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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 – Gynecology – Unnecessary Biopsies Performed When Lumps Are Noted on A Patient’s Breasts
Between December 2010 and August 2013, a patient presented to her gynecologist.
On 5/19/2011, the gynecologist found small, smooth, mobile lumps in the patient’s left and right breasts.
On 6/17/2011, the gynecologist performed a right breast biopsy on the patient. The gynecologist noted that the right breast lump was likely a fibroadenoma. The biopsied right breast tissue was found to be benign.
On 7/5/2011, the gynecologist performed a left breast biopsy on the patient. The gynecologist noted that the left breast lump was likely a fibroadenoma. The biopsided left breast tissue was found to be benign.
At all times, the patient was at a low risk for having breast cancer.
The Board judged the gynecologist’s conduct to be below the minimum standard of practice given that the prevailing professional standard of care required that the gynecologist medically manage the patient’s left and right breast lumps with breast exams, breast sonographies, and/or mammograms. The obstetrician’s performance of left and right breast biopsies on the patient was medically unnecessary.
The Board ordered that the gynecologist pay a fine of $16,000 against his license. Also, the Board ordered that the case fine be set at $9,486.57. The Board ordered that the gynecologist complete five hours of continuing medical education in “Risk Management.”
State: Florida
Date: December 2017
Specialty: Gynecology, Gynecology
Symptom: Mass (Breast Mass, Lump, etc.)
Diagnosis: N/A
Medical Error: Failure to order appropriate diagnostic test, Unnecessary or excessive treatment or surgery
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
Florida – Family Medicine – Diagnosis Of Deep Cellular Fibrous Histiocytoma With A Differential Diagnosis Of Myofibroblastic Sarcoma
On 3/28/2014, a patient presented to a family practitioner with complaints of a right forearm mass.
On 4/4/2014, the family practitioner excised a 3-4 cm mass from the patient’s right forearm. The family practitioner sent the specimen out for review by a pathologist.
On 4/15/2014, the pathologist via a pathology report listed a diagnosis of deep cellular fibrous histiocytoma with a differential diagnosis of low grade myofibroblastic sarcoma. The pathology report further stated that re-excision was ‘“strongly recommended.”
On 4/16/2014, at a follow-up appointment, the family practitioner informed the patient that the mass was benign. He informed the patient that a wait-and-see approach would be appropriate, and, if the mass returned, further excision would be recommended. The family practitioner did not inform the patient of the differential diagnosis listed on the pathology report. He also did not advise the patient that a re-excision was strongly recommended by the pathologist.
On 1/30/2015, the mass on the patient’s forearm returned and was larger.
On 3/5/2015, a general surgeon performed a second excision on the patient.
On 3/11/2015, the pathology report of the second excision stated a diagnosis of high grade myxofibrosarcoma.
The Board judged the family practitioners conduct to be below the minimum standard of competence given that he failed to fully inform the patient of the pathology report findings and advise the patient that re-excision wass strongly recommended.
It was requested that the Board order one or more of the following penalties for the family practitioner: 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: November 2017
Specialty: Family Medicine
Symptom: Mass (Breast Mass, Lump, etc.)
Diagnosis: Cancer
Medical Error: Underestimation of likelihood or severity, Failure of communication with patient or patient relations
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Gynecology – MRI Reveals Two Adjacent Large Intraperitoneal Complex Cystic Masses With Plan For Removal
On 11/19/2013, a 44-year-old female presented to a gynecologist for abdominal/pelvic discomfort.
The gynecologist performed an ultrasound and reported a “large ovarian cyst 14 cm in greatest extent… simple in nature.” The gynecologist ordered additional imaging of the patient’s abdomen and pelvis to further evaluate the cyst.
The patient was scheduled for surgical removal of the cyst to be performed by the gynecologist on 11/27/2013.
On 11/22/2013, an MRI of the patient’s pelvis was performed, which indicated the presence of “two adjacent large intraperitoneal complex cystic masses.”
On 11/27/2013, preoperatively, the gynecologist indicated that he read the history and physical and examined the patient and that there were “no changes.”
After receiving and reviewing the MRI report, the gynecologist failed to further evaluate, or alternatively, did not create, keep, or maintain adequate legible documentation of evaluating, whether a malignancy was present.
Prior to the surgery on 11/27/2013, the gynecologist failed to discuss, or alternatively, did not create, keep, or maintain adequate legible documentation of discussing, with the patient her desired plan-of-care in the event that the cysts contained malignant cells.
The gynecologist attempted to remove the cysts laparoscopically, by intentionally puncturing and aspirating the cysts. Prior to intentionally puncturing the cysts, the gynecologist did not place the cysts into a specimen bag to prevent contamination in the event that the cysts contained malignant cells. During the procedure, the contents of the cysts spilled into the patient’s abdominal cavity.
Intraoperatively, the procedure was converted to a laparotomy and the gynecologist removed the patient’s left ovary in its entirety and sent it to pathology. The pathology report indicated that the specimen was “of at least low malignant potential” indicating possible higher grade abnormality.
Accordingly, the gynecologist performed a total abdominal hysterectomy and removal of the right ovary.
The Board judged the gynecologist’s conduct to be below the minimal standard of competence given that he failed to further evaluate, preoperatively, to determine whether a malignancy was present, proceed with the correct surgical approach on 11/27/2013, by performing a laparotomy and removing the cysts intact, or by placing a specimen bag around the cysts prior to intentionally puncturing and aspirating the cysts, and discussing with the patient, preoperatively, to determine the patient’s desired plan-of-care for the possibility of malignancy.
It was requested that the Board order one or more of the following penalties for the gynecologist: 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: July 2017
Specialty: Gynecology
Symptom: Abdominal Pain, Mass (Breast Mass, Lump, etc.)
Diagnosis: Gynecological (Endometrial, Ovarian, Cervical) Cancer
Medical Error: Underestimation of likelihood or severity, Failure of communication with patient or patient relations, Procedural error
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Gastroenterology – Patient And Provider Not Notified Of Amended Pathology Biopsy Results From Colonoscopy
On 5/6/2013, a 55-year-old female presented to a digestive health center for a colonoscopy with biopsy. During the colonoscopy, a gastroenterologist found a mass in the patient’s rectosigmoid region. He obtained multiple biopsies of the mass and sent the specimens for in-house pathologic evaluation. The colonoscopy was completed without complication and the patient was brought to recovery in stable condition.
On 5/7/2013, an in-house pathologist rendered a preliminary gastrointestinal pathology report which reported that the specimen was highly suspicious for a signet ring adenocarcinoma. The initial pathology report indicated that the case was sent to a second pathologist for another opinion.
The gastroenterologist received and reviewed the initial pathology report. He referred the patient to a colorectal surgeon for surgical intervention.
On 5/8/2013, the second pathologist issued a pathology report which stated that the specimen was negative for signet cells and adenocarcinoma and recommended a re-biopsy to completely rule out malignancy. The gastroenterologist received and reviewed the copy of the report by the second pathologist.
On 5/16/2013, the in-house pathologist issued an amended gastrointestinal pathology report which stated that the specimen was negative for signet ring cells. The gastroenterologist received and reviewed the amended pathology report.
Despite receiving and reviewing the pathology report from both the pathologists, the gastroenterologist failed to notify the patient of the change in the reading of the specimen. The gastroenterologist also failed to ensure that the colorectal surgeon was notified of the change in the reading of the specimen.
On 6/11/2013, the patient underwent a low anterior resection, mobilization of splenic flexure, and diverting loop ileostomy with colonic J pouch.
The Board judged the gastroenterologists conduct to be below the minimal standard of competence given that he failed to notify the patient of the change in the reading of the specimen and ensure that the colorectal surgeon was notified of the change in the reading of the specimen.
The Board issued a letter of concern against the gastroenterologist’s license. The Board ordered that the gastroenterologist pay a fine of $10,000 against his license and pay reimbursement costs of a minimum of $3,008.71 and not to exceed $5,008.71. The Board also ordered that the gastroenterologist complete five hours of continuing medical education in “risk management.”
State: Florida
Date: June 2017
Specialty: Gastroenterology
Symptom: Mass (Breast Mass, Lump, etc.)
Diagnosis: Cancer
Medical Error: Failure of communication with patient or patient relations, False positive, Failure of communication with other providers
Significant Outcome: N/A
Case Rating: 5
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
Florida – Obstetrics – Breast Biopsy For Small, Smooth, Mobile Lump In Patient’s Right Breast
A patient was born on 4/3/1993. Between February 2011 and September 2012, she presented to an obstetrician.
On 6/29/2011, the obstetrician found a small, smooth, mobile lump in the patient’s right breast.
On 7/18/2011, the obstetrician performed a right breast biopsy on the patient. The obstetrician noted that the right breast lump was likely a fibroadenoma. The biopsied right breast tissue was found to be benign.
The Medical Board of Florida judged the obstetricians conduct to be below the minimal standard of competence given that he failed to medically manage the patient’s right breast lump with breast exams, breast sonographies, and/or mammograms. The obstetrician’s performance of a right breast biopsy on the patient was medically unnecessary.
It was requested that the Medical Board of Florida 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 Medical Board of Florida deemed appropriate.
State: Florida
Date: May 2017
Specialty: Obstetrics
Symptom: Mass (Breast Mass, Lump, etc.)
Diagnosis: N/A
Medical Error: Unnecessary or excessive treatment or surgery, Failure to order appropriate diagnostic test
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
Florida – Emergency Medicine – Mass Shown On Chest X-Ray Of Patient Discharged After Upper Respiratory Infection Treatment
On 12/20/2013, a 71-year-old female presented to the emergency department with a complaint of coughing.
An ED physician, as the patient’s attending physician, ordered a chest x-ray. The chest x-ray revealed a 4-centimeter mass-like density.
The ED physician discharged the patient with a diagnosis of upper respiratory infection, bronchitis, and viral syndrome.
The patient was not given any follow-up instructions regarding the 4-centimeter mass-like density, which resulted in a delay of diagnosis and treatment.
The Medical Board of Florida judged the ED physicians conduct to be below the minimal standard of competence given that he failed to inform the patient of the 4-centimeter mass on the chest x-ray and refer her for a follow-up with a pulmonologist or alternatively a primary care physician for further testing.
It was requested that the Medical Board of Florida order one or more of the following penalties for the ED physician: 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 Medical Board of Florida deemed appropriate.
State: Florida
Date: May 2017
Specialty: Emergency Medicine
Symptom: Mass (Breast Mass, Lump, etc.), Cough
Diagnosis: Cancer
Medical Error: Failure to follow up, Referral failure to hospital or specialist, Failure of communication with patient or patient relations
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
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