Found 74 Results Sorted by Case Date
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New Jersey – Gastroenterology – Pathology Diagnoses Polyp Removed During Colonoscopy As Adenocarcinoma



A payment of $775,000 had been made on the gastroenterologist’s behalf to settle a civil malpractice action brought against him by a patient.

It was alleged the gastroenterologist failed to follow-up on pathology results that revealed cancer after he had performed a colonoscopy on the patient, which led to a delay in the diagnosis of colorectal cancer.

On 8/12/2009, a 55-year-old woman presented to a gastroenterologist with complaints of abdominal pain and rectal bleeding.  The patient’s medical history revealed a family history of colon cancer.  The gastroenterologist recommended that the patient have a diagnostic colonoscopy to evaluate her persistent rectal symptoms.

On 9/17/2009, the gastroenterologist performed a colonoscopy on the patient.  During the procedure, the gastroenterologist identified internal hemorrhoids associated with a sessile polyp in the mid-rectum.  The gastroenterologist removed the polyp and submitted the specimen for pathologic analysis.  The patient was discharged from the hospital on 9/17/2009.

On 9/18/2009, pathology diagnosed the polyp to be a moderately differentiated adenocarcinoma arising within a tubular adenoma.  On 10/6/2009, the gastroenterologist entered a progress note in the patient’s hospital chart directly documenting the finding of adenocarcinoma made in the pathology report.  Despite entering that chart note, the gastroenterologist never advised the patient of the finding of adenocarcinoma that had been made.

The gastroenterologist thereafter had no further contact with the patient until he saw her in his office on 8/23/2010, approximately eleven months after the colonoscopy had been performed.  At that visit, the gastroenterologist diagnosed the patient with hemorrhoids and prescribed steroid suppositories; however, he once again failed to inform her of the finding of cancer that had been made following the September 2009 colonoscopy.  Additionally, the gastroenterologist did not then recommend that the patient schedule a repeat colonoscopy.

The patient ultimately had a repeat colonoscopy performed by another physician on 4/27/2011.  Following that procedure, she was found to have an invasive carcinoma of the mid-rectum, and she commenced receiving treatment for colon cancer.

When appearing before the panel, the gastroenterologist testified that he was aware of the pathology findings that had been made following the colonoscopy but did not specifically advise the patient of those findings because he considered the pathology findings to be “benign.”  The gastroenterologist further testified that he was confident that he had removed the entirety of the rectal polyp at the time of the colonoscopy.  The gastroenterologist maintains that, after completing the colonoscopy, he advised the patient that she would need to see him again in “about” a year, but there is no documentation in either the gastroenterologist’s medical record or the hospital chart which memorializes respondent’s having advised the patient to have a repeat colonoscopy within one year.  Further, although the gastroenterologist entered a note in the patient’s hospital chart on 10/6/2009 documenting the pathology findings, he failed to record the pathology findings in his office medical record, and he failed to obtain and/or maintain a copy of the pathology report in his office record.

The Board judged the gastroenterologist’s conduct to have fallen below the standard of care given failure to document that he advised the patient to have a repeat colonoscopy performed within one year of the date on which the original colonoscopy was performed and failure to have documented the pathology findings of adenocarcinoma in his office record.

The Board assessed a fine against the gastroenterologist with stipulations to complete courses in medical record keeping and medical ethics.

State: New Jersey


Date: March 3017


Specialty: Gastroenterology


Symptom: Blood in Stool, Abdominal Pain


Diagnosis: Colon Cancer


Medical Error: Failure to follow up, Failure of communication with patient or patient relations, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Oncology – Rectal Mass And Bloody Stool Misdiagnosed As Cancer Instead Of Endometriosis



On 4/15/2015, a 48-year-old female presented to the Mayo Clinic for an assessment regarding cancer treatment.

The patient presented with a history of a palpable rectal mass and bloody stool.  The patient presented to an oncologist after undergoing a colonoscopy and after a CT scan at Borland Grover Clinic revealed tumors suspicious for metastases.

The Borland Grover Clinic took a biopsy of the affected area.  Initial pathology indicated suspicion for adenocarcinoma.  Borland Grover clinic sent the sample to Cleveland Clinic for confirmation.  Cleveland Clinic returned a diagnosis of endometriosis, not cancer.

The oncologist did not obtain the pathology reports from Borland Grover Clinic or Cleveland Clinic.  The oncologist diagnosed the patient with rectal cancer with possible spread to the liver, lungs, and mediastinum.  The oncologist ordered an endobronchoscopic ultrasound (EBUS). The patient’s EBUS showed some concern for cancer, but the pathologist deemed the results of the EBUS insufficient for a definitive cancer diagnosis.

Despite not having a pathologic diagnosis of cancer, from May to July 2015, the oncologist ordered the patient receive a port placement and three chemotherapy treatments.

Due to continuing rectal pain, on 7/6/2015, the oncologist referred the patient to a colorectal surgeon.  As part of his review, the colorectal surgeon obtained the patient’s pathologic results from Borland Grover Clinic and Cleveland Clinic, which showed that the patient had endometriosis and not cancer.

On 7/16/2015, a Mayo Clinic pathologist reviewed the patient’s previous biopsy sample and came to a final diagnosis of endometriosis.  On 9/3/2015, two doctors performed a procedure to remove the endometrioma.

The Board judged that the oncologist’s conduct to be below the minimum standard of competence given her failure to obtain a pathologic diagnosis of cancer prior to initiating cancer treatment for the patient.

The Board ordered the oncologist have her license revoked, pay an administrative fine, and have remedial education.

State: Florida


Date: December 2017


Specialty: Oncology, Internal Medicine


Symptom: Blood in Stool, Mass (Breast Mass, Lump, etc.)


Diagnosis: Gynecological Disease


Medical Error: Diagnostic error


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



Florida – Obstetrics – Lack Of Maternal Serum Alpha-Fetoprotein Testing With Pregnancy Complications



On 2/24/2014, a 36-year-old female presented to an obstetrician for fatigue, breast tenderness, and absence of menstruation.  At the aforementioned visit, the obstetrician diagnosed the patient with amenorrhea and sent her to have blood work.

On 2/25/2014, the patient was notified of her positive pregnancy test.

On 3/10/2014, 3/17/2014, 3/24/2014. 4/24/2014, 8/7/2014, and 9/25/2015, the obstetrician ordered obstetrical ultrasounds and/or sonograms for the patient.

On 4/23/2014 and 8/20/2014, the patient presented to the obstetrician with thick vaginal fluid and blood discharge, morning sickness, nausea, chills, fever, and back pain.

On 5/23/2014, 6/20/2014, 7/16/2014, 8/15/2014, 9/12/2014, 10/13/2014, 10/20/2014, and 10/27/2014, the patient presented to the obstetrician for follow-up visits.

On 11/2/2014, the patient gave birth to her son, who was born with spina bifida/myelomeningocele.

The obstetrician failed to diagnose neural tube defect on imaging studies.

The obstetrician failed to order a maternal serum alpha-fetoprotein (MSAFP) test and did not maintain adequate legible documentation of ordering an MSAFP test.

The obstetrician failed to order an anatomical survey sonogram.

The Board ordered that the obstetrician pay a fine of $7000 against his license. The Board ordered that the obstetrician pay reimbursements costs of a minimum of $3,786.18 and not to exceed $5,786.18.  The Board also ordered that the obstetrician complete a course on “Quality Medical Record Keeping for Health Care Professionals” and that he  complete five hours of continuing medical education on “Risk Management.”

State: Florida


Date: December 2017


Specialty: Obstetrics


Symptom: Fever, Bleeding, Nausea Or Vomiting, Back Pain


Diagnosis: Obstetrical Complication, Spinal Injury Or Disorder


Medical Error: Failure to order appropriate diagnostic test, Failure to follow up, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Gynecology – Blood With Urination Not Due To Bleeding From Bladder Or Kidneys



On 4/5/2015, an 80-year-old female presented to a gynecologist with a complaint of pink drainage with urination.  The patient had a prior cystoscopy and a CT through the urology department, which was negative for hematuria. The gynecologist conducted an examination of the patient and noted: (1) no blood in the vagina; and (2) that the vaginal epithelium was atrophic.  The gynecologist did not order a pelvic ultrasound of the patient. The gynecologist failed to evaluate any postmenopausal bleeding with either an endometrial biopsy or an ultrasound of the uterus, and she failed to order or conduct any assessment to exclude malignancy.

On 2/21/2014, the patient was seen by a urologist for continued hematuria.  Cystoscopy was performed and revealed no bleeding from the bladder or kidneys.  On 2/25/2014, the patient was seen by another gynecologist who ordered a pelvic ultrasound that ultimately showed an intrauterine vascular mass.  On 3/3/2014, an endometrial biopsy was performed on the patient by a different provider, which showed adenocarcinoma.

The Medical Board of California judged that the gynecologist’s conduct departed from the standard of care because she failed to evaluate any postmenopausal bleeding with either an endometrial biopsy or an ultrasound of the uterus and to order or conduct any assessment to exclude malignancy.

The Medical Board of California issued a public reprimand and ordered the obstetrician to complete an education course (at least 15 hours) dedicated in the area of diagnosis and patient care in OB/GYN cases.

State: California


Date: August 2017


Specialty: Gynecology


Symptom: Bleeding


Diagnosis: Gynecological (Endometrial, Ovarian, Cervical) Cancer


Medical Error: Failure to order appropriate diagnostic test


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Obstetrics – Missed Indicators Of A Neural Tube Defect



On 2/24/2014, a 36-year-old female presented to an obstetrician for fatigue, breast tenderness, and absence of menstruation.  At the aforementioned visit, the obstetrician diagnosed the patient with amenorrhea and sent her to have blood work.

On 2/25/2014, the patient was notified of her positive pregnancy test.

On 3/20/2014, 3/17/2014, 3/24/2014, 4/24/2014, 8/7/2014, and 9/25/2015, the obstetrician ordered obstetrical ultrasounds and/or sonograms on the patient.

On 4/23/2014 and 8/20/2014, the patient presented to the obstetrician with thick vaginal fluid and bloody discharge and/or morning sickness, nausea, chills, fever, and back pain.

On 5/23/2014, 6/20/2014, 7/16/2014, 8/15/2014, 9/12/2014, 10/13/2014, 10/20/2014, and 10/27/2014, the patient presented to the obstetrician for follow-up visits.

On 11/2/2014, the patient gave birth to her son.  The child was born with a neural tube defect called spina bifida/myelomeningocele.

The obstetrician failed to observe on imaging studies, and follow-up on, known indicators that the patient’s child may have had a neural tube defect, or alternatively, did not create, keep, or maintain adequate legible documentation of observing on imaging studies, and following up on known indicators that the patient’s child may have had a neural tube defect.

The obstetrician failed to order maternal serum alpha-fetoprotein (MSAFP) test, or alternatively, did not create, keep, or maintain adequate legible documentation of ordering a MSAFP test.

The obstetrician failed to order an anatomical survey sonogram, or alternatively, did not create, keep, or maintain adequate legible documentation of ordering an anatomical survey sonogram.

It was requested that the Board order one or more of the following penalties for the obstetrician: 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: Obstetrics


Symptom: Weakness/Fatigue, Bleeding, Abnormal Vaginal Discharge, Back Pain


Diagnosis: Neurological Disease


Medical Error: Failure to order appropriate diagnostic test, Failure to follow up, Lack of proper documentation


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 1


Link to Original Case File: Download PDF



California – Otolaryngology – Public Letter Of Reprimand For Delayed Care And Failure To Inform Patient Of Potential Complication Of Epistaxis Treatment



An otolaryngologist failed to inform a patient of the potential for a septal perforation during treatment for epistaxis.

In another patient, there was a delay in care.  The otolaryngologist made an initial diagnosis of a nasopharyngeal mass.  However, there was a prolonged period of time between that initial diagnosis and when the biopsy was actually performed.

These actions were deemed to have constituted gross negligence and repeated negligent acts.

A Public Letter of Reprimand was issued against him.

State: California


Date: June 2017


Specialty: Otolaryngology


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


Diagnosis: Hemorrhage, Post-operative/Operative Complication


Medical Error: Failure of communication with patient or patient relations, Delay in proper treatment


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Kansas – Physician Assistant – Lovenox Prescribed For DVT In A Patient With A History Of GI Bleeding



On 11/19/2015, a patient presented to a family care clinic with complaints of swelling and pain in the right lower extremity (“RLE”).

The patient was seen by the APRN who documented the patient’s history of GI bleeding, noting the patient had experienced a RLE deep vein thrombosis (“DVT”) and pulmonary embolism (“PE”) on October 2015, that had been treated with an IVC filter in a medical center.

The APRN further documented in the patient’s chart, “No [sic] on anticoagulants due to GI Bleed,” and “Recent [history] GI bleed.”

The patient was referred to cardiology for the management of his anticoagulation.  He was to follow up on the morning of 11/20/2015 to have a complete blood count (“CBC”) drawn.

On 11/20/2015, the patient presented to a physician assistant with right leg and foot swelling with new onset pain rated a 1/10.  The physician assistant did not document a patient history and did not review the APRN’s notes from 11/19/2015.  The physician assistant diagnosed the patient with DVT of the right popliteal vein and mild anemia.  The physician assistant improperly prescribed Lovenox 60 mg SQ twice a day for one week with a follow-up to confirm dissolution of the clot.

On 11/23/2015, the patient awoke during the night with chest pain and was transported via ambulance to the emergency department where it was determined the patient had a GI bleed.  The patient’s hemoglobin (“HGB”) dropped abnormally low to 7.7, and his hematocrit (“HCT”) was also abnormally low at 27.4%.

The physician assistant’s response, received by the Board on 3/29/2016, noted, “There was no indication in the note from the previous day, nor in any clinic note that he was not a candidate for anticoagulation therapy.”  However, the original notes received by the Board on 10/6/2016 from the hospital indicated that the patient had a history of GI bleed and no anticoagulants should have been prescribed.

The Board judged the physician assistant’s conduct to be below the minimum standard of competence given his inappropriate prescribing of Lovenox.

For this allegation and others, the Board ordered the physician assistant to contact The Center for Personalized Education for Physicians, (“CPEP”) for a competence assessment, follow all recommendations of the CPEP assessment, and complete a medical record keeping seminar.

State: Kansas


Date: April 2017


Specialty: Physician Assistant, Emergency Medicine, Internal Medicine


Symptom: Blood in Stool, Extremity Pain, Swelling


Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Deep Vein Thrombosis/Intracardiac Thrombus, Pulmonary Embolism


Medical Error: Improper medication management, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Obstetrics – Postpartum Hemorrhage Diagnosed As Uterine Atony



On 1/15/2014, an obstetrician performed a Cesarean section on a patient.  The obstetrician documented no complications and a 600 ml blood loss.  Shortly after reaching the recovery room, the patient began vaginally hemorrhaging postpartum from what was diagnosed as uterine atony.  The obstetrician determined the patient was unstable and would need to return to the operating room (OR) after administering fluids and blood products and conducting a uterine massage.  Once in the OR, the patient was stabilized, yet continued persistent vaginal bleeding.  The decision was made by the obstetrician to reopen the abdomen and explore the prior Cesarean section.  After inspecting the uterus, the obstetrician made the determination that a supracervical hysterectomy was necessary.

A supracervical hysterectomy was performed by the obstetrician and another physician.  Once completed, a bimanual exam showed ongoing bleeding from the cervix.  An unsuccessful attempt was made to control the bleeding.  At this point, the determination was made to remove the cervix through the abdominal incision and a full hysterectomy was performed by the obstetrician and another physician. After the second surgery, the patient was taken to recovery in stable condition.

A discharge summary of the patient showed both placenta accreta and placenta increta in the endometrium and upper myometrium.

When the patient began hemorrhaging postpartum, the obstetrician appropriately returned to the patient’s bedside and examined her and ordered fluids and blood products as she alerted staff that the patient would need to return to the OR.

Once in the OR, however, the obstetrician failed to attempt more conservative therapies, including B-lynch suture, intrauterine balloon, uterine artery ligation, hypogastric artery ligation, and dilation and curettage.  There is no documentation that the obstetrician considered these options or ruled them out as potential actions prior to performing a hysterectomy on the patient.

On 6/7/2016, the obstetrician underwent an evaluation by a Board appointed psychiatrist.  The psychiatrist concluded that the obstetrician suffers from Major Depressive Disorder, Recurrent, and an Unspecified Anxiety Disorder, conditions that impair her ability to safely practice medicine.

The obstetrician was placed on probation for three years with stipulations to complete 40 hours annually for each year of probation of continuing medical education, complete a medical record keeping course, and undergo psychotherapy.

State: California


Date: March 2017


Specialty: Obstetrics


Symptom: Bleeding


Diagnosis: Obstetrical Hemorrhage


Medical Error: Improper treatment, Lack of proper documentation, Practicing while not being sound physically or mentally


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Gastroenterology – Multiple Endoscopic Studies For Ulcerative Esophagitis



A patient had been seen by a gastroenterologist, as an outpatient, since sometime in 2005 for chronic gastroesophageal reflux disease (GERD).  The patient had received long-term treatment with acid-reducing medications and prokinetic agents. Between 2005 and 2009, the patient underwent 23 separate endoscopic studies.  The gastroenterologist’s hand-written documentation of his care and treatment of the patient was scant, illegible, and failed to state the gastroenterologist’s thoughts regarding evaluating and/or modifying the patient’s clinical course.

Sometime in June 2010 and again in July 2010, the patient was admitted to the hospital with upper GI tract bleeding.  On 7/13/210, the gastroenterologist dictated an admission summary, which failed to provide any meaningful historical details regarding the patient.  The gastroenterologist used PT billing code 99223 indicating a “complex” level of assessment for the consultation.

From 6/16/2010 through 10/9/2010, the gastroenterologist performed a total of 7 endoscopic studies to evaluate the patient.  The studies demonstrated that the patient had severe ulcerative esophagitis, secondary to reflux and/or vomiting. The gastroenterologist documented that he cauterized areas of hemorrhagic mucosa in the esophagus.  However, the gastroenterologist’s dictated procedure reports failed to document any additional anatomy or physiology related to these studies and treatment.

The Medical Board of California judged that the gastroenterologist’s conduct departed from the standard of care because he failed to properly manage the patient’s reflux disease, performed an excessive number of endoscopic procedures that provided no relief to the patient’s symptoms or improvement in clinical outcome, failed to maintain adequate or accurate records of his care and treatment of the patient, and submitted billing using the CPT billing code 99223, which as not supported by the physician’s documentation of his care and treatment of the patient.

For this case and others, the Medical Board of California issued a public reprimand and ordered the gastroenterologist to complete an education course (at least 40 hours) and clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California


Date: February 2017


Specialty: Gastroenterology


Symptom: GI Symptoms (GERD, Abdominal Distention, Dysphagia), Bleeding, Nausea Or Vomiting


Diagnosis: Gastrointestinal Disease


Medical Error: Unnecessary or excessive diagnostic tests, Improper treatment, Lack of proper documentation


Significant Outcome: Hospital Bounce Back


Case Rating: 2


Link to Original Case File: Download PDF



California – Gastroenterology – Repeated Colonoscopies And Gastroscopies For Left-Sided Colitis And Improper Billing



Sometime in May 2009, a patient presented to a gastroenterologist with a history of sporadic rectal bleeding and chronic reflux-type complaints.  An index colonoscopy conducted on 5/7/2009 demonstrated predominantly left-sided colitis. The patient was treated with oral and topical mesalamine preparations.  Initially, the patient’s symptoms responded to the treatment, but then worsened several months later.

On 8/24/2009, the patient underwent a second colonoscopy.  The patient was prescribed oral budesonide to treat what was believed to be an extension of the colitis.  The patient continued to have ongoing symptoms. On 11/9/2009, the patient underwent a third colonoscopy, which showed reduced activity of disease.  On 1/8/2010, the patient underwent a gastroscopy and a fourth colonoscopy in order to determine the course of future treatment. The colitis was believed to be inactive, and the patient was continued on oral mesalamine preparations.  The patient’s increased bleeding was believed to be hemorrhoidal in origin, and internal hemorrhoids were cauterized. The biopsy from the distal esophagus demonstrated inflammatory changes without Barrett’s metaplasia.

The patient had difficulty swallowing (dysphagia) and abdominal pain.  The patient underwent gastroscope on 2/15/2010, 3/25/2010, 5/20/2010, and 4/19/2011.  In each instance, biopsies from the gastric antrum and distal esophagus/gastroesophageal junction were obtained, and mild chronic inflammatory changes were observed.  In each instance, the gastroenterologist did not obtain biopsies from the esophageal body. Repeated esophageal dilutions were performed in order to alleviate dysphasia symptoms.  The gastroenterologist did not document the presence or absence of constricting pathology.

The patient underwent additional colonoscopies on 8/24/2010, 4/11/2011, and 12/7/2012.  The patient underwent additional gastroscopies on 12/30/2011, 4/3/2012, 9/21/2012, 1/11/2013, and 3/1/2013.  In each instance, biopsies form the distal esophagus demonstrated inflammatory changes without Barrett’s metaplasia.

The gastroenterologist maintained handwritten notes of each visit.  Some of the handwritten notes were not legible. The gastroenterologist consistently failed to note any assessment and/or plan based on the assessment.  The gastroenterologist consistently billed using CPT billing code 99213, in the absence of documenting any expanded problem focused history or medical examination or medical decision-making.

The Medical Board of California judged that the gastroenterologist’s conduct departed from the standard of care because he performed repeated colonoscopies and gastroscopies of the patient without medical indication or necessity, failed to maintain adequate and accurate medical records of his care and treatment of the patient, and submitted billing for his care and treatment of the patient using the CPT billing code 99213, which was not supported by the physician documentation of his care and treatment of the patient.

For this case and others, the Medical Board of California issued a public reprimand and ordered the gastroenterologist to complete an education course (at least 40 hours) and clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California


Date: February 2017


Specialty: Gastroenterology


Symptom: Bleeding, GI Symptoms (GERD, Abdominal Distention, Dysphagia), Abdominal Pain


Diagnosis: Gastrointestinal Disease


Medical Error: Unnecessary or excessive diagnostic tests, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



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