Found 86 Results Sorted by Case Date
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Virginia – Neurosurgery – All-Terrain Vehicle Rollover Accident Causes L1 Compression Fracture



On 1/19/2008, a 32-year-old man suffered an L1 compression fracture following an all-terrain vehicle rollover accident.  He saw a neurosurgeon who placed him in a rigid back brace and prescribed pain medications.  The patient’s fracture appeared to be clinically stable and appeared to be improving.  The Board deemed the long-term risk of developing a kyphotic deformity low in this patient.

On 3/7/2008,  the neurosurgeon performed a kyphoplasty of the spine the patient.  During the kyphoplasty, the vertebral body was too dense to accept the cement.  As a consequence, the cement extruded out of the fracture plans into the epidural space.

The neurosurgeon addressed this complication by performing a posterior laminectomy and decompression of the thecal sac.  The Board stated that the laminectomy procedure subjected the patient to a far greater risk for development of kyphosis than had existed prior to the kyphoplasty.

The Board considered the surgery unwarranted and issued a reprimand.  The neurosurgeon was ordered to complete 10 hours of continuing medical education in the subject of patient selection for spinal surgery.

State: Virginia


Date: November 2017


Specialty: Neurosurgery


Symptom: Back Pain


Diagnosis: Spinal Injury Or Disorder, Fracture(s)


Medical Error: Unnecessary or excessive treatment or surgery, Procedural error


Significant Outcome: N/A


Case Rating: 5


Link to Original Case File: Download PDF



Virginia – Psychiatry – Adjusting Lithium Dosage Based Only On Patient Symptoms



A psychiatrist increased and decrease a patient’s lithium dosage based on the patient’s symptoms.  She did not test the patient’s lithium blood serum level.

On 8/28/2015, the patient was admitted to a hospital for lithium toxicity.  The psychiatrist stated that lithium blood serum levels for long-term lithium patients should be tested at least annually, but also at any time a patient complains of adverse side effects.  The psychiatrist admitted her failure to test the patient’s lithium levels and stated that it “was an inadvertent oversight for which [she] is remorseful.”  The psychiatrist reported that following the patient’s hospitalization for lithium toxicity, she reviewed the charts for her other patients on lithium and determined if they needed testing for lithium blood serum levels.

She provided evidence that she completed 99 hours of CME in psychiatry in 2015 and 58 credit hours of CME in psychiatry in 2017.  She provided a spreadsheet that she created for use in monitoring her patients on lithium.  She was reprimanded by the Virginia Board of Medicine.

State: Virginia


Date: October 2017


Specialty: Psychiatry


Symptom: N/A


Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Psychiatric Disorder


Medical Error: Improper medication management, Failure to properly monitor patient


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Virginia – Emergency Medicine – Chest Pain Radiating To The Neck, Throat, And Back



On 11/15/2013, a patient presented to the emergency department complaining of chest pain with radiation to the neck, throat, and back.  The patient expired the next day due to cardiac arrest.  The ED physician failed to perform a CT scan of the patient’s chest and failed to admit the patient for observation.  The ED physician discharged the patient with the diagnosis of “musculoskeletal chest pain.”

He was ordered a fine and to complete 5 hours of continuing medical education in each of the topics of medical record keeping and risk management.

State: Virginia


Date: August 2017


Specialty: Emergency Medicine


Symptom: Chest Pain, Back Pain, Head/Neck Pain


Diagnosis: Cardiovascular Disease


Medical Error: Diagnostic error


Significant Outcome: Death


Case Rating: 1


Link to Original Case File: Download PDF



Virginia – Pulmonology – Progression Of Interstitial Lung Disease And Pulmonary Nodules



In 2005, a 71-year-old male was diagnosed with pulmonary fibrosis.

In 2010, the patient began seeing a pulmonologist for follow-up and treatment of interstitial fibrosis with marked progression of interstitial lung disease.

On 5/11/2010, CT imaging identified nodules in the upper and lower left lung and consolidative process in the left lung base.

On 8/5/2010 and 8/302010, follow-up imaging noted significant and progressive increase in the size of the nodule in the left upper lobe, highly suspicious for malignancy.  There was also a slight increase in the density in the left lower lobe, concerning for malignancy.

On 10/15/2010, a CT guided lung biopsy was performed, which was complicated by pneumothorax.  The biopsy revealed atypical bronchial cells and multinucleated giant cells.  The pulmonologist did not follow-up with repeat imaging.

On 9/12/2011, repeat imaging study showed growth of the left lower lobe mass.

On 12/15/2011, follow-up PET scan showed a large hypermetabolic focus in the left lower lobe.

On 4/11/2012, the patient presented to the emergency room with progressive shortness of breath, increasing abdominal distention, and poor appetite.

On 4/16/2012, the patient was diagnosed with stage 4 adenocarcinoma with metastasis to the abdomen, pleural effusion positive for metastatic carcinoma, and possible post-obstructive pneumonia.

In his statement dated 6/8/2016, the pulmonologist stated that the failure to follow up with repeat imaging after the patient’s biopsy on 10/15/2010 was a breach of patient care.

The Board issued the pulmonologist a reprimand.

State: Virginia


Date: June 2017


Specialty: Pulmonology


Symptom: N/A


Diagnosis: Lung Cancer


Medical Error: Failure to follow up


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



Virginia – Gastroenterology – Colonoscopy With Significant Amount Of Liquid Stool In Bowel



On 2/5/2015, a 50-year-old female underwent a colonoscopy conducted by a gastroenterologist.

Although the gastroenterologist noted a significant amount of liquid stool remaining in the bowel and hard stool adhering to mucosa, he continued the procedure and repeatedly injected saline and air into the bowel in an effort to clear the visual field.

Although the gastroenterologist knew that the suction button on the colonoscopy was continually sticking, thus making the necessary suctioning difficult and/or impossible, the gastroenterologist continued the procedure.

After approximately 31 minutes, the gastroenterologist stopped the procedure when he noted that the patient’s abdomen was distended.  He then ordered x-rays and requested an immediate surgical consultation.

The x-rays revealed free air in the abdomen.  The patient underwent emergency surgery to repair a baro-rupture of her cecum.  Subsequently, the patient developed sepsis and multi-organ failure and died on 2/12/2015.

The gastroenterologist was permanently restricted from performing invasive procedures.

State: Virginia


Date: April 2017


Specialty: Gastroenterology


Symptom: N/A


Diagnosis: Post-operative/Operative Complication, Acute Abdomen


Medical Error: Procedural error


Significant Outcome: Death


Case Rating: 5


Link to Original Case File: Download PDF



Virginia – Pathology – Excised Tissue Determined As “Changes Consistent With Tonsillitis”



On 8/1/2013, Pathologist A examined excised tissue from a 55-year-old male and diagnosed “changes consistent with tonsillitis.”

In September 2014, the patient discovered a palpable nodule in the right submandibular region of his throat, which was aspirated on 10/20/2014, and determined to be squamous cell carcinoma.

In December 2014, Pathologist B reexamined the original pathology tissue, determined that Pathologist A’s diagnosis had been incorrect, and found that the specimen showed “squamous cell carcinoma poorly differentiated.”

Histologic evidence showed that the poor differentiation of the malignant cells clearly distinguished them from the surrounding benign lymphocytes, and the tumor was present in approximately 80% of the excised tissue.

Pathologist A’s erroneous diagnosis resulted in a fourteen-month delay in the diagnosis and treatment of the patient’s cancer.

The Board issued a Reprimand.

State: Virginia


Date: February 2017


Specialty: Pathology, Otolaryngology


Symptom: Mass (Breast Mass, Lump, etc.)


Diagnosis: Cancer


Medical Error: False negative


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Virginia – Family Practice – Prescription Of A Higher Dose Of Oxycodone Than Previously Prescribed



From June 2014 to January 2015, a family practitioner treated a 52-year-old female for complaints of chronic neck, back, knee, and elbow pain.

In November 2009, the family practitioner began treating the patient for unclear diagnoses with oxycodone, gabapentin, and alprazolam until late March 2014, when his license was temporarily restricted from prescribing those medications.

After the restrictions on his license had been lifted, the family practitioner resumed treating the patient on 6/6/2014.

That day, she reported that during the interim she had been prescribed medications by her primary care provider (“PCP”).  However, the family practitioner neither requested records from the patient’s PCP nor confirming her report by reviewing the Virginia Prescription Monitoring Program.

On 6/14/2014, without such confirmatory information, the family practitioner prescribed oxycodone at a dose of 120 mg/day down from 240 mg/day which he had prescribed her previously without documenting how he determined the dosage and without instructing the patient on medication titration.  He did not obtain any diagnostic studies to determine the cause of the pain.

Between 6/6/2014 and January 2015, the family practitioner failed to adequately monitor and manage the patient’s medication use.  He did not order any urine drug screens.  He did not conduct any pill counts.  He did not review data from the Virginia Prescription Monitoring Program.  If reviewed, it would have shown that the patient’s PCP prescribed between 60 mg and 90 mg a day.

The family practitioner saw the patient 10 times and prescribed her oxycodone with doses escalating up to 180 mg/day.  He did not refer her to any specialists despite the fact that she had a history of heart disease and was hospitalized several times since 2009 for COPD.  Between 6/4/2014 and 1/21/2015, the patient fell at least three times.

On 1/21/2015, the family practitioner prescribed the patient oxycodone 30 mg, 180 pills.

On 2/7/2015, the patient was found dead at home.  Law enforcement officers found two marijuana pipes in her bedroom along with “multiple prescription bottles and a saucer with a straw and pill residue…laying on the nightstand by [her] bed.”  On her death certificate, cause of death was noted to be oxycodone and alprazolam intoxication.  The manner of death was “Snorting abuse of prescribed pharmaceutical opioid.”  Blood toxicology revealed 0.368 mg/L of oxycodone.

The Board indefinitely suspended the family practitioner’s license.

State: Virginia


Date: February 2017


Specialty: Family Medicine, Internal Medicine


Symptom: N/A


Diagnosis: Drug Addiction, Drug Overdose, Side Effects, or Withdrawal


Medical Error: Improper medication management


Significant Outcome: Death


Case Rating: 1


Link to Original Case File: Download PDF



Virginia – Family Practice – Prescription Of Oxycodone At High Doses



In December 2009, a family practitioner began treatment for a 38-year-old male given a diagnosis of post-laminectomy syndrome.  He continued to regularly prescribe oxycodone, alprazolam, and baclofen until late March 2014, when the family practitioner was temporarily restricted from prescribing Schedule II and III medications.

After the restrictions on his license had been lifted, the family practitioner resumed treating the patient at an office visit on 6/9/2014.

On 6/9/2014, he did not document any change in the patient’s functional abilities since he had last seen him in March.  The family practitioner did not order a urine drug screen, review the patient’s Prescription Monitoring Program (“PMP”) record, or document how the patient had treated his pain in the interim period.

The family practitioner resumed prescribing oxycodone at 240 mg/day down from 480 mg/day prior to the gap in treatment.  The family practitioner did not document instructing the patient on medication titration, although the patient informed the family practitioner that in his absence, he “had to cut [his]meds back so far that its [sic] hard to get out of bed.”

In the 6-month period from 6/9/2014 to December 2014, the family practitioner did not order any drug screens, did not check the patient’s PMP record, did not communicate with the patient’s PCP or psychiatrist to independently confirm what medications other providers were prescribing, and did not conduct any pill counts.

On 1/27/2015, the patient was found dead at home in his bed with “multiple prescription pill bottles clutched in [his] right hand” and with “[p]araphernalia such as pill cutter and spoons found at bedside.”  One unlabeled pill bottle with multiple orange pills, all cut in half and later identified as 60 mg oxycodone, was also present.  The death certificate noted the cause of death as being from oxycodone and clonazepam intoxication.  Blood toxicology revealed an oxycodone level of 0.374 mg/L.

The Board indefinitely suspended the family practitioner’s license based on this case and multiple others.

State: Virginia


Date: February 2017


Specialty: Family Medicine, Internal Medicine


Symptom: N/A


Diagnosis: Drug Addiction, Drug Overdose, Side Effects, or Withdrawal


Medical Error: Improper medication management


Significant Outcome: Death


Case Rating: 1


Link to Original Case File: Download PDF



Virginia – General Surgeon – Insertion Of Trocar Causes Laceration Of The Right Common Iliac Artery



On 2/2/2012, a 33-year-old female was undergoing exploratory laparotomy conducted by a general surgeon.  At 10:30 p.m., the general surgeon inserted a trocar into the right lower abdomen under direct visualization.  During the insertion, the general surgeon used such force sufficient to cause a laceration of the right common iliac artery.

The patient became hypotensive and tachycardic.  At 10:50 p.m., the general surgeon converted to an open laparotomy.  She converted to an open laparotomy when she noted active bleeding.

The general surgeon stated that she believed the Board would be informed of the medical malpractice payment automatically as a result of the report to the National Practitioner Data Bank.  The general surgeon did not intend to mislead or not adhere to the Board’s requirement of separately reporting medical malpractice to the Board.

She failed to report the medical malpractice settlement she made in September 2014 to the Board within 30 days, as required by Virginia Code.  She failed to update her practitioner’s profile on the Board’s website to include that she made a malpractice settlement within 30 days, as required by the Board’s General Regulations.

The Board issued a reprimand and fine.

State: Virginia


Date: January 2017


Specialty: General Surgery


Symptom: Bleeding


Diagnosis: Post-operative/Operative Complication


Medical Error: Procedural error


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Virginia – Orthopedic Surgery – Metal Fragment From Drill Bit Breaks Off During Total Knee Replacement



On 7/27/2009, while an orthopedic surgeon was performing a right total knee replacement on a patient, a metal fragment that was the tip of a drill bit or metal pin used to guide the drill, broke off below the surface of the bone and was left in place in the patient’s knee.  The orthopedic surgeon did not note the occurrence in his operative report or records of the patient’s follow-up treatment, other than in a note relating to a March 2014 right knee x-ray that he ordered and read.

The patient told the Board’s investigator that the orthopedic surgeon never told her about the drill bit or complications from the surgery during any of her follow-up visits and that she learned this information in April 2015 from another orthopedist who had viewed an x-ray of her knee.

The orthopedic surgeon stated that he expected hospital nursing staff present during the patient’s knee surgery would have reported the retained metal fragment as an “adverse event.”  He also stated that he believes he would have told the patient about the occurrence when she was in the hospital following surgery, although he acknowledged that no such conversation was documented in his records.

The orthopedic surgeon further stated that during surgery, he had opted to leave the fragment in place, as it was located within the bone and away from any vital structures, and the risk of damage from removing it outweighed any potential benefit to the patient.

The Board issued a reprimand.

State: Virginia


Date: January 2017


Specialty: Orthopedic Surgery


Symptom: N/A


Diagnosis: N/A


Medical Error: Retained foreign body after surgery, Failure of communication with patient or patient relations, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



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