Found 144 Results Sorted by Case Date
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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



California – Obstetrics – Postpartum Hemorrhage Diagnosed As Uterine Atony



On 1/15/2014, an obstetrician performed a Cesarean section on a patient.  The obstetrician documented no complications and a 600 ml blood loss.  Shortly after reaching the recovery room, the patient began vaginally hemorrhaging postpartum from what was diagnosed as uterine atony.  The obstetrician determined the patient was unstable and would need to return to the operating room (OR) after administering fluids and blood products and conducting a uterine massage.  Once in the OR, the patient was stabilized, yet continued persistent vaginal bleeding.  The decision was made by the obstetrician to reopen the abdomen and explore the prior Cesarean section.  After inspecting the uterus, the obstetrician made the determination that a supracervical hysterectomy was necessary.

A supracervical hysterectomy was performed by the obstetrician and another physician.  Once completed, a bimanual exam showed ongoing bleeding from the cervix.  An unsuccessful attempt was made to control the bleeding.  At this point, the determination was made to remove the cervix through the abdominal incision and a full hysterectomy was performed by the obstetrician and another physician. After the second surgery, the patient was taken to recovery in stable condition.

A discharge summary of the patient showed both placenta accreta and placenta increta in the endometrium and upper myometrium.

When the patient began hemorrhaging postpartum, the obstetrician appropriately returned to the patient’s bedside and examined her and ordered fluids and blood products as she alerted staff that the patient would need to return to the OR.

Once in the OR, however, the obstetrician failed to attempt more conservative therapies, including B-lynch suture, intrauterine balloon, uterine artery ligation, hypogastric artery ligation, and dilation and curettage.  There is no documentation that the obstetrician considered these options or ruled them out as potential actions prior to performing a hysterectomy on the patient.

On 6/7/2016, the obstetrician underwent an evaluation by a Board appointed psychiatrist.  The psychiatrist concluded that the obstetrician suffers from Major Depressive Disorder, Recurrent, and an Unspecified Anxiety Disorder, conditions that impair her ability to safely practice medicine.

The obstetrician was placed on probation for three years with stipulations to complete 40 hours annually for each year of probation of continuing medical education, complete a medical record keeping course, and undergo psychotherapy.

State: California


Date: March 2017


Specialty: Obstetrics


Symptom: Bleeding


Diagnosis: Obstetrical Hemorrhage


Medical Error: Improper treatment, Lack of proper documentation, Practicing while not being sound physically or mentally


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Obstetrics – Postpartum Bleeding Following Early Labor In A Patient With A History Of Anemia



On 9/7/2012 at 8:00 p.m., a 27-year-old female presented to a medical center with a complaint of early labor.  The patient had a history of anemia.

At 8:50 p.m., a biophysical profile was ordered for the patient due to heart tracing concerns for the fetus.

By the time the patient arrived back from her biophysical profile, she was found to have made cervical changes from 1-½ cm to 4 cm, and she then very rapidly went from 4 cm to 9 cm.

At 11:15 p.m., the patient’s membranes were artificially ruptured and meconium stained fluid was obtained.  At this time, the cervix was now completely dilated.

At 11:55 p.m., an obstetrician applied a fetal scalp lead to better evaluate the monitor tracing.

At 12:15 a.m., the obstetrician then called in additional medical personnel and proceeded to apply a Kiwi vacuum extractor.

At 12:17 a.m., a second vacuum was applied and at 12:27 a.m. a third vacuum was applied.

At 12:27 a.m., the fetus was delivered with the baby weight 9 pounds and 8 ounces

The patient then experienced a severe postpartum hemorrhage, and the obstetrician inspected the cervix and found there to be no lacerations.  The obstetrician used appropriate medications to cause the uterus to clamp down.

At 12:45 a.m., the obstetrician repaired episiotomy and third-degree perineal laceration, and the uterus was still boggy in spite of the medications. The bleeding continued.

At 1:00 a.m., the uterus was described as firm, the bleeding had decreased and the patient was sleepy but responsive.

At 1:15 a.m., the patient had a steady trickle of lochia resulting in the obstetrician being called back into the room.

At 1:20 a.m., the obstetrician performed a repair of laceration.

At 1:25 a.m., the patient was administered a Foley catheter per the obstetrician’s instructions.

At 1:35 a.m., following repair of the laceration, the patient was bleeding dark blood vaginally.  Additionally, the patient was hypotensive and lethargic.

Sometime after 1:35 a.m. but before 2:10 a.m., the obstetrician left the hospital.

At 2:00 a.m., the patient continued to bleed vaginally, small to moderately.

At 2:10 a.m., the patient’s family called medical staff to the room due to the patient “acting funny” as the patient was lying on her stomach and moving her legs and moaning that she was hurting but would not say where.

At 2:10 a.m., the patient was noted to have bloody fluid in the Foley catheter.

The obstetrician was not present in the hospital at the time.  The obstetrician was informed of the patient’s behavior and the continuation of her steady trickle of blood.

At 2:25 a.m., a registered nurse stayed in the room with the patient as the patient became more combative and a large amount of blood poured from the patient’s vagina.

At 2:25 a.m., the obstetrician was called to return to the hospital.

At an unidentified time, the obstetrician was called again to ensure she was on her way back to the hospital.

At 2:55 a.m., the obstetrician arrived back in the hospital room with the patient.

At 3:14 a.m., the patient became unresponsive and a code blue was called.  The patient experienced cardiac arrest and cardiopulmonary resuscitation was started.

At 6:03 a.m., the patient was pronounced dead.

The Medical Board of Florida judged the obstetricians conduct to be below the minimal standard of competence given that she failed to determine the source of the bleeding for the patient who had been bleeding heavily after a vaginal delivery.  The obstetrician failed to transfer the patient to the operating room for evaluation. She also failed to remain at the physical location of the hospital to monitor the patient who had been bleeding continuously.

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 her 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: February 2017


Specialty: Obstetrics


Symptom: Abnormal Vaginal Bleeding


Diagnosis: Obstetrical Hemorrhage


Medical Error: Underestimation of likelihood or severity, Failure to examine or evaluate patient properly, Failure to properly monitor patient


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Arizona – Obstetrics – Pregnancy With Elevated Blood Pressure And Proteinuria



On 02/02/2015, a 37-year old-woman was evaluated for vaginal bleeding in the emergency department.

On 02/04/2015, she established care with an obstetrician.  She had received prenatal care on two prior occasions from other providers.  An ultrasound was performed and a sub-chorionic hemorrhage was identified along with fibroids.  Blood pressure was noted to be 139/79.

On 03/18/2015, she was noted to have elevated blood pressure at an appointment with the obstetrician.

On 04/14/2015, the blood pressure was elevated and 2+ protein was present.  The obstetrician sent the patient to her family practitioner for evaluation, and the family practitioner then sent the patient to the hospital, where she was treated with labetalol and discharged with no further evaluation.

On 04/16/2015, the patient was seen at the obstetrician’s office with continued significantly high blood pressure.  The obstetrician ordered a 24-hour urine and pregnancy induced hypertension labs.  The patient then went home.

On 04/17/2015, the lab studies showed significant abnormalities consistent with severe pregnancy induced hypertension.  The patient went to the hospital.  She subsequently had an intrauterine fetal death at approximately 22 weeks gestation with delivery.

The Board judged obstetrician’s conduct to be below the minimum standard of competence given failure to evaluate the patient for preeclampsia with a history and physical, serial blood pressure evaluations, and laboratory studies.  He failed to admit the patient to a hospital for treatment.

The Board ordered the obstetrician be reprimanded, be placed on probation for a period of 6 months, and take 5 hours of CME in hypertensive disorders in pregnancy.

State: Arizona


Date: February 2017


Specialty: Obstetrics


Symptom: Gynecological Symptoms


Diagnosis: Preeclampsia


Medical Error: Diagnostic error


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



Massachusetts – Obstetrics – Postpartum Bleed With Difficulty Identifying The Source Of Bleed



At 12:35 a.m. on 4/2/2009, an obstetrician performed an unscheduled Cesarean section on a patient who began to bleed heavily after birth.  The obstetrician incorrectly identified the major source of bleeding as a uterine tear.  The obstetrician failed to properly administer medications to stop the bleeding pursuant to a uterine hemorrhage protocol.  The obstetrician failed to obtain assistance until between 2:00 and 2:15 a.m.  A trauma resident arrived at 2:30 a.m. and another physician from the obstetrician’s practice arrived at 2:45 a.m., who repaired a laceration of the uterine artery.

Ultimately, the Board revoked the obstetrician’s license.

State: Massachusetts


Date: January 2017


Specialty: Obstetrics


Symptom: Bleeding


Diagnosis: Obstetrical Hemorrhage


Medical Error: Procedural error, Delay in proper treatment, Diagnostic error, Improper treatment


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



North Carolina – Obstetrics – Delay In The Management Of Progressive Proteinuria And Hypertension



The Board reviewed the care rendered by an obstetrician who submitted an application to the North Carolina Medical Board.

The Board obtained patient records regarding a specific patient and sent them to a qualified independent medical expert for review.

The independent medical expert judged the obstetrician’s conduct to be below the minimum standard of competence.  The expert raised concern that the delivery should have occurred sooner in light of the patient’s progressive proteinuria and hypertension.  Patient monitoring was deficient and abnormal labs were not addressed.  The management of the patient’s hypertension was deficient.  The neurological assessments following delivery were inadequate.  Lastly, the use of NSAID for pain control was inappropriate.  The expert believed that the seriousness of the patient’s situation was not recognized.

The Board issued a public letter of concern, which was reported to the Federation of State Medical Boards.  It was not reported to the National Practitioner Data Bank.

State: North Carolina


Date: December 2016


Specialty: Obstetrics


Symptom: N/A


Diagnosis: Obstetrical Complication


Medical Error: Delay in proper treatment, Failure to properly monitor patient


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Obstetrics – Pregnancy And Delivery Complicated With Obesity, Hypertension, Shoulder Dystocia, Variable Decelerations, And Meconium



A 17-year-old obese female first presented to an obstetrician on 11/9/2008.  The patient was pregnant for the first time. Her estimated gestational age was 15 weeks and 4 days.  The patient saw the obstetrician on several occasions during the ensuing 5 months. The patient’s last prenatal visit was on 4/17/2008.  On that day, the patient had a markedly elevated blood pressure of 178/108. The obstetrician did not immediately schedule an induction of labor or otherwise address the patient’s hypertension.

On 4/18/2008, the patient was admitted to the hospital.  There was no documentary evidence that the obstetrician advised the patient to admit herself on that day.  On 4/19/2008, a vacuum assisted vaginal delivery was performed by the obstetrician. The hospital records showed that the head of the patient’s newborn son was delivered in the occiput anterior position at 6:40 p.m.  The patient’s newborn son’s body followed approximately 3 minutes later, concluding 1 hour 13 minutes of second stage of labor. A median episiotomy was cut.

The delivery was complicated by shoulder dystocia, variable decelerations, and meconium.  The patient’s newborn son was admitted to the NICU due to respiratory distress and meconium aspiration syndrome, which required intubation and ventilation.  The applicable standard of care requires that a physician and surgeon, in the course of rendering prenatal care, identify and address all high-risk factors including but not limited to risk factors for shoulder dystocia and the development of gestational hypertension and/or preeclampsia.  The applicable standard of care requires that when considering an operative vaginal delivery, as was done in this case, the physician and surgeon advise the patient of the risks, benefits, and other available options. Also, upon recognizing a shoulder dystocia, the physician and surgeon should institute six different measures rapidly: 1) discontinue oxytocin, 2) cease application of forces, 3) instruct the mother to cease pushing, 4) lower the head of the bed, 5) call for assistance, and 6) start a clock.

The Medical Board of California judged that the obstetrician’s conduct departed from the standard of care because she failed to schedule the patient for immediate induction of labor or otherwise address the patient’s markedly elevated blood pressure on 4/17/2008, address or document that she addressed the high-risk factors, advise the patient of the risks, benefits, and other available options for a successful delivery, assess or document that she assessed the estimated fetal weight, station, position, and the application of negative pressure necessary to carry out a successful operative vaginal delivery, and institute the six measures to be followed upon recognizing a shoulder dystocia.

The Medical Board of California placed the obstetrician on probation for 35 months and ordered the obstetrician to complete a medical record-keeping course and an education course for at least 40 hours for every year of probation.

State: California


Date: November 2016


Specialty: Obstetrics


Symptom: N/A


Diagnosis: Obstetrical Complication


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


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Obstetrics – Preeclampsia Pregnancy Complicated By Postpartum Abdominal Pain And Vaginal Discharge



An obstetrician was a physician supervisor for a nurse midwife who was following a patient’s prenatal course through spring and summer 2013.  At the 39 weeks gestation visit, the midwife recorded the patient’s blood pressure as 131/90.  At the next week’s visit, the patient’s blood pressure was measured at 186/101 and her proteinuria was 3+.  The midwife was apparently monitoring the patient for preeclampsia.

There was no indication that the obstetrician was actively supervising the high-risk patient.  The midwife elected to induce labor to address the evolving preeclampsia.  The consequent labor resulted in a vaginal delivery of the patient’s healthy baby in hospital on 8/15/2013.

The obstetrician was called in after the delivery and performed a manual removal of the placenta and a postpartum curettage under general anesthesia.  Over the course of the delivery and postpartum surgery, the patient lost 2-3 liters of blood and her hematocrit level dropped from 41 to 27.  The patient was discharged from the hospital two days after the birth.

Fourteen days later the patient presented with complaints of abdominal pain and vaginal discharge.  The obstetrician treated the patient on an outpatient basis, prescribing oral antibiotics.  The patient’s symptoms did not improve and she was seen in the emergency department, where she was given the first intravenous dose of a long-acting antibiotic.  The patient underwent a diagnostic ultrasound the following day, which was read as revealing “retained products of conception.“

The obstetrician immediately performed another dilation and curettage; the pathology report found “inflamed decidua” but no placental tissue.  The patient was prescribed additional oral antibiotics and discharged from the hospital.  She returned four days later with continuing abdominal pain; physical examination found peritoneal irritation.  She was admitted to the hospital with a diagnosis of peritonitis.  The patient was treated with intravenous antibiotics and improved quickly.  She was released symptom-free from the hospital three days after admission.

The Board judged the obstetrician’s conduct as having fallen below the minimum level of competence given his failure to adequately supervise the midwife’s prenatal monitoring of the patient’s severe preeclampsia and his failure to have a plan of hospital admission if the antibiotics used to treat the patient’s abdominal pain and vaginal discharge two weeks postpartum were unavailing.

For this allegation and others, the Board ordered the obstetrician be placed on probation for a period of three years, complete 40 hours of continuing education per year of probation, enroll in a clinical or educational program equivalent to the Physician Assessment and Clinical Education Program (PACE), be prohibited from supervising any physician assistants, and have a practice monitor assigned to him.

State: California


Date: November 2016


Specialty: Obstetrics


Symptom: Bleeding, Abdominal Pain


Diagnosis: Preeclampsia, Acute Abdomen


Medical Error: Failure to properly monitor patient, Referral failure to hospital or specialist


Significant Outcome: Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



Arizona – Obstetrics – Failure To Thoroughly Evaluate Possibility Of Rupture Of Membranes Leads To Birth Complications



The Board was notified of a malpractice settlement involving the treatment of a 33-year-old woman.

On 12/24/2010, a patient presented to determine whether she had experienced a rupture of membranes for 11 hours.  Her history included a positive GBS (Group B Streptococcus) culture.  Nursing staff evaluated her and reported to the obstetrician that she had not experienced a rupture of membranes.

The medical records document that a digital vaginal examination was performed by the nursing staff, but do not indicate that other testing was done.  The obstetrician was in the hospital but did not personally see the patient or examine her.  The obstetrician did not review the fetal tracing at the time.  Upon later review, the respondent noted “variables” along with hyper-variability of which she was not informed.

The patient returned the following morning with chorioamnionitis and was delivered by Cesarean section.  The infant died due to sepsis, hypoxic ischemic encephalopathy, and disseminated intravascular coagulation.

The Board judged obstetrician’s conduct to be below the minimum standard of competence given failure to perform a thorough evaluation and obtain an ultrasound when there was a question of rupture of membranes.

The Board ordered the obstetrician to be reprimanded.

State: Arizona


Date: November 2016


Specialty: Obstetrics


Symptom: N/A


Diagnosis: Obstetrical Complication


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


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



Kansas – Obstetrics – Administering Vaccines In A Pregnant Patient Without Consent



On 3/6/2013, a patient presented for a newborn screening. No pregnancy or labor and delivery history were documented.  A family history was documented; however, no detail of family history was documented.  The patient was not seen until eleven days after discharge.

On 7/3/2013, the patient presented to the obstetrician for her four month well exam.  At that appointment, the patient was administered the following vaccines: Hib, PEDIARIX, PCV 13, and Rota.  No consent form for the aforementioned vaccines was found in the record.

On 9/10/2013, the patient presented to the obstetrician for her six-month exam.  The obstetrician electronically signed the record on 9/27/2013, approximately seventeen days later.

The Board judged the obstetrician’s conduct to be below the minimum standard of competence given his failure to describe the services rendered to the patient.

The Board ordered that the obstetrician attend and successfully complete the Medical Record Keeping Seminar at Center for Personalized Education for Physicians (“CPEP”). Also, the Board ordered that the obstetrician hire a medical scribe. Finally, the Board ordered that the obstetrician have another obstetrician monitor his work.

State: Kansas


Date: October 2016


Specialty: Obstetrics


Symptom: N/A


Diagnosis: N/A


Medical Error: Failure of communication with patient or patient relations, Ethics violation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



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