Found 92 Results Sorted by Case Date
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Florida – Gynecology – Unnecessary Biopsies Performed When Lumps Are Noted on A Patient’s Breasts



Between December 2010 and August 2013, a patient presented to her gynecologist.

On 5/19/2011, the gynecologist found small, smooth, mobile lumps in the patient’s left and right breasts.

On 6/17/2011, the gynecologist performed a right breast biopsy on the patient.  The gynecologist noted that the right breast lump was likely a fibroadenoma.  The biopsied right breast tissue was found to be benign.

On 7/5/2011, the gynecologist performed a left breast biopsy on the  patient.  The gynecologist noted that the left breast lump was likely a fibroadenoma.  The biopsided left breast tissue was found to be benign.

At all times, the patient was at a low risk for having breast cancer.

The Board judged the gynecologist’s conduct to be below the minimum standard of practice given that the prevailing professional standard of care required that the gynecologist medically manage the patient’s left and right breast lumps with breast exams, breast sonographies, and/or mammograms.  The obstetrician’s performance of left and right breast biopsies on the patient was medically unnecessary.

The Board ordered that the gynecologist pay a fine of $16,000 against his license. Also, the Board ordered that the case fine be set at $9,486.57.  The Board ordered that the gynecologist complete five hours of continuing medical education in “Risk Management.”

State: Florida


Date: December 2017


Specialty: Gynecology, Gynecology


Symptom: Mass (Breast Mass, Lump, etc.)


Diagnosis: N/A


Medical Error: Failure to order appropriate diagnostic test, Unnecessary or excessive treatment or surgery


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Gynecology – CBC Tests Show Neutropenia And Leukopenia At An Annual Gynecological Exam



On 8/15/2013, a 34-year-old female presented to a gynecologist for an annual gynecological exam.  At the exam, the patient expressed concerns about infertility.  The gynecologist and the patient discussed various tests that may be used to address infertility and the gynecologist began ordering tests.

On 2/23/2015, the patient gave blood for a complete blood count (“CBC”) test that was ordered by the gynecologist.

On 3/5/2015, the gynecologist received and signed for the results of the CBC test.  The CBC test indicated the patient had an abnormal white blood cell count, marked leukopenia, and severe neutropenia.

The gynecologist failed to notify the patient of the abnormal results of the CBC test.

The gynecologist failed to ensure that the patient had otherwise established a plan of care to address the abnormal results of the CBC test.

On 5/28/2015, the patient presented to the gynecologist for an annual gynecological exam.  At the exam, it was determined that the patient was pregnant, and the gynecologist ordered blood tests for the patient.  The gynecologist failed to order a repeat CBC test.

On 7/17/2015, the gynecologist received and signed for the results of the repeat CBC test.  The repeat CBC test indicated that the patient’s white blood cell count had decreased further, the neutropenia had worsened, and she now had pancytopenia with a drop in the red blood cell and platelet count.

On 7/30/2015, the gynecologist notified the patient of the results of her repeat CBC test and referred her to a hematologist.

On 8/8/2015, the patient experienced a massive intracranial hemorrhage with herniation, as well as severe pancytopenia.

On 8/12/2015, the patient expired in the hospital.  The fetus was also lost at that point.

The Medical Board of Florida judged the gynecologists conduct to be below the minimal standard of competence given that she failed to ensure that the patient had been notified of the abnormal results of the CBC test.  The gynecologist failed to ensure that the patient had otherwise established, a plan of care to address the abnormal results of the CBC test.  The gynecologist failed to order a repeat CBC test at the patient’s May exam.

The Medical Board of Florida issued a letter of concern against the gynecologist’s license.  The Medical Board of Florida ordered that the gynecologist pay a fine of $8,500 against her license and pay reimbursement costs for the case at a minimum of $3,126.31 and not to exceed $5,126.31.  The Medical Board of Florida ordered that the gynecologist complete five hours of continuing medical education in “risk management.”

State: Florida


Date: December 2017


Specialty: Gynecology, Obstetrics


Symptom: N/A


Diagnosis: Hematological Disease, Intracranial Hemorrhage


Medical Error: Failure to follow up, Delay in proper treatment, Failure of communication with patient or patient relations


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



California – Gynecology – High Grade Dysplasia Scheduled For Follow Up In 6 Months



On 12/31/2013, a 27-year-old female had a pap smear that showed Atypical Squamous Cells of Undetermined Significance (ASCUS) with a positive showing for HPV.  On 1/30/2014, the patient presented to a gynecologist for colposcopy. Biopsies confirmed Cervical Intraepithelial Neoplasia (CIN) 2 at two biopsy sites, and CIN 1 at a single biopsy site with an insufficient endocervical curettage (ECC).

On 2/10/2014, the patient again presented to the gynecologist for a follow-up examination.  The gynecologist diagnosed the patient with Moderate Cervical Dysplasia, CIN 2, and advised the patient to follow-up in 1 year with a PAP/HPV examination.  On 2/28/2014, after speaking with a colleague, the gynecologist telephoned the patient and advised the patient to return in 6 months for an examination of the abnormal PAP.

The Medical Board of California judged that the gynecologist’s conduct departed from the standard of care because she failed to follow-up with the patient sooner than 6-12 months, and in light of the inadequate ECC, failed to proceed with either a diagnostic excisional procedure or an excision/ablation procedure to treat the high grade dysplasia known to the gynecologist.

The Medical Board of California issued a public reprimand and ordered the obstetrician to complete an education course (at least 15 hours) dedicated in the area of diagnosis and patient care in OB/GYN cases.

State: California


Date: August 2017


Specialty: Gynecology


Symptom: N/A


Diagnosis: Gynecological Disease


Medical Error: Delay in diagnosis


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Gynecology – Blood With Urination Not Due To Bleeding From Bladder Or Kidneys



On 4/5/2015, an 80-year-old female presented to a gynecologist with a complaint of pink drainage with urination.  The patient had a prior cystoscopy and a CT through the urology department, which was negative for hematuria. The gynecologist conducted an examination of the patient and noted: (1) no blood in the vagina; and (2) that the vaginal epithelium was atrophic.  The gynecologist did not order a pelvic ultrasound of the patient. The gynecologist failed to evaluate any postmenopausal bleeding with either an endometrial biopsy or an ultrasound of the uterus, and she failed to order or conduct any assessment to exclude malignancy.

On 2/21/2014, the patient was seen by a urologist for continued hematuria.  Cystoscopy was performed and revealed no bleeding from the bladder or kidneys.  On 2/25/2014, the patient was seen by another gynecologist who ordered a pelvic ultrasound that ultimately showed an intrauterine vascular mass.  On 3/3/2014, an endometrial biopsy was performed on the patient by a different provider, which showed adenocarcinoma.

The Medical Board of California judged that the gynecologist’s conduct departed from the standard of care because she failed to evaluate any postmenopausal bleeding with either an endometrial biopsy or an ultrasound of the uterus and to order or conduct any assessment to exclude malignancy.

The Medical Board of California issued a public reprimand and ordered the obstetrician to complete an education course (at least 15 hours) dedicated in the area of diagnosis and patient care in OB/GYN cases.

State: California


Date: August 2017


Specialty: Gynecology


Symptom: Bleeding


Diagnosis: Gynecological (Endometrial, Ovarian, Cervical) Cancer


Medical Error: Failure to order appropriate diagnostic test


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Gynecology – Hormone Replacement Therapy, A History Of Heart Disease, And Elevated Glucose Levels



On 5/16/2014, a 47-year-old female presented to a gynecologist for a routine gynecological exam.  The patient had a significant history of heart disease, including a quadruple bypass surgery in 2009.

The patient had complaints of hot flashes, inability to lose weight, insomnia, night sweats, irritability, and mild bladder leakage.  The gynecologist diagnosed the patient as menopausal.  The gynecologist recommended hormone replacement therapy.  He ordered hormone and thyroid level lab work.  He did not order tests for cholesterol levels or basic metabolic status, despite the patient’s metabolic lab result, dated 2/6/2012, indicating an abnormally high glucose level.

On 6/11/2014, the patient presented to the gynecologist for follow-up.  The gynecologist prescribed compounded creams containing the hormones estrogen, progesterone, and testosterone.  He also prescribed Armour Thyroid, a thyroid hormone replacement drug containing the hormones T3 and T4.

At all times material to this complaint, the prevailing standard of care dictated that a physician prescribing hormone replacement therapy to a patient with a significant history of heart disease obtain appropriate medical clearance prior to prescribing such therapies.

The gynecologist did not obtain medical clearance prior to prescribing hormone replacement therapy to the patient, despite a significant history of heart disease.

The prevailing standard of care dictated that a physician prescribing hormone replacement therapy to a patient with a prior abnormal glucose value order or obtain sufficient blood work prior to prescribing hormone replacement therapy.

The gynecologist did not obtain sufficient blood work prior to prescribing hormone replacement therapy to the patient, despite the patient’s prior abnormal glucose value.

At all times material to this complaint, the prevailing standard of care dictated that a physician discuss the full risks and benefits of hormone replacement therapy with the patient prior to initiating the treatment.  The gynecologist failed to discuss, or did not create or maintain adequate, legible documentation of discussing the full risks and benefits of hormone replacement therapy with the patient.

The Board issued a letter of concern against the gynecologist’s license.  The Board ordered that the gynecologist pay a fine of $5,000 against his license and pay reimbursement costs for the case for a minimum of $7,244.87 and not to exceed $9,244.87.  Also, the Board ordered that gynecologist complete ten hours of continuing medical education in “hormone replacement therapy” and five hours of continuing medical education in “risk management.”

State: Florida


Date: July 2017


Specialty: Gynecology


Symptom: Urinary Problems


Diagnosis: N/A


Medical Error: Failure to order appropriate diagnostic test, Failure of communication with patient or patient relations, Improper medication management


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Gynecologist – Complications After A Laparoscopic Assisted Vaginal Hysterectomy For Irregular Bleeding And Abdominal Pain



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



Florida – Gynecology – MRI Reveals Two Adjacent Large Intraperitoneal Complex Cystic Masses With Plan For Removal



On 11/19/2013, a 44-year-old female presented to a gynecologist for abdominal/pelvic discomfort.

The gynecologist performed an ultrasound and reported a “large ovarian cyst 14 cm in greatest extent… simple in nature.”  The gynecologist ordered additional imaging of the patient’s abdomen and pelvis to further evaluate the cyst.

The patient was scheduled for surgical removal of the cyst to be performed by the gynecologist on 11/27/2013.

On 11/22/2013, an MRI of the patient’s pelvis was performed, which indicated the presence of “two adjacent large intraperitoneal complex cystic masses.”

On 11/27/2013, preoperatively, the gynecologist indicated that he read the history and physical and examined the patient and that there were “no changes.”

After receiving and reviewing the MRI report, the gynecologist failed to further evaluate, or alternatively, did not create, keep, or maintain adequate legible documentation of evaluating, whether a malignancy was present.

Prior to the surgery on 11/27/2013, the gynecologist failed to discuss, or alternatively, did not create, keep, or maintain adequate legible documentation of discussing, with the patient her desired plan-of-care in the event that the cysts contained malignant cells.

The gynecologist attempted to remove the cysts laparoscopically, by intentionally puncturing and aspirating the cysts.  Prior to intentionally puncturing the cysts, the gynecologist did not place the cysts into a specimen bag to prevent contamination in the event that the cysts contained malignant cells.  During the procedure, the contents of the cysts spilled into the patient’s abdominal cavity.

Intraoperatively, the procedure was converted to a laparotomy and the gynecologist removed the patient’s left ovary in its entirety and sent it to pathology.  The pathology report indicated that the specimen was “of at least low malignant potential” indicating possible higher grade abnormality.

Accordingly, the gynecologist performed a total abdominal hysterectomy and removal of the right ovary.

The Board judged the gynecologist’s conduct to be below the minimal standard of competence given that he failed to further evaluate, preoperatively, to determine whether a malignancy was present, proceed with the correct surgical approach on 11/27/2013, by performing a laparotomy and removing the cysts intact, or by placing a specimen bag around the cysts prior to intentionally puncturing and aspirating the cysts, and discussing with the patient, preoperatively, to determine the patient’s desired plan-of-care for the possibility of malignancy.

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

State: Florida


Date: July 2017


Specialty: Gynecology


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


Diagnosis: Gynecological (Endometrial, Ovarian, Cervical) Cancer


Medical Error: Underestimation of likelihood or severity, Failure of communication with patient or patient relations, Procedural error


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Gynecology – Increased Pain, Hypotension, Tachycardia, And Tachypnea After Cesarean Section And Bilateral Tubal Ligation



On 7/26/2014, a gynecologist performed a Cesarean section and bilateral tubal ligation on a 32-year-old female.

At 10:30 a.m. on 7/26/2014, the patient complained of increased pain.  After she complained of pain, the patient’s vital signs began deteriorating.

At 1:45 p.m., the patient was transferred to the ICU and a rapid response call was placed to the gynecologist because the patient was diaphoretic, pale, and hypotensive.  From 1:45 p.m. to 2:30 p.m., the patient was hypotensive, tachycardic, and had an increased respiratory rate.

At 2:30 p.m., the gynecologist called the patient’s primary OB/GYN for a consultation regarding her condition.

At 2:45 p.m. the patient was intubated and received a transfusion of 2 L of blood.

At 3:30 p.m., the patient underwent an ultrasound examination that revealed a mild amount of free fluid in the patient’s upper abdomen.

At 4:10 p.m., the patient underwent a CT scan that indicated mild to moderate fluid in the patient’s abdomen, especially adjacent to the liver and along the right paracolic gutter.

Between 7:00 p.m. and 8:52 p.m., the patient received a transfusion of 4 L of blood.  Subsequent to that transfusion, the patient had a hemoglobin level of 8.3

At 9:42 p.m., the patient underwent an exploratory laparotomy that revealed an inferior epigastric bleed, which was repaired.

The Medical Board of Florida judged that the gynecologist did not properly assess, or did not create or maintain adequate documentation of properly 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’s intra abdominal bleed and hemorrhagic shock.  The gynecologist did not timely perform or order an exploratory laparotomy based on the patient’s pain and deteriorating vital signs.  He did not timely perform or order an exploratory laparotomy after the patient was intubated.  Also, the gynecologist did not recognize, or did not create or maintain adequate documentation of recognizing, that the fluid in the patient’s abdomen, in conjunction with the patient’s other symptoms indicated an intra abdominal bleed.  The gynecologist did not timely perform or order an exploratory laparotomy based on the fluid in the patient’s abdomen.  He did not create or maintain adequate progress notes related to his treatment of the patient or maintain adequate documentation elucidating a plan of treatment for the patient.  He did not create or maintain adequate documentation notes related to the 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


Symptom: Pain


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


Medical Error: Diagnostic error, Delay in proper treatment, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Gynecology – Bilateral Tubal Ligation Error Results In Complications Of Tachycardia, Hypotension, Respiratory Failure, And Hypotension



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



Wisconsin – Gynecology – Pregnancy Test Performed Prior To Hysterectomy Turns Positive



On 12/27/2012, a patient with a history of uterine fibroids by ultrasound, two laparoscopies for adhesiolysis with bladder injury, presented to Gynecologic Oncologist A with complaints of a pelvic mass and endometriosis.  It was noted that there was an enlarged tender mass on exam consistent with endometriosis and fibroids and that the patient wanted definitive surgical intervention.

The patient was scheduled for an elective robotic hysterectomy with bilateral salpingo-oophorectomy on 1/17/2013.  The patient was planned for pre-operative lab testing, including a pregnancy test, within 72 hours of the scheduled surgery date.

The patient presented on 1/15/2013 to have pre-operative labs drawn.  The lab results were logged into the patient’s chart the next day.  These lab results included a positive pregnancy test.  Registered Nurse A was responsible for collecting lab findings prior to the operation on a form.  On that form, the “pregnant” and “lactating” questions were answered with a “no.”

On the day of surgery, Registered Nurse B was responsible for reviewing physician orders and labs.  Registered Nurse C did not confirm the results of the patient’s pre-op pregnancy test.  Anesthesiologist A signed an anesthesia pre-op order form which called for a pregnancy test on all patients similar to the patient, unless specifically waived.  Anesthesiologist A did not obtain a waiver and did not confirm the results of the patient’s pre-op pregnancy test.

Gynecologic Oncologist A performed surgery on patient A, during which it was found that the patient was pregnant.

Anesthesiologist A and Gynecologic Oncologist A were deemed to have engaged in unprofessional conduct by engaging in conduct which increases the risk of danger to the health, welfare, or safety of a patient.

State: Wisconsin


Date: May 2017


Specialty: Gynecology, Anesthesiology


Symptom: Mass (Breast Mass, Lump, etc.), Gynecological Symptoms


Diagnosis: Gynecological Disease


Medical Error: Failure to follow up, Failure of communication with other providers, Lack of proper documentation, Procedural error


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



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