Found 10 Results Sorted by Case Date
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Colorado – Radiology – MRI Read As Spinal Stenosis With Missed Diagnosis



In March 2013, a patient had an MRI performed.  A radiologist read the MRI as showing spinal stenosis.  The patient was diagnosed one year later with a thoracic spinal tumor.  The finding was visible on the March 2013 MRI, which revealed approximately 1.5 cm tail of a benign fibrous epidural thoracic tumor at the level of T6-T8 with the small extension down to the level of T9-T10.

The Board judged the radiologist’s conduct as having fallen below the minimum level of competence given failure to interpret the patient’s MRI as revealing a thoracic spinal tumor.

The Board issued a letter of admonition.

State: Colorado


Date: June 2016


Specialty: Radiology


Symptom: N/A


Diagnosis: Neurological Disease


Medical Error: False negative


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Colorado – Radiology – PET/CT Scan Read As Negative For Cancer In A Female With An Abnormal Carcinoembryonic Antigen Test



In 2012, a 57-year-old female was found to have an abnormal carcinoembryonic antigen test.  In January 2013, she had a PET/CT scan performed.  A radiologist interpreted the scans as “no PET CT evidence of local or distant metastatic disease.”

Ten months later, the patient had a subsequent PET/CT scan, which revealed an enlarging hypermetabolic mass in the medial segment of the left lobe of the patient’s liver.  The finding was visible on the patient’s January 2013 scans.

The Board judged the radiologist’s conduct as having fallen below the standard of care given failure to correctly interpret the patient’s PET/CT scans, leading to delay in the diagnosis of her liver cancer.

The Board issued a letter of admonition.

State: Colorado


Date: March 2016


Specialty: Radiology


Symptom: N/A


Diagnosis: Cancer


Medical Error: False negative


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Colorado – Urology – Testosterone Pellets And Testosterone Level Monitoring



In September 2013, a 56-year-old male was evaluated by a urologist for decreased testosterone level and urinary symptoms.  The urologist documented a low normal testosterone level, androgen deficiency, and other symptoms.  Afterwards, the urologist implanted testosterone pellets on four separate occasions.  The patient developed a 1 cm abscess at the third implantation visit, which was drained and resolved.  The urologist ordered labs prior to the fourth testosterone implantation which indicated the patient’s testosterone level was 1,058 (normal listed as 250-1100) with an elevated free testosterone of 212.4 (normal listed as 35-155) and estrogen level of 425 (normal listed as 130 or less).

The Board judged urologist’s care to be below the minimum standard of competence given failure to review the follow up lab tests prior to performing a fourth testosterone implantation.

State: Colorado


Date: March 2016


Specialty: Urology


Symptom: Urinary Problems


Diagnosis: Urological Disease


Medical Error: Failure to follow up


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Colorado – Radiology – Headache, Vertigo, And Vomiting With Head CT Read As Having No Acute Pathology



In September 2009, a patient presented to the emergency department with complaints of headaches, vertigo, dizziness, and vomiting.  The treating ED physician ordered a non-contrasted head computed tomography (CT) as part of the patient’s workup.  The final report for this head CT recommended a contrast-enhanced head CT and magnetic resonance imaging for further evaluation.

The radiologist read the subsequent contrast-enhanced head CT as essentially negative with “no definite hemorrhage” and “no acute intracranial pathology.”  The patient was discharged home and the next day was readmitted to the ED with a decreased level of consciousness, went into a coma, and was ultimately diagnosed with posterior fossa subdural hematoma.  The finding was visible on the 2009 contrast-enhanced head CT.

The Board judged the radiologist’s conduct as having fallen below the generally accepted standards of practice for a radiologist.

The Board issued a letter of admonition.

State: Colorado


Date: February 2016


Specialty: Radiology


Symptom: Headache, Dizziness, Nausea Or Vomiting


Diagnosis: Intracranial Hemorrhage


Medical Error: False negative


Significant Outcome: Hospital Bounce Back


Case Rating: 2


Link to Original Case File: Download PDF



Colorado – Radiology – CT Scan Of Abdomen And Pelvis Read As Mild Pelvic Inflammation And Probable Ileus



In October 2007, a 44-year-old female presented to the emergency department with complaints of abdominal pain and vomiting.  A computerized tomography (CT) scan of the patient’s abdomen and pelvis was obtained for evaluation of the patient’s symptoms.

The radiologist interpreted a “preliminary report” of the CT scan as “mild pelvic inflammation, which may be secondary to menses or pelvic inflammatory disease.  Consider pelvic ultrasound for further evaluation.”  In addition, prominent loops of small bowel were noted, consistent with probable “ileus.”

The patient was later diagnosed with metastatic colorectal cancer in 2008.  The finding was visible on the patient’s 2007 CT scan.

The Board judged the radiologist’s conduct as having fallen below the minimum level of competence given failure to correctly interpret the patient’s 2007 CT scan as metastatic colorectal cancer.

A Board issued a letter of admonition.

State: Colorado


Date: December 2015


Specialty: Radiology


Symptom: Abdominal Pain, Nausea Or Vomiting


Diagnosis: Colon Cancer


Medical Error: Diagnostic error


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Colorado/California – Pulmonology – Reading A STAT Portable Chest Radiograph For Respiratory Decompensation Under Pressure



A patient was admitted to the hospital in February 2011 with shortness of breath, hypoxemia, and progressive bilateral interstitial lung infiltrates.  A pulmonologist performed a diagnostic bronchoscopy, a broncho-alveolar lavage in the patient’s right middle lobe, and a trans-bronchial biopsy in the left lower lobe.  The patient developed respiratory decompensation after the procedure, and as an iatrogenic pneumothorax was suspected.

The pulmonologist ordered a STAT portable chest radiograph.  The radiographic image was unavailable for transmission to the bronchoscopy suite and the radiologist’s reading station.  The pulmonologist left the patient in the care of a respiratory therapist and nurse, ran to another floor where the plate reader was located, and hastily reviewed the 90 degree rotated image.  The pulmonologist misread the side of the pneumothorax displayed on the chest radiograph, and as a result, he incorrectly placed a chest tube on the left side. The patient did not improve with the insertion of the chest tube, and another portable chest radiograph was requested.  The second radiograph image was loaded onto the hospital network, and the radiologist called to report that the chest tube was on the side away from the pneumothorax. The pulmonologist placed a right-sided chest tube, and the patient stabilized. The pulmonologist did not request assistance from a radiologist to read the radiograph initially, but left the patient to read the image himself at a time when the patient was unstable.  A delay in correctly placing the chest tube resulted.

The Medical Board of Colorado revoked the pulmonologist’s license.  The Medical Board of California ordered the pulmonologist to surrender his license.

State: Colorado, California


Date: January 2014


Specialty: Pulmonology


Symptom: Shortness of Breath


Diagnosis: Pneumothorax, Pulmonary Disease


Medical Error: Accidental error, Diagnostic error, Procedural error


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Colorado – Anesthesiology – Hydromorphone And Bupivacaine Administration Results In Thoracic Granuloma



On 1/15/2007, a patient complained of escalating back and leg symptoms after the anesthesiologist had previously inserted a spinal catheter in the patient and administered high doses and concentrations of hydromorphone and bupivacaine.

In his medical chart the anesthesiologist noted the patient “has progressive weakness in his leg as it ascends up.”  The anesthesiologist also documented his concern that the patient may have had a “spinal block.”

The anesthesiologist ordered an MRI of the patient’s lumbar spine but did not order an MRI of the patient’s thoracic spine.  The anesthesiologist also failed to alert the radiologist to the fact that the patient had a pain pump.

The anesthesiologist did not take sufficient steps to investigate the “spinal block.”  The patient lost all feeling below the waist and was hospitalized.

Eventually, the patient was diagnosed with a thoracic granuloma with spinal cord compression resulting in paraplegia.  A thoracic granuloma is a rare complication that can be caused by the high concentration of hydromorphone and bupivacaine interfusing into the intrathecal space using a pain pump.

The Board ordered placed the anesthesiologist’s license on indefinite probation.  The Board also put a restriction for the anesthesiologist to be a solo practitioner in any practice environment or setting.  The anesthesiologist was required to complete continuing medical education on professional/problem based ethics program and enroll in the Center for Personalized Education for Physicians.  The Board ordered that the anesthesiologist pay a fine of $5,000.

State: Colorado


Date: July 2013


Specialty: Anesthesiology


Symptom: Numbness, Weakness/Fatigue


Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Spinal Injury Or Disorder


Medical Error: Improper medication management, Diagnostic error, Failure of communication with other providers


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 3


Link to Original Case File: Download PDF



Colorado – Anesthesiology – Insertion Of Catheter At The Wrong Angle Causes Spinal Lesion



On 5/25/2007, an anesthesiologist improperly performed a procedure to place a permanent spinal catheter in the patient’s spine.  The patient had complications.  A general surgeon ordered a Doppler ultrasound, because he was concerned about the patient getting venous clots.  The anesthesiologist cancelled the Doppler ultrasound.  The patient experienced deep venous thrombosis and a pulmonary embolism, which may have been avoided had the anesthesiologist not cancelled the ultrasound.  The anesthesiologist inserted the patient’s catheter too high and at the wrong angle which also caused a lesion on the patient’s spine.

The Board ordered the anesthesiologist’s license be put on indefinite probation.  The Board also put a restriction for the anesthesiologist to be a solo practitioner in any practice environment or setting.  The anesthesiologist was required to complete continuing medical education on professional/problem based ethics program and enroll in the Center for Personalized Education for Physicians.  The Board ordered that the anesthesiologist pay a fine of $5,000.

State: Colorado


Date: July 2013


Specialty: Anesthesiology


Symptom: N/A


Diagnosis: Deep Vein Thrombosis/Intracardiac Thrombus, Spinal Injury Or Disorder, Pulmonary Embolism


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


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Colorado – Anesthesiology – Oversedation Using Propofol And Incorrect Needle Placement In A Patient Results in Quadriplegia



On 11/20/2007, an anesthesiologist injured a patient while performing a cervical medial branch nerve procedure.  The anesthesiologist oversedated the patient for the procedure and had incorrect needle placement.  The needle slipped off the lamina and penetrated the patient’s spinal cord.  The anesthesiologist did not stop the procedure to consult with a neurologist.  In the first medical note the anesthesiologist prepared regarding the procedure, the anesthesiologist stated that the patient “suffered no complications.”  Sedation was noted as “480 mg propofol incremental.”  The anesthesiologist did not document motor testing and did not document whether fluoroscopic guidance was used during the patient’s procedure.  When the patient awakened after the procedure, he could not feel his legs.  The anesthesiologist did not seek immediate emergency care for the patient.  The anesthesiologist delayed transporting the patient to the hospital for thirty minutes.  The patient was diagnosed with quadriplegia.  The next day, the anesthesiologist prepared a second medical record concerning the patient’s procedure.  In the second report, the anesthesiologist changed the amount of sedation to “Propofol 260 mg.”  Again, the anesthesiologist did not document motor testing.

The Board ordered the anesthesiologist’s license be put on indefinite probation.  The Board also put a restriction for the anesthesiologist to be a solo practitioner in any practice environment or setting.  The anesthesiologist was required to complete continuing medical education on professional/problem based ethics program and enroll in the Center for Personalized Education for Physicians.  The Board ordered that the anesthesiologist pay a fine of $5,000.

State: Colorado


Date: July 2013


Specialty: Anesthesiology, Neurology


Symptom: Numbness


Diagnosis: Post-operative/Operative Complication, Drug Overdose, Side Effects, or Withdrawal, Spinal Injury Or Disorder


Medical Error: Procedural error, Ethics violation, Failure of communication with other providers, Improper medication management, Lack of proper documentation


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 4


Link to Original Case File: Download PDF



Colorado – Anesthesiology – Oversedation Using Propofol And Improper Needle Placement In Patient Results In Spinal Cord Injury



On 5/16/2008, an anesthesiologist performed bilateral C1-C2 facet injections and a C6-C7 intralaminar steroid injection on a patient to alleviate what he believed was cervogenically mediated headaches and back pain.  The anesthesiologist oversedated the patient with Propofol, did not use appropriate fluoroscopy during needle placement, improperly inserted the needle, and injured the patient’s spinal cord.  Shortly after the procedure, the patient experienced mild neck pain and sensation of heaviness in her left arm and leg.  The patient’s condition improved over time, but she did not fully recover.

The Board ordered the anesthesiologist’s license be put on indefinite probation.  The Board also put a restriction for the anesthesiologist to be a solo practitioner in any practice environment or setting.  The anesthesiologist was required to complete continuing medical education on professional/problem based ethics program and enroll in the Center for Personalized Education for Physicians.  The Board ordered that the anesthesiologist pay a fine of $5,000.

State: Colorado


Date: July 2013


Specialty: Anesthesiology


Symptom: Headache, Back Pain, Head/Neck Pain, Weakness/Fatigue


Diagnosis: Post-operative/Operative Complication, Drug Overdose, Side Effects, or Withdrawal, Spinal Injury Or Disorder


Medical Error: Procedural error, Improper medication management


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 2


Link to Original Case File: Download PDF



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