Found 206 Results Sorted by Case Date
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Wisconsin – Gynecology – Pregnancy Test Performed Prior To Hysterectomy Turns Positive



On 12/27/2012, a patient with a history of uterine fibroids by ultrasound, two laparoscopies for adhesiolysis with bladder injury, presented to Gynecologic Oncologist A with complaints of a pelvic mass and endometriosis.  It was noted that there was an enlarged tender mass on exam consistent with endometriosis and fibroids and that the patient wanted definitive surgical intervention.

The patient was scheduled for an elective robotic hysterectomy with bilateral salpingo-oophorectomy on 1/17/2013.  The patient was planned for pre-operative lab testing, including a pregnancy test, within 72 hours of the scheduled surgery date.

The patient presented on 1/15/2013 to have pre-operative labs drawn.  The lab results were logged into the patient’s chart the next day.  These lab results included a positive pregnancy test.  Registered Nurse A was responsible for collecting lab findings prior to the operation on a form.  On that form, the “pregnant” and “lactating” questions were answered with a “no.”

On the day of surgery, Registered Nurse B was responsible for reviewing physician orders and labs.  Registered Nurse C did not confirm the results of the patient’s pre-op pregnancy test.  Anesthesiologist A signed an anesthesia pre-op order form which called for a pregnancy test on all patients similar to the patient, unless specifically waived.  Anesthesiologist A did not obtain a waiver and did not confirm the results of the patient’s pre-op pregnancy test.

Gynecologic Oncologist A performed surgery on patient A, during which it was found that the patient was pregnant.

Anesthesiologist A and Gynecologic Oncologist A were deemed to have engaged in unprofessional conduct by engaging in conduct which increases the risk of danger to the health, welfare, or safety of a patient.

State: Wisconsin


Date: May 2017


Specialty: Gynecology, Anesthesiology


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


Diagnosis: Gynecological Disease


Medical Error: Failure to follow up, Failure of communication with other providers, Lack of proper documentation, Procedural error


Significant Outcome: N/A


Case Rating: 2


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



Wisconsin – Physician Assistant – 25-Year-Old Man With Cough, Fever, Chills, And Night Sweats



On 12/15/2003, a 25-year-old non-smoking man presented to a clinic with 10 days of cough, fever, chills, and night sweats.  He was noted to have a heart rate of 142 and a respiratory rate of 24.  He was on amoxicillin, doxycycline, and prescription cough medication.

Physician Assistant A switched him to a different cough medication.  He reported that he had re-checked the heart rate, but there was no documentation of the re-check.  He recommended that the patient continue with amoxicillin and doxycycline.  A TB skin test was ordered.  Physician A was supervising Physician Assistant A.  She reviewed and signed the note sometime after 2/13/2004.

On 12/18/2003, the patient returned to the clinic to have his TB test read.  At that time, he was doing worse.  He saw Physician Assistant B, who was also being supervised by Physician A.  Physician Assistant B reviewed Physician Assistant A’s notes and documented that “his cough seems to be worse” and that the antibiotics “do not seem to be helping.”  His temperature was noted to be 101.3, respiratory rate 32, and on physical exam, it was noted that he was coughing, the coughing intensified when he was reclined, he had a headache with coughing, he had bilateral lower pleuritic pain, and he had “decreased breath sounds to the right base.”   The TB test was negative.  He was diagnosed with “probable pneumonia.”

She recommended a chest x-ray and a CBC, but the patient declined due to cost.  Antibiotics were changed to gatifloxacin 400 mg daily.  It was recommended that he increase fluid intake.  On 12/19/2003, Physician Assistant B dictated the note for the patient visit from the prior day.  The note contained her signature, but not the date.  The medical records reflected that Physician A reviewed and signed the note, but did not reflect when she reviewed or signed it.  On review of the chart, oxygen saturation was not documented.  Physician A did not contact the patient or direct Physician Assistant B to contact the patient, in order to obtain an updated oxygen saturation.

On 12/23/2003, the patient was admitted to the ICU.  Oxygen saturation was at 71%.  On 12/26/2003, he was placed on a mechanical ventilator.  On 1/1/2004, the patient suffered cardiac arrest and could not be resuscitated.

The cause of death was noted to be acute respiratory distress syndrome secondary to pneumonia due to blastomycosis.  On 10/2/2009, a jury concluded that Physician A was negligent in her supervision of Physician Assistant A and B.  The jury attributed 35% of the total causal negligence to Physician A.

The Board addressed the issue of whether Physician A should have sought to obtain an oxygen saturation level.  The Board ultimately decided that Physician A was within the standard of care.

Physician Assistant B’s conduct in her treatment of the patient was below the minimum standards for the profession in the following respects: she failed to document in the patient’s chart that the chest x-ray and CBC were not done “against medical advice”; failed to recommend admission for the patient; failed to consult with her supervising physician; and failed to request a pulmonary consult.

The Board ordered Physician Assistant B be reprimanded, complete 4 hours of continuing medical education in the areas of evaluation and treatment of pneumonia and respiratory distress, and pay the costs of the proceeding.

State: Wisconsin


Date: January 2017


Specialty: Physician Assistant, Internal Medicine


Symptom: Cough, Fever, Headache, Chest Pain, Shortness of Breath


Diagnosis: Pneumonia


Medical Error: Improper treatment, Failure to order appropriate diagnostic test, Failure of communication with other providers, Referral failure to hospital or specialist, Improper supervision, Lack of proper documentation


Significant Outcome: Death, Hospital Bounce Back


Case Rating: 5


Link to Original Case File: Download PDF



Wisconsin – Gynecology – Woman With History Of Breast Cancer, Rectal Cancer, Colorectal Resection, With Post-Menopausal Bleeding



In October 2013, a 62-year-old woman with a history of breast cancer, rectal cancer, colorectal resection, and ileostomy reversal presented to Gynecologist A for post-menopausal bleeding.  Abdominal hysterectomy and bilateral salpingo-oophorectomy was recommended and a consent form was signed.

On 10/29/2013, Gynecologist A noted on the ultrasound the presence of a uterus and ovaries.  Gynecologist A documented that the patient neither had a uterus nor ovaries.

On 11/25/2013, Gynecologist A performed an exploratory laparotomy with lysis of adhesions on the patient.  As documented, Gynecologist A discussed with the patient and the family that she neither had a uterus nor ovaries.

On 3/10/2014, a gynecologist oncologist performed a total abdominal hysterectomy and bilateral salpingo-oophorectomy on the patient.  It is not reported if the patient was eventually diagnosed with cancer.

The Board stated that Gynecologist A engaged in unprofessional conduct by increasing risk of harm to the patient.  She was reprimanded with order for payment of costs.

State: Wisconsin


Date: November 2016


Specialty: Gynecology


Symptom: Gynecological Symptoms


Diagnosis: Gynecological Disease


Medical Error: Diagnostic error, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Wisconsin – Radiology – Chest Wall Pain And Mass With Only Interstitial Lung Disease Reported On CT



In February 2009, a patient presented to his primary care physician with chronic chest pain.  A CT scan was performed.  On 3/9/2009, Radiologist A reviewed the CT scan of the chest and documented interstitial disease.

A high resolution CT scan was performed on 3/19/2009.  Radiologist B reviewed the CT scan of the chest and affirmed findings of interstitial lung disease.

In August 2009, the patient followed up with his primary care physician and complained of a chest mass.  A nurse noted that he had “a large mass in the middle of [his] chest.”

On 8/24/2009, Radiologist C remotely reviewed the patient’s CT scan of the chest.  The 3/5/2009 and 3/9/2009 studies were made available to him.  The clinical history stated “CT Chest Mass in Mid Chest.”  The report stated, “Old granulomatous disease and chronic interstitial lung disease.  Nodular pleural thickening right middle lobe.  Stable findings compared to earlier examination.”

On January 2010, the patient presented to his physician with growing mass.  A biopsy was performed revealing a solitary plasmacytoma of the sternum.

The patient died on 4/25/2010 after radiation treatment.  Radiologist D reviewed all three CT scans and testified that the chest wall mass was present in all three.

Radiologist B and C were reprimanded for engaging in conduct that tends to constitute a danger to the health, welfare, and safety of a patient.

State: Wisconsin


Date: November 2016


Specialty: Radiology


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


Diagnosis: Cancer


Medical Error: False negative


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



Wisconsin – General Surgery – Colorectal Mass, Bleeding, And Abdominal Discomfort With Subsequent Abdominal Perineal Resection And Colonoscopy



On 8/24/2009, a 39-year-old woman was referred to Surgeon A for a colorectal mass, bleeding, and abdominal discomfort.  A rectal exam was not documented.  The plan stated: “I will try to get the report from [Physician A] about the colonoscopic examination.  In the meantime, we will go ahead and order a CT of the abdomen and pelvis.”

On 8/25/2009, after obtaining CT and colonoscopy pathology results, the following noted: “CT rectal mass, etiology?  She needs biopsy before doing surgery.  I will talk to [Physician A] … Pathology report at Columbia St. Mary.”

“It is adenocarcinoma, the lesion is very low, and needs abdominoperineal resection and permanent colostomy.  The procedure is explained to her.  She is willing to have surgery.”

On 8/26/2009, a consent form was signed and the surgeon performed an abdominal perineal resection with permanent colostomy.  On 8/29/2009, the patient saw an oncologist, and on 9/4/2009, she saw a radiation oncologist.  Subsequently, adjuvant therapies of chemotherapy and radiation were recommended and performed.

On 2/1/2009, the patient underwent revision of colostomy performed by Surgeon B.

Surgeon A was deemed to have fallen below the standard of minimal competence given that he failed to determine the exact location of the tumor within the rectum and did not perform a sphincter sparing surgery, which should have avoided the needed for a permanent colostomy.  Surgeon A failed to offer Patient A the option of preoperative radiation and chemotherapy.  He failed to recommend an oncology consultation prior to the initial surgery.

State: Wisconsin


Date: October 2016


Specialty: General Surgery, Gastroenterology, Oncology


Symptom: Abdominal Pain, Bleeding, Mass (Breast Mass, Lump, etc.)


Diagnosis: Colon Cancer


Medical Error: Unnecessary or excessive treatment or surgery, Diagnostic error, Failure of communication with other providers, Failure of communication with patient or patient relations


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 2


Link to Original Case File: Download PDF



Wisconsin – Radiology – Evaluation Of Mediport Placement



On 3/6/2015, a 68-year-old woman had a right subclavian mediport placed for palliative chemotherapy.  Radiologist A reviewed the chest x-ray that was done after the procedure.  He noted that the tip of the port was at the confluence of the innominate veins.

On 4/1/2015, an additional chest x-ray was taken given concern for malposition of the port.  Radiologist B reviewed the chest x-ray and noted: “The distal tip overlies the medial aspect of the aortic arch.  Correlation with clinical history and examination of the mediport is recommended to exclude the possibility of an intraarterial positioning.”

Further studies revealed that the mediport tip was in an artery.  The mediport was surgically removed.

The Board deemed Radiologist A had engaged in unprofessional conduct.  He was reprimanded and ordered to pay costs.

State: Wisconsin


Date: October 2016


Specialty: Radiology


Symptom: N/A


Diagnosis: Post-operative/Operative Complication


Medical Error: Diagnostic error


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Wisconsin – Pediatrics – Post-Operative Tachycardia And Low Blood Pressure In Pediatric Patient With Multiple Serious Conditions



A fourteen-year old-boy with multiple serious medical conditions including cerebral palsy, type I diabetes mellitus, and dysarthria was scheduled to undergo a laparoscopic lysis of adhesions, a laparoscopic jejunostomy placement, and a laparoscopic-assisted abdominoperineal resection.  He had previously undergone a total colectomy with ileostomy placement and J-tube placement and replacement by interventional radiology.

On 1/13/2011, the patient presented for surgery.  A pediatrician and a surgeon agreed that if the surgical procedures went well, the patient would not be placed in the pediatric intensive care unit, but would be cared for postoperatively on an inpatient pediatric unit, which was also being staffed by the pediatrician.

At approximately 4 p.m. the patient was transferred from recovery to a room in inpatient pediatrics on unit 4 West with no noted complications.  The pediatrician saw the patient on unit 4 West at approximately 5:15 p.m. and 7:20 p.m.

The pediatrician’s note of the 5:15 p.m. visit indicates that the patient seemed to be doing well.  The pediatrician’s note from the 7:20 p.m. visit indicates that the patient’s vital signs were stable.  The patient’s records indicate that around 7:20 p.m., he had a small amount of bloody drainage from the rectum suture line and that he was running a low-grade fever.  The pediatrician left the hospital shortly thereafter.

Between approximately 9:30 p.m. on 1/13/2011, and 3:00 a.m. on 1/14/2011, the pediatrician was provided updates on the patient’s condition by telephone and notified that the patient was experiencing tachycardia and decreased blood pressure.  The pediatrician entered several orders but failed to take urgent action to address the patient’s declining condition.

At approximately 3:30 a.m. the patient began experiencing respiratory distress.  The pediatrician was contacted and he ordered chest x-rays and lab tests.  A blood transfusion had also been ordered and administered, but the patient’s condition became critical and he died at approximately 4:45 a.m. on 1/14/20114.

The Board judged the pediatrician’s conduct to be below the minimum standard of competence given his failure to provide appropriate urgent action to address the patient’s declining condition.

The Board ordered the pediatrician be reprimanded and pay a fine.

State: Wisconsin


Date: July 2016


Specialty: Pediatrics


Symptom: Shortness of Breath, Bleeding, Fever, Shortness of Breath


Diagnosis: Post-operative/Operative Complication, Sepsis


Medical Error: Improper treatment, Delay in proper treatment


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



Wisconsin – Radiology – CT Scan Interpretation For Unrelenting Postprandial Abdominal Pain



A patient presented with postprandial abdominal pain at an ER in Virginia.  The abdominal pain was described as “unrelenting” and diffuse.

A CT abdomen/pelvis was ordered.  The radiologist interpreted the CT scan by tele-radiology.  The history provided included “right upper quadrant and epigastric pain, vomiting, and WBC of 14.9.”

2 days later after presentation in the evening, an MRA was performed and interpreted by Radiologist B.  It revealed superior mesenteric, celiac, and inferior mesenteric artery occlusions. The patient was taken to surgery.  The next day, he died.

The radiologist acknowledged the findings of superior mesenteric and celiac artery occlusions and acknowledged that he did not report them, either from not observing them or given that there were no other findings to suggest acute ischemia.

Further education on CT scan reading was recommended.

State: Wisconsin


Date: June 2016


Specialty: Radiology, Emergency Medicine


Symptom: Abdominal Pain, Nausea Or Vomiting


Diagnosis: Acute Abdomen


Medical Error: False negative


Significant Outcome: Death


Case Rating: 5


Link to Original Case File: Download PDF



Wisconsin – Family Medicine – Liquid Burn Injury With Second Degree Burns Over Two-Thirds Of His Chest On The Left Side And One Third Of His Back



A patient presented to the clinic after the parents reported that the patient had a liquid burn injury.  He was noted to have second degree burns over two-thirds of his chest on the left side and one third of his back.  The family practitioner noted that he “explained to them that this is a not significant burn and does not need attention.”

They opted to treat at home. “I did show them the techniques from John Kelm and B&W salve.  Mother makes some ointments which are similar and elected to use her own ointment.  We discussed pain control and making sure he keeps up with with fluid intake.”  A morphine dose was administered to the patient.

2 days later a follow-up visit was scheduled.  The day before the visit, the patient’s parent reported that the patient was in significant pain.  Acetaminophen with codeine was prescribed.  The family practitioner did not direct the parents to seek medical attention in the ED or at the clinic.  The next day, the patient presented to the family practitioner, who documented that the plan was to “continue with the herbal remedies the parents are concocting” and to closely monitor him until “we start seeing good skin healing.”

A follow-up appointment was made for the next day.  The patient presented to the clinic as scheduled.  The family practitioner noted that the burn injuries were not improving.  He consulted a physician in the burn center at a hospital in St. Paul, Minnesota.  The next day at 8 a.m., the family practitioner was notified that the patient had died.

The cause of death was liquid burn, thermal injury, and liquid thermal injury.  Anatomic diagnosis reported second-degree burn over 17% of the patient’s body, bilateral acute to subacute pneumonitis, increased sinusoidal neutrophils of the liver, and elevated codeine levels.

The family practitioner was deemed to have engaged in unprofessional conduct.

State: Wisconsin


Date: May 2016


Specialty: Family Medicine, Internal Medicine


Symptom: N/A


Diagnosis: Trauma Injury


Medical Error: Improper treatment


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



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