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Florida – Urology – Stent Placed For Kidney Stone Placed In Wrong Ureter
On 7/16/2016, a 50-year-old male presented to the medical center emergency department with abdominal pain.
The patient was diagnosed with renal kidney stones and admitted to the hospital.
The patient was taken to the operating room for a planned cystoscopy, right ureteroscopy, and placement of right ureteral stent.
Informed consent was obtained from the patient for the placement of the right ureteral stent.
On 7/20/2016, a urologist placed a stent in the patient’s left ureter (wrong site), rather than the right ureter (correct site). The patient was then discharged home.
On 7/25/2016, the patient returned to the hospital with complaints of abdominal pain.
A CT scan of the patient’s abdomen and pelvis revealed right distal ureteral stones with moderate right hydronephrosis. The CT scan also revealed a left ureteral without left hydronephrosis.
On 7/26/2016, the patient was informed by the Chief Medical Officer of the hospital that the surgery was performed on the wrong side.
On 7/26/2016, the patient underwent a second procedure to remove the foreign body (left stent) and right ureteroscopy with laser lithotripsy and placement of right ureteral stent.
The second surgery was performed without incident and the patient was discharged home on 7/27/2016.
It was requested that the Board order one or more of the following penalties for the urologist: 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: Urology
Symptom: Abdominal Pain
Diagnosis: Renal Disease
Medical Error: Wrong site procedure
Significant Outcome: Hospital Bounce Back
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Urology – Fluorescence In Situ Hybridization Ordered For A Patient With Incomplete Bladder Emptying And Renal Cysts
From 4/25/2012 to 1/29/2014, a 66-year-old female was treated by a urologist for incomplete bladder emptying and renal cysts.
On 4/25/2012 and 1/15/2014, the patient underwent urinalysis tests which returned negative for blood in the urine.
On 1/15/2014, the patient underwent fluorescence in situ hybridization (FISH) ordered by the urologist, which returned negative.
At all times material to this complaint, the patient displayed no indications to receive FISH testing.
The Board judged the urologist’s conduct to be below the minimal standard of competence given that he failed to document his plan to order FISH testing in the patient’s medical records and that the urologist’s ordering of FISH testing for the patient was medically unnecessary.
It was requested that the Board order one or more of the following penalties for the urologist: 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: Urology
Symptom: Urinary Problems
Diagnosis: Urological Disease
Medical Error: Unnecessary or excessive diagnostic tests, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
Florida – Urology – Unnecessary Laparoscopic Radical Prostatectomy With Bilateral Pelvic Lymph Node Dissection Performed
On 2/1/2016, a 66-year-old male presented to a urologist for a prostate biopsy. The urologist or his agents sent the specimens from the patient’s biopsy to pathology.
On 2/10/2016, a pathology report diagnosing the patient with adenocarcinoma of the prostate was issued.
On 2/16/2016 and 2/29/2016, the patient presented to the urologist to review the prostate biopsy pathology.
On 3/16/2016, the urologist performed a robotic assisted laparoscopic radical prostatectomy with bilateral pelvic lymph node dissection on the patient. The urologist or his agents sent the specimens from the patient’s surgical procedure to pathology.
On 3/25/2016, a pathology report indicating the specimens were “negative for malignancy” was issued.
On 3/25/2016, the urologist or his agents swabbed the patient to obtain a DNA sample to cross-check the DNA profile of the biopsied specimens (from the 2/1/2016 appointment) with the patient’s known DNA sample.
On 4/5/2016, a DNA report was issued, confirming that the DNA profile from the biopsied specimens (from the 2/1/2016 appointment) did not match the DNA profile of the patient.
On 3/16/2016, the urologist performed health care services that were medically unnecessary when he performed the surgical procedure on the patient.
It was requested that the Board order one or more of the following penalties for the urologist: 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: Urology
Symptom: N/A
Diagnosis: N/A
Medical Error: Unnecessary or excessive treatment or surgery, False positive
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 2
Link to Original Case File: Download PDF
Florida – Urology – Failure to Follow-Up On Chest X-Rays Ordered In A Patient With Micro Hematuria And Stone Disease
A urologist treated a patient from 2/3/2011 to 3/4/2011.
On 2/3/2011, the patient first presented to the urologist with micro hematuria and stone disease.
On 2/9/2011, the urologist ordered pre-operative blood work and chest x-rays for the patient.
The radiology report of the chest x-ray dated 2/9/2011 revealed a “newly developed 2.5 cm irregular contoured nodule located in the right lower lobe” that was “suspicious for potential malignancy and chest CT correlation [was] recommended…”
The urologist did not review the 2/9/2011 chest x-ray or radiology report and subsequently did not notify the patient and the patient’s primary care physician of the radiology findings.
On July 2012, the patient’s primary care physician ordered a chest x-ray, which demonstrated a 5 cm mass with metastasis.
A medical malpractice lawsuit was filed against the urologist.
The Board judged the urologist conduct to be below the minimal standard of competence given that he failed to review the chest x-ray and radiology report that were ordered by his staff and inform the patient and the patient’s primary care physician of the findings of the chest x-ray.
It was requested that the Board order one or more of the following penalties for the urologist: 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: Urology
Symptom: Urinary Problems
Diagnosis: Urological Disease, Cancer, Renal Disease
Medical Error: Failure to follow up
Significant Outcome: N/A
Case Rating: 4
Link to Original Case File: Download PDF
Washington – Physician Assistant – Groin Rash, Swelling, And Hard Left Testicle Found On Infant
On 1/3/2015, a seven-month-old patient was brought to an urgent care facility where he was seen by a physician assistant. His history included over several months of groin rash that was being treated with steroid cream. The patient’s mother reported that the patient’s left testicle was hard. Over the past two days, his symptoms had worsened. The physician assistant examined the patient and found a rash and swelling at the scrotum only. He diagnosed the patient with a diaper rash.
On 1/4/2015, the patient’s grandparents brought the patient to the emergency department, where he was examined by a second provider. The patient’s grandparents reported that the patient seemed uncomfortable and that his left scrotum appeared red, swollen, and firm. An ultrasound found the patient’s left testicle with decreased blood flow. The patient was transferred to another facility and testicular torsion was confirmed. The patient underwent emergency surgery where his testicle was found nonviable and removed.
The physician assistant did not consider testicular torsion in the differential diagnosis and failed to order an ultrasound to rule out this condition.
The Commission stipulated the physician assistant reimburse costs to the Commission, complete a continuing medical education course in assessment and diagnosis of acute scrotal conditions, and submit a paper of no less than one thousand words, with references, on the subject of acute scrotal conditions.
State: Washington
Date: April 2017
Specialty: Physician Assistant, Pediatrics, Urology
Diagnosis: Testicular Torsion
Medical Error: Failure to order appropriate diagnostic test
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 3
Link to Original Case File: Download PDF
California – Urology – Treatments Options For Renal Mass In An Elderly Man With History Of Bladder And Renal Cancer
Sometime around 2000, a 77-year-old male presented to a urologist for treatment of hematuria and benign prostatic hyperplasia. Between 2000 and 2008, the patient continued to receive treatment from the urologist for various medical problems, which included but was not limited to, a right radical nephrectomy for cancer in 2001, a history of bladder cancer recurrence requiring transurethral resection and instillation of BCG (immune therapy) into the bladder, approximately twenty-five cystoscopies, and high grade prostate cancer treated with radiation and androgen deprivation in 2008.
On 12/18/2009, the then 86-year-old patient presented to the urologist with complaints of gross hematuria with clots for one week. At that time, the urologist ordered a CT scan of the patient’s abdomen and pelvis.
On 12/22/2009, the urologist underwent a CT scan, which revealed a 5.7 cm mass in the upper pole cortex consistent with renal cell carcinoma.
On 12/29/2009, the urologist saw the patient for a follow-up visit. Having reviewed the CT scan results, the urologist considered various options for treatment, including watchful waiting versus nephrectomy versus nephrectomy/cystectomy. The urologist did not consider a partial nephrectomy.
On 1/6/2010, the urologist performed an uneventful total left nephrectomy, total cystoprostatectomy, and urinary diversion. The pathology report showed a 6 cm clear cell cancer of the left kidney, nuclear grade 4/4, and the renal vein and renal sinus were not involved. The bladder showed papillary transitional cell high-grade multifocal carcinoma in situ. No tumor invasion was present in the bladder wall.
On 1/9/2010, the patient had developed some hypertension and was noted to have some greenish discharge from his surgical wound. The patient was returned to surgery for an emergent laparotomy performed by the urologist and a co-surgeon. During the laparotomy, it was discovered that the patient had small bowel perforations secondary to extensive bowel ischemia. During the surgery, a bowel resection, jejunostomy, and double barrel colostomy were performed. At the conclusion of the procedure, the patient had a cardiac arrest and died.
The Board expressed concern that the urologist practiced at a level below the standard of care by not considering less aggressive options such as a partial nephrectomy in a very elderly man with comorbidities.
The Board issued a reprimand and ordered continuing medical education of 40 hours. It was also recommended that the urologist enrolls in the Physician Assessment and Clinical Education Program offered at the University of California – San Diego School of Medicine.
State: California
Date: February 2017
Specialty: Urology
Symptom: Mass (Breast Mass, Lump, etc.), Urinary Problems
Diagnosis: Post-operative/Operative Complication, Cancer
Medical Error: Improper treatment
Significant Outcome: Death
Case Rating: 3
Link to Original Case File: Download PDF
North Carolina – Urology – Difficult Robotic Assisted Laparoscopic Prostatectomy Leads To Extensive Bleeding And A Prolonged Procedure
On 12/30/2013, a 73-year-old male with prostate cancer underwent a Da Vinci robotic-assisted laparoscopic prostatectomy. The general surgeon encountered various problems with difficult visualization and dissection, leading to extensive bleeding which resulted in a prolonged procedure. After the procedure, the patient was transferred to the ICU in critical condition. The following morning, the patient died despite attempted resuscitation.
The Board obtained the patient’s records and sent them to a qualified independent medical expert for review. The independent medical expert expressed concern that the procedure took longer than would be expected and involved extensive blood loss.
The Board received two Affidavits from physicians knowledgeable about the urologist, which included a urologist who performs robotic laparoscopic prostatectomies and a family medicine practitioner who has referred urology patients to the urologist for thirteen years. Both physicians opined that the complication involving the patient was an aberration.
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: January 2017
Specialty: Urology
Symptom: N/A
Diagnosis: Prostate Cancer
Medical Error: Procedural error
Significant Outcome: Death
Case Rating: 1
Link to Original Case File: Download PDF
Florida – Internal Medicine – Undiagnosed Fever, Urinary Retention, And Hematuria Results In Death
On 12/23/2013, a 63-year-old male presented to a medical center with complaints of fever, insomnia, urinary retention, and hematuria, lasting the past six days.
Upon admission to the medical center, the patient was examined by an internist, and the internist diagnosed the patient with a urinary tract infection and urinary retention.
Based on this diagnosis, the internist ordered the administration of ceftriaxone, the placement of a Foley catheter, a urinalysis work-up, and a consultation with a urologist.
The patient’s urinalysis came back negative, and the Foley catheter enabled the patient’s bladder to void.
While a consultation with a urologist was ordered, it was never actually completed.
There was no documentation in the patient’s medical records that indicated the underlying causes of the patient’s urinary retention, hematuria, fever, and pain.
The internist failed to perform and failed to document performing an examination of the patient’s abdomen, lower back, kidneys, and genitourinary system that was sufficiently detailed enough to confirm or rule out the possible underlying causes of the patient’s urinary retention, hematuria, fever, and pain.
The internist failed to order and failed to document ordering additional laboratory and imaging testing of the patient’s abdomen, lower back, kidneys, and genitourinary system, after the patient’s urinalysis came back negative.
The internist failed to follow up on and failed to document following up on the urology consultation and the urology consultation results ordered for the patient.
The internist stated in his discharge summary that the patient “was seen by urology and workup was negative.”
On 12/25/2013, the patient was discharged from the hospital with instructions to follow up with his primary care physician and an outpatient urology practice.
On 12/28/2013, the patient’s condition deteriorated and he expired in his home as a result of undiagnosed peritonitis.
The Medical Board of Florida judged the internist’s conduct to be below the minimal standard of competence given that he failed to perform an examination of the patient’s abdomen, lower back, kidneys, and genitourinary system that was sufficiently detailed enough to confirm or rule out the possible underlying causes of the patient’s urinary retention, hematuria, fever, and pain. The internist also failed to follow up on additional laboratory and imaging testing of the patient’s abdomen, lower back, kidneys, and genitourinary system until the underlying causes of the patient’s urinary retention, hematuria, fever, and pain was determined. The internist failed to follow up on the urology consultation and/or results of the urology consultation that was ordered for the patient. Also, the internist failed to reevaluate and reassess the patient’s condition prior to his discharge from the hospital.
The Medical Board of Florida issued a letter of concern against the internist’s license. Also, the Medical Board of Florida ordered that the internist pay a fine of $8,000 against his license and pay reimbursement costs for the case at a minimum of 3,462.89 and not to exceed $5,462.89. The Medical Board of Florida ordered that the internist complete five hours of continuing medical education in the “diagnosis and treatment of urinary retention and hyponatremia” and complete five hours of continuing medical education in “risk management.”
State: Florida
Date: November 2016
Specialty: Internal Medicine, Urology
Symptom: Fever, Bleeding, Pain, Urinary Problems
Diagnosis: Infectious Disease, Urological Disease
Medical Error: Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Failure of communication with other providers, Failure to follow up, Lack of proper documentation
Significant Outcome: Death
Case Rating: 3
Link to Original Case File: Download PDF
California – Urology – Swollen Right Testicle With A History Of Left Testicle Removed
In 1990, a patient had his left testicle surgically removed.
On 5/27/2011, the patient first presented to a urologist complaining of swelling in the right hemiscrotum that had lasted for several weeks. The patient provided a medical history which was recorded by the urologist as follows:
“He complains of a swollen testicle on the right. The symptoms have been present several weeks. He states there was no history of trauma prior to the swelling. There is tenderness but no pain. The mas [sic] has been getting larger. The swelling gets worse with sitting. No dysuria noted. He has no frequency. No hematuria is present. He has no nocturia. H/O L cord lipoma x2/L orchiectomy 1990.”
The urologist ordered an ultrasound for the patient. The urologist claims that he was never made aware, until 7/18/2013, that the patient had a liposarcoma in 1990.
However, on 6/16/2011, an ultrasound of the patient was performed at a community hospital. The ultrasound report stated, “Patient with history of spermatic cord liposarcoma.” The ultrasound report was provided to the urologist.
On 6/21/2011, the urologist again saw the patient. The medical history generated by the urologist for this visit is identical to the medical history of 5/27/2011, stating:
“He complains of a swollen testicle on the right. The symptoms have been present several weeks. He states there was no history of trauma prior to the swelling. There is tenderness but no pain. The mas [sic] has been getting larger. The swelling gets worse with sitting. No dysuria noted. He has no frequency. No hematuria is present. He has no nocturia. H/O L cord lipoma x2/L orchiectomy 1990.”
The urologist also wrote in the medical record for the 6/21/2011 visit that the patient’s “left testicle is normal to palpation. No masses or tenderness noted. Size normal.”
On 12/15/2011, the urologist again saw the patient. Again, the medical history generated by the urologist is identical to the medical history of 5/27/2011, stating:
“He complains of a swollen testicle on the right. The symptoms have been present several weeks. He states there was no history of trauma prior to the swelling. There is tenderness but no pain. The mas [sic] has been getting larger. The swelling gets worse with sitting. No dysuria noted. He has no frequency. No hematuria is present. He has no nocturia. H/O L cord lipoma x2/L orchiectomy 1990.”
The urologist also wrote in the medical record for the 12/15/2011 visit that “both testicles appear to be of normal size and location.”
On 12/6/2012, the urologist saw the patient. The urologist noted an elevated prostate-specific antigen (PSA) but elected a conservative treatment plan, which consisted of observing the patient without ordering a prostate biopsy.
The urologist also wrote in the medical record for the 12/6/2012 visit that “both testicles are normal to palpation.”
On 1/17/2013, the urologist saw the patient. Even though the visit was some sixteen months after the first visit, the medical history generated by the urologist appears to be “cut-and-pasted” from the medical history of 5/27/2011, stating:
“He complains of a swollen testicle on the right. The symptoms have been present several weeks. He states there was no history of trauma prior to the swelling. There is tenderness but no pain.”
On 7/18/2013, the urologist saw the patient. The urologist noted a presence of a moderate sized lipoma in the left inguinal region. Additionally, the urologist noted for the first time in the medical records for the patient a history of liposarcoma being resected in 1990.
The urologist also wrote in the medical record for the 7/18/2013 visit that “Both testicles appear to be of normal size and location.”
Again, part of the medical history generated by the urologist for the 7/18/2013 visit is identical to the prior medical history of 5/27/2011 stating:
“He complains of a swollen testicle on the right. The symptoms have been present several weeks. He states there was no history of trauma prior to the swelling. There is tenderness but no pain.”
The remainder of the medical history continued with the following:
“There has been no change in size since it was first discovered. The swelling gets worse with sitting. No dysuria noted. He has no frequency. No hematuria is present. Patient states that there is occasional urinary hesitancy. He has no nocturia. H/O L cord liposarcoma x2/L orchiectomy 1990.”
The urologist again elected to observe the patient and a follow-up appointment was ordered.
On 1/21/2014, the urologist met with the patient. Medical records make no mention of any examination of the patient’s genitalia, groin or inguinal canals, and the records make no mention regarding the presence, absence, or change of the left inguinal lipoma.
The medical history generated by the urologist for the 1/21/2014 visit is identical to the prior medical history of 7/18/2013 and stated:
“He complains of a swollen testicle on the right. The symptoms have been present several weeks. He states there was no history of trauma prior to the swelling. There is tenderness but no pain. There has been no change in size since it was first discovered. The swelling gets worse with sitting. No dysuria noted. He has no frequency. No hematuria is present. Patient states that there is occasional urinary hesitancy. He has no nocturia. H/O L cord lipoma x2/L orchiectomy 1990.”
On 6/6/2014, the patient was examined at Stanford University after being referred by the urologist due to complaints of a large, growing, and symptomatic left inguinal mass noted by the patient’s primary care physician.
Ultimately, on 7/23/2014, the patient underwent a left hemiscrotectomy and pelvic dissection for a mass abutting the urethra and corporeal bodies of the penis, extending to the lateral bulb of the urethra and anterior above the inguinal ligament over the symphysis.
Pathology revealed this mass to be a large well-differentiated liposarcoma measuring 23 centimeters by 15 centimeters by 5.5 centimeters.
The Board judged the urologist’s conduct as having fallen below the standard of care given failure to address the mass in the left groin with imaging, biopsy, excision, or referral to a specialist in the field, and given misrepresentation that he had completed an examination of the left testicle of the patient when in fact he had not done so.
A hearing was conducted. At the conclusion of the hearing, the Board placed the urologist on probation for five years with stipulations for the urologist to complete a professionalism program and a clinical training program equivalent to the Physician Assessment and Clinical Education Program.
State: California
Date: November 2016
Specialty: Urology
Symptom: Mass (Breast Mass, Lump, etc.), Swelling
Diagnosis: Cancer
Medical Error: Diagnostic error, Failure to examine or evaluate patient properly, Underestimation of likelihood or severity, Referral failure to hospital or specialist, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
Arizona – Urology – Hepatic Artery, Portal Vein, and Common Bile Duct Transected During Partial Nephrectomy
The Board was notified of a malpractice settlement regarding the treatment of a 76-year-old woman.
On 02/14/2012, a woman was evaluated by a urology regarding a renal lesion that had been found on a CT scan. The urologist ordered a CT scan which was performed on 11/28/2012 and which revealed no no significant change in size of the 0.9 cm lesion located on the upper pole of the right kidney. The lesion had a slightly thickened and irregular enhancing wall. There was a small ventral wall hernia. The urologist documented the renal lesion as being complex and enhancing with no significant enlargement. It was around 1 cm in diameter and was not causing the patient any symptoms. The urologist recommended a biopsy.
On 01/24/2013, the patient underwent a right renal biopsy. Pathology revealed probable clear cell renal cell carcinoma Fuhrman grade 2.
On 01/30/2013, the urologist documented that he discussed the risks and benefits with the patient regarding surgery. The urologist offered a hand assisted approach to allow for repair of the patient’s hernia. The patient gave consent for the procedure.
On 04/17/2013, the patient was admitted for right nephrectomy via hand assisted laparoscopy. Per the anesthesia record, the anesthesia start time was 1:51 p.m. and surgery start time was 2:26 p.m. The surgery end time was 5:54 p.m. The urologist’s operative note documented adhesions and significant bleeding he initially thought was due to injury of the inferior vena cava. The patient received two packed red blood cell transfusions and the operation was converted to an open procedure.
At 3:00 p.m., the anesthesia record stated that the blood pressure was 60/30.
At 3:47 p.m., a general surgeon was consulted and arrived in the operating room. The surgeon noted that there was bleeding along the anterolateral edge of the patient’s duodenum and pancreas. The portal vein, common bile duct, and hepatic artery were transected. The urologist stated that he proceeded with a radical nephrectomy prior to liver vascular repair to avoid further liver vascular damage. Per the general surgeon’s note, hepatic warm ischemia time was one hour and fifteen minutes. After the nephrectomy was completed, the hepatic artery, portal vein, and common bile duct were repaired, including graft replacement.
At 5:30 a.m. on 04/18/2013, the urologist dictated his operative report.
On 04/18/2013, the patient was taken back to surgery after sanguineous fluid was found in the drain output. The general surgeon’s intraoperative findings included 1500 ml of intra-abdominal blood along with bleeding from a gonadal vessel and from the insertion of the renal vein on the vena cava. The family requested DNR status for the patient. The patient subsequently died.
The Board judged urologist’s conduct to be below the minimum standard of competence given failure to use proper surgical technique with correct tissue transection/ligation, failure to timely convert to an open procedure, and failure to consider hepatic artery and portal vein repair prior to proceeding with the performance of the nephrectomy.
The Board ordered the urologist to be reprimanded.
State: Arizona
Date: November 2016
Specialty: Urology, General Surgery, Nephrology, Oncology
Symptom: N/A
Diagnosis: Post-operative/Operative Complication, Cancer
Medical Error: Procedural error
Significant Outcome: Death
Case Rating: 3
Link to Original Case File: Download PDF