Found 29 Results Sorted by Case Date
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Alaska – Neurosurgery – Extradural Abscess Beneath Skull Prosthesis



On 04/28/2014, a patient filed a complaint against the Alaska State Medical Board against a neurosurgeon alleging a standard of care violation.

On 06/2013, the patient was involved in an accident that required a craniotomy.  On 02/17/2014, the patient underwent a cranioplasty by neurosurgeon A to repair her skull defect.  On 03/24/2014 and 03/28/2014, the patient had two seizures.  During the second seizure, the patient fell hitting her head.  In both cases, the patient was taken to the emergency department for evaluation and treatment.  The work-ups performed at these ED visits were unclear.  On 04/02/2014, the patient noticed that her wound was leaking.

On 04/04/2014, neurosurgeon A evaluated the patient and did not find any neurological deficit.  He noticed clear drainage out of her left temporal scalp wound.  A CT scan of the head was ordered revealing “a large extradural abscess of the left parietal region, beneath the skull prosthesis with considerable brain edema, and midline left to the right shift.”  Neurosurgeon A recommended removal of the prosthesis and drainage of the brain abscess.

Neurosurgeon A scheduled the patient for surgery on 04/09/2014 and, on 04/04/2014, he discharged her home from the clinic.  Neurosurgeon A’s clinic note, which was dictated on 04/07/2014, stated that he intended to get her into surgery on 04/07/2014.

On 04/04/2014, neurosurgeon B saw the patient’s CT scan on the monitor, which showed a large epidural abscess with midline shift.

On 04/05/2014, neurosurgeon B discovered that the patient had not been admitted to the hospital and that her surgery was scheduled for the following week as an elective procedure.  Neurosurgeon B summoned the patient to the emergency department immediately for emergent surgical treatment of her brain abscess.  Neurosurgeon B ordered another MRI of the brain, which confirmed a “large brain abscess with considerable brain edema with left to right shift.”  Neurosurgeon B immediately operated on the patient and evacuated a large epidural abscess and another larger subdural empyema, which was under considerable pressure.

On 04/11/2014, the patient was discharged by neurosurgeon B from the hospital.

An outside reviewer of the case determined that neurosurgeon A’s care of the patient fell below the standard of care and indicated professional incompetence.  The reviewer noted, “Intracranial epidural abscesses with mass effect and midline shift are life threatening, and the patients should have surgical intervention expeditiously.”  The reviewer also documented that neurosurgeon A should have ordered an MRI of the brain to obtain further information about the extent of the intracranial infection to evaluate for possibilities like subdural empyema or cerebritis.

Neurosurgeon A was reprimanded and he was ordered to pay a fine.

State: Alaska


Date: August 2016


Specialty: Neurosurgery, Infectious Disease


Symptom: Seizure


Diagnosis: Neurological Disease


Medical Error: Delay in proper treatment


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



Alaska – Internal Medicine – Phentermine Prescribed In A Patient with Cardiomyopathy



On 04/27/2007, a patient with a history of cardiomyopathy presented to a physician’s office for weight loss and hormone evaluation.  A physical exam was conducted along with laboratory studies.  The Board noted that he did not conduct an adequate abdominal or neurological examination of the patient.

The physician prescribed thyroid hormone for the patient at a dose of four grains of Armour Thyroid daily.  The Board noted this dose to be excessive.

The physician also prescribed phentermine for weight loss.

Between 04/27/2007 and 09/14/2007, the patient filled five prescriptions of phentermine and four prescriptions of Armour Thyroid from the physician.

On 03/07/2008, the patient suffered cardiac arrest and hit her head on the table after having dinner with her husband.  She was rushed to the hospital, but died soon after arrival.

On 10/3/2012, a hearing was conducted.  The Administrative Law Judge (ALJ) issued a decision on 04/18/2014.  The ALJ found that the physician’s prescription of phentermine with known cardiomyopathy was not below the standard of care.  In addition, the ALJ found that the physician’s prescription of four times the recommended dosage of thyroid hormone in a patient with normal thyroid levels was not below the standard of care.  This decision was made despite the testimony of the Board’s expert in endocrinology and internal medicine and despite contraindications mentioned in the product literature.

The Board reversed the decision given concern that not doing so would send a message to the medical community that contraindications and dosage limits could be freely ignored.

They noted that the ALJ took the position that recommendations in the product literature represented a manufacturer’s risk assessment and did not represent the standard of care.  The ALJ also took the position that there were no studies to support avoiding phentermine in the setting of cardiovascular disease.  The Board, however, believed that there was sufficient evidence to support the recommendations of the product literature to avoid phentermine in the setting of cardiomyopathy.  They noted that studies to determine if phentermine increased the risk of death in patients with cardiovascular disease would be unethical.

It was noted that in Ancier v. State, Department of Health, an expert testified that phentermine could precipitate angina or heart attacks in patients predisposed to cardiovascular disease and was known to cause chemical dependence.

It was noted that in another case, a Washington physician testified that phentermine was inappropriate for patients with liver failure, hypertension, hypothyroidism, sleep apnea, or cardiovascular disease.

It was noted that in a medical malpractice case, the jury awarded $7 million in damages given that a patient with coronary artery disease had been prescribed phentermine, which the court determined was contraindicated in patients with cardiovascular disease.

It was noted that paradoxically the ALJ relied on the product literature to make the decision that the thyroid hormone dose prescribed by the physician was not below the standard of care.

The Board ultimately revoked the physician’s license.

State: Alaska


Date: May 2014


Specialty: Internal Medicine, Family Medicine


Symptom: N/A


Diagnosis: Cardiovascular Disease


Medical Error: Improper medication management


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



Alaska – Emergency Medicine – Pressure Washer Leads To Foot Injury



On 08/08/2011, a patient accidentally hit his foot with a pressure washer.  The pressure from the water blew through his boot.  He went to Urgent Care (UC) and was treated by an UC physician, who cleaned and sutured the wound.  He prescribed Augmentin and hydrocodone with acetaminophen.  The records noted instructions for the patient to return in 7 days.

That night, despite taking his prescribed medications, the patient had a fever and his foot was throbbing.  The next day, he went to the emergency department.  X-rays revealed foreign debris in the patient’s foot, which required surgery to remove.  The debris caused an infection that spread up the patient’s leg.  He required several days in the intensive care unit.

On 08/16/2011, he was released.

The UC physician was placed on probation with stipulation to undergo continuing medical education.

State: Alaska


Date: March 2014


Specialty: Emergency Medicine, Family Medicine, Internal Medicine


Symptom: Extremity Pain


Diagnosis: Trauma Injury


Medical Error: Diagnostic error


Significant Outcome: Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



Alaska – Cardiothoracic Surgery – Pleural Effusion In A Patient With A History Of Smoking And Drinking



In July 2007, a 50-year-old female with a history of smoking one pack of cigarettes per day, whose father died of lung cancer at age 56, and drank 5 bourbons a day, presented with 2 weeks of cough.  The physician discovered a pleural effusion and placed a catheter in the patient.  He ordered repeat radiographic studies and saw her on a frequent basis.  The catheter was removed the next month.

In January 2008, he placed another pleural catheter.  In February 2008, the catheter was removed.  The physician continued to treat the patient until April 2008.  He was unable to determine the cause of the effusion, but believed it was due to the patient’s life long smoking and heavy drinking.  During his treatment of her, he did not send the fluid for cytology analysis.

The patient was subsequently diagnosed with stage III B non-small cell lung cancer that was widely metastatic.

In March 2009, she died.

In February 2010, a complaint was filed.  In February 2010, a Board investigator informed the physician in writing that he was the subject of an official investigation regarding the medical care he provided to the patient.

In October 2010, when the physician applied for renewal of his physician license, he answered “No” to the question “Have you been the subject of an investigation by any licensing jurisdiction or are you currently under investigation by any licensing authority or is any such action pending?”  The physician testified that the non-disclosure was not an attempt to mislead and was an error.

The Board judged the physician’s conduct to be below the minimum standard of competence given failure to send cytology out for a pleural effusion in a patient with risk factors for lung cancer.

The Board ordered the physician be reprimanded, pay a fine, and take 20 hours of continuing medical education on thoracic surgery.

State: Alaska


Date: November 2011


Specialty: Cardiothoracic Surgery, Family Medicine, Internal Medicine


Symptom: Cough


Diagnosis: Lung Cancer


Medical Error: Failure to order appropriate diagnostic test


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Alaska – Neurosurgery – Lack Of Documentation Of An Anterior Cervical Decompression And Fusion Procedure Associated With Complications



On 08/08/2000, a patient was admitted to the hospital, and a neurosurgeon operated on his back in the early morning hours.  An anterior cervical decompression and fusion was performed.

An intra-operative event occurred during the operation that caused damage to the patient’s spinal cord.  The patient had almost complete quadriplegia when he awoke from the procedure.  Prior to the operation, the patient had no motor impairment.

When the patient’s chart was reviewed, there was no pre-operative history or exam, or admission note.  It was found that the neurosurgeon had dictated the admission note within the operative report.  In his post-operative admission note, the neurosurgeon noted that the patient had disc herniations.  However, in his operative note, which was dictated at the same time, he noted only osteophytes.  There was no record of an assistant in the operative or anesthesia records.

The neurosurgeon did not comment in the record on the post-operative x-rays, MRI, or CT scan.  The MRI, however, revealed abnormalities.  The neurosurgeon did not visit the patient on 08/12/2000, 08/13/2000, or 08/16/2000.

The neurosurgeon did not dictate his discharge summary on the patient until four months after the patient was discharged.

Later, the patient was admitted to a VA hospital.  He underwent surgery to address instability caused by the neurosurgeon’s procedure done at the first hospital.

The neurosurgeon was the subject of a medical malpractice lawsuit regarding this patient.

In 2009, the Alaska State Medical Board found that the neurosurgeon did not report the medical malpractice lawsuit within the time required.

The Alaska State Board judged the neurosurgeon’s conduct to be below the minimum standard of competence given failure to appropriately document the hospitalization and operation.  He failed to report the lawsuit within a timely manner.  However, it is noted that the Washington State Board did not find that the neurosurgeon had been below the standard of care in performing the procedure itself.

The neurosurgeon underwent an extensive investigation by the Alaska State Board after which there remained concern over documentation issues.  The Board ordered that his operative charts be subject to peer review.

State: Alaska


Date: December 2010


Specialty: Neurosurgery


Symptom: N/A


Diagnosis: Post-operative/Operative Complication, Spinal Injury Or Disorder


Medical Error: Lack of proper documentation


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 1


Link to Original Case File: Download PDF



Alaska – Neurosurgery – T10 And T11 Spinal Compression Fractures Treated With Kyphoplasty



On 03/22/2007, a patient suffered a back injury while making a jump on a snow machine.  She did not seek medical attention given lack of insurance.  The pain subsided, and she was able to work again.  She changed jobs and became a unit secretary at a hospital after realizing that she would need medical insurance.

In August 2007, her pain increased, and she was seen at the emergency department, where she was diagnosed with T10 and T11 spinal compression fractures.

On 11/08/2007, the patient met with a neurosurgeon for an evaluation.  Options were discussed, including kyphoplasty, a procedure which uses medical grade cement (methyl methacrylate).  An MRI was scheduled for 11/27/2007.  She was referred to a sports medicine physician for nonsurgical treatment.

On 12/27/2007, the patient met again with the neurosurgeon to discuss her options.  She decided to undergo kyphoplasty.

On 01/04/2008, the neurosurgeon performed the kyphoplasty procedure.  He first worked on the T11 level.

A kyphoplasty procedure requires inserting balloons into the vertebrae and expanding them to create a space for cement.  In placing one of the balloons, he penetrated the front of the vertebral body.  He used a technique to plug the hole.  Then, there was a balloon rupture within the vertebral body, with a little leakage of fluid and contrast through the anterior wall of the body.  Some of the cement filling leaked through the anterior wall.  The leakage was considered to be a benign event as described by the Administrative Law Judge (ALJ) reviewing the case.

There were no significant complications.  He then worked on the T10 level.  The initial needle pass from the left side was too far medial and extended too far to the rear, and it passed through the spinal canal.  This channel was developed to the point of having a working cannula in it before the neurosurgeon realized it was in the wrong location.  He did not realize, however, that he had breached the spinal canal.  He withdrew and developed a new channel in the correct location.

After balloon inflations in the T10 vertebral body, the neurosurgeon began to inject cement.  Less than thirty seconds after the neurosurgeon began injecting on the left side at T10, the fluoroscopic images showed extravasation of dark material traveling in a smooth-sided vertical channel upward and downward from T10.  The neurosurgeon apparently did not notice this finding.

The neurosurgeon continued to inject cement while the vertical shadow became more and more pronounced.  After a minute and forty seconds, on review, the shadow could be clearly seen extending all the way past the T9 level and into the T8 level.  Injection continued for another minute so that the period of injection after the leakage first became visible was at least two minutes and forty seconds.  During the early part of this period, there was some contrast circulating in the imagery, which was traced to a pain injection.

The ALJ explained that one could surmise from the images that the leakage was either anterior or posterior to the vertebral body based on the A/P images alone, but the lateral images (which were not available given a limit in how many images could be saved) would have indicated that the leakage was most likely posterior to the vertebral body.   A posterior leakage has the potential to infect pressure or heat damage on the spinal cord.

During testimony, the neurosurgeon recalled being puzzled by the images as he completed the kyphoplasty, but apparently did not appreciate the gravity of the situation.  It was noted that the batch of methyl methacrylate used in the procedure was recalled given that it was too slow to cure to the right viscosity, although the surgeon is supposed to test the cement before injection to confirm it has reached the correct viscosity.

The neurosurgeon then injected pain relief medications around T10.  He dictated an operative report and noted no complications.

Following the procedure, the patient was transferred to the Post Anesthesia Care Unit (PACU).  After awakening, she was found to have bilateral weakness of her legs.  A CT scan later showed compression of the spinal cord due to the cement that had leaked into the spinal canal.

The patient was taken back to the operating room, where the neurosurgeon performed an emergency laminectomy to remove the cement.  The cement had been in the canal for two and a half hours.  The amount of cement in the canal was considered “tremendous.”

During the second surgery, the patient continued to suffer a dense left paraplegia and right paraplegia, which failed to resolve.  A post-operative CT scan revealed residual methyl methacrylate that had not been removed during the second surgery.

The patient required intensive rehabilitation with physical and occupational therapy after the operations.  She was discharged on 02/12/2008.

The patient continued to suffer neurological deficits after the hospitalization.  She underwent two subsequent surgical procedures and was left with permanent, irreversible injuries, including lower extremity weakness and bladder and bowel dysfunction.

The Board judged the neurosurgeon’s conduct to be considered professional incompetence, gross negligence, or repeated negligent conduct.

The neurosurgeon underwent an extensive investigation by the Board given concern over his conduct.  His license was restricted in that he was ordered not to conduct surgery in which operative instruments are visualized by fluoroscopy unless he does so in the presence of a licensed surgeon or radiologist.

State: Alaska


Date: December 2010


Specialty: Neurosurgery


Symptom: Back Pain


Diagnosis: Post-operative/Operative Complication, Spinal Injury Or Disorder


Medical Error: Procedural error


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 4


Link to Original Case File: Download PDF



Alaska – Dermatology – Use of Intermittent Pulse Light Leads To Scarring



An Ob/Gyn physician advertised specializing in cosmetic dermatology despite not holding a certification in dermatology.

On 05/01/2006, the Ob/Gyn physician saw a patient with redness of her cheeks and chin.  The Ob/Gyn physician diagnosed her with rosacea and used Intermittent Pulse Light (IPL) on her cheeks, nose, and chin.  The patient developed swelling, bruising, and a 1.5 cm blister involving her left cheek.

In 3 weeks, the Ob/Gyn physician told the patient that her skin issues would respond to an Obagi chemical peel program.  The patient developed scarring involving her cheeks, which she described as white blotches within red areas involving her cheek.

The medical records lacked any record of a complete dermatological exam, and there was no documentation to support the diagnosis of rosacea.  The operative report lacked detail in how IPL was administered.

The Board ordered that the Ob/Gyn physician cease the practice of dermatology and cease advertising of dermatological services.  He was placed on probation for 5 years and ordered to complete 12 hours of medical education.  He was reprimanded and fined.

State: Alaska


Date: September 2009


Specialty: Dermatology


Symptom: Dermatological Abnormality


Diagnosis: Dermatological Issues


Medical Error: Improper treatment, Ethics violation, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Alaska – Dermatology – Use Of Intermittent Pulse Light Leads To Left Eye Swelling And Scarring



An Ob/Gyn physician advertised specializing in cosmetic dermatology despite not holding a certification in dermatology.

On 06/19/2006, a patient presented to the Ob/Gyn physician with erythema of the cheeks and nose.  The patient was diagnosed with rosacea.  The Ob/Gyn physician treated the patient using Intermittent Pulse Light (IPL)  on her face and failed to provide eye protection.  The patient developed swelling and blistering on the skin of her cheeks when driving home from the physician’s office.  Her left eye was swollen shut for several days.

On 06/21/2006, the Ob/Gyn physician saw the patient on follow-up and diagnosed her with a first-degree burn.  The Ob/Gyn physician said that the swelling, bruising, and blistering would heal in 10 days.  The patient developed a permanent scar on her face.

On 08/11/2006, the patient presented to a dermatologist for a second opinion.  He noted erythematous plaques overlaying the right and left malar cheeks with induration of the skin and sclerosis at the inferior margin of the “scar” on the left malar cheek.  He diagnosed erythematous scarring induced by IPL for telangiectasias of the cheeks.

The Board judged the Ob/Gyn physician’s conduct to be gross negligence given failure to provide eye protection to the patient during the use of IPL.  The medical records lacked any record of a complete dermatological exam, and there was no documentation to support the diagnosis of rosacea.

The Board ordered that the Ob/Gyn physician cease the practice of dermatology and cease advertising of dermatological services.  He was placed on probation for 5 years and ordered to complete 12 hours of medical education.  He was reprimanded and fined.

State: Alaska


Date: September 2009


Specialty: Dermatology


Symptom: Dermatological Abnormality


Diagnosis: Dermatological Issues


Medical Error: Improper treatment, Ethics violation, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Alaska – Dermatology – Fluconazole Prescribed For A 10.5 Month Old With A Skin Rash



An Ob/Gyn physician advertised specializing in cosmetic dermatology despite not holding a certification in dermatology.

On 06/14/2005, the Ob/Gyn physician saw a 10.5 month old given skin rash of the feet that was spreading to involve the body.  It was documented that the patient had erythematous dry patches involving the thigh, trunk, scrotum, and chest.  The physician diagnosed systemic mycosis and placed the patient on fluconazole for 14 days.

On a later date, the mother took the patient to a dermatologist for a second opinion.  The patient was diagnosed with seborrheic dermatitis with distribution involving the scalp, trunk, and extremities.  The dermatologist treated the patient’s condition with Nizoral shampoo, topical corticosteroids, and antipruritic topical creams.

The Board judged the Ob/Gyn’s conduct to be below the standard of care given that he provided improper treatment for seborrheic dermatitis and failed to refer the patient to a dermatologist.  The Board noted that the medical records lacked any record of a complete dermatological examination.

The Board ordered that the Ob/Gyn physician cease the practice of dermatology and cease advertising of dermatological services.  He was placed on probation for 5 years and ordered to complete 12 hours of medical education.  He was reprimanded and fined.

State: Alaska


Date: September 2009


Specialty: Dermatology


Symptom: Dermatological Abnormality


Diagnosis: Dermatological Issues


Medical Error: Improper treatment, Ethics violation, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Alaska – Dermatology – Use Of IPL For Rosacea Leads To Complications



An Ob/Gyn physician advertised specializing in cosmetic dermatology despite not holding a certification in dermatology.

On 08/18/2005, the Ob/Gyn physician saw a patient who presented with redness, bumps, and swelling on her face.  The physician diagnosed her condition as rosacea and recommended noritate cream.

On 09/19/2005, the patient returned to the Ob/Gyn physician, who treated the patient’s facial erythema with Intermittent Pulse Light.  The patient had excessive pain for 14 days after the procedure.  Her facial erythema did not resolve with treatment.

The patient also had a rash on her hands.  The Ob/Gyn physician diagnosed the rash as eczema, and recommended use of a light box.

The patient saw a second opinion from a dermatologist, who took a biopsy of the rash, which revealed granuloma annulare.

According to the Board, the medical records did not adequately document the history, symptoms, and physical exam findings.  There was no formal operative report for the IPL treatment.

The Board ordered that the Ob/Gyn physician cease the practice of dermatology and cease advertising of dermatological services.  He was placed on probation for 5 years and ordered to complete 12 hours of medical education.  He was reprimanded and fined.

State: Alaska


Date: September 2009


Specialty: Dermatology


Symptom: Dermatological Abnormality


Diagnosis: Dermatological Issues


Medical Error: Improper treatment, Ethics violation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



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