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Florida – Orthopedic Surgery – Documentation Error Of Laceration Of Flexor Pollicis Longus Leads To Wrong Site Surgery
On 5/16/2014, a patient presented to an orthopedic outpatient surgery center with a left-hand work-related injury. During the visit, an orthopedic surgeon properly diagnosed the patient with a flexor pollicis longus (FPL) tendon laceration of her left thumb.
The FPL tendon laceration was confirmed by the MRI scan performed on the patient on 7/3/2014.
On 8/7/2014, during the follow-up visit, the orthopedic surgeon wrongly documented the patient’s injury as an extensor pollicis longus (EPL) tendon laceration in the patient’s medical records
Consequently, on 9/10/2014, the patient presented to the orthopedic surgeon at the center, for an EPL tendon surgery (the wrong site, and/or medically unnecessary procedure) of her left thumb. During the EPL tendon surgery, the orthopedic surgeon realized that the FPL tendon laceration repair should have been performed on the patient instead. On 10/10/2014, the orthopedic surgeon performed the FPL tendon laceration repair on the patient’s left thumb.
The Board ordered the orthopedic surgeon pay a fine of $3,000 to the Board. Also, the Board ordered the orthopedic surgeon pay a reimbursement cost of $4,670.40. The Board ordered that the orthopedic surgeon complete five hours of continuing medical education in “Risk Management.” The Board ordered that the orthopedic surgeon complete one hour of lecture on wrong site procedure.
State: Florida
Date: December 2017
Specialty: Orthopedic Surgery
Symptom: N/A
Diagnosis: Musculoskeletal Disease, Trauma Injury
Medical Error: Wrong site procedure, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Orthopedic Surgery – Damage To Inferior Vena Cava And Other Complications After Guidewire Improperly Placed In Disk Space
On 12/24/2014, a 59-year-old female was admitted to a medical center for a Microscopic Extraforaminal Lumbar Discectomy of L4-L5. An orthopedic surgeon was assigned to perform the patient’s procedure. He began the procedure by utilizing image intensification to use a guidewire for initial placement of dilators in the patient’s spine.
After removal of the guidewire, the orthopedic surgeon noted that he felt the guidewire had gone into the disk space slightly.
After sixty percent of the procedure was completed, the orthopedic surgeon was advised by the anesthesiologist that there was a decrease in the patient’s CO2. It was subsequently noted that the patient’s blood pressure began to drop.
The orthopedic surgeon then placed an OpSite over the patient’s incision, turned the patient to a supine position, and called for assistance from a vascular surgeon.
On 12/24/2014, after becoming hypotensive and then experiencing pulseless electrical activity during the lumbar discectomy, the patient underwent an exploratory laparotomy with repair of inferior vena cava injury.
During the exploratory laparotomy, after approximately one hour of cardiopulmonary resuscitation and advanced cardiac life support protocol, the patient expired on the operating table.
At all times relevant to this case, the prevailing professional standard of care requires that when dealing with patients such as this one, a physician should place instruments into a patient’s body in a manner to do the least possible harm.
The Board judged the orthopedic surgeons conduct to be below the minimal standard of competence given that he allowed an instrument to pass into the patient’s cavity in such a way that injured underlying structures and by failing to recognize the penetration of the guidewire at the time of placement of the initial dilator, which lead to the injury of the patient’s inferior vena cava.
It was requested that the Board order one or more of the following penalties for the orthopedic surgeon: 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: Orthopedic Surgery
Symptom: N/A
Diagnosis: Post-operative/Operative Complication, Spinal Injury Or Disorder
Medical Error: Procedural error
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF
Florida – Neurosurgery – Laminectomy Performed On The Patient’s L3-L4 Level Instead of L4-L5 Level
In March 2016, a 72-year-old male sought treatment from a neurosurgeon for low back pain. The neurosurgeon diagnosed the patient with lumbar spondylosis and lumbar spinal stenosis.
Informed consent was obtained from the patient for an L4-L5 laminoforaminotomy for the decompression of the spinal cord and partial medial facetectomy.
On 3/23/2016, the neurosurgeon performed a laminectomy at the patient’s L3-L4 level (wrong site) rather than at the L4-L5 level (correct site).
Approximately three months after the surgery, the patient saw his primary care physician because his back pain had returned. The patient’s primary care physician obtained an MRI on 7/6/2016. The MRI results revealed spinal stenosis at the patient’s L4-L5 level and post-operative changes at the L3-L4 level.
After reviewing the patient’s post-surgery MRI, the neurosurgeon realized that she performed the procedure at the L3-L4 level.
It was requested that the Board order one or more of the following penalties for the neurosurgeon: 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: Neurosurgery, Orthopedic Surgery
Symptom: Back Pain
Diagnosis: Spinal Injury Or Disorder
Medical Error: Wrong site procedure
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
Florida – Neurosurgery – Laminotomy And Foraminotomy Performed At One Level Lower Than Intended
On 12/9/2015, a patient presented to a neurosurgeon at the Laser Spine Institute with complaints of lower back pain and bilateral lower leg pain.
The neurosurgeon reviewed a previous MRI result for the patient which indicated that the patient had a lumbarized sacrum, foraminal stenosis at L5-S1 bilaterally, and L4-5 facet hypertrophy.
The neurosurgeon also reviewed previous nerve root block results, which indicated 20% relief at L5 and 80% relief when performed at L4-5.
The neurosurgeon recommended that the patient undergo a right laminotomy and foraminotomy at the L4-5 level.
On 12/11/2015, the patient returned for the recommended procedure. The neurosurgeon performed a right laminotomy and foraminotomy on the patient at what he thought was the L4-5 previously identified at the 12/9/2015 visit.
The neurosurgeon relied on intraoperative imaging to find the operative level.
Due to the patient’s vertebral anatomy, on 12/11/2015, the neurosurgeon actually performed the procedure one level below the level he previously identified on the 12/9/2015 visit. The level the neurosurgeon performed the procedure was the incorrect site and was not the site the neurosurgeon identified as the operative level at the 12/9/2015 visit.
On 2/24/2016, the neurosurgeon performed a second right laminotomy and foraminotomy on the patient, this time at the correct site, which was one level above the surgery he performed on 12/11/2015, and the same level he identified at the 12/9/2015 visit.
It was requested that the Board order one or more of the following penalties for the neurosurgeon: 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: Neurosurgery, Orthopedic Surgery
Symptom: Back Pain, Extremity Pain
Diagnosis: Spinal Injury Or Disorder
Medical Error: Wrong site procedure
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
Florida – Pediatrics – Deep Laceration Of The Right Knee Treated With Debridement, Irrigation, And Suturing
On 12/7/2011, an 8-year-old male presented to a medical emergency department with a deep laceration to his right knee. The laceration was a full thickness cut with visualization of the capsule. An x-ray revealed air in the knee joint.
A pediatrician examined the patient’s knee and performed debridement, cleaning by irrigation, and suturing of the laceration. Bacitracin and dressing were applied to the patient’s knee.
On 12/10/2011, the patient returned to the emergency department with complaints of right knee swelling, redness, and pain. The patient was admitted to the pediatric floor.
Further examination revealed septic arthritis in the patient’s right knee, which required two operations and the introduction of a PICC line for long-term antibiotic therapy. The patient sustained cartilage damage as a result of the septic arthritis and suffered from significant knee pain.
The Board judged the pediatrician’s conduct to be below the minimal standard of competence given that he failed to refer the patient to an orthopedic surgeon and to fully wash out the patient’s joint by performing an open debridement under anesthesia.
The Board issued a letter of concern against the pediatrician’s license. The Board ordered the pediatrician to pay a fine of $10,000 against his license and pay reimbursement costs at a minimum of $5,496.59 and not to exceed $7,496.59. The Board also ordered that the pediatrician complete ten hours continuing medical education in pediatric orthopedic diagnosis and treatment and complete five hours of continuing medical education in “risk management.”
State: Florida
Date: June 2017
Specialty: Pediatrics, Orthopedic Surgery
Symptom: Joint Pain, Swelling
Diagnosis: Trauma Injury, Septic Arthritis
Medical Error: Improper treatment, Referral failure to hospital or specialist
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 4
Link to Original Case File: Download PDF
North Carolina – Orthopedic Surgery – Wrong Site Surgery When Performing Arthrodesis Of The Left Great Toe
The Board was notified of a professional liability payment made on 8/30/16.
A patient presented to an orthopedic surgery for arthrodesis of her left great toe. In preparing the patient for surgery, the orthopedic surgeon stated that he did not see the markings on the left leg, given that they had been covered by stockings. The orthopedic surgeon erroneously prepared the patient for surgery on the right toe based on what he believed he saw on the x-ray. Despite performing appropriate timeout procedures, none of the surgical team appreciated the error until the end of the procedure.
The Board expressed concern that the orthopedic surgeon’s conduct was below the standard of care. The Board acknowledged that the orthopedic surgeon implemented several practice improvement procedures in response to this event.
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: June 2017
Specialty: Orthopedic Surgery
Symptom: N/A
Diagnosis: Musculoskeletal Disease
Medical Error: Wrong site procedure
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
North Carolina – Orthopedic Surgery – Wrong Site Surgery Of A Piriformis Tendon Release
The Board was notified of a professional liability payment paid on 6/21/16.
The Board expressed concern that the orthopedic surgeon performed a left sided sciatic neuroplasty and piriformis tendon release on the wrong side of the patient. The orthopedic surgeon indicated that all pre-operative verification procedures and timeouts were conducted, including placing a mark on the intended surgical site. In spite of these precautions, everyone in the room failed to recognize that the patient had been turned on the wrong side. The error was not recognized until the completion of the patient’s procedure.
The Board noted that the orthopedic surgeon implemented several further practice improvement policies in response to the event.
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: June 2017
Specialty: Orthopedic Surgery
Symptom: N/A
Diagnosis: N/A
Medical Error: Wrong site procedure
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
Florida – Pain Management – Infection Of Left Prosthetic Knee Following Injections Of Zeel And Traumeel With Bupivacaine
On 9/15/2011, a 57-year-old male presented to a pain management specialist with complaints of knee pain in his prosthetic knees.
On 10/13/2011, the pain management specialist established a treatment plan to obtain x-rays of the patient’s knees and refer him to an orthopedic surgeon for evaluation of his prosthetic knees.
The pain management specialist failed to review, or document reviewing, x-rays of the patient’s prosthetic knees. He also failed to refer the patient to an orthopedic surgeon for evaluation of his knee pain, per his treatment plan.
On 2/2/2012, the pain management specialist injected Zeel and Traumeel (both homeopathic products) with bupivacaine into the patient’s prosthetic left knee.
The pain management specialist did not create or maintain records documenting an examination of the patient’s left knee for the 2/2/2012 appointment.
On 2/8/2012, the pain management specialist performed a second injection of Zeel and Traumeel with bupivacaine into the patient’s prosthetic left knee. He did not create or maintain records documenting an examination of the patient’s left knee for the 2/8/2012 appointment.
Shortly after the second injection, the patient’s left knee began to swell, and on 2/21/2012, he presented to an orthopedic institute with complaints of pain, swelling, and redness.
An orthopedic surgeon admitted the patient to a hospital for further evaluation. At the hospital, the patient was diagnosed with acutely infected left total knee arthroplasty and, on 2/25/2012, underwent surgery to remove part of the left knee prosthesis, insert an antibiotic disc and PICC line, and begin IV antibiotics.
The Medical Board of Florida judged the pain management specialists conduct to be below the minimal standard of competence given that he should not have injected homeopathic substances into the patient’s prosthetic left knee and he did not refer the patient to an orthopedic surgeon for evaluation of his left knee pain.
It was requested that the Medical Board of Florida order one or more of the following penalties for the pain management specialist: 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: April 2017
Specialty: Pain Management, Anesthesiology, Orthopedic Surgery
Symptom: Joint Pain, Swelling
Diagnosis: Procedural Site Infection
Medical Error: Unnecessary or excessive treatment or surgery, Failure to examine or evaluate patient properly, Referral failure to hospital or specialist, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
Washington – Orthopedic Surgery – Complex Wrist Fracture After A Fall With A Screw Within The Radiocarpal Joint
On 5/26/2012, a patient presented to an emergency department after falling and fracturing the distal radius, at his right wrist. The operating room was unavailable so the orthopedic surgeon opted for a non-surgical (closed reduction) procedure, aligning the patient’s wrist and arm into a splint until he could return for surgery the following week
On 6/1/2012, the patient presented to the orthopedic surgeon for open reduction surgery and internal fixation. This type of surgery involves surgically aligning the broken bones and using items like plates and screws to hold broken bones together to encourage healing in the correct position. The orthopedic surgeon positioned a plate adjacent to the fracture and secured the plate to the fracture area with screws.
On 6/13/2012, the patient returned to the orthopedic surgeon for a follow-up. Imaging found one of the plate’s screws appeared to be within the patient’s radiocarpal joint (where the wrist and palm meet). The orthopedic surgeon told the patient of the potential for hardware to intrude into the joint. The orthopedic surgeon noted that if the positioning of the hardware continued to remain a concern, then further imaging and hardware removal would be discussed.
On 7/11/2012, the orthopedic surgeon contacted the patient to discuss the findings of a CT scan performed two days prior. He assessed the patient’s wrist to be healing nicely, but the CT scan confirmed one of the screws was protruding through the radiocarpal joint. The orthopedic surgeon decided to go forward with removing the screws and hardware.
On 7/26/2012, the orthopedic surgeon performed his second open surgery on the patient’s wrist, this time removing all of the hardware. A significant amount of scar tissue and new bone formation had to be cleared in order to reach the hardware. The orthopedic surgeon found the fracture reasonably stable with gentle flexion-extension movements. The fracture itself seemed to move as a single unit when doing this, and he felt no further hardware was necessary.
On 8/28/2012, the patient returned to the orthopedic surgeon. The orthopedic surgeon found the patient’s distal radius had healed abnormally with some displacement of the wrist joint. The orthopedic surgeon proposed the patient get a specialist’s opinion regarding feasibility for further constructive work.
On 9/27/2012, the patient saw a hand specialist for a second opinion. The patient described having diminished nerve sensation near the wound area. The specialist discovered that the patient’s July 2012 CT scan showed the plate had partially dislodged itself. Upon examination, the specialist noted a displacement deformity at the hand on the forearm. The patient’s wrist had healed improperly, leaving a significant dorsal prominence of the joint surface and the remaining part of his wrist displaced at the palm. The patient’s right wrist had limited motion.
The Commission stipulated the orthopedic surgeon reimburse costs to the Commission and write and submit a paper of at least 1000 words, with an annotated bibliography, on knowing his limitations, especially with complex wrist fractures, and complete a continuing education course on complex wrist fractures.
State: Washington
Date: April 2017
Specialty: Orthopedic Surgery
Symptom: N/A
Diagnosis: Fracture(s)
Medical Error: Procedural error
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 2
Link to Original Case File: Download PDF
Washington – Orthopedic Surgery – Bilateral Shoulder Pain After A Motor Vehicle Accident And Repair Attempt Of Os Acromiale
On 1/4/2011, a patient was involved with a head on motor vehicle collision. The patient sought care the following day at a hospital.
On 1/20/2011, the patient followed up with his primary care provider (PCP). A magnetic resonance imaging (MRI) of the patient’s right shoulder was performed. The MRI showed an abnormal rotator cuff, areas of a partial tear, and an injury to the tendon.
On 2/3/2011, the patient presented to an orthopedic surgeon’s clinic with complaints of right shoulder pain. The orthopedic surgeon reviewed the previous MRI and performed a physical examination. The orthopedic surgeon diagnosed the patient with rotator cuff tendinosis with possible tear, degenerative arthritis of the acromioclavicular joint, and inflammation of the tendon around the biceps muscle.
For the following four months, the orthopedic surgeon continued to see the patient. Though the orthopedic surgeon encouraged the patient to engage in conservative treatment, including physical therapy, the patient’s pain did not completely resolve.
On 6/1/2011, the patient complained of pain in both of his shoulders. The orthopedic surgeon discussed surgical options with the patient. The patient consented to have surgery.
On 6/9/2011, the orthopedic surgeon performed right shoulder surgery. During the surgery, the orthopedic surgeon discovered the patient had an unfused os acromiale (a developmental aberration in which the acromion fails to fuse). Without the patient’s consent, the orthopedic surgeon decided to attempt to repair the os acromiale. The orthopedic surgeon claims he placed two pins within the acromion and a screw down the center. K wires (stainless steel sharpened pins) were cut and placed.
On 7/6/2011, the patient had x-rays taken of his right shoulder. The orthopedic surgeon believed the x-rays showed the hardware was placed appropriately in the patient’s shoulder. Later, the patient saw a different physician, who took a new set of x-rays and believed the hardware was angled inappropriately and the wires were loose. He also believed based on the new x-rays that the screw thread appeared to be just barely in the bone.
Following the patient’s surgery, the patient continued to experience varying degrees of shoulder pain and soreness. On 9/9/2011, the orthopedic surgeon took x-ray images of the patient’s left shoulder, which revealed the patient had bilateral os acromiale.
On 11/21/2011, x-rays were taken of the patient’s right shoulder and showed the screw had pulled out, the bone had not fused, and the wire was broken. The orthopedic surgeon had allegedly failed to appropriately place the original fixation and should have been aware of this when reviewing earlier x-ray images.
The Commission stipulated the orthopedic surgeon reimburse costs to the Commission and write and submit a paper of at least 1000 words with annotated bibliography on the diagnosis and proper treatment of os acromiale.
State: Washington
Date: February 2017
Specialty: Orthopedic Surgery
Symptom: Extremity Pain
Diagnosis: Musculoskeletal Disease
Medical Error: Procedural error, Diagnostic error, Ethics violation
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF