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

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

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

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

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

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

State: Florida

Date: December 2017

Specialty: General Surgery

Symptom: N/A

Diagnosis: Gastrointestinal Disease

Medical Error: Wrong site procedure

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

State: California

Date: July 2017

Specialty: Gynecology, General Surgery

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

Diagnosis: Post-operative/Operative Complication, Gynecological Disease

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

Significant Outcome: N/A

Case Rating: 3

Link to Original Case File: Download PDF

On 4/21/2014, a gynecologist performed a Cesarean section and bilateral tubal ligation on a 29-year-old female at 36 weeks gestation.

The patient suffered from gestational hypertension associated with right upper quadrant abdominal pain and elevated liver function tests consistent with HELLP (Hemolysis, Elevated Liver Enzymes, and Low Platelet Count) Syndrome.

At 5:00 p.m. on 4/21/2014, the patient became hypotensive and tachycardic and was pale and lethargic.

Between 5:00 p.m. and 6:30 p.m. on 4/21/2014, a critical care consultant diagnosed the patient with acute hemorrhagic shock, possibly due to an intraabdominal bleed, transferred the patient to the ICU, ordered a transfusion of 4 L of blood, and called the gynecologist for a possible exploratory laparotomy to control the bleeding.

At 7:11 p.m., the patient was intubated and placed on ventilation due to respiratory failure.

At 9:10 p.m., an ultrasound examination was performed on the patient’s abdomen and pelvis that revealed moderate fluid in the right and left upper quadrants of the patient’s abdomen.

Immediately following the ultrasound examination, the gynecologist diagnosed the patient with a liver rupture.  The patient’s lab testing results did not support or corroborate the gynecologist’s diagnosed.

The gynecologist called the on-call general surgeon and discussed the patient’s case.  After the conversation, at 9:23 p.m., the gynecologist initiated the transfer of the patient to a medical center.

At 1:45 a.m. on 4/22/2014, the patient was transferred to the medical center with a tachycardic heart rate of 140 beats per minute and a hypotensive blood pressure of 89/44.  The gynecologist and a surgeon performed an exploratory laparotomy on the patient, which revealed that the patient had an arterial bleed from the tubal ligation procedure.

The Medical Board of Florida judged that the gynecologist did not appropriately assess, or did not create or maintain adequate documentation of assessing, the patient’s symptoms and condition. He did not timely diagnose, or did not create or maintain adequate documentation of timely diagnosing, the patient with an intraabdominal bleed and hemorrhagic shock.  The gynecologist did not timely perform or order an exploratory laparotomy based on the patient’s deteriorating vital signs.  He did not timely order an ultrasound examination of the patient’s abdomen and pelvis on the patient’s deteriorating vital signs.  Also, the gynecologist did not timely perform or order an exploratory laparotomy based on the patient’s respiratory failure.  He did not recognize, or did not create or maintain adequate documentation of recognizing, that the fluid in the right and left upper quadrants of the patient’s abdomen, in conjunction with the patient’s other symptoms, indicated an intraabdominal bleed.  He did not perform or order an exploratory laparotomy based on the fluid in the right and left upper quadrants of the patient’s abdomen.  The gynecologist inappropriately diagnosed the patient with a liver rupture when the patient’s lab testing results did not support or corroborate the diagnosis.  He also did not order, or did not create or maintain adequate documentation of ordering, a surgery consultation for a surgeon to physically examine the patient upon diagnosing the patient with liver rupture.  He did not consult, or did not create or maintain adequate documentation of consulting, with one or more other OB/GYNs who might have had experience dealing with a patient with a liver rupture or a patient with similar complications and symptoms as the patient had.  The gynecologist did not timely perform or order an exploratory laparotomy after diagnosing the patient with liver rupture.  He also inappropriately transferred the patient to a medical center when the patient was unstable due to being tachycardic and hypotensive.  The gynecologist did not create or maintain adequate documentation related to his diagnosis and treatment of the patient.

The Medical Board of Florida issued a reprimand against the gynecologist’s license.  The Medical Board of Florida ordered that the gynecologist pay a fine of $22,500 against his license and pay reimbursement costs for the case at a minimum of $4,335.85 and not to exceed $6,335,85.  The Medical Board of Florida also ordered that the gynecologist complete ten hours of continuing medical education in diagnosis management of complications relating to cesarean sections, complete five hours in emergency obstetric care, and complete five hours of continuing medical education in “risk management.”

State: Florida

Date: May 2017

Specialty: Gynecology, Critical Care Medicine, General Surgery

Symptom: Abdominal Pain

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

Medical Error: Diagnostic error, Delay in proper treatment, Failure to order appropriate diagnostic test, Referral failure to hospital or specialist, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 3

Link to Original Case File: Download PDF

A patient was referred to a general surgeon specialized in colorectal surgery by his primary care doctor.  The patient presented to the general surgeon on 4/10/2012 as a 35 year-old-man with anal pain since age 16.

The patient’s medical history included a 12/30/2003 colonoscopy with biopsies by a gastroenterologist, who made a postoperative diagnosis of anal fissure, rectal polyp, and two small sigmoid polyps.  The biopsies revealed benign hyperplastic polyps.  In 2009, the patient had a lumbar discectomy at L4-L5.  In October 2011, the patient was referred to, and seen by, a cardiologist.  The cardiologist found “no evidence of any fixed coronary arterial disease in the left dominant system…elevated resting left ventricular end-diastolic pressure suggests left ventricular diastolic non-compliance likely due to history of hypertension and obesity.”  In sum, the patient presented to the general surgeon with morbid obesity, hypertension, dyslipidemia, post-two back surgeries, with a resulting DVT, cardiac complaints, and a list of prescription medications; and a social history including a one pack per day smoking habit, cannabis use, and occasional alcohol use.

The patient appeared with his wife for his appointment with the general surgeon.  The patient was given a two-page medical questionnaire to complete.  The patient filled in page one of the questionnaire and the patient signed page two, leaving blank the box on page two asking the patient to circle symptoms applicable to their current condition (e.g., headaches, shortness of breath, chest pains, blood in stool, etc.).  The patient was called out of the lobby by a medical assistant, who took his vital signs and questioned him about the information listed on the questionnaire.  The medical assistant learned that the patient was allergic to penicillin, which the patient had not listed on the questionnaire.  The medical assistant reported that the patient’s vital signs to the general surgeon on a yellow sticky note was as follows: “Temp-98.2 F, Weight-341 lbs., Height-72 in., BP [Blood Pressure]-139/77, Pulse-84, RR[Respiratory Rate]-21, BMI [Body Mass Index]-46.3.”

The medical assistant then escorted the patient to an examination room. The general surgeon entered and spoke to the patient. The general surgeon took notes by hand, indicating the following:

“hemorrhoids three times after laminectomy[1l in January; symptoms greatly increased over the last six months; Bowel Habits-small stools, tenesmus [urge to defecate, but cannot], and mucus discharge; hiatal hernia; colonoscopy negative; History of polyps; no sigmoidoscopy.”

The general surgeon and the medical assistant created the chart note for the patient’s visit, which reports out the following:

CC [Current Complaint]: Hemorrhoids

HPI [History of Present Illness]: The patient is a pleasant 35- year-old referred here by [his primary care physician]. He is here because of a 3-year history of hemorrhoids with progressive painful BM’s [bowel movements], tenesmus, BRBPR [bright red blood per rectum], and small stools last 6 months. Known history of fissure. Last colonoscopy negative.

ROS [Review of Systems]: General-denies fever, night sweats, weight loss; Neurological-denies loc [loss of consciousness], ha [headaches], diplopia [double vision], tinnitus [ringing in the ears], vertigo [dizziness], numbness, tingling, incoordination; Respiratory-denies sob [shortness of breath], wheezing, coughing, hemoptysis [coughing up blood]; CV [cardiovascular system ]-denies angina, palpitation, leg cramps, pedal edema, pnd [ difficulty breathing], nocturia [ excessive urination at night], orthopmea [shortness of breath while lying down], claudication [cramping leg pain caused by exercise]; GI [gastrointestinal system]-denies nausea, vomiting, hematochezia [fresh blood in stool], hematemesis [vomiting blood], jaundice, diarrhea, incontinence, heartburn, indigestion, dysphagia [difficulty swallowing], poor appetite, constipation; GU [genitourinary]-denies dysuria [painful urination], hematuria [blood in urine], incontinence, impotence, pneumaturia [passage of gas with urine], fecuria [fecal matter in the urine]; MS [musculoskeletal]-denies stiffness, arthralgia joint pain], weakness, atrophy, bone pain, Raynaud’s [severe blood flow reaction to blood vessels in the cold in fingers and toes]; Endocrine-denies heat intolerance, cold intolerance, dry skin, dry hair, hoarseness, polydipsia [abnormally large thirst], polyuria [production of abnormally large levels of diluted urine]; Hematologic-denies bleeding, bruising, ecchymosis [discoloration of the skin resulting from bleeding underneath], pk [Pyruvate kinase deficiency, one of the most common enzymatic defects of the erythrocyte].

PMH [Past medical history]: Medical-hypertension, dyslipidemia [high cholesterol]; Surgical-lumbar laminectomy, micro-discectomy.

SH [Social history]: Patient denies recreational drug use; Smokes 1 pack/day for 15 years; Occasional alcohol consumption.

FH [Family history]: Mother- 69 alive with hypertension [high blood pressure]; Father-DEC [deceased] at 65 heart attack; Siblings- 1 brother alive at 41 with CVD [cardiovascular disease], 2 sisters alive, 1 with diabetes another with CVD.

Allergies: Penicillin.

Meds:

acetaminophen-hydrocodone 325 mg.-7.5 mg. [Norco] oral tablet, folic acid 1 mg oral tablet, Xanax XR 0.5 mg oral tablet, extended release, zolpidem [ Ambien] 10 mg oral tablet.

Vitals: T [temperature]-98.2 F, Wt [weight]-341 lbs., Ht [height]-72 in., BP [Blood Pressure]-139/77, P [pulse]-84, RR [Respiratory Rate]-21, BMI [Body Mass Index]-46.3.

PE [Physical examination]: General-WD/WN [well­-developed/well-nourished] in NAD [no abnormality detected]; HEENT[head, eyes, ears, nose, throat]-PERRLA [Pupils equal, round & reactive to light & accommodation], EOMl, [extraocular movements intact], ENT [ear, nose, throat] wnl [within normal limits]; Neck-not thyromegally [enlargement of the thyroid gland] or masses, no ND [jugular venous distension] or bruits [a systolic murmur heard in the neck]; Chest-clear to auscultation and percussion; Cardiac-no murmur or gallop; Abdomen-no masses or organomegaly [enlargement of the viscera], non-tender; Extremities-no clubbing, cyanosis or edema, full range of motion; Neuro-grossly intact; Anorectal­: inspection showed posterior fissure, with spasm, no further exam. Large skin tag RPQ [right posterior quadrant]. Cannot rule out hemorrhoids.

A/P [assessment/plan]:

#ANAL fissure (565.0);

#HYPERLIPIDEMIA OT/UNSPEC (272.4);

#HYPERTENSION UNSPEC (401.9).

Fissurectomy, lateral sphincterotomy, possible hemorrhoidectomy. The risks, benefits, and alternatives, including the slight chance of incontinence, are discussed.

Following the examination, the patient signed two information and consent forms: Hemorrhoids-Surgical Hemorrhoidectomy and Anal Fissure-Fissurectomy and Sphincterotomy.

No surgery was scheduled, and the patient left the general surgeon’s office. The general surgeon did not request the patient’s medical file from the primary care doctor.

On 4/23/2014, at approximately 9:00 a.m., the patient called the general surgeon’s office, complaining of terrible pain and pleading for relief. At the time, the general surgeon was in surgery at a surgery center. The general surgeon was contacted in the operating room (OR) by his office on behalf of the patient. Although the general surgeon was scheduled for a full day of surgeries, he offered to operate on the patient at the end of his surgical schedule that day. The patient accepted. The general surgeon’s office transmitted a Pre-Admission form, with Physician’s Orders, to the surgery center at approximately 10:00 a.m., requesting the patient have the following tests prior to surgery: “EKG [electrocardiogram]; CBC [complete blood count], without Differential (includes Platelets); UA[urine analysis]/Culture if indicated.”

At 3:44 p.m., the patient was admitted to the surgery center for his surgical procedures. The Admission’s Nurse completed the Admission Profile with the patient and the wife, noting, among other things: “Previous hospitalizations/surgeries-microdiscectomy 2010, lumbar laminectomy 2009, with DVT after laminectomy; Comprehensive Pain Assessment­ pain scale 10, rectum, onset at 16 years old, burning; Cardiovascular-high blood pressure, weird heartbeat about 8 months ago at cardiologist; Hema/Hepatic/GI-hemorrhoids, fissure; Psychiatric-Anxiety; Social Habits-smoker 1 PPD [pack per day], alcohol 2-4 times per month.”

The general surgeon completed a Short Form history and physical for the patient, noting: “Chief Complaint-Anal pain; History of Present Illness-severe pain secondary to anal fissure. Past Medical/Surgical History: HTN [hypertension]; Current Medications and Allergies: See-home medication list; Physical Exam-Head/Neck-normal,-Airway normal,-Neuro normal, Chest/Lungs normal, Heart normal, GI normal, GU normal, Extremities normal; Significant findings-anal fissure with right posterior skin tag; Diagnosis-Anal fissure; Plan-fissurectomy, sphincterotomy, and hemorrhoidectomy; Pre-Sedation Assessment For Procedure Without an Anesthesiologist-ASA2 II – mild systemic disease.”

At 4:12 p.m., a patient provided a urine sample and blood was taken for labs. At 4:53 p.m., labs revealed normal sodium, potassium, hemoglobin, and hematocrit. At 5:11 p.m., a pre-anesthetic evaluation was completed on the patient by an anesthesiologist. At 5:29 p.m., the patient was placed under general anesthesia. At 5:46 p.m., the general surgeon performed a hemorrhoidectomy, fissurectomy, and a right lateral sphincterotomy on the patient. The surgery was completed at 6:42 p.m., and the patient was in the recovery room at 7:00 p.m. The general surgeon prescribed the patient “Norco 10/325 mg., one tablet every four hours, as needed for pain; Valium 2 mg., one every six hours, as needed for pain; and Toredal (sic) 10 mg., one every six hours.” At 8:15 p.m., The patient was discharged.

The general surgeon drafted an Operative Report, noting, among other things:

“Preoperative Diagnosis-anal fissure; Postoperative Diagnosis-anal fissure and hemorrhoids; Procedures Performed-hemorrhoidectomy, fissurectomy, right lateral internal sphincterotomy; Anesthesia-general; Findings-anal stenosis with deep posterior anal fissure with large 3-quadrent (sic) hemorrhoids in the usual distribution, in the right anterior quadrant hemorrhoidal group there with chronic strangulation and gangrenous changes.”

On 4/24/2014, Post-Surgical Day 1 (PSDl), the patient’s wife called the general surgeon’s office four times: at 9:46 a.m., 10:32 a.m., 3:10 p.m., and 4:38 p.m. At 9:46 a.m., the patient’s wife reported that the patient had blood in his urine; the patient’s wife was told that the patient had a urinary catheter during surgery and blood in the urine was normal on PSDI. At 10:32 a.m., the patient’s wife reported the patient was vomiting and had diarrhea; the patient’s wife was told this was normal for PSDl. At 3:10 p.m., the patient’s wife reported the patient was still vomiting; a prescription for Reglan (anti-nausea) was called in. The patient’s wife collected the prescription, but the patient could not keep the Reglan down.

At 4:38 p.m., the patient’s wife reported the patient was still vomiting, with diarrhea, and feels hot, although his temperature is normal; the patient’s wife was told that the symptoms are normal for PSDl, and get fluids into the patient. The general surgeon did not return the calls from the patient’s wife on 4/24/2014.

On 4/25/2014, Post-Surgical Day 2 {PSD2); at 5:58 p.m., the patient’s wife called the surgery center and reported the patient was still vomiting, with diarrhea, and feels hot; the patient’s wife was told the symptoms were normal for PSD2, but to call the general surgeon’s office. The patient’s wife called the general surgeon’s office, spoke to the answering service, and requested a callback.

At 6:40 p.m., the general surgeon telephoned the patient’s wife. The patient’s wife reported pus at the surgical site and that the stitches looked ripped open and yellow; the general surgeon said they were breakaway stitches and the appearance was normal for PSD2. They did not discuss the patient’ s symptoms from PSD 1.

On 4/26/2014, the patient began speaking nonsensically. He complained about pain in his legs. The patient’s wife called the general surgeon’s office at 12:36 p.m. and 12:40 p.m., but the office was closed for lunch and the patient’s wife did not leave a message with the exchange.

The patient’s wife then telephoned the surgery center at 12:46 p.m. and 12:47 p.m. The patient’s wife reported the patient was speaking nonsensically, with purple, blotchy legs, purple lips, and slurred speech; the patient’s wife was told to bring the patient into the hospital. At 12:58 p.in., 911 was called. Paramedics appeared and transported the patient to the surgery center.

The patient arrived at the surgery center at 1:35 p.m. In the ambulance, the patient was intubated and described by EMS as “acutely cyanotic and mottled.” Upon arrival, the patient was treated by an ED physician in the ED for two hours.

The ED physician drafted an ED Report, indicating, among other things: “This is a 36-year-old white male who comes to the emergency room by ambulance in extremis [at the point of death]. He was intubated in the field by the paramedics.”

“On arrival in the department he was purple mottled, unresponsive with a heart rate in the 60s which later proceeded to become bradycardic into the 20s.” ” … [A] temperature of 41 Centigrade [105.8 Fahrenheit] was noted.”

“Examination of the rectum revealed maceration and postoperative changes. It does appear consistent with an infection in the area.”

“Labs later returned showing renal failure with a creatinine of 9. Potassium was elevated.”

“Diagnosis-septic shock, renal failure, perineal infection, status post hemorrhoidectomy. His prognosis seems exceedingly poor.”

“Total critical care time 120 minutes.”

At 2:50 p.m., the ED physician contacted the general surgeon regarding the patient, reporting sepsis, renal failure, hyperlipidemia, recent hemorrhoidectomy with local infection. The general surgeon telephoned the surgery center to reserve an OR for the patient, scheduling the first available OR at 5 p.m.

At approximately 3:30 p.m., the patient was admitted to the surgery center and his care was transferred to an internist. After 5:00 p.m., the patient was taken to interventional radiology (IR) for placement of an IVC [inferior vena cava] filter (5:35 p.m.) and a temporary dialysis catheter (5:43 p.m.).

At 5:50 p.m., the patient was moved from IR into the OR, where the general surgeon waited. On arrival to the OR, the transport staff reported a change in heart rhythm. A Code Blue was called at 6:05 p.m. Resuscitative measures commenced but were unsuccessful, and time of death was called at 6:41 p.m.

The internist charted a Discharge Summary, noting: “Discharge Diagnosis-(1) patient died, (2) severe septic shock, (3) most likely perirectal phlegmon [inflammatory process with pus] versus fasciitis [inflammation of connective tissue]. History of Hospital Stay-This was a 36-year-old gentleman admitted at [the hospital] with septic shock. He was hypotensive, unresponsive, intubated in the field. While in the emergency room, the patient had episodes of bradycardia [abnormally slow heart action]. He was found to have multi-organ system failure with acute kidney insufficiency. He was taken to the OR for an emergent exploratory laparotomy [a surgical incision into the abdominal cavity, for diagnosis or in preparation for surgery]. Unfortunately, he coded on the OR table.”

The general surgeon wrote a Death Note in the chart, indicating: “Patient came in with septic shock. Code blue called in route to OR. CPR commenced in the OR per ACLS [advanced cardiac life support] protocol. Planned perineal debridement and colostomy never took place. Code was called after 22 min of resuscitative effort then resumed after seemingly having spontaneous cardiac electrical activity and pulse, but this was transient, and soon patient became pulseless without meaningful cardiac activity. Patient after hemorrhoidectomy and has perineal gangrene.”

An autopsy was performed on April 28, 2012, at the Fresno County Coroner’s Office. A blood culture was taken, revealing gram-negative rods isolated [bacterial infection]. The cause of death is listed as probable cardiac arrhythmia due to idiopathic hypertrophic cardiomyopathy.

The general surgeon was placed on probation for three years with stipulations of completing an education course and undergoing monitoring by another physician.

State: California

Date: May 2017

Specialty: General Surgery, Internal Medicine

Symptom: GI Symptoms (GERD, Abdominal Distention, Dysphagia), Fever, Nausea Or Vomiting, Pain, Urinary Problems

Diagnosis: Sepsis

Medical Error: Delay in proper treatment, Failure of communication with patient or patient relations, Improper treatment

Significant Outcome: Death

Case Rating: 4

Link to Original Case File: Download PDF

On 2/2/2012, a 33-year-old female was undergoing exploratory laparotomy conducted by a general surgeon.  At 10:30 p.m., the general surgeon inserted a trocar into the right lower abdomen under direct visualization.  During the insertion, the general surgeon used such force sufficient to cause a laceration of the right common iliac artery.

The patient became hypotensive and tachycardic.  At 10:50 p.m., the general surgeon converted to an open laparotomy.  She converted to an open laparotomy when she noted active bleeding.

The general surgeon stated that she believed the Board would be informed of the medical malpractice payment automatically as a result of the report to the National Practitioner Data Bank.  The general surgeon did not intend to mislead or not adhere to the Board’s requirement of separately reporting medical malpractice to the Board.

She failed to report the medical malpractice settlement she made in September 2014 to the Board within 30 days, as required by Virginia Code.  She failed to update her practitioner’s profile on the Board’s website to include that she made a malpractice settlement within 30 days, as required by the Board’s General Regulations.

The Board issued a reprimand and fine.

State: Virginia

Date: January 2017

Specialty: General Surgery

Symptom: Bleeding

Diagnosis: Post-operative/Operative Complication

Medical Error: Procedural error

Significant Outcome: N/A

Case Rating: 1

Link to Original Case File: Download PDF

A patient’s primary care physician (PCP) referred her to a general surgeon for a right upper quadrant mass after suspecting a hernia.  In his written referral to the general surgeon, the PCP stated that the patient’s present illness was “Abdominal pain in RUQ from hernia…Refer to surgeon to evaluate RUQ mass/pain.”

In October 2008, the general surgeon examined the patient and noted that the patient presented with “a painful bulge in the R lateral abdominal wall,” she was 75 years old, 5’4” tall, 240 pounds, and suffered from hypertension.  The pre-operative note also indicated that the patient would not accept a blood transfusion.  This is significant considering that the patient’s pre-operative laboratory report showed a low platelet count of 84,000.

Although the patient had been experiencing significant pain and her PCP had suspected and noted the likelihood of a hernia, the general surgeon believed the abdominal mass to be a lipoma.  The general surgeon did not obtain any pre-operative image studies.  Instead, the general surgeon scheduled the patient for surgery at an outpatient, ambulatory surgery center, where he works.  The general surgeon did not take into account that complex hernia repairs that require bowel repair or resection are not appropriate for same day surgical procedures and outpatient centers are not equipped for such procedures.  At a minimum, without a preoperative image study, the general surgeon should have scheduled the patient for surgery at the hospital so that whatever issue was encountered could be properly addressed.

In November 2008, the general surgeon attempted surgery on the patient at the ambulatory surgery center.  The general surgeon used the subcostal approach and discovered that in fact, the patient had a hernia and not the lipoma he had anticipated.  A hernia was stuck to the undersurface of the abdominal area where the general surgeon found dense adhesions.

The surgery had to be stopped 25 minutes after its start because the surgery center lacked the instrumentation and equipment for hernia surgery.  As a result of the more difficult and involved surgery required, the conscious sedation started by the anesthesiologist was insufficient to control the patient’s discomfort, and a laryngeal mask airway was needed and provided.  The patient was immediately transferred by ambulance to the hospital.

The surgery center’s anesthesiologist’s report stated that the patient had a “likely bowel perforation.” If the anesthesiologist’s note is correct, the requisite delay in repairing the perforation could potentially expose the patient to an increased risk of wound infection.  A bowel perforation requires emergent repair, and any delay poses serious consequences.

The general surgeon denied perforating the patient’s bowel during the surgery at the surgery center but his own hospital admission report states that the patient had “a probable perforation of the hepatic flexure.”  The hospital’s report also contains a contradicting note where the general surgeon states that the patient had begun outpatient surgery to remove a right-sided abdominal mass which “ended up perforating bowel.”  This hospital’s report further acknowledged that the patient was admitted for “bowel resection as this could not be done at the surgery center.”

At the hospital, the general surgeon undertook the more extensive surgery which confirmed that the bowel was perforated.  The general surgeon performed this second surgery with a subcostal retroperitoneal approach despite his recognition of dense adhesions and presumed bowel injury, as well as the earlier difficulty in exposing the large hernia in the morbidly obese patient.

The general surgeon’s discharge summary states that the patient had experienced purulent drainage from her incision.  However, the general surgeon did not document his evaluation of the patient’s wound prior to discharging the patient from the hospital, nor did the general surgeon document the patient’s complaint of pain.  The general surgeon discharged the patient to a rehabilitation center.

Within 24 hours of discharge, the patient immediately returned to the hospital by ambulance with a grossly infected wound.  The patient appeared septic, experienced constant, intense pain, with fever, chills and brown, bilious-colored material draining from her surgical incision.

A CT scan showed draining fecal matter in her right abdomen.  The patient stated that her abdominal pain and wound drainage began three days prior to discharge from the hospital.  The scan also revealed the patient had a significant intra-abdominal process that likely festered for some time.  This fact raises the possibility that the drainage in the abdominal wound was the continuum of a process that was occurring intra-abdominally.

The patient returned for a third surgery.  The general surgeon again performed the surgery, this time using a midline incision.  The general surgeon described the surgery as mildly bloody.  During this surgery, in a purulent area in the right side of the abdomen, the general surgeon identified a perforation in the patient’s colon which was leaking air.  The general surgeon resected the patient’s colon and broke down some hard adhesions.  Because of the extensive peritonitis that had developed, the patient had to have a colostomy.  The patient’s health rapidly declined following the third surgery.

The patient died less than thirty days after the general surgeon’s initial surgery.  The general surgeon prepared the death certificate, and he failed to accurately reflect that the patient died of multi-organ system failure as a consequence of a bowel perforation that occurred from his abdominal surgery to repair a hernia.  There was no mention for reason of organ failure and the only pathology mentioned were various organ system failures that occurred just before death.  A death certificate should accurately reflect the course of events leading up to a patient’s demise.  The general surgeon neglected to properly document the actual cause of the patient’s death.

The Commission stipulated the general surgeon reimburse costs to the Commission, arrange for the manager of the Quality Review Committee at all facilities where he provides patient care to submit quarterly reports addressing whether any surgical cases involving the general surgeon were discussed at the Quality Review Committee meetings,  and write and submit a paper of at least 1500 words, with annotated bibliography, discussing the Communication and Resolution Program (CRP) principles and the importance of integrating these principles into practice.

State: Washington

Date: January 2017

Specialty: General Surgery

Symptom: Abdominal Pain

Diagnosis: Post-operative/Operative Complication, Sepsis, Procedural Site Infection

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

Significant Outcome: Death, Hospital Bounce Back

Case Rating: 5

Link to Original Case File: Download PDF

On 4/14/2011, a surgeon performed a laparoscopic ventral hernia repair on a 70-year-old female.  The patient had a history of hypertension, an increased body mass index of 41, coronary artery disease with a past history of myocardial infarction, and a previous coronary angioplasty procedure with stent placement.

A pre-operative cardiac test determined that the patient had a normal cardiac ejection fraction.  The patient had reported pre-surgical symptoms of shortness of breath with exertion that was of undetermined etiology.  She had not previously required home oxygen therapy and her resting room air oxygen saturation on the morning of the surgery was 95%.

The patient’s post-anesthesia note indicated that she had some mild wheezing after completion of the surgical procedure.

Postoperatively, on 4/14/2011 at 8:00 p.m., the patient had a low oxygen level 87% after standing at her bedside, despite being on oxygen at 2 liters per minute at the time.  Her oxygen levels on the night of 4/14/2011 subsequently improved.

On 4/15/2011 at 9:00 a.m., the surgeon evaluated the patient, determined she was ready for discharge, wrote discharge orders, and requested the patient follow up in his office in two weeks.

On 4/15/2011 at 1:24 p.m., nursing staff attempted to wean the patient off oxygen in preparation for hospital discharge but found that the patient’s oxygen level was low at 88% on room air and dropped to 82% with ambulation.  Nursing staff informed the surgeon of the patient’s abnormal oxygenation.  The surgeon reportedly indicated that the patient’s respiratory status was her “norm” and that she had no heart problems or chronic lung disease, and that she needed to be discharged.

The nurse then asked whether the surgeon wanted to send the patient home with oxygen treatment.  Chart notes document that the surgeon stated he was not concerned about the poor oxygenation and he advised nursing to discharge the patient without oxygen therapy.  The nurse, who remained concerned about the patient’s respiratory status, discussed the situation with the nursing supervisor.  Nursing then contacted the patient’s primary care provider who did order home oxygen therapy and asked for the patient to be evaluated in their clinic the following day.  The patient left the hospital at 4 p.m. on 4/15/2011 on 2 liters per minute of oxygen.

Patients with room air oxygen saturation equal or less than 89% qualify for home oxygen therapy.  The patient’s oxygen level of 82% while on 2 liters of oxygen supplementation was markedly worse than this qualifying criterion.  The patient’s low oxygen saturation should have been of concern to the surgeon and warranted further evaluation by the surgeon.

The Commission ordered the surgeon pay a fine, have his license placed on probation for a period of two years, allow a representative of the Commission make semi-annual visits to the surgeon’s practice to review compliance with the Commission’s order, and write and submit a paper of at least 1000 words, with bibliography, on appropriate use of supplemental oxygen when discharging patients.  The surgeon will also make a presentation to the medical staff at his workplace on this subject.

State: Washington

Date: January 2017

Specialty: General Surgery

Symptom: Shortness of Breath

Diagnosis: Gastrointestinal Disease

Medical Error: Improper treatment

Significant Outcome: N/A

Case Rating: 1

Link to Original Case File: Download PDF

On 5/11/2015, a patient underwent a routine colonoscopy.  The colonoscopy revealed a small colon polyp; a subsequent biopsy of the polyp revealed it to be colon cancer.

On 5/18/2015, the patient presented to a hospital for bowel resection to be performed by a general surgeon.

During the course of the procedure, the general surgeon removed a portion of omentum and requested an endocatch bag, which was not added to the surgical count, to temporarily store the omentum.

The contents of the endocatch bag were too large to remove through the endocatch, and the general surgeon released the endocatch bag into the patient’s abdomen to be removed at the end of the procedure through the extraction site.

At the conclusion of the procedure the extraction site was closed and the endocatch bag was not removed from the patient’s body.

On 5/19/2015, the general surgeon verified with staff that the endocatch bag had not been removed and the patient was returned to surgery where the endocatch bag was successfully removed.

The general surgeon left a foreign body in a patient by leaving an endocatch bag inside the patient during a bowel resection procedure on 5/18/2015.

The Medical Board of Florida issued a letter of concern against the general surgeon’s license.  The Medical Board of Florida ordered that he pay a fine of $4,000 against his license and pay reimbursement costs for the case at a minimum of $1,563.30 and not to exceed $3,563.30.  The Medical Board of Florida also ordered that the general surgeon complete five hours of continuing medical education in “risk management” and complete a one-hour lecture/seminar on retained foreign body objects.

State: Florida

Date: December 2016

Specialty: General Surgery

Symptom: N/A

Diagnosis: Post-operative/Operative Complication, Colon Cancer

Medical Error: Retained foreign body after surgery

Significant Outcome: N/A

Case Rating: 3

Link to Original Case File: Download PDF

On 10/18/2012, a general surgeon performed a laparoscopic nissen fundoplication procedure on a patient for gastroesophageal reflux disease and a large hiatal hernia.

During the operation, an EGD was performed, during which the patient suffered perforation of the upper esophagus/posterior pharynx.  Subsequently, following completion of the initial laparoscopic repair, the patient developed hypotension and was found to have a laceration of the infrarenal aorta.

Multiple attempts were made to control the bleeding.  Efforts to resuscitate the patient were unsuccessful, and the patient died.

The Board obtained the patient’s records and sent them to a qualified independent medical expert for review.  The independent medical expert judged the general surgeon’s conduct to be below the minimum standard of competence given failure to terminate the procedure when the patient suffered perforation of the upper esophagus/posterior pharynx.  The expert also expressed concern regarding the general surgeon’s use of a bladed trocar and the adequacy of the general surgeon’s documentation of the operation.  Documentation lacked information regarding the decision to proceed after the perforation of the upper esophagus/posterior pharynx; information about the trocar placement; and information about anatomic findings, details of gastric mobilization, or what type of retraction was used on the liver.

The Board ordered general surgeon to be reprimanded.

The Consent Order was reported to the Federation of State Medical Boards and the National Practitioner Data Bank.

State: North Carolina

Date: December 2016

Specialty: General Surgery

Symptom: N/A

Diagnosis: Gastrointestinal Disease

Medical Error: Procedural error, Lack of proper documentation

Significant Outcome: Death

Case Rating: 1

Link to Original Case File: Download PDF

A 70-year-old cirrhotic patient with a history of diabetes and hypertension presented for a surgical evaluation by General Surgeon A on 6/6/2014 with a lesion on his back, which had been present for two years, and was noted as consistent with atypical nevus.

The patient also presented with periumbilical pain and tenderness that had been present for two years.  No ascites was noted by General Surgeon A.  General Surgeon A discussed with the patient removal of the lesion and repair of the hernia.  He also discussed the signs that would indicate possible emergency incarceration or strangulation.  The patient consented to surgery for lesion removal and hernia repair.

On 6/16/2014, an operation for removal of the lesion and hernia repair was performed by General Surgeon A.

On 6/23/2014, the patient returned for a post surgery follow-up with General Surgeon A and was noted to have ascites on 6/27/2014.  The patient did not return to General Surgeon A for a follow-up but was admitted to the hospital on 6/28/2014 and admitted by General Surgeon B, who recommended exploratory surgery.  At this surgery, debridement of the abdominal wall and umbilical hernia repair was again performed.

General Surgeon A failed to appreciate pre-operative test results related to the patient’s chronic liver disease and failed to obtain other pre-operative studies to fully evaluate the patient’s risk prior to performing surgery.

General Surgeon A failed to adequately obtain an appropriate pre-surgical consultation or clearance after being informed of a finding of bilateral pneumonia although the normal white blood count put into question that diagnosis and possibly suggested fluid overload instead.  The patient had no fever and examination of the chest was within normal limits.

On 7/9/2014, the patient was discharged to a skilled nursing facility.

On 8/2/2014, the patient passed away.

Mitigating factors include the following:

1. The panel considered the risk of a strangulated or incarcerated hernia and the possible complications if surgery had not been recommended in this patient.
2. The general surgeon had not been the subject of a prior disciplinary action.
3. In determining the appropriate sanctions in this matter the panel considered that the general surgeon cooperated in the investigations to the allegations related to this case.

The Board issued a public reprimand against the general surgeon with orders to “complete continuing medical education in risk management and patient assessment with a focus on liver failure/liver disease.”

State: California

Date: December 2016

Specialty: General Surgery, Internal Medicine

Symptom: Abdominal Pain

Diagnosis: Gastrointestinal Disease

Medical Error: Diagnostic error

Significant Outcome: Death, Hospital Bounce Back

Case Rating: 1

Link to Original Case File: Download PDF