Found 49 Results Sorted by Case Date
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Florida – Radiology – Gastrografin GI Series Performed to Ascertain GI Leak But No Leak Reported By Radiologist



On 6/23/2014, a 66-year-old male presented to the Physicians Regional Medical Center for gastric bypass surgery.

Following the gastric bypass procedure, on 6/24/2014, a radiologist performed a Gastrografin upper GI series on the patient to ascertain whether there was a leak or obstruction in the patient’s digestive tract.  A leak of contrast material was visible on radiographic images obtained by the radiologist during the procedure;  however, the radiologist failed to detect the leak in the patient’s digestive tract and reported a negative GI series.  The patient was subsequently discharged from the hospital.

Approximately thirty hours after his discharge, the patient returned to the hospital suffering from abdominal pain and sepsis.  It was discovered that the patient had a perforation in his digestive tract.  During surgery to repair this perforation, the patient suffered cardiac arrest and anoxic brain injury.  The patient ultimately expired as a result of these complications on 7/10/2014

The Board judged the radiologist’s conduct to be below the minimum standard of competence given his failure to detect a leak in the patient’s digestive tract during the performance of a Gastrografin upper GI series.

State: Florida


Date: December 2017


Specialty: Radiology


Symptom: N/A


Diagnosis: Acute Abdomen


Medical Error: False negative


Significant Outcome: Death, Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Radiology – Mammogram And Ultrasound Of Breast Mass Interpreted As A Cyst



On 6/30/2011, a 50-year-old female presented to a breast center for a bilateral digital diagnostic mammogram with computer-aided detection and right breast ultrasound (“mammogram and ultrasound”) for a palpable abnormality (“mass”).

On 6/30/2011, a radiologist interpreted the mammogram and ultrasound in her final report as follows: “[T]here has been no interval change in the appearance of the breasts with no evidence for malignancy.  At the 7 o’clock position, 7 cm away from the nipple, correlating to the [mass] is a simple cyst….”

The radiologist recommended “[M]ammography and yearly physical examination per ACS guidelines, supplemented with monthly self-examination,  If clinically indicated, the cyst could be aspirated.”  At no time did the radiologist recommend a biopsy of the mass.

The radiologist rated the mammogram as a BI-RADS Category II, “[B]enign.”  A correct interpretation of the mass would have indicated that it had lobular and angular margins, and increased through transmission.  The mammogram should have been rated BI-RADS category V, “[H]ighly suspicious: [A]ppropriate action should be taken.”  The radiologist should have recommended a biopsy of the mass.

On 1/23/2012, the patient was advised by a subsequent treating physician that she had invasive ductal carcinoma, Stage III.

The Board judged the radiologist’s conduct to be below the minimum standard of competence given her failure to correctly interpret the mammogram and ultrasound and recommend a biopsy of the mass.

The Board ordered that the radiologist pay a fine of $6,500 against her license and that the radiologist pay a reimbursement cost to the case of a minimum of $2,924.06 but not to exceed $4,924.06.  The Board ordered that the radiologist complete ten hours of continuing medical education in identification and diagnosis of malignancies with a focus on interpretation of breast imaging studies.

State: Florida


Date: November 2017


Specialty: Radiology


Symptom: N/A


Diagnosis: Breast Cancer


Medical Error: False negative, Failure to order appropriate diagnostic test


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Radiology – Back Pain With Subsequent MRI And Missed Incidental Finding



In 2009, a patient with a history of smoking developed back pain.  Her primary care physician sent her to a hospital for two MRIs of her spine: one on 3/9/2009 and another on 4/13/2009.  Radiologist A at the hospital obtained the MRI images and sent them to a teleradiology company for review.  Radiologist B at the teleradiology company reviewed the MRIs.  Neither of his reports mentioned any lung abnormalities.

In 2010, the patient developed a cough and was sent to the hospital for a chest x-ray.  Radiologist A reviewed the x-ray and reported that he found no significant pathology.

After suffering from continued bouts of coughing, the patient was sent to the hospital for another chest x-ray in 2012.  Radiologist A reviewed the x-ray and reported that he found no significant pathology.

In 2013, Radiologist A received a chest x-ray for asthma.  Radiologist A reviewed the x-ray and found a mass on the patient’s right lung.  Radiologist A recommended that the patient undergo a computed tomography (CT) scan.  The CT scan revealed a 4.8 by 2.5 centimeter mass, which was subsequently identified as cancerous.  The patient was diagnosed with unresectable Stage IIIA non-small cell lung cancer metastatic to the lymph nodes.  The patient underwent 33 radiation treatments and multiple rounds of chemotherapy.

In January 2014, the patient filed a complaint against Radiologist A and Radiologist B asserting medical malpractice.  She claimed that her lung cancer diagnosis was delayed by four years given failure to detect the mass when they reviewed her MRIs and chest x-rays.

In November 2015, prior to the start of the trial, the patient began to have breathing issues, balance problems, dizziness, and difficulty with memory.  On 11/3/2015, her primary care physician ordered a CT scan, which revealed that the cancer had metastasized to her brain.

On 11/13/2015, the jury returned a verdict in favor of the patient with liability spread equally among Radiologist A and Radiologist B.  The jury awarded the patient a total of $3 million.

The California Board issued a public reprimand against Radiologist B given his failure to report the medical malpractice case to the Hawaiian Board.

State: California


Date: October 2017


Specialty: Radiology


Symptom: Cough, Back Pain


Diagnosis: Lung Cancer


Medical Error: False negative


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Radiology – Two Patients With The Same First Name, Last Name, And Year Of Birth



On 12/23/2014, Patient A and Patient B, both 89-year-old females, presented to the radiology department.  Patient A presented for a carotid ultrasound while Patient B presented for a PICC line insertion.  Both patients had the same first name and last name and were born the same year, but were born on different dates.

After undergoing a carotid ultrasound, Patient A was erroneously transported to the special procedures unit for a PICC line insertion.  A radiologist injected the patient with lidocaine in preparation of performing the PICC line insertion.

The radiologist began to insert the PICC line guidewire but stopped when the accompanying nurse recognized that Patient A was not the correct patient.

The radiologist did not create or maintain documentation of properly performing a timeout procedure.

The Medical Board of Florida issued a letter of concern against the radiologist’s license.  Also, the Medical Board of Florida ordered that the radiologist pay a fine of $2,500 against his license and pay reimbursement costs for the case at a minimum of $2,276.31 and not to exceed $4,276.31.  The Medical Board of Florida ordered that the radiologist complete five hours of continuing medical education in “risk management” and complete a one hour lecture on “wrong site surgeries” including information on “wrong patient procedures.”

State: Florida


Date: August 2017


Specialty: Radiology


Symptom: N/A


Diagnosis: N/A


Medical Error: Accidental error, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Radiology – Epidural Injection With Subsequent Lower Extremity Pain And Sensory And Motor Function Loss



On 1/15/2010, a 61-year-old female underwent an epidural injection.  Following the procedure, she complained of sharp pain in the lower extremities, followed by sensory and motor function loss below the T10 and T11 level.  The patient was transferred by ambulance to the emergency department.

A thoracic and lumbar MRI was performed and interpreted by a radiologist.  The final report for the lumbar spine states “Mild desiccation and degenerative changes of the disc but no disc bulge or herniation is noted.”  His final report of the thoracic spine demonstrates “normal MRI of the thoracic spine…A repeat study of the thoracolumbar spine is recommended without contrast infusion in both projections to better evaluate this area as this is on the edge of the study on the current images both lumbar and thoracic is not well delineated.”  Although the images were suboptimal, the epidural hematoma of the lower thoracic spine was evident in the axial images.

On 1/19/2010, a repeat MRI was performed.  The radiologist interpreted the MRI stating there is “abnormal signal focus demonstrated in the spinal canal from approximately the T10-T11 disc space inferiorly through the T12-L1 disc space located mostly in the posterior and posterolateral aspect of the spinal canal displacing the cords slightly anteriorly and causing a slight mass effect on the cord and subarachnoid sac.  This is consistent with a subdural or epidural hematoma.”

The Board judged the radiologist’s conduct as having fallen below the standard of care given failure to observe and document all pertinent findings on diagnostic imaging studies, failure to discuss findings requiring urgent treatment with the referring physician, failure to diagnose the abnormality found on MRI, and failure to document his discussion with the referring physician regarding the abnormality on MRI.

A public reprimand was issued against the radiologist.

State: California


Date: June 2017


Specialty: Radiology, Emergency Medicine


Symptom: Extremity Pain, Numbness, Weakness/Fatigue


Diagnosis: Spinal Injury Or Disorder


Medical Error: False negative, Failure of communication with other providers, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Radiology – Motor Vehicle Accident With Missed Diagnosis After Review Of The CT Scan



On 8/14/2013, a 63-year-old female patient presented to a hospital with trauma sustained in a car accident.

X-rays of the patient’s chest and ankle were performed.  CT scans of the patient’s head, face, cervical spine, chest, abdomen, and pelvis were performed.  A radiologist read the x-rays and CT scans performed on the patient.  The radiologist recognized several transverse process fractures in the patient’s lumbar spine.  The radiologist failed to diagnose an L4 vertebral body fracture that was present on one or more CT images.  The radiologist failed to order further CT or MRI scans of the patient’s lumbar spine.

The Board judged the radiologist’s standard of care to be below the minimum standard of competence given his failure to recognize and diagnose the L4 vertebral body fracture present on one or more CT images for the patient and order further CT or MRI scans of the lumbar spine.

The Board ordered that the radiologist pay a fine of $7,500 against his license and that the radiologist pay reimbursement costs from a minimum of $3,004.65 to a maximum of $5,004.65.  The Board also ordered that the radiologist complete six hours of continuing medical education in radiological studies/interpretation.

State: Florida


Date: June 2017


Specialty: Radiology


Symptom: N/A


Diagnosis: Fracture(s), Spinal Injury Or Disorder


Medical Error: Diagnostic error, Failure to order appropriate diagnostic test


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Radiology – Failure To Diagnose Subdural Hematoma From Radiology Report



On 10/27/2015, a patient presented to the emergency department after suffering a fall.

An emergency department physician ordered a computerized tomography (CT) scan of the patient’s head.

Radiologist A reviewed the CT scan.  Radiologist A failed to recognize or failed to report the presence of a significant subdural hematoma.  Radiologist A erroneously reported that the CT scan showed no acute intracranial abnormalities.

The patient’s wounds from the fall were treated, and the patient was discharged home.  That night, the patient became unresponsive at home and was transported back to the hospital.

A second CT scan was performed and was reviewed by Radiologist B.  Radiologist B compared the second CT scan to the first CT scan performed earlier that day.

Radiologist B noted that the first CT scan showed a 6 mm hematoma.  He reported that the second CT scan showed that the hematoma had markedly increased in size to 28 mm since the first scan taken approximately six hours before.

The patient expired the morning of 10/28/2015, due to complications from an acute subdural hematoma.

The Board judged Radiologist A’s conduct to be below the minimal standard of competence given that she failed to recognize and report any significant abnormalities present on a patient’s CT scan.

It was requested that the Board order one or more of the following penalties for Radiologist A: 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 Board deemed appropriate.

State: Florida


Date: June 2017


Specialty: Radiology


Symptom: N/A


Diagnosis: Intracranial Hemorrhage, Trauma Injury


Medical Error: False negative


Significant Outcome: Death, Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



Rhode Island – Radiology – CT Scan After A Laparoscopic Cholecystectomy



In 2013, a patient underwent a laparoscopic cholecystectomy.  A CT scan was ordered.  The radiologist did not detect a bowel perforation that was present on the CT scan.

The Board issued a reprimand with stipulations to pay a fine and complete 8 hours of continuing medical education.

State: Rhode Island


Date: April 2017


Specialty: Radiology


Symptom: N/A


Diagnosis: Acute Abdomen


Medical Error: False negative


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Wisconsin – Radiology – CT Scan Showing Wedged-Shaped Splenic Infarct After Motor Vehicle Accident



On 7/13/2015, a 50-year-old woman was involved in a motor vehicle accident.  She was transported by helicopter to Hospital A.

The ED physician ordered a CT of the chest, abdomen, and pelvis with IV contrast.  Radiologist A performed a preliminary reading of the CT scan having been provided with “50 years old, female, Chest, abdominal, and pelvis pain post mvc.”

Radiologist A interpreted the CT scan as showing a “probable anterior wedged shaped splenic infarct.” The patient was discharged from Hospital A.

The CT scan was subsequently reviewed by Radiologist B, who read the scan as revealing splenic lacerations and hemorrhage.

Hospital A staff attempted to reach the patient regarding these findings.  The patient then presented to Hospital B, where additional diagnostic imaging confirmed bleeding.  The patient underwent emergent evacuation of a massive hemoperitoneum, lysis of adhesions, and splenectomy.  She died on 7/13/2015.

Radiologist A was deemed to have fallen below the standard of care and it was recommended that he complete a course on emergent CT interpretation in an emergency/trauma setting.

State: Wisconsin


Date: January 2017


Specialty: Radiology, Emergency Medicine


Symptom: Chest Pain, Abdominal Pain, Pelvic/Groin Pain


Diagnosis: Trauma Injury


Medical Error: Diagnostic error, False negative


Significant Outcome: Death, Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Radiology – Radiologist Reports Negative Findings On A CT Scan For A Pediatric Patient Who Fell Down A Flight Of Stairs



A 30-month-old boy presented to the emergency department on 8/29/2011, after falling down a flight of stairs.

Following his presentation to the emergency department, a CT scan of the patient’s brain and neck was performed, and a radiologist interpreted the results of the scan as negative.

On 9/1/2011, the patient presented to his pediatrician with significant neurological problems.  Based on the patient’s symptoms, the patient’s pediatrician contacted the radiologist to discuss the case.

As part of his discussion with the patient’s pediatrician, the radiologist re-reviewed the patient’s CT scan and determined that his previous negative findings were incorrect.  The radiologist noted that a “subtle but focal increased density within the spinal cord” was evident on the patient’s CT scan.

Based on this finding, the radiologist coordinated with the patient’s pediatrician to have the patient returned to the emergency department for evaluation and treatment.

In preparation for the patient’s return to the emergency department, the radiologist attached an addendum to his previous report that explained that he failed to identify a hematoma within the patient’s spinal cord.

Upon the patient’s return to the emergency department, the patient was given additional imaging studies.  These studies revealed that the hematoma within the patient’s spinal cord had grown since the original CT scan.

Based on this finding, the patient underwent surgical evacuation of the hematoma.  The patient’s hematoma was successfully evacuated, but the patient ultimately left functionally quadriplegic as a result of damage already caused by the bleed.

The Medical Board of Florida judged the radiologist’s conduct to be below the minimal standard of competence given that he failed to correctly interpret the patient’s CT scan and identify the hematoma within the patient’s spinal cord.  The radiologist was unable to correctly interpret the patient’s CT scan, and the standard of care required him to refer the patient’s CT scan results to a pediatric radiologist or a neuroradiologist for review.

The Medical Board of Florida issued a letter of concern against the radiologist’s license.  The Medical Board of Florida ordered that the radiologist pay a fine of $5,500 against his license and pay reimbursement costs for the case at a minimum of $3,190.96 and not to exceed $5,190.96.  The Medical Board of Florida also ordered that the radiologist complete five hours of continuing medical education in the area of “pediatric radiology” and complete five hours of continuing medical education in the area of “diagnosis and treatment of hematoma.”

State: Florida


Date: December 2016


Specialty: Radiology, Pediatrics


Symptom: N/A


Diagnosis: Hemorrhage, Spinal Injury Or Disorder


Medical Error: False negative, Referral failure to hospital or specialist


Significant Outcome: Permanent Loss Of Functional Status Or Organ, Hospital Bounce Back


Case Rating: 4


Link to Original Case File: Download PDF



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