnormality, Cough, Rash, Fever, Headache, Nausea Or Vomiting


Diagnosis: Meningitis/Encephalitis


Medical Error: Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Ethics violation, Lack of proper documentation


Significant Outcome: Death


Case Rating: 5


Link to Original Case File: Download PDF



Wisconsin – Dermatology – Removal Of Cyst On Left Upper Cheek With Prescription Of Antibiotics



On 3/11/2008, a patient was seen by Dermatologist A for a sore on his upper left cheek.  Dermatology A made a diagnosis of an infected sebaceous cyst.  Antibiotics were prescribed.  Recommendation was for the patient to return for excision of the cyst.  The patient returned 5/27/2008, with inflammation and swelling at the site of the prior cyst.  Dermatologist A diagnosed recurrent sebaceous cyst.  He excised the growth and prescribed antibiotics.  He did not send any tissue to the pathology lab.

In September 2009, the patient saw his primary care physician for a recurrent left cheek infection.  A biopsy revealed squamous cell carcinoma that was now widespread into the lower eyelid, up to the inferior orbital rim, and up to the frontal process of the maxillary bone.  Ultimately, the patient had a total loss of vision of the left eye, a residual facial defect, and required surgery along with radiation treatments.

The Board judged that Dermatologist A fellow below standard care by not submitting the tissue for pathology review.

State: Wisconsin


Date: December 2013


Specialty: Dermatology


Symptom: Swelling


Diagnosis: Cancer


Medical Error: Diagnostic error


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 4


Link to Original Case File: Download PDF



Wisconsin – Dermatology – Dark Slightly Raised Rash On Left Forearm



On 6/20/2006, a nurse addressed a patient’s complaint of a breakout of rashes on his arm.  The nurse described the rash as a dark, slightly raised lesion measuring 2.54 cm x 3.81 cm on his left forearm.  The physician prescribed topical triamcinolone (TMC) 0.1% to be applied on the rash two to three times per day as needed.

On 7/11/2006, the patient again presented to the physician concerned with the dark, irregular, and slightly elevated skin lesion.  The lesion continued to be very itchy and bothersome despite the TMC, and the patient found the antifungal 2% miconazole cream, prescribed for his athlete’s foot, worked best.

On 8/8/2006, the patient presented to a nurse practitioner complaining of side effects resulting from the Hepatitis C (HCV) treatment he was receiving.  During this appointment, the nurse practitioner described a 4 cm circumferential pruritic lesion on the patient’s left anterior forearm.  The patient explained that the lesion was present prior to the first HCV treatment on 4/21/2006, and that antifungal creams had not been effective.  The nurse practitioner noted the cause of the lesion was unknown, and she believed a dermatology evaluation would “bring some assurance.”  The physician agreed that a dermatology consult should be considered but he felt strongly that he could expedite the diagnosis so that the proper therapy could be directed appropriately and promptly, as it was not unusual for dermatology appointments to schedule out three to six months.

On 8/29/2006, the physician review the histopathology report of the patient’s skin lesion.  The specimen was a 5.1 cm x 3.0 cm skin segment, excised to the greatest depth of 0.6 cm.  A 3.3 cm x 2.6 cm irregular, gray/brown lesion was centrally located on the epidermis.  The pathologist concluded that the tissue was benign and diagnosed psoriasiform lichenoid dermatitis.

The physician’s conduct fell below minimum standards of competency for the medical profession when he failed to refer the patient to a dermatologist; failed to use a more appropriate biopsy method such as a “punch” or “shave” biopsy; and performed a skin biopsy in which the size was greater than necessary for a diagnosis.

The Board ordered the physician be reprimanded, pay the costs of the proceeding, and complete a four day session on skin problems and diseases.

State: Wisconsin


Date: December 2011


Specialty: Internal Medicine, Dermatology


Symptom: Rash


Diagnosis: Dermatological Issues


Medical Error: Procedural error


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



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