Found 144 Results Sorted by Case Date
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Florida – Obstetrics – Lack Of Maternal Serum Alpha-Fetoprotein Testing With Pregnancy Complications



On 2/24/2014, a 36-year-old female presented to an obstetrician for fatigue, breast tenderness, and absence of menstruation.  At the aforementioned visit, the obstetrician diagnosed the patient with amenorrhea and sent her to have blood work.

On 2/25/2014, the patient was notified of her positive pregnancy test.

On 3/10/2014, 3/17/2014, 3/24/2014. 4/24/2014, 8/7/2014, and 9/25/2015, the obstetrician ordered obstetrical ultrasounds and/or sonograms for the patient.

On 4/23/2014 and 8/20/2014, the patient presented to the obstetrician with thick vaginal fluid and blood discharge, morning sickness, nausea, chills, fever, and back pain.

On 5/23/2014, 6/20/2014, 7/16/2014, 8/15/2014, 9/12/2014, 10/13/2014, 10/20/2014, and 10/27/2014, the patient presented to the obstetrician for follow-up visits.

On 11/2/2014, the patient gave birth to her son, who was born with spina bifida/myelomeningocele.

The obstetrician failed to diagnose neural tube defect on imaging studies.

The obstetrician failed to order a maternal serum alpha-fetoprotein (MSAFP) test and did not maintain adequate legible documentation of ordering an MSAFP test.

The obstetrician failed to order an anatomical survey sonogram.

The Board ordered that the obstetrician pay a fine of $7000 against his license. The Board ordered that the obstetrician pay reimbursements costs of a minimum of $3,786.18 and not to exceed $5,786.18.  The Board also ordered that the obstetrician complete a course on “Quality Medical Record Keeping for Health Care Professionals” and that he  complete five hours of continuing medical education on “Risk Management.”

State: Florida


Date: December 2017


Specialty: Obstetrics


Symptom: Fever, Bleeding, Nausea Or Vomiting, Back Pain


Diagnosis: Obstetrical Complication, Spinal Injury Or Disorder


Medical Error: Failure to order appropriate diagnostic test, Failure to follow up, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


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 – Obstetrics – Induction For A Patient With A Bishop Score Of 4 And Continued Pitocin Use Despite Fetal Heart Tracing Abnormalities



A 24-year-old female was transferred from a physician to an obstetrician.  The patient first saw the obstetrician on 6/24/2009, and she was due with her first child in July 2009.  Her patient chart listed her at 120 lbs and 4’0” tall, but when she came to see the obstetrician, she weighed 170 lbs.

The patient was seen by the obstetrician twice in June and every week in July until 7/27/2009.  The patient was scheduled to be induced 7/29/2009. There was nothing in the records about her bony pelvic exam or pelvic adequacy for vaginal delivery.  The obstetrician did not do an ultrasound. The patient was admitted to the hospital on 7/29/2009. There was no risk assessment, no estimate fetal size, no ultrasound ordered, and a Bishop score of 4.

The patient was started on Pitocin at 9:30 a.m. and had made no progress by 6:00 p.m. that evening.  The patient was allowed to rest, and the next morning, on 7/30/2009 at 7:30 a.m., Pitocin was started again.  During this time, it was noted that she had “reactive” fetal heart tracings. The nurses did not place an order for an internal fetal monitor.  When the fetal heart tones were low, the Pitocin should be turned off. If the mother keeps having contractions, the baby gets no rest, which is what likely occurred in this case.

At 8:18 p.m., she was only dilated 4-5 cm.  The patient had spontaneous rupture of the membranes with thick meconium noticed.  At 8:50 p.m., the patient was dilated to 8 cm, 0 station. There was no mention of a possible Cesarean section in the notes.  On 7/31/2009, a female infant weighing 9 lbs 5 oz was delivered using a vacuum because a shoulder dystocia was encountered. Unfortunately, the baby was deceased.

The Medical Board of California judged that the obstetrician’s conduct departed from the standard of care because he failed to estimate the fetal size, fetal lie, and pelvic adequacy.  The obstetrician also did not mention the application of a fetal electrode. This is important because the obstetrician did not know if the heart rate was coming from the mother or the baby; thus, an internal electrode would have been an accurate way to measure the baby’s heart rate.  Review of the fetal monitor strips showed back to back contractions and inadequate recordings. During labor and delivery, Pitocin should have been stopped in the contractions showed a low fetal heart rate and tachysystole (no rest between contractions). This patient was also a poor candidate for induction because she had a Bishop score of 4.  When the membranes were ruptured with 3+ meconium, this should have alerted the obstetrician that the baby was somehow compromised and action by the obstetrician was required. Also, the patient was a transfer patient, but the obstetrician did not order lab studies or an ultrasound. There were many errors which lead to the untimely demise of this baby.  Had there been an estimate of fetal weight, or an ultrasound performed within 6 weeks of induction of labor, the obstetrician would have known the patient was having a big baby, and the obstetrician might have performed a Cesarean section.

The Medical Board of California issued a public reprimand and ordered the obstetrician to complete a clinical competence assessment program.

State: California


Date: November 2017


Specialty: Obstetrics


Symptom: N/A


Diagnosis: Obstetrical Complication


Medical Error: Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Failure to properly monitor patient, Improper treatment, Improper medication management


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Florida – Obstetrics – Obstetrician Unavailable During Labor With Fetal Heart Decelerations



On 1/24/2014 a 21-year-old female presented to a hospital with spontaneous rupture of membranes and meconium-stained amniotic fluid at about thirty-nine weeks of pregnancy.

Upon admission, the patient was placed on a fetal monitor, which documented variable decelerations of the fetal heart rate.  In response to the monitor tracings, an obstetrician ordered the administration of intravenous fluids.  Shortly thereafter, the obstetrician ordered the performance of an amnioinfusion.

Over the next couple of hours, the fetal monitor began documenting recurrent late fetal heart rate decelerations and loss of fetal heart rate variability, indicative of probable insufficient fetal oxygenation.  The obstetrician was notified of the recurrent late fetal heart rate decelerations and loss of fetal heart rate variability.

In response to the monitor tracings, the obstetrician ordered the rate of IV fluid administration increased.  Despite the monitor tracings indicating probable fetal distress, the obstetrician did not diagnose, or did not document diagnosing, fetal intolerance to labor and allowed the trial of labor to continue.

At some point in time between 6:15 p.m. and 7:30 p.m., the obstetrician decided to manage the trial of labor from outside of the hospital.  Based on the patient’s presentation, the obstetrician should have continued to manage the trial of labor, in person, at the hospital. The fetal monitor continued to document recurrent late fetal heart rate decelerations and a loss of fetal heart rate variability over the next several hours.  The obstetrician was notified of the recurrent late fetal heart rate decelerations and loss of fetal heart rate variability on multiple occasions during that time span.  Despite the monitor tracings indicating probably continued fetal distress, the obstetrician did not promptly return to the hospital to deliver the baby.

Shortly after midnight on 12/25/2014, the obstetrician was again notified of the recurrent late fetal heart rate decelerations and loss of fetal heart rate variability.  At 1:28 a.m., the obstetrician returned to the hospital, presented to the delivery room, and shortly thereafter delivered the baby.

The baby was in full cardiac arrest at the time of delivery.  Efforts to resuscitate the baby were abandoned after about 20 minutes.  The final diagnosis was stillborn.

The obstetrician did not dictate or write any progress notes during the trial of labor.

The Board judged the obstetrician’s conduct to be below the minimum standard of competence given that she failed to diagnose fetal intolerance to labor, manage the trial of labor, in person, at the hospital, and promptly return to the hospital and deliver the baby upon receiving continued reports of probably fetal distress.

The Board ordered that the obstetrician pay a fine of $5,000 against her license and pay reimbursement costs for the case at a minimum of $3,949.77 and not to exceed $5,949.77.  The Board also ordered that the obstetrician complete five hours continuing medical education in the area of obstetric medicine and five hours of continuing medical education in “Risk Management.”

State: Florida


Date: November 2017


Specialty: Obstetrics


Symptom: N/A


Diagnosis: Obstetrical Complication


Medical Error: Diagnostic error, Failure to properly monitor patient, Lack of proper documentation


Significant Outcome: Death


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Obstetrics – Excessive And Unindicated Antepartum Testing Performed Over the Course Of A Pregnancy



Between May 2011 and December 2011, an obstetrician provided obstetric services to a 16-year-old female and followed the course of her pregnancy.

The patient had an estimated delivery date of 12/1/2011 and ultimately delivered her baby on 12/1/2011.

On 5/5/2011 and 5/19/2011, the obstetrician performed first-trimester ultrasounds on the patient to monitor the patient’s fetus.

On 6/17/2011, the obstetrician performed a second-trimester ultrasound on the patient to monitor the patient’s fetus.

On 10/11/2011, the obstetrician performed a third-trimester ultrasound on the patient to monitor the patient’s fetus.  The patient’s fetus was in the 29th percentile for growth, which was normal.

On 10/20/2011, the obstetrician performed a third-trimester ultrasound on the patient to monitor the patient’s fetus.  The patient’s fetus was in the 44th percentile for growth, which was normal.

There was no indication for the third-trimester ultrasound that the obstetrician performed on the patient on 10/20/2011.

On 10/28/2011, the obstetrician performed a biophysical profile with ultrasound on the patient and her fetus in order to monitor the patient’s fetus.

The indications documented for the biophysical profile with ultrasound that the obstetrician performed for the patient and her fetus on 10/28/2011 were intrauterine growth restriction and “size less than dates.”  Both intrauterine growth restriction and “size less than dates” were ruled out by the ultrasound conducted on 10/11/2011 and 10/20/2011.

There was no indication for the biophysical profile with ultrasound that the obstetrician performed on the patient and her fetus on 10/28/2011.

On 11/4/2011, the obstetrician performed a biophysical profile with ultrasound on the patient and her fetus in order to monitor the patient’s fetus.  The indications documented for the biophysical profile with ultrasound that the obstetrician performed on the patient and her fetus on were intrauterine growth restriction and “size less than dates.”

Both intrauterine growth restriction and “size less than dates” were ruled out by the ultrasound conducted on 10/11/2011 and 10/20/2011, and the biophysical profile performed on 10/28/2011.

There was no indication for the biophysical profile with ultrasound that the obstetrician performed on the patient and her fetus on 11/4/2011.

On 11/11/2011, the obstetrician performed a third-trimester ultrasound on the patient to monitor the patient’s fetus.  The patient’s fetus was in the 34th percentile for growth, which was normal.  There was no indication for the third-trimester ultrasound the obstetrician performed on the patient on 11/11/2011.

On 11/18/2011, the obstetrician performed a third-trimester ultrasound on the patient to monitor the patient’s fetus.  The patient’s fetus was in the 68th percentile for growth, which was normal.  There was no indication for the third-trimester ultrasound that the obstetrician performed.

The standard of care required that the obstetrician adequately manage the patient’s pregnancy through the use of only indicated antepartum testing and to refrain from performing excessive and unindicated antepartum testing.

It was requested that the Board order one or more of the following penalties for the internist: 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: October 2017


Specialty: Obstetrics


Symptom: N/A


Diagnosis: N/A


Medical Error: Unnecessary or excessive diagnostic tests


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Obstetrics – Missed Indicators Of A Neural Tube Defect



On 2/24/2014, a 36-year-old female presented to an obstetrician for fatigue, breast tenderness, and absence of menstruation.  At the aforementioned visit, the obstetrician diagnosed the patient with amenorrhea and sent her to have blood work.

On 2/25/2014, the patient was notified of her positive pregnancy test.

On 3/20/2014, 3/17/2014, 3/24/2014, 4/24/2014, 8/7/2014, and 9/25/2015, the obstetrician ordered obstetrical ultrasounds and/or sonograms on the patient.

On 4/23/2014 and 8/20/2014, the patient presented to the obstetrician with thick vaginal fluid and bloody discharge and/or morning sickness, nausea, chills, fever, and back pain.

On 5/23/2014, 6/20/2014, 7/16/2014, 8/15/2014, 9/12/2014, 10/13/2014, 10/20/2014, and 10/27/2014, the patient presented to the obstetrician for follow-up visits.

On 11/2/2014, the patient gave birth to her son.  The child was born with a neural tube defect called spina bifida/myelomeningocele.

The obstetrician failed to observe on imaging studies, and follow-up on, known indicators that the patient’s child may have had a neural tube defect, or alternatively, did not create, keep, or maintain adequate legible documentation of observing on imaging studies, and following up on known indicators that the patient’s child may have had a neural tube defect.

The obstetrician failed to order maternal serum alpha-fetoprotein (MSAFP) test, or alternatively, did not create, keep, or maintain adequate legible documentation of ordering a MSAFP test.

The obstetrician failed to order an anatomical survey sonogram, or alternatively, did not create, keep, or maintain adequate legible documentation of ordering an anatomical survey sonogram.

It was requested that the Board order one or more of the following penalties for the obstetrician: 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: August 2017


Specialty: Obstetrics


Symptom: Weakness/Fatigue, Bleeding, Abnormal Vaginal Discharge, Back Pain


Diagnosis: Neurological Disease


Medical Error: Failure to order appropriate diagnostic test, Failure to follow up, Lack of proper documentation


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 1


Link to Original Case File: Download PDF



New York – Physician Assistant – Lack Of Lab Work For Routine Visit For A 37-Year-Old Female



On 11/3/2008, a 37-year-old female presented to a physician assistant for a physical and PAP smear.  During the examination, the physician assistant performed a pelvic examination and found normal female genitalia without lesion or discharge.  A PAP smear was obtained without incident.  The physician assistant’s examination of the patient’s abdomen revealed the abdomen was soft and nontender.  The physician assistant’s plan was to reassess the patient in three months unless otherwise indicated.

The physician assistant did not order the patient to undergo any lab work, such as an hCG test.

On 11/12/2008, the patient presented to the hospital with a full-term pregnancy and delivered a baby on the same date.

The Board judged that the physician assistant’s medical care of the patient deviated from accepted standards of care given failure to recognize signs of pregnancy.

State: New York


Date: July 2017


Specialty: Physician Assistant, Family Medicine, Internal Medicine, Obstetrics


Symptom: N/A


Diagnosis: N/A


Medical Error: Failure to order appropriate diagnostic test, Failure to examine or evaluate patient properly


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Obstetrics – Disregarding Patient’s Desire For Cesarean Section And Concerning Fetal Heart Rate Tracings



On 8/27/2010, a patient came under an obstetrician’s care and treatment for prenatal and obstetric care.  The patient, a 41-year-old Spanish-speaking primigravida in the third trimester of pregnancy, had not been receiving prenatal care prior to August 2010.

Previously, on 8/10/2010, she had been seen at the hospital for complaints of decreased fetal movement and was discharged after being reassured of fetal well-being by an ultrasound examination.  She had also returned to the hospital on 8/24/2010 and was discharged with a diagnosis of early latent labor and instructions to establish care with an obstetrician.  At her initial visit with the obstetrician, an estimated delivery date of 9/21/2010 was established by a third trimester ultrasound.  The patient was examined and given instructions on counting fetal kicks and labor precautions and was given an order for laboratory tests.

On 8/30/2010, the patient returned with complaints of pelvic pressure.  Her cervix was closed but 50% effaced and the fetal head had descended from -3 position to -1.  Although it is not documented in the obstetrician’s chart, the patient and her partner reported that they had advised the obstetrician of the patient’s desire for delivery by Cesarean section when the time came.  The patient was told to return in one week.

On 9/4/2010, the patient presented to the hospital in spontaneous labor.  She stated that contractions had started at approximately 4:00 a.m.  At 11:30 a.m., the cervix was approximately 6 cm dilated, 100% effaced, with the vertex at -2 station.  The patient was admitted by another physician, who contacted the obstetrician to take over intrapartum management.

The obstetrician arrived and assumed responsibility for the care and labor management of the patient.  In the obstetrician’s note timed 2:00 p.m., she recorded a fetal heart rate (“FHR”) of 145 beats per minute (“bpm”), with moderate variability and no decelerations.  The obstetrician noted that excellent progress in labor had been made and she anticipated a spontaneous delivery.

The obstetrician’s next note is timed at 4:30 p.m. and states that the patient had an epidural placed and was comfortable.  The FHR was reported as 145 bpm with moderate variability and accelerations and the fetal tracings were, overall, consistent with a classification of Category I, i.e., with no specific action required.  Contractions were 2-3 minutes apart.  The cervical exam was anterior lip, 100% effaced, zero station.  In her progress note timed 4:30 p.m. – albeit the obstetrician indicated that the labor was progressing well – the obstetrician documented her plan for oxytocin augmentation of labor.

The patient began pushing at approximately 5:00 p.m., with contractions coming every 1-2 minutes, at which time the obstetrician found the cervix to be complete with the head at zero to +1 station.  At this point, the tracing showed moderate variability, but recurrent variable decelerations with contractions and pushing effort.  This was consistent with Category II, i.e., requiring evaluation, continued surveillance, reevaluation and possibly ancillary tests to assure fetal well-being.  Oxytocin was increased to 6 mU/min.  During the approximate period of 5:00 p.m. to 5:40 p.m., the patient was pushing while the obstetrician coached her in Spanish.  By approximately 5:30 p.m., the fetal heart rate baseline became tachycardic and the variable decelerations more deep and prolonged.  A nurse who was present at the time noted that there were multiple late and variable decelerations and she advised the obstetrician of this.  Although it is not charted, the nurse recalled that the patient repeatedly stated that she wanted a Cesarean section, but that the obstetrician urged her to continue pushing.

At approximately 5:40 p.m., the obstetrician was called away to attend a delivery for another patient whose obstetrician was still en route to the hospital.  According to her notes, she returned at approximately 6:20 p.m.  The fetal heart tracing progressively worsened, with continued tachycardia and gradual loss of variability until, at approximately 6:40 p.m., variability is absent from the tracing.  At this point in time, the fetal heart tracing was consistent with Category III, i.e., associated with abnormal fetal acid-base status, requiring immediate evaluation, expeditious efforts to resolve the abnormal FHR pattern and, failing resolution, expedited delivery.

At 7:00 p.m., the obstetrician noted that the FHR decreased “to 60’s” for 5-6 minutes.  At that time, the obstetrician reported that she was advised there was not an available operating room, so she instructed the patient to stop pushing and had the patient change positions.  The obstetrician discontinued the oxytocin at 7:02 p.m. and terbutaline was administered at approximately 7:12 p.m.  Despite these efforts to improve the fetal status, the FHR did not improve to the point that it could be considered reassuring.

The patient was moved to the operating room at about 7:22 p.m. and arrived at 7:25 p.m.  She consented in Spanish to a vacuum-assisted delivery, with the possibility of Cesarean section.  Two attempts with the Mityvac, each approximately 20 seconds, were made at 7:34 p.m. and 7:35 p.m. without fetal descent.  The anesthesiologist arrived at about the time of the second attempt.  A Cesarean section was called by the obstetrician at 7:37 p.m.  The incision was made at 7:45 p.m. and the infant delivered at 7:47 p.m.  The obstetrician described the infant as having poor tone and pale color after delivery.  The anesthesiology note states that the infant was not crying and was not breathing.  An emergency intubation was performed, and the infant was taken to the newborn intensive care unit (“NICU”).  Apgar scores were 2, 3, and 5.

The Board judged the obstetrician’s conduct as having fallen below the standard of care for the following reasons:

1) The obstetrician failed to recognize non-reassuring fetal heart tracings consistent with abnormal fetal acid-base status.

2) The obstetrician failed to undertake appropriate steps to expedite delivery in the circumstance of Category III fetal heart tracing that had not resolved despite steps to improve fetal status.

3) The obstetrician prescribed oxytocin when the labor pattern was adequate and continued administration after the fetal heart tracing had developed to a Category III.

4) The obstetrician failed to perform a Cesarean section in response to the patient’s request and the non-reassuring fetal testing in the second stage of labor.

The Board issued a public reprimand against the obstetrician with stipulations to complete a clinical competence assessment program.

State: California


Date: June 2017


Specialty: Obstetrics


Symptom: N/A


Diagnosis: Obstetrical Complication


Medical Error: Procedural error, Diagnostic error, Improper medication management


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Obstetrics – Breast Biopsy For Small, Smooth, Mobile Lump In Patient’s Right Breast



A patient was born on 4/3/1993.  Between February 2011 and September 2012, she presented to an obstetrician.

On 6/29/2011, the obstetrician found a small, smooth, mobile lump in the patient’s right breast.

On 7/18/2011, the obstetrician performed a right breast biopsy on the patient.  The obstetrician noted that the right breast lump was likely a fibroadenoma.  The biopsied right breast tissue was found to be benign.

The Medical Board of Florida judged the obstetricians conduct to be below the minimal standard of competence given that he failed to medically manage the patient’s right breast lump with breast exams, breast sonographies, and/or mammograms.   The obstetrician’s performance of a right breast biopsy on the patient was medically unnecessary.

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

State: Florida


Date: May 2017


Specialty: Obstetrics


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


Diagnosis: N/A


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


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Emergency Medicine – Pregnant Patient With Abdominal Pain And Green Pelvic Discharge Diagnosed With Cervicitis And Urinary Tract Infection



On 3/24/2015, a 22-year-old female presented to an ED physician in the emergency department with complaints of abdominal pain.

The ED physician ordered the patient to undergo a urine pregnancy test and, based on the results, diagnosed her with pregnancy.

The ED physician ordered that the patient undergo a pelvic ultrasound, after performance of which the technician advised the ED physician the fetus estimated gestational age was thirty-five weeks and six days.  The ED physician performed a pelvic examination of the patient which revealed abnormal green discharge.

The ED physician ordered the patient undergo further urinalysis and based on the results, diagnosed her with cervicitis and urinary tract infection.

The ED  physician failed to consider possible premature rupture of membranes.  He also failed to consider possible premature labor.

The ED physician prescribed parenteral and oral antibiotics to the patient and discharged her home.

The patient’s medical condition required further emergent evaluation by an obstetrician.  The ED physician failed to arrange or failed to document arranging for transfer of the patient to an obstetrician for further evaluation.

On 3/25/2015, the ultrasound report was read by the radiologist whose impressions included: single live intrauterine pregnancy, a large disparity in estimated age based on measurements, and potential premature rupture of membranes.

Following an examination, the patient was emergently transferred to the labor and delivery department where the baby was delivered stillborn.

The Medical Board of Florida issued a letter of concern against the ED physician’s license.  The Medical Board of Florida ordered that the ED physician pay a fine of $10,000 against his license and pay reimbursement costs for the case at a minimum of $4,445.91 and not to exceed $6,445.91.  The Medical Board of Florida also ordered that the ED physician complete five hours of continuing medical education in the area of high-risk emergency medicine, complete a medical records course, and complete five hours of continuing medical education in “risk management.”

State: Florida


Date: April 2017


Specialty: Emergency Medicine, Obstetrics


Symptom: Abdominal Pain, Abnormal Vaginal Discharge


Diagnosis: Obstetrical Complication


Medical Error: Diagnostic error, Referral failure to hospital or specialist, Lack of proper documentation


Significant Outcome: Death, Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



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