Found 11 Results Sorted by Case Date
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California – Gastroenterology – Complication During Endoscopy With Colonoscopy For Nausea, Vomiting, And Epigastric Pain After Bone Marrow Transplant



On 11/17/2011, a 56-year-old female underwent a colonoscopy performed by a gastroenterologist.  The patient had undergone a bone marrow transplant for chronic lymphocytic leukemia.  After the procedure, the patient complained of nausea, vomiting, and epigastric pain.  An endoscopy was performed the prior day to rule out graft versus host disease or cytomegalovirus infection and the colonoscopy was a part of that procedure.

The gastroenterologist performed the coloscopy to the terminal ileum.  The patient was sedated with midazolam 8 mg IV, fentanyl 175 micrograms IV, and diphenhydramine 50 mg IV in divided doses as the patient exhibited any signs of discomfort.  Biopsies and cultures were obtained and submitted for evaluation.  Pathology results indicated apoptosis of the ileum and right colon, but negative findings for CMV.

During the course of the colonoscopic procedure, full sedation was not achieved.  The patient became drowsy, but she became fully awake during the procedure more than once, complained of pain, and asked that the procedure be stopped.  The gastroenterologist continued and completed the procedure despite the patient’s urgent requests.

The Board issued a public reprimand against the gastroenterologist.  Stipulations included continuing medical education in the topics of pre-operative patient evaluation, informed consent, sedation, and medical record keeping.

State: California


Date: May 2017


Specialty: Gastroenterology, Anesthesiology, Hematology


Symptom: Abdominal Pain, Nausea Or Vomiting


Diagnosis: Post-operative/Operative Complication, Hematological Disease


Medical Error: Procedural error


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Pediatrics – Fourteen-Year-Old Male With A Hemoglobin Of 8.2



On 7/30/2013, a 14-year-old male was seen by a pediatrician for a well-child assessment.  The pediatrician reviewed the patient’s height, weight, temperature, and blood pressure and administered hearing and vision tests.  She reviewed the patient’s development, including body image, home situation, education, school progress, risk-taking behaviors, sexuality, and mental health.  A complete physical examination was performed.

On 7/30/2013, the patient received a routine HPV immunization.  Routine diagnostic laboratory tests were ordered, including urinalysis.  A hemoglobin test by finger stick was performed.  The patient’s urinalysis test result was normal, but his hemoglobin result of 8.2 was significantly lower than normal.  The pediatrician repeated the hemoglobin test by finger stick but did not order a complete blood count by venipuncture.  The patient’s hemoglobin result was again 8.2.  The pediatrician started the patient on iron supplement therapy and instructed him to follow up in three months.  No additional diagnostic tests were done during this visit.

On 8/18/2013, the clinic received a report that the patient was experiencing shortness of breath and chest pain.  The patient was instructed to go to an emergency room.

At the emergency room, the patient experienced a full cardiac arrest.  His complete blood count revealed severe anemia, with a hemoglobin result of 7.5, a hematocrit of 21, 99 atypical lymphocytes, and a critically low platelet count of 39,000.  The patient’s cause of death was acute lymphoblastic leukemia/lymphoma.

The Board deemed the pediatrician’s level of conduct to be below the standard of care given failure to order a complete blood count by venipuncture for the follow-up blood test, failure to schedule a visit and lab check at an earlier date, and failure to consider other diagnoses in addition to iron deficiency anemia.

The Board issued a public reprimand against the pediatrician.  Stipulations included performing sixty hours of free services to a community or a non-profit organization, conducting 40 hours of continuing medical education, enrolling in a professionalism program, and undergoing a clinical competency assessment program.

State: California


Date: May 2017


Specialty: Pediatrics, Hematology


Symptom: Shortness of Breath, Chest Pain


Diagnosis: Cancer, Hematological Disease


Medical Error: Failure to order appropriate diagnostic test, Delay in proper treatment


Significant Outcome: Death


Case Rating: 5


Link to Original Case File: Download PDF



California – Pathology – Biopsies Of Patient’s Eleventh, Twelfth, And Thirteenth Thoracic Vertebrae To Evaluate Fractures



On 2/21/2013, a patient had biopsies of his eleventh, twelfth, and thirteenth thoracic vertebrae to evaluate fractures.  On 3/2/2013, a pathologist reviewed the biopsies.  The pathologist provided a diagnosis of no malignancy.  He reviewed slides H and E in making his diagnosis.

In July 2013, slides H and E were sent to an outside laboratory and the outside laboratory determined that the patient suffered from myeloma, a malignant tumor of the bone marrow.  Further immunohistochemistry was conducted which confirmed the diagnosis of myeloma.

The pathologist failed to recognize that a mid to elderly patient with vertebral fractures could be suffering from myeloma and failed to observe the findings on the slides that indicated the presence of myeloma.

Based on this case and others, the Board revoked the pathologist’s license and placed him on probation for 35 months with stipulations that the pathologist complete at least 40 hours of continuing medical education in the areas of deficient practice and undergo monitoring.

The Board restricted the pathologist’s practice in clinical pathology with the terms that the restriction could be put in abeyance once he found a clinical proctor to proctor him on 50 clinical pathology cases.

State: California


Date: September 2016


Specialty: Pathology, Hematology, Internal Medicine


Symptom: N/A


Diagnosis: Cancer, Hematological Disease


Medical Error: False negative


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Pathology – Incorrect Differentiation Between Myeloblasts And Basophilis On Flow Cytometry Analysis In Chronic Myelogenous Leukemia



On 5/18/2011, a hematopathologist reported on his review of a patient’s peripheral blood that was sent for flow cytometry in a case of chronic myelogenous leukemia (CML).  In his final diagnosis, the hematopathologist reported “Approximately 15-20% myeloblasts. Together with high leukocyte count, basophilia, and eosinophilia, circulating blasts are consistent with chronic myelogenous leukemia in accelerated phase, tending to myeloid blast crisis. Recommend bone marrow study including cytogenetics for confirmation of diagnosis.”  The hematopathologist found that there were two abnormal populations and each represented myeloblasts: population (a) comprising 6-7% of the total cells, and population (b) comprising 11-12% of the total cells.  However, a review of the flow cytometric histograms revealed that while population (a) represented true myeloblasts, which were positive for CD34, population (b), in fact, represented basophils.  Population (b) had all the characteristics of basophils including level of CD45 expression (at a level between the lymphocytes and true blasts), low side scatter, CD11b expression, and negativity for HLA-DR.  The hematopathologist erroneously grouped this population of basophils with myeloblasts.  Based upon this error, the reporting of the number of blasts was incorrect, 15-20% instead of the correct range of 6-7%.

Chronic myelogenous leukemia has three phases: the chronic phase, the accelerated phase, and the blast phase (blast crisis).  The flow cytometric studies showed 6-7% blasts, and the correct classification of disease was the chronic phase.  The hematopathologist incorrectly classified the disease as being in the accelerated phase tending to blast.  The hematopathologist failed to recognize basophils in the flow cytometric study and confused the basophil population with blast population.  In his report, he counted basophils as a second population of blasts, and consequently, he reported the number of blasts at 15-20%, which was significantly higher than the correct number of 6-7%.  This resulted in the hematopathologist incorrectly classifying the disease.  Based upon this incorrect classification of the disease as aggressive tending to blast crisis, more aggressive treatment was incorrectly indicated for the patient.

The hematopathologist’s failure to recognize basophils by flow cytometric analysis in the case of the patient represented incompetence and/or inadequate and/or inaccurate record-keeping for a hematopathologist.

For this case and others, the Medical Board of California issued a public reprimand and ordered the hematopathologist to complete a medical record-keeping course.

State: California


Date: April 2015


Specialty: Pathology, Hematology


Symptom: N/A


Diagnosis: N/A


Medical Error: Diagnostic error


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Pathology – Interpreting Immunohistochemical Stains To Diagnose Either Classical Hodgkin’s Lymphoma Or EBV-Positive DLBCL



A hematopathologist incorrectly interpreted a patient’s disease (in the biopsy of the patient’s right neck lymph node) as classical Hodgkin lymphoma, when in fact, the patient had EBV-positive diffuse large B-cell lymphoma (DLBCL).

On 3/12/2011, another physician originally diagnosed the patient with EBV-positive DLBCL.  Then, on 4/11/2011, the hematopathologist re-evaluated the patient, and he believed the patient’s condition to be classical Hodgkin lymphoma, but pending outside consultation.  On 5/16/2011, the case was sent to another consulting physician, who diagnosed the patient with EBV-positive DLBCL.  The hematopathologist then issued an addendum after expert consultation.

However, the hematopathologist’s original report made on 4/11/2011 exhibited incompetence and/or inadequate and/or inaccurate record-keeping in its morphologic assessment and interpretation of the immunohistochemical stains in this case.  His interpretation of the immunohistochemical stains was incorrect with respect to certain key stains including CD15 and CD30 leading to the wrong diagnosis of classical Hodgkin lymphoma.  The hematopathologist disregarded sheets of CD20 large lymphoid cells in this case.  A few of the large cells were CD30 positive, which was an activation marker, but the majority of the neoplastic cells were negative for CD30.  CD15 was negative in neoplastic cells while scattered benign histiocytes were positive for Cd15.  Yet, the hematopathologist reported both stains (CD15 and CD30) as strongly positive in neoplastic cells.  The hematopathologist dismissed significant morphologic findings and instead concentrated on a few less important ones.  The hematopathologist’s report demonstrated that he had put too much emphasis on scattered and few CD30+ activated large B-cells and interpreted benign histocytes as CD15+ neoplastic cells.  At the same time, the hematopathologist failed to pay enough attention to numerous CD20+ large B-cells seen in sheets.

For this case and others, the Medical Board of California issued a public reprimand and ordered the hematopathologist to complete a medical record-keeping course.

State: California


Date: April 2015


Specialty: Pathology, Hematology


Symptom: N/A


Diagnosis: Cancer


Medical Error: Diagnostic error


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Wisconsin – Hematology – Anemia, Leukocytosis, And Thrombocytosis



A 63-year-old man presented to his primary care physician with anemia.  He was sent to hematologist A.  Hemoglobin was noted to be 7.6, WBC 17.7, platelet count 847, iron level 15, TIBC 189, iron saturation 8%, and ferritin 587.

He was diagnosed with iron deficiency and treated with ferrous sulfate and vitamin C.

3 weeks later, he presented to hematologist B who ordered a bone marrow biopsy and diagnosed myeloproliferative disorder.

State: Wisconsin


Date: September 2014


Specialty: Hematology, Internal Medicine, Oncology


Symptom: N/A


Diagnosis: Cancer


Medical Error: Failure to order appropriate diagnostic test


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Washington – Family Medicine – Methotrexate In The Elderly For Psoriasis



On 8/2/2012, an 86-year-old woman asked her family practitioner for a dermatology referral because of persistent severe psoriasis on the back of her hands and around her ears.  The patient had a history of skin disorders, hypothyroidism, depression, and a fifty-year smoking habit.  The family practitioner did not refer the patient to a dermatologist.  Instead, the family practitioner prescribed methotrexate 7.5 mg to be taken three times a week.

Methotrexate is a cancer medicine which can be prescribed to treat psoriasis if other therapies are ineffective.  The family practitioner noted that the patient should have lab work performed in two months to monitor her blood cell counts which can be adversely affected by methotrexate.  However, the family practitioner failed to order the lab work.  The family practitioner also failed to direct office staff to schedule the patient’s follow-up office visit even though the family practitioner continued to authorize methotrexate prescription refills.

On 11/7/2012, the patient contacted the family practitioner’s office to make an appointment to have a skin rash on her backside treated.  The patient also believed she should have her annual lab work performed.  The family practitioner informed the patient that the annual lab work scheduled in March 2013 would be adequate.  The family practitioner did not discuss methotrexate-related lab work.

At the 11/15/2012 office visit, the family practitioner treated the skin rash on the patient’s backside with topical cream.  The family practitioner also documented in the chart notes that the patient’s psoriasis improved with methotrexate.  The family practitioner made no reference in the chart notes about methotrexate-related lab work.

On 11/19/2012, the patient called the family practitioner’s office complaining of sore throat, cough, and streaks of blood in the saliva.  A nurse advised the patient to gargle with salt water and to seek care if fever or pain persisted.

On 11/26/2012, the patient went to the hospital because she continued to experience mouth bleeding.  The treating hospital physician suggested possible pharyngitis, though throat cancer could not be ruled out.  The physician advised the patient to follow up with her primary care provider.

On 11/29/2012, the patient had a follow-up visit where the family practitioner diagnosed oral candidiasis and treated the patient with oral medication.  The family practitioner had concerns about possible oral cancer because of the patient’s lifelong smoking habit.  The family practitioner documented the patient’s assessment plan to include smoking cessation and continued oral medication for her throat pain.  The family practitioner noted that the patient’s psoriasis had excellent improvement with methotrexate but the family practitioner made no reference to methotrexate-related lab work.

Between January 2013 and March 2013, the patient developed lesions and ulcers in her mouth and throat.  It is unclear if the patient communicated directly with the family practitioner during this time frame but the medical records indicate that the family practitioner continued to approve methotrexate prescription refills without indication for follow-up lab work or other monitoring.

On 3/27/2013, the patient presented to another clinic because of progressively painful mouth lesions and symptoms of pneumonia.  The clinic physician ordered lab work and referred the patient to an oncologist for an evaluation of pancytopenia.

On 3/28/2013, the oncologist noted that the patient’s lab work report indicated substantially low blood counts possibly caused by advanced leukemia or myelodysplasia.  He planned to perform a bone marrow biopsy and admitted the patient to the hospital.  After discussing concerns with the hospitalist, the oncologist discovered that the patient neglected to list methotrexate as one of her regular medications.  Both the oncologist and hospitalist determined the patient suffered from pancytopenia caused by chronic methotrexate use.  The patient remained hospitalized for two weeks and underwent treatment for methotrexate toxicity.  The patient’s blood cell count improved after discontinuing methotrexate.

On 4/18/2013, the patient was discharged from the hospital.  She returned to the oncologist for follow-up care.  The family practitioner, unaware of the patient’s hospitalization and transfer of care to another provider, continued to authorize methotrexate medication refills through November 2013.

The Commission stipulated the family practitioner reimburse costs to the Commission and write and submit a paper of at least 1000 words regarding appropriate methotrexate treatment of psoriasis in geriatric patients by primary care physicians.

State: Washington


Date: September 2014


Specialty: Family Medicine, Hematology, Internal Medicine


Symptom: Cough, Bleeding


Diagnosis: Drug Overdose, Side Effects, or Withdrawal


Medical Error: Failure to properly monitor patient


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



Wisconsin – Oncology – Patient With Leukemia On Chlorambucil Found To Have Renal Failure



A 68-year-old man with chronic lymphocytic leukemia, splenomegaly, and acute renal failure presented to a hematologist.

Oral chlorambucil was initiated.  The hematologist conducted no further testing for the renal failure.  He had hoped that chlorambucil would treat the leukemia and consequently resolve the renal failure.  However, it is noted that leukemia is rarely the cause of renal failure, and one would not expect renal failure to resolve with leukemia treatment.

Subsequently, the patient did not get appropriate treatment for his renal failure.

State: Wisconsin


Date: September 2014


Specialty: Oncology, Hematology


Symptom: N/A


Diagnosis: Renal Disease, Cancer


Medical Error: Improper treatment


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Wisconsin – Oncology – Small Bowel Neuroendocrine Tumor With Metastasis To The Liver



A 66-year-old man presented to a hematologist with a small bowel neuroendocrine tumor that had metastasized to the liver.

Cisplatin and etoposide were initiated.  Pancytopenia developed.

The Oncology Department determined that chemotherapy was not warranted.

Appropriate therapy was deemed symptom management alone.

State: Wisconsin


Date: September 2014


Specialty: Oncology, Hematology


Symptom: N/A


Diagnosis: Drug Overdose, Side Effects, or Withdrawal


Medical Error: Improper medication management


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Wisconsin – General Surgery – Hernia Repair For An Obese Patient With An Upper Respiratory Infection



On 02/15/2008, a 58-year-old obese woman was referred to the general surgeon for an endoscopy and a colonoscopy, during which the general surgeon found a large right lower quadrant incisional hernia.  A large segment of the right colon was in the hernia sac, but the patient was only occasional symptomatic.

On 05/16/2008, the patient returned to see the general surgeon to arrange for a repair, which was scheduled on 06/19/2008.

On 06/12/2008, the patient phone her primary care physician to report a sinus infection with yellow drainage.  Her primary care physician prescribed doxycycline 100 mg twice a day.  On 06/16/2008, the patient went to her primary care physician wondering if she should cancel the surgery given worsening sinus congestion, drainage, and fullness.  She was prescribed azithromycin for an upper respiratory tract infection and told to inform the general surgeon if she did not improve within 48 hours.  The patient did not contact the general surgeon prior to 06/19/2008, the date of the elective surgery.

On 06/19/2008, the patient reported for surgery.  The intake nurse’s note indicates that the patient was getting over a sinus infection.  The general surgeon documented that the patient’s head, ears, eyes, nose, and throat were within normal limits on exam.  The nurse anesthetist noted that the patient had sinusitis.  Labs were normal and the patient was afebrile.

The general surgeon performed incisional hernia repair with mesh, after which the patient went home.  That evening, the patient fell off the edge of a bed and became unresponsive momentarily.  She went to the emergency department where she was diagnosed with syncope secondary to nausea and vomiting.  The general surgeon was notified of this admission, but he did not treat her during it.

On 06/22/2008, the patient was discharged and prescribed amoxicillin/clavulanate 875 mg twice a day for 10 days for acute sinusitis.

On 07/03/2008, the patient presented to the general surgeon for follow up and reported pain after eating.  The general surgeon performed an ultrasound of the gallbladder.

On 07/10/2008, the general surgeon saw the patient, who reported persistent lethargy and lightheadedness.  Abdominal exam revealed an obvious subcutaneous fluid collection in the area of the patient’s previous hernia.

On 07/11/2008, a CT abdomen was ordered, and the radiologist’s report noted the following: “Large 5×10 cm fluid collection subcutaneous tissues right side lower abdomen.  Within the intra-abdominal wall, more ill-defined 5x5cm focus containing multiple air bubbles.  Conceivably this could represent an abscess.”

On 07/14/2008, the patient was admitted to the hospital by the general surgeon for post-operative abscess.  The general surgeon’s admitting history and physical stated the following:

The patient underwent a CT scan of the abdomen last Friday, which showed fluid collection felt to possibly represent postoperative infectious process versus seroma.  The patient was started on a Z-Pak for treatment of chronic sinusitis and this was felt to potentially cover any postoperative infectious process and decision was made in conjunction with the patient to see how she did on the oral antibiotics.  Over the weekend, the pain has grown progressively worse with right-sided abdominal swelling near her previous incision, increased abdominal pain, fevers and shaking chills…”

The general surgeon ordered IV metronidazole and IV piperacillin/tazobactam.  Deep vein thrombosis prophylaxis was not ordered.  The general surgeon ordered drain placement, which was performed by the interventional radiologist.

On 07/15/2008, the general surgeon ordered a CT scan.  The radiologist noted: “When compared to the previous study on July 11, the size of the superficial fluid collection has increased, although there is a drainage catheter in place…”  The radiologist also documented:

IMPRESSION:  Significant inflammation both deep and superficially at the ventral hernia repair site in the right lower quadrant as detailed above, with a large complex fluid collection superficially containing an indwelling drainage catheter; the deeper inflammatory process containing a small amount of fluid but more significantly containing fat and air without a definite or significant drainable component.  Communication between the two is indeterminate at this time.

On 07/16/2008, the general surgeon incised and drained the superficial fluid collection in the patient’s hospital room.

On 07/17/2008, CT scan revealed an anterior fluid collection (which went from 17.7 cm x 5.8 cm to 14.3 cm x 3.1 cm in size) and an internal abdominal fluid collection (which went from 6.2 cm to 6.1 cm in length).

On 07/18/2008, the general surgeon removed the mesh, which was found to be infected.  Intraoperatively, the anesthesiologist had difficulty ventilating the patient.  After surgery, the patient was placed on sequential compression devices for deep vein thrombosis.  She was continued on the mechanical ventilator given concern for respiratory failure secondary to residual sedative effects from perioperative medications, morbid obesity, and effects of the surgery.

On 07/19/2008, the patient self-extubated and was initiated on enoxaparin for deep vein thrombosis by another physician.

On 07/21/2008, enoxaparin was discontinued when heparin-induced thrombocytopenia was suspected.  Lepirudin was initiated for anticoagulation.  The patient appeared to improve, but on the following day, she died from pulmonary embolism after being repositioned in bed.

The Board judged care to have fallen below minimum standards of competence given that the general surgeon failed to defer elective surgery given the sinus infection and failed to order deep vein thrombosis prophylaxis on admission.

In June 2012, the general surgeon attended a conference called “Abdominal Wall Reconstruction” sponsored by Georgetown University Hospital for 8.5 hours of continuing medical education credit.  He was reprimanded by the Board and ordered to pay a fine.

State: Wisconsin


Date: August 2012


Specialty: General Surgery, Family Medicine, Hematology, Hospitalist, Internal Medicine


Symptom: Dizziness, Weakness/Fatigue


Diagnosis: Acute Abdomen, Hematological Disease, Pulmonary Embolism


Medical Error: Improper treatment


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



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