Found 31 Results Sorted by Case Date
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Washington – Internal Medicine – Proper Monitoring Of Thyroid Dysfunction And High Blood Pressure



Beginning in June 2014, a physician began treating Patients A and B for thyroid dysfunction and Patient C for high blood pressure. The physician communicated with Patient A and B through phone consultation and met Patient C in social situations and during at least two office visits. The physician reviewed previous lab work on thyroid functions for Patients A and B. The physician based Patient C’s treatment upon his physical observation of her conditions, two Zytoscans (device that measures electrical currents in the skin), and taking her blood pressure. Patient A and B’s lab work indicated both patients having lower than normal thyroid function. The physician started both Patients A and B on a thyroid hormone supplement. He prescribed medication commonly used for treating high blood pressure for Patient C based upon his observations, oral reports of Patient C, and the Zytoscans. The physician failed to do lab work, took minimal chart notes, and did not schedule follow-up examinations for Patients A, B, or C.

For several months, the physician continued prescribing for Patients A, B, and C without ever seeing the patients in person for further work up. The physician’s interactions with Patients A and B were solely over the phone, while the physician notes state that he had two office visits with Patient C. The physician did not order thyroid stimulating hormone (TSH) testing to further verify if continuing the thyroid hormone supplement would be appropriate in managing Patient A and B’s conditions.

In June 2015, Patient A presented to another provider with concerns of heart palpitations. Patient A told the provider he noticed the palpitations reduced when he reduced his thyroid hormone supplement dosage. During this consultation, Patient A disclosed his treatment with the physician which alerted the provider to have Patient A’s TSH levels checked. Patient A’s lower than normal TSH result prompted the provider to immediately begin weaning Patient A off of his thyroid hormone supplement.

Patient B also presented to the same provider in June 2015. At her visit, Patient B presented with a rash on her chest which she had for over a month. The new provider assessed the rash being unrelated to her treatment with the physician; however, due to her receiving similar treatment as Patient A, the provider had Patient B’s TSH level tested. Patient B’s results indicated her TSH level was below the normal range.

On 8/26/2015, the physician saw Patient C for what he thought was a urinary tract infection. The physician first prescribed Keflex but changed it to ciprofloxacin based upon the results of a Zytoscan. Caution is required when giving ciprofloxacin to patients with hypokalemia.

On or about 9/9/2015, Patient C presented to the hospital emergency department where she was diagnosed with significant hypokalemia (lowered levels of potassium in the blood) and hyponatremia (lowered levels of sodium in the blood) which caused Patient C to suffer fatigue and heart palpitations. Patient C went immediately from the emergency department to a new care provider. After an oral interview with Patient C, the new care provider learned that Patient C was taking a number of medications prescribed by the physician. The new care provider attempted to contact the physician a number of times to obtain the physician’s chart notes, lab studies, and other medical records for Patient C but was unsuccessful. Patient C told her new care provider that the physician had been giving her medications for a number of years. She stated, “I tell him what I need.” In the physician’s response to the Commission, he stated that “if [Patient C] called me to have a prescription filled, I would do that for her.”

The Commission stipulated the physician reimburse costs to the Commission and write and submit a paper of at least 2000 words, with references and annotated bibliography, regarding Washington State rules for physicians forming and maintaining patient/physician relationships, the differential diagnosis of hyperthyroidism and hypothyroidism, the proper monitoring of electrolyte levels for patients with high blood pressure, and the importance of complying with Commission sanctions.

State: Washington


Date: November 2017


Specialty: Internal Medicine, Family Medicine


Symptom: Palpitations, Rash


Diagnosis: Endocrine Disease


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


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Family Practice – Unnecessary Excisions Performed For Multiple Lesions



On 6/15/2012, a 47-year-old female presented to a family practitioner with multiple lesions on her back, chest, and arms.

The family practitioner informed the patient that the lesions on her left humerus, right upper abdomen, mid upper back, left anterior mid chest, lower back, right lower back, and/or right upper anterior chest were malignant and/or potentially malignant.

On 7/6/2012, the family practitioner documented that the patient had a history of keloid formation after surgical excision.

On 6/15/2012, the family practitioner excised a lesion on the patient’s left humerus.  The lesion excised from the patient’s left humerus measured approximately 3 mm by 3 mm.  The family practitioner made an excision 4 cm by 4 cm or sixteen square centimeters to excise the lesion on the patient’s left humerus.

On 6/19/2012, a dermatopathology report determined that the excision taken from the patient’s left humerus was not malignant or premalignant.

On 6/27/2012, the family practitioner excised a lesion on the patient’s right upper abdomen.  The lesion on the patient’s right upper abdomen measured 3 mm.   The family practitioner made an excision 7 cm by 6 cm, or forty-two square centimeters to excise the lesion on the patient’s right upper abdomen.

On 6/29/2012, a dermatopathology report determined that the excision taken from the patient’s right upper abdomen was not malignant or premalignant.

On 7/6/2012, the family practitioner excised a lesion the patient’s mid upper back.  The lesion on the patient’s back measured approximately 3 mm.   The family practitioner made an excision 5 cm by 7 cm, or thirty-five square centimeters to excise the lesion on the patient’s mid upper back.

On 7/13/2012, the family practitioner excised a lesion on the patient’s left anterior mid chest.  The lesion on the patient’s left anterior mid chest measured approximately 4 mm by 4 mm.
The family practitioner made an excision 8 cm by 6 cm or forty-eight square centimeters to excise the lesion on the patient’s left anterior mid chest. He referred the patient for radiation treatment to prevent keloid formation.

On 7/20/2012, a dermatopathology report determined that the excision taken from the patient’s left anterior mid chest was not malignant or premalignant.

On 8/3/2012, the family practitioner excised a lesion the patient’s left lower back.  The lesion on the patient’s left lower back measured 5 mm by 4 mm.  The family practitioner made an excision 9 cm by 7 cm or sixty-three square centimeters to excise the lesion on the patient’s left lower back.

On 8/7/2012, a dermatopathology report determined that the excision taken from the patient’s left lower back was not malignant or premalignant.

On 8/10/2012, the family practitioner excised a lesion on the patient’s right lower back.  The lesion on the patient’s right lower back measured 4 mm by 4 mm.  The family practitioner made an excision 9 cm by 8 cm or seventy-two square centimeters to excise the lesion on the patient’s right lower back.

On 8/14/2012, a dermatopathology report determined that the excision taken from the patient’s right lower back was not malignant or premalignant.

On 8/27/2012, the family practitioner excised a lesion on the patient’s right upper anterior chest.  The lesion on the patient’s right upper anterior chest measured 2 mm by 2 mm.   He made an excision 10 cm by 7 cm, or seventy square centimeters to excise the lesion on the patient’s right upper anterior chest.

On 8/29/2012 a dermatopathology report determined that the excision taken from the patient’s right upper anterior chest was not malignant or premalignant.

The Board judged that the family medicine practitioners conduct to be below the minimal standard of competence given that he failed to perform a complete and comprehensive physical examination of the patient’s lesions; adequately consider the characteristics of the lesions, including the size, color, regularity, and degree of pigmentation; refer the patient for consultation with a dermatologist; refrain from diagnosing the patient with malignant and/or potentially malignant lesions without having adequate justification; accurately and appropriately diagnose the patient’s condition; confirm that each of the lesions on the patient was malignant or premalignant prior to excising the lesion; perform a shave biopsy, punch biopsy, or limited excisional biopsy with 1 mm margins on each of the lesions on the patient to determine whether the lesion was malignant or premalignant; make an excision with margins no greater than 5 mm to excise each of the lesion on the patient; refrain from making an excision on the patient without having adequate justification; avoid potential keloid formation on the patient, by making the fewest and/or smallest excisions appropriate and/or justifiable.

The family practitioner agreed to voluntarily cease practicing medicine and agreed to never reapply for licensure as a medical doctor in the state of Florida.

State: Florida


Date: August 2017


Specialty: Family Medicine, Dermatology


Symptom: Dermatological Abnormality


Diagnosis: Dermatological Issues


Medical Error: Unnecessary or excessive treatment or surgery, Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Referral failure to hospital or specialist, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Plastic Surgery – Laser Treatment For Lipoma At The Back Of The Head



On 9/6/2011, a 51-year-old male consulted with a family practitioner performing cosmetic procedures for the removal of a lipoma located at the back of his head.  The patient’s history included hyperthyroidism, for which he was seeing a physician, and atrial fibrillation, for which the patient chose not to take blood thinners.  The family practitioner’s assessment and plan was “LipoLite of lipoma of occiput.”  The patient signed a consent form.  However, there was no mention of the potential for a burn pertaining to the type of laser used by the family practitioner.  In addition, there was no verbal discussion of potential risks and complications.

On 9/9/2011, the patient returned to the family practitioner for LipoLite removal of the lipoma.  The only documentation in the medical record of the visit is a procedure note.  There are no vital signs recorded in the procedure note, no indication of the number of joules, or energy that was delivered, and no mention of temperature monitoring.  There are start and end times for the infiltration of lidocaine with epinephrine and a start and end time indicating a 15 minute treatment with LipoLite laser with 2.5 zones treated.  The family practitioner noted sloughing of the skin at the left upper part of the lipoma near an old scar and the epithelium is noted to have a slight blister formation.  The family practitioner monitored tissue temperature with his hand and by the patient’s reaction to various levels of pain.

On 9/14/2011, the family practitioner noted mild edema and erythema of the site and surrounding area.  On 9/19/2011, there was drainage from the wound and the family practitioner noted the central area with a dark firm scabbed layer with pink erythema at the lower left with no abscess or seroma and mild tenderness.  On 9/28/2011, the patient returned reporting that the wound had been leaking for approximately five days.  The patient was continued on wound care.

On 10/5/2011, the patient noted a hard scabbed area with a surrounding white area.  The family practitioner referred the patient to a wound care clinic.

The Board deemed the family practitioner’s conduct as having fallen below the standard of care for failing to perform a history and physical examination at the initial consultation, for failing to record vital signs before and during a surgical procedure, and for failing to obtain sufficient knowledge of the laser prior to use.  The Board noted a failure to recognize a blister during a laser procedure and a scab or eschar in the post-operative period as representing a possible full-thickness skin loss as well as failure to obtain cultures from a draining wound.

The Board issued a public reprimand against the physician.  Stipulations included 30 hours of continuing medical education in the area of cosmetic laser surgery and a continuing medical education course in medical record keeping.

State: California


Date: May 2017


Specialty: Plastic Surgery, Dermatology, Family Medicine


Symptom: Mass (Breast Mass, Lump, etc.), Dermatological Abnormality, Wound Drainage


Diagnosis: Post-operative/Operative Complication


Medical Error: Procedural error, Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, 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



Arizona – Dermatology – Failure To Adequately Conduct Mohs Surgery



The Board received a complaint alleging failure to adequately conduct Mohs surgery.  During the Board’s investigation, the Medical Consultant reviewed the charts of three patients regarding the dermatologist’s performances of Mohs surgery for a patient with basal cell carcinoma of the left ear, a patient with squamous cell carcinoma of the left ear and preauricular face, and a patient with basal cell carcinoma of the right ear.  The Mohs histology slides prepared for each patient were reviewed.  The Medical Consultant concluded that in each case the dermatologist’s removal of either the basal cell carcinoma or squamous cell carcinoma was incomplete.  It was noted that there was insufficient tissue present on the histology slides to represent a complete margin of a 2 cm tumor of the ear.  The dermatologist’s Medical Consultants disagreed.

The Medical Consultants noted in that the patient with the basal cell carcinoma of the right ear, there was poor correlation with Mohs Map, the operative report, and the findings in the histology slides.  In addition, there was no documentation discussing adjuvant therapies, further staging work up, or the persistent tumor with the patient at the time of Mohs surgery.

These patients had documented recurrences of their skin cancers that required additional Mohs surgery and in some cases, lead to tissue loss, nerve damage, and the need for reconstruction.

The Board judged the dermatologist’s conduct to be below the minimum standard of competence given failure to completely remove the tumor for three patients.

The Board ordered dermatologist be reprimanded.

State: Arizona


Date: April 2017


Specialty: Dermatology


Symptom: Dermatological Abnormality


Diagnosis: Cancer, Dermatological Issues


Medical Error: No error found


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Internal Medicine – RN Conducts Fractional Laser Treatments For Age Spots



On 5/18/2012, a 39-year-old female went to an internist’s clinic for SmartSkin Fractional CO2 laser treatments to remove black spots (age spots) on her hands and face.  The patient paid $2,100 for two laser treatments and associated products. The patient received the second laser treatment on 6/24/2012. The fractional laser treatments were conducted by an RN employed by the internist.

On 7/30/2012, the patient was seen by an RN for her one-month post-laser treatment follow-up.  The RN noted that the patient should continue using hydroquinone (a skin bleaching topical ointment) for hyperpigmentation.  The internist was not called in to look at the hyperpigmentation to the patient’s skin. Hyperpigmentation is a known complication of laser treatments.

The internist only personally saw the patient on 2 occasions, 9/23/2012 and 12/2/2013 for post-Smart-Lipo follow-up appointments.  During her interview with the Board, the internist specifically disavowed any knowledge about the laser treatments provided by her staff to the patient or the work done by the RN.

On 12/6/2012, an RN saw the patient and noted that the patient was pleased with her results except for her hands, where there was little-to-no change in the black spots.  The internist’s staff sold the patient “total skin lightening serum” and recommended additional chemical peels.

The Medical Board of California judged that the internist’s conduct departed from the standard of care because she failed to provide adequate supervision of the RN performing laser skin treatments, particularly when there was a known complication (hyperpigmentation) following the use of the laser.

For this case and others, the Medical Board of California placed the internist on probation for 4 years and ordered the internist to complete a professionalism program (ethics course), a  medical record keeping course, an education course (at least 25 hours per year for eat year of probation), and a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.  The internist was assigned a monitor for practice and billing, and she was prohibited from practicing or attempting to perform liposuction or laser skin treatments. The internist was also prohibited from supervising physician assistants.

State: California


Date: April 2017


Specialty: Internal Medicine


Symptom: Dermatological Abnormality


Diagnosis: N/A


Medical Error: Improper supervision


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Internal Medicine – Excessive Wound Drainage, Weakness, And Dizziness After Smart-Lipo On 32-Year-Old Obese Patient



On 9/18/2014, a 32-year-old female had a Smart-Lipo consultation with an internist.  On the patient registration form, the patient indicated that she was interested in Smart-Lipo to her upper and lower abdomen, hips, waist/flank area, back bra rolls, outer thighs, and upper arms.  She indicated that she had a history of anemia, cold sores, keloid scarring, irregular periods, and depression. On the “Smart-Lipo History Intake” form, the patient indicated that she was 5’0.5” tall and weighed 178 pounds.  Under a list of possible medical conditions that the patient had, the patient circled chest pain, recent weight loss or gain, cold sores, back pain, difficulty swallowing, depression, heart murmur, Lap-Band surgery in 2008, removal of Lap-Band in 2011, gastric sleeve in 2013, and removal of her gallbladder in 2014.  The patient indicated that she took Latuda for depression and has an ultrasound of her heart done every 5 years.

On 12/9/2014, the patient completed a second “Smart-Lipo History Intake” form.  On this form, the patient now indicated that she was suffering from anemia and “microvalve prolapse.”  She also listed her height as 5’1” with a weight of 190 pounds. On the “Pre-Operative Screening” form, the patient stated that she was taking Adderall, lansoprazole, and Latuda.  The patient’s weight was noted as 193.5 pounds with a BMI of 36.6. Measurements were also taken of the areas where surgery was to be performed. Blood was also collected for standard blood testing as well as an EKG.  The patient also completed a Smart Lipo “Pre-Operative Screening” form/High BMI consent form. The form explained what a high BMI is, what obesity is, and why an obese patient should have Smart-Lipo performed.

Also, the form stated that the patient must obtain medical clearance from her primary care provider before the internist performed the procedure.  The internist admitted during the interview with investigators on behalf of the Board that she never obtained medical clearance from any of the patient’s medical provides, despite the notation on the form.  The informed consent forms were completed by the patient and an LVN. The internist never went through the informed consent forms or discussed the risks and benefits of the surgery with the patient before the day or surgery.  The records also did not contain any documentation that the internist even discussed the risks and benefits of the surgery with the patient at any time.

On 12/16/2014, the internist performed Smart-Lipo on the patient’s hips, upper arm, upper and lower abdomen, and waist/flanks.  On the pre-printed Smart-Lipo OR Package form, it was noted that the patient “had a light meal before coming.” The NP checking in the patient did not document exactly what the “light meal” consisted of or when it was consumed.  The internist wrote that the patient had keloid scarring, but the location of the scarring was not legible. She also wrote that the patient was planning on having a tummy tuck in the future and had excessive skin laxity on her abdomen.  The internist listed the patient as ASA Category I. Prior to surgery, the pictures were taken of the patient showing “bat wing” deformity of the arms (hanging skin), truncal obesity, and smooth abdominal skin contour with small keloids.

According to the progress note, the procedure started at 1:00 p.m. and finished at 3:25 p.m.  About 30 minutes into the procedure, the patient complained of 8 out of 10 pain, and the comment portion of the note read ‘VV (2-3 sec).”  Then about an hour and twenty minutes into the procedure, the patient reported pain on a scale of 4 out of 10. During the two-hour and 15-minute surgery, the patient’s vital signs were not continuously monitored.

During the internist’s subject interview on 3/15/2016, the internist initially did not know what “VV (2-3 sec)” meant, but she eventually stated that she believed it meant the patient had a vasovagal episode, meaning she passed out during the procedure.  This is generally caused by sudden drops of blood pressure and heart rate.

According to the progress note, 10,720 ml of tumescent fluid was infused into the patient’s body, which contained 3,090 mg of lidocaine (the safe dose of lidocaine should never exceed 3,076.5 mg), and 4,240 ml of fluid was removed from the patient’s arms and abdomen, of which 1,900 ml was fat, which left 6,470 ml of tumescent fluid remaining in the patient.  The medical record failed to indicate where and how much fat was removed from each region the internist performed Smart-Lipo surgery on.

There was no indication in the medical record that the internist warmed the tumescent fluid to body temperature before infusing it into the patient.  There was also no indication in the medical record that the patient utilized compression boots during the surgery. The patient was discharged from the facility at 3:40 p.m. following a 30-minute observation period.

On 12/17/2014, the patient returned for her follow-up appointment.  She indicated that she was weak, her pain over the night was a 6 out of 10, approximately 2 cups of fluid drained from the surgical sites, and she was light headed.  It was difficult to determine from the medical record whether the internist ever saw the patient, but it did not appear that she did.

On 1/16/2015, the patient returned for her one-month follow-up appointment.  The measurements were taken, along with a height and weight. The patient still weighed 193 pounds with a BMI of 36.5.  In response to the question “How do you feel about your results”, the patient answered ‘good.”

On 6/8/2015, the patient returned for her 6-month follow-up appointment.  The patient reported that while she had seen improvements, she was not happy with the results of the Smart-Lipo surgery.  Measurements were taken along with the patient’s weight, showing a 7 pound weight gain. The internist wrote “skin laxity is an issue, will pursue tummy tuck.”  the internist did not recommend a revision surgery, and the patient never returned. According to the patient, the internist told her “she wasn’t a good candidate [for Smart-Lipo] to being with.”  She also complained that at the 6-month post-procedure mark, she gained 7 pounds, but her arms looked the same, and her stomach was deformed and protruded from her abdomen. Pictures were taken of the patient at several visits, but none of the photographs were dated making it impossible to determine the progress of the patient’s recovery.

The Medical Board of California judged that the internist’s conduct departed from the standard of care because she failed to maintain adequate and accurate medical records and warm the tumescent fluid to body temperature to avoid life-threatening arrhythmias and left an unsafe amount of fluid remaining in the patient.  The patient was not an appropriate candidate for the procedure, the internist lacked knowledge or understanding of the risks posed by infusing large amounts of tumescent fluid containing lidocaine while the patient was also taking Latuda and Adderall, a potentially fatal drug interaction.  Also, the internist failed to meet with the patient before the day of surgery to discuss the risks and benefits of the surgery with the patient and allowed an LVN to go through the informed consent process.

For this case and others, the Medical Board of California placed the internist on probation for 4 years and ordered the internist to complete a professionalism program (ethics course), a medical record keeping course, an education course (at least 25 hours per year for each year of probation), and a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.  The internist was assigned a monitor for practice and billing, and she was prohibited from practicing or attempting to perform liposuction or laser skin treatments. The internist was also prohibited from supervising physician assistants.

State: California


Date: April 2017


Specialty: Internal Medicine, Plastic Surgery


Symptom: Weakness/Fatigue, Dermatological Abnormality, Dizziness, Chest Pain, Wound Drainage


Diagnosis: Post-operative/Operative Complication


Medical Error: Unnecessary or excessive treatment or surgery, Failure of communication with patient or patient relations, Failure to properly monitor patient, Improper medication management, Lack of proper documentation, Procedural error


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Washington – Physician Assistant – Groin Rash, Swelling, And Hard Left Testicle Found On Infant



On 1/3/2015, a seven-month-old patient was brought to an urgent care facility where he was seen by a physician assistant.  His history included over several months of groin rash that was being treated with steroid cream.  The patient’s mother reported that the patient’s left testicle was hard.  Over the past two days, his symptoms had worsened.  The physician assistant examined the patient and found a rash and swelling at the scrotum only.  He diagnosed the patient with a diaper rash.

On 1/4/2015, the patient’s grandparents brought the patient to the emergency department, where he was examined by a second provider.  The patient’s grandparents reported that the patient seemed uncomfortable and that his left scrotum appeared red, swollen, and firm.  An ultrasound found the patient’s left testicle with decreased blood flow.  The patient was transferred to another facility and testicular torsion was confirmed.  The patient underwent emergency surgery where his testicle was found nonviable and removed.

The physician assistant did not consider testicular torsion in the differential diagnosis and failed to order an ultrasound to rule out this condition.

The Commission stipulated the physician assistant reimburse costs to the Commission, complete a continuing medical education course in assessment and diagnosis of acute scrotal conditions, and submit a paper of no less than one thousand words, with references, on the subject of acute scrotal conditions.

State: Washington


Date: April 2017


Specialty: Physician Assistant, Pediatrics, Urology


Symptom: Rash, Swelling


Diagnosis: Testicular Torsion


Medical Error: Failure to order appropriate diagnostic test


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Dermatology – Pathologist Performs Botox And Radiesse Injections Resulting In Complications



On 6/20/2014, a pathologist performed Botox injection to a patient’s forehead and Radiesse injections to her cheeks in the pathologist’s home.

Three days later, on 6/23/2014, the patient complained of severe swelling and redness at the injection sites on her cheeks.

The pathologist advised the patient to use a cold compress, to apply hydrocortisone cream, to take Claritin and ibuprofen, and to return for follow up in two days.

Shortly thereafter, the patient began to experience more swelling and draining at the injection sites.

On 6/26/2014, the patient presented to the pathologist for a follow-up appointment.  The pathologist documented that the patient’s swelling had subsided and that her pain was mainly relieved.  The patient was instructed to continue to take Claritin and ibuprofen for two weeks.

On 7/10/2015, the patient presented to a physician with complaints of pain, swelling, and drainage at the injection sites.  The physician treated the patient for abscesses that had occurred at the injection sites.

The Medical Board of Florida judged the pathologists conduct to be below the minimal standard of competence given that the pathologist did not record the lot number of the Radiesse in the patient’s chart.  Also, the pathologist placed the injection too close to the patient’s eye area.  The pathologist placed the injections too superficially in the patient’s skin.  The pathologist incorrectly diagnosed the patient with a hypersensitivity reaction.

The Medical Board of Florida issued a letter of concern against the pathologist’s license.  The Medical Board of Florida ordered that the pathologist pay a fine of $5,000 against her license and pay reimbursement costs for the case at a minimum of $5,175.43 and not to exceed $7,175.43.  The Medical Board of Florida also ordered that the pathologist complete a records course within one year of the final order, complete ten hours of continuing medical education in cosmetic procedures, and complete five hours of continuing medical education in “risk management.”

State: Florida


Date: March 2017


Specialty: Dermatology, Pathology


Symptom: Dermatological Abnormality, Swelling, Wound Drainage


Diagnosis: Dermatological Issues


Medical Error: Diagnostic error, Lack of proper documentation, Procedural error


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Washington – Dermatology – Intense Pulsed Light Device Use In Cosmetic Treatments



A physician was the co-owner and medical director of a dermal spa.  A patient received hair removal, photofacial, and skin tightening treatments at the dermal spa from 8/4/2014 through 9/10/2014.  These treatments were performed using an intense pulsed light (IPL) device.  The use of IPL devices, among other devices, is regulated by WAC 246-919-605 – commonly referred to as the “laser rules,” though that title is under-inclusive.

Contrary to laser rules, prior to initiating treatment with the IPL device, the physician failed to document or perform a history and physical examination.  The physician performed and supervised the patient’s treatments without creating a sufficient medical record or ensuring that a sufficient medical record was created.  The physician failed to provide or document the provision of instructions for emergency and follow-up care, as required by the laser rules.

The informed consent document signed by the patient, prior to her treatment, did not record that the patient was informed that a non-physician may operate the IPL device, as required by the laser rules.  Contrary to laser rules, the physician failed to ensure the existence of a quality assurance program and failed to have written office protocols for supervised professional staff to follow before delegating the use of the IPL device.

The physician delegated the performance of the final three treatments to an esthetician.  Following the final treatment on 8/4/2015, the dermal spa records indicated that the patient developed slight burns on her chest and forearms.  The notes further indicated that the patient “said she had sun exposure before treatments.”  The physician indicated that patients are advised to avoid sun exposure prior to treatment and advised to inform the dermal spa staff if they are exposed to the sun before treatment so that adjustments can be made to the IPL device.  However, there was no further documentation regarding this potential complication, or regarding the physician’s involvement or availability to treat potential complications or provide consultation.

The Commission stipulated the physician write and submit a paper of at least 1000 words, with annotations, regarding the Washington State “Laser Rules” and her plan for ensuring that she is in compliance with the laser rules, write and implement a quality assurance program at the dermal spa, ensure that each patient receiving treatment with the IPL has a complete medical record, and reimburse costs to the Commission.

State: Washington


Date: January 2017


Specialty: Dermatology


Symptom: Dermatological Abnormality


Diagnosis: Post-operative/Operative Complication, Dermatological Issues


Medical Error: Procedural error, Failure to follow up, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Dermatology – Rosacea Treated With Intense Pulsed Light Treatment



On 5/5/2011, a patient presented to a cosmetic laser clinic.  At this initial appointment, a nurse recommended that the patient receive Intense Pulsed Light treatment (“IPL”) utilizing the Lumenis One machine to treat rosacea, redness, and discoloration on his neck and chest.  On 5/5/2011, a dermatologist approved the nurse’s treatment recommendations.  The proposed IPL treatments were to be administered over three clinical visits.  The patient was not informed of the potential risk of severe burn and significant scarring associated with IPL treatment.

On 5/16/2011, the patient underwent his first IPL treatment without any adverse outcome.

On 8/15/2011, the dermatologist performed the second IPL treatment on the patient’s neck and chest using the Lumenis One machine.  At the time that respondent performed the second IPL on the patient, she had not previously reviewed the clinic’s written IPL protocol.  The dermatologist did not adjust the settings on the Lumenis One machine and instead relied on the preset settings.  The patient complained of extreme pain during this administration of the IPL treatment.  The patient asked the dermatologist to stop the IPL treatment at least four times during the course of the treatment.  The dermatologist did not stop the treatment, but only hesitated momentarily to wait for the patient to regain his composure.

The dermatologist continually made comments to coax the patient to proceed with the IPL treatment.  The dermatologist did not adjust the settings on the Lumenis One machine during the course of the IPL treatment.

On 8/15/2011, following the IPL treatment, the patient observed two large purple spots with blistering on his chest.

On 8/19/2011, the patient returned to the clinic for an IPL follow-up appointment with the dermatologist.  During this visit, the dermatologist diagnosed the patient with post-IPL second-degree burns to the neck and chest area.

On 6/7/2012, the patient returned to the clinic for an IPL follow-up appointment with the dermatologist.  The dermatologist noted that the patient had hypopigmented rectangles on his chest.

The dermatologist failed to adequately inform the patient of the potential risks of IPL treatment including burns and scarring.  The dermatologist failed to read the protocol governing the Lumenis One machine prior to treating the patient and failed to adjust the machine to a lower energy prior to treating the patient.

The Board issued a reprimand to the dermatologist and ordered the dermatologist to enroll in a clinical in-service training provided by the vendor of the IPL medical device.

State: California


Date: October 2016


Specialty: Dermatology


Symptom: Dermatological Abnormality


Diagnosis: Dermatological Issues


Medical Error: Procedural error


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



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