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Florida – General Surgery – Right Colectomy Of The Patient’s Ascending Colon Instead Of A Left Colectomy Of The Descending Colon
A 49-year-old female presented to a general surgeon for a colonoscopy. During the colonoscopy the general surgeon documented a 25mm polyp in the patient’s descending colon. Due to its size, the general surgeon was only able to partially resect the polyp. He placed a hemostatic clip to prevent bleeding and tattooed the area.
The patient was subsequently referred to the general surgeon for surgical resection of the left colon.
On 7/15/2015, the patient presented to the general surgeon for a preoperative history and physical. On 7/15/2015, the general surgeon documented that a doctor incompletely resected a polyp in the patient’s colon, and identified the planned procedure as a right colectomy.
On 7/20/2016, the patient presented to the general surgeon at a community hospital. On 7/20/2016, the general surgeon performed a right colectomy of the patient’s ascending colon.
The Board judged that the general surgeon’s conduct to be below the minimum standard of competence given that he performed a wrong-site procedure when he performed a right colectomy of the patient’s ascending colon instead of a left colectomy of her descending colon.
The Board ordered the general surgeon to pay a fine of $4,015.23. The general surgeon was ordered to complete five hours of continuing medical education in “Risk Management.” Also, the Board ordered that the general surgeon present a one hour lecture/seminar on wrong site and/or wrong procedures to medical staff at an approved medical facility.
State: Florida
Date: December 2017
Specialty: General Surgery
Symptom: N/A
Diagnosis: Gastrointestinal Disease
Medical Error: Wrong site procedure
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
Florida – Radiology – Gastrografin GI Series Performed to Ascertain GI Leak But No Leak Reported By Radiologist
On 6/23/2014, a 66-year-old male presented to the Physicians Regional Medical Center for gastric bypass surgery.
Following the gastric bypass procedure, on 6/24/2014, a radiologist performed a Gastrografin upper GI series on the patient to ascertain whether there was a leak or obstruction in the patient’s digestive tract. A leak of contrast material was visible on radiographic images obtained by the radiologist during the procedure; however, the radiologist failed to detect the leak in the patient’s digestive tract and reported a negative GI series. The patient was subsequently discharged from the hospital.
Approximately thirty hours after his discharge, the patient returned to the hospital suffering from abdominal pain and sepsis. It was discovered that the patient had a perforation in his digestive tract. During surgery to repair this perforation, the patient suffered cardiac arrest and anoxic brain injury. The patient ultimately expired as a result of these complications on 7/10/2014
The Board judged the radiologist’s conduct to be below the minimum standard of competence given his failure to detect a leak in the patient’s digestive tract during the performance of a Gastrografin upper GI series.
State: Florida
Date: December 2017
Specialty: Radiology
Symptom: N/A
Diagnosis: Acute Abdomen
Medical Error: False negative
Significant Outcome: Death, Hospital Bounce Back
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Orthopedic Surgery – Documentation Error Of Laceration Of Flexor Pollicis Longus Leads To Wrong Site Surgery
On 5/16/2014, a patient presented to an orthopedic outpatient surgery center with a left-hand work-related injury. During the visit, an orthopedic surgeon properly diagnosed the patient with a flexor pollicis longus (FPL) tendon laceration of her left thumb.
The FPL tendon laceration was confirmed by the MRI scan performed on the patient on 7/3/2014.
On 8/7/2014, during the follow-up visit, the orthopedic surgeon wrongly documented the patient’s injury as an extensor pollicis longus (EPL) tendon laceration in the patient’s medical records
Consequently, on 9/10/2014, the patient presented to the orthopedic surgeon at the center, for an EPL tendon surgery (the wrong site, and/or medically unnecessary procedure) of her left thumb. During the EPL tendon surgery, the orthopedic surgeon realized that the FPL tendon laceration repair should have been performed on the patient instead. On 10/10/2014, the orthopedic surgeon performed the FPL tendon laceration repair on the patient’s left thumb.
The Board ordered the orthopedic surgeon pay a fine of $3,000 to the Board. Also, the Board ordered the orthopedic surgeon pay a reimbursement cost of $4,670.40. The Board ordered that the orthopedic surgeon complete five hours of continuing medical education in “Risk Management.” The Board ordered that the orthopedic surgeon complete one hour of lecture on wrong site procedure.
State: Florida
Date: December 2017
Specialty: Orthopedic Surgery
Symptom: N/A
Diagnosis: Musculoskeletal Disease, Trauma Injury
Medical Error: Wrong site procedure, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Gynecology – CBC Tests Show Neutropenia And Leukopenia At An Annual Gynecological Exam
On 8/15/2013, a 34-year-old female presented to a gynecologist for an annual gynecological exam. At the exam, the patient expressed concerns about infertility. The gynecologist and the patient discussed various tests that may be used to address infertility and the gynecologist began ordering tests.
On 2/23/2015, the patient gave blood for a complete blood count (“CBC”) test that was ordered by the gynecologist.
On 3/5/2015, the gynecologist received and signed for the results of the CBC test. The CBC test indicated the patient had an abnormal white blood cell count, marked leukopenia, and severe neutropenia.
The gynecologist failed to notify the patient of the abnormal results of the CBC test.
The gynecologist failed to ensure that the patient had otherwise established a plan of care to address the abnormal results of the CBC test.
On 5/28/2015, the patient presented to the gynecologist for an annual gynecological exam. At the exam, it was determined that the patient was pregnant, and the gynecologist ordered blood tests for the patient. The gynecologist failed to order a repeat CBC test.
On 7/17/2015, the gynecologist received and signed for the results of the repeat CBC test. The repeat CBC test indicated that the patient’s white blood cell count had decreased further, the neutropenia had worsened, and she now had pancytopenia with a drop in the red blood cell and platelet count.
On 7/30/2015, the gynecologist notified the patient of the results of her repeat CBC test and referred her to a hematologist.
On 8/8/2015, the patient experienced a massive intracranial hemorrhage with herniation, as well as severe pancytopenia.
On 8/12/2015, the patient expired in the hospital. The fetus was also lost at that point.
The Medical Board of Florida judged the gynecologists conduct to be below the minimal standard of competence given that she failed to ensure that the patient had been notified of the abnormal results of the CBC test. The gynecologist failed to ensure that the patient had otherwise established, a plan of care to address the abnormal results of the CBC test. The gynecologist failed to order a repeat CBC test at the patient’s May exam.
The Medical Board of Florida issued a letter of concern against the gynecologist’s license. The Medical Board of Florida ordered that the gynecologist pay a fine of $8,500 against her license and pay reimbursement costs for the case at a minimum of $3,126.31 and not to exceed $5,126.31. The Medical Board of Florida ordered that the gynecologist complete five hours of continuing medical education in “risk management.”
State: Florida
Date: December 2017
Specialty: Gynecology, Obstetrics
Symptom: N/A
Diagnosis: Hematological Disease, Intracranial Hemorrhage
Medical Error: Failure to follow up, Delay in proper treatment, Failure of communication with patient or patient relations
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF
Florida – Radiology – Mammogram And Ultrasound Of Breast Mass Interpreted As A Cyst
On 6/30/2011, a 50-year-old female presented to a breast center for a bilateral digital diagnostic mammogram with computer-aided detection and right breast ultrasound (“mammogram and ultrasound”) for a palpable abnormality (“mass”).
On 6/30/2011, a radiologist interpreted the mammogram and ultrasound in her final report as follows: “[T]here has been no interval change in the appearance of the breasts with no evidence for malignancy. At the 7 o’clock position, 7 cm away from the nipple, correlating to the [mass] is a simple cyst….”
The radiologist recommended “[M]ammography and yearly physical examination per ACS guidelines, supplemented with monthly self-examination, If clinically indicated, the cyst could be aspirated.” At no time did the radiologist recommend a biopsy of the mass.
The radiologist rated the mammogram as a BI-RADS Category II, “[B]enign.” A correct interpretation of the mass would have indicated that it had lobular and angular margins, and increased through transmission. The mammogram should have been rated BI-RADS category V, “[H]ighly suspicious: [A]ppropriate action should be taken.” The radiologist should have recommended a biopsy of the mass.
On 1/23/2012, the patient was advised by a subsequent treating physician that she had invasive ductal carcinoma, Stage III.
The Board judged the radiologist’s conduct to be below the minimum standard of competence given her failure to correctly interpret the mammogram and ultrasound and recommend a biopsy of the mass.
The Board ordered that the radiologist pay a fine of $6,500 against her license and that the radiologist pay a reimbursement cost to the case of a minimum of $2,924.06 but not to exceed $4,924.06. The Board ordered that the radiologist complete ten hours of continuing medical education in identification and diagnosis of malignancies with a focus on interpretation of breast imaging studies.
State: Florida
Date: November 2017
Specialty: Radiology
Symptom: N/A
Diagnosis: Breast Cancer
Medical Error: False negative, Failure to order appropriate diagnostic test
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Family Medicine – Three Patients Seen At Once Without Proper Examination and Documentation
On 9/21/2012, Patient A, Patient B, and Patient C presented to a geriatric practitioner at the same time in his office. The geriatric practitioner saw the patients for less than nine minutes total. At no time were the patients separated for individual assessments. The patients were an undercover detective and two informants, using pseudonyms. The appointment was audiotaped and videotaped.
The geriatric practitioner failed to perform a physical examination on any of the three patients. The geriatric practitioner failed to create a treatment plan for any of the three patients. He also sent the three patients for x-rays without a physical examination. Per the geriatric practitioner’s instructions, all three patients presented for x-rays; however, only Patient A and Patient C actually had x-rays performed. The geriatric practitioner failed to create or maintain documentation of referring the three patients for x-rays.
On 10/30/2012, the three patients presented to the geriatric practitioner for a follow-up visit. At that time, the geriatric practitioner failed to review readily available medical records from the patients’ first visit, failed to inquire about x-ray results, failed to review physical therapy results, failed to perform physical examinations and/or failed to create treatment plans for all three patients.
The Board judged the geriatric practitioner’s actions to be below the minimum standard of competence given his failure to perform a physical examination, perform a complete individual physical examination for each patient prior to referral for x-rays, other diagnostic testing, or further treatment. Also, the geriatric practitioner failed to review any medical records or results at a follow-up visit, including x-rays, from prior visits, and/or procedures and review and analyze the physical therapy progress of the patients, and create treatments plans for each patient.
The Board ordered that the geriatric practitioner pay a fine of $12,000 against his license and pay reimbursement costs for the case for a minimum of $37,421.80 and not to exceed $39,421.80. The Board also ordered that the geriatric practitioner complete a medical records course and complete five hours of continuing medical education on “Risk Management.” The Board put the geriatric practitioner’s license on probation and required that he have indirect supervision to practice by a Board-approved physician.
State: Florida
Date: November 2017
Specialty: Family Medicine
Symptom: N/A
Diagnosis: N/A
Medical Error: Failure to examine or evaluate patient properly, Ethics violation, Failure to follow up, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
Florida – Neurosurgery – Cervical Microdiscectomy At Levels C5/7 And C6/7 Instead Of Levels C4/5 And C5/6
On 11/17/2014, a patient presented to a neurosurgeon for an anterior cervical microdiscectomy for decompression with allograft fusion at cervical levels C4/5 and C5/6. During the procedure, it was discovered that the initial localization x-ray was misinterpreted and that the neurosurgeon performed the fusion at cervical levels C5/7 and C6/7 instead of cervical levels C4/5 and C5/6. After the neurosurgeon discovered the error, he proceeded to perform the fusion at the correct cervical levels, C4/5 and C5/6.
The Board judged the neurosurgeons conduct to be below the minimum standard of competence given that he performed the procedure on the wrong site.
The Board ordered that the neurosurgeon pay a fine of $5,000 against his license and pay reimbursement costs of a minimum of $1,859.22 but not to exceed $3,859.22. The Board also ordered that the neurosurgeon complete five hours of continuing medical education in “Risk Management” and complete a one hour lecture/seminar on wrong site surgeries.
State: Florida
Date: November 2017
Specialty: Neurosurgery
Symptom: N/A
Diagnosis: Spinal Injury Or Disorder
Medical Error: Wrong site procedure
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
Florida – Anesthesiology – Proceeding With A Colonoscopy With A Non-Functioning End Tidal CO2 Monitor
A 59-year-old female presented to an anesthesiologist during her colonoscopy. The anesthesiologist conducted a pre-operative anesthesia assessment of the patient. She was then transported to the procedure room where a certified registered nurse anesthetist (“CRNA”) was to provide total intravenous anesthesia to the patient.
The end-tidal CO2 monitor (“ETCO2 monitor”) located in the scheduled procedure room was non-functional on the day before the surgery and a functioning ETCO2 monitor had not been received on the day of the surgery.
The anesthesiologist instructed the CRNA to proceed with the anesthesia without the ETCO2 monitor. The anesthesiologist did not delay the procedure or postpone it for another date to allow time to obtain a functioning ETCO2 monitor. The anesthesiologist did not transfer the patient to another procedure room that had a functioning ETCO2 monitor. The anesthesiologist did not implement additional precautionary measures by closely monitoring the patient with his presence since he elected to proceed without an ETCO2 monitor as recommended by the ASA (American Society of Anesthesiologists). The anesthesiologist was not present in the procedure room during the procedure.
The CRNA experienced difficulties with the patient’s airway soon after the induction of anesthesia. The oral airway was inserted to assist the patient’s breathing, and the amount of oxygen flow was increased to help with the falling oxygen saturation. Despite the increase in the amount of oxygen flow, the CRNS reported transient desaturations and reported repositioning the pulse oximeter numerous times throughout the procedure.
The patient developed bradycardia, which culminated to intubation and cardiac arrest, and the anesthesiologist’s presence was requested in the procedure room. The anesthesiologist started chest compressions and resuscitated the patient.
The Board judged the anesthesiologist’s conduct to be below the minimum standard of competence given that he should have delayed the procedure, or postponed it for another date to allow time to obtain a functioning ETCO2 monitor. He should also have transferred the patient to another procedure room that had a functioning ETCO2 monitor and implemented additional precautionary measures by closely monitoring the patient with since he elected to proceed without an ETCO2 monitor.
The Board ordered that the anesthesiologist pay a fine of $5,000 against his license and pay reimbursement costs for the case for a minimum of $6,841.07 and not to exceed $8,841.07. The Board also ordered that the anesthesiologist complete five hours of continuing medical education in general anesthesia and complete five hours of continuing medical education in “Risk Management.”
State: Florida
Date: November 2017
Specialty: Anesthesiology
Symptom: N/A
Diagnosis: Post-operative/Operative Complication
Medical Error: Failure to properly monitor patient
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Obstetrics – Obstetrician Unavailable During Labor With Fetal Heart Decelerations
On 1/24/2014 a 21-year-old female presented to a hospital with spontaneous rupture of membranes and meconium-stained amniotic fluid at about thirty-nine weeks of pregnancy.
Upon admission, the patient was placed on a fetal monitor, which documented variable decelerations of the fetal heart rate. In response to the monitor tracings, an obstetrician ordered the administration of intravenous fluids. Shortly thereafter, the obstetrician ordered the performance of an amnioinfusion.
Over the next couple of hours, the fetal monitor began documenting recurrent late fetal heart rate decelerations and loss of fetal heart rate variability, indicative of probable insufficient fetal oxygenation. The obstetrician was notified of the recurrent late fetal heart rate decelerations and loss of fetal heart rate variability.
In response to the monitor tracings, the obstetrician ordered the rate of IV fluid administration increased. Despite the monitor tracings indicating probable fetal distress, the obstetrician did not diagnose, or did not document diagnosing, fetal intolerance to labor and allowed the trial of labor to continue.
At some point in time between 6:15 p.m. and 7:30 p.m., the obstetrician decided to manage the trial of labor from outside of the hospital. Based on the patient’s presentation, the obstetrician should have continued to manage the trial of labor, in person, at the hospital. The fetal monitor continued to document recurrent late fetal heart rate decelerations and a loss of fetal heart rate variability over the next several hours. The obstetrician was notified of the recurrent late fetal heart rate decelerations and loss of fetal heart rate variability on multiple occasions during that time span. Despite the monitor tracings indicating probably continued fetal distress, the obstetrician did not promptly return to the hospital to deliver the baby.
Shortly after midnight on 12/25/2014, the obstetrician was again notified of the recurrent late fetal heart rate decelerations and loss of fetal heart rate variability. At 1:28 a.m., the obstetrician returned to the hospital, presented to the delivery room, and shortly thereafter delivered the baby.
The baby was in full cardiac arrest at the time of delivery. Efforts to resuscitate the baby were abandoned after about 20 minutes. The final diagnosis was stillborn.
The obstetrician did not dictate or write any progress notes during the trial of labor.
The Board judged the obstetrician’s conduct to be below the minimum standard of competence given that she failed to diagnose fetal intolerance to labor, manage the trial of labor, in person, at the hospital, and promptly return to the hospital and deliver the baby upon receiving continued reports of probably fetal distress.
The Board ordered that the obstetrician pay a fine of $5,000 against her license and pay reimbursement costs for the case at a minimum of $3,949.77 and not to exceed $5,949.77. The Board also ordered that the obstetrician complete five hours continuing medical education in the area of obstetric medicine and five hours of continuing medical education in “Risk Management.”
State: Florida
Date: November 2017
Specialty: Obstetrics
Symptom: N/A
Diagnosis: Obstetrical Complication
Medical Error: Diagnostic error, Failure to properly monitor patient, Lack of proper documentation
Significant Outcome: Death
Case Rating: 2
Link to Original Case File: Download PDF
California – Obstetrics – Induction For A Patient With A Bishop Score Of 4 And Continued Pitocin Use Despite Fetal Heart Tracing Abnormalities
A 24-year-old female was transferred from a physician to an obstetrician. The patient first saw the obstetrician on 6/24/2009, and she was due with her first child in July 2009. Her patient chart listed her at 120 lbs and 4’0” tall, but when she came to see the obstetrician, she weighed 170 lbs.
The patient was seen by the obstetrician twice in June and every week in July until 7/27/2009. The patient was scheduled to be induced 7/29/2009. There was nothing in the records about her bony pelvic exam or pelvic adequacy for vaginal delivery. The obstetrician did not do an ultrasound. The patient was admitted to the hospital on 7/29/2009. There was no risk assessment, no estimate fetal size, no ultrasound ordered, and a Bishop score of 4.
The patient was started on Pitocin at 9:30 a.m. and had made no progress by 6:00 p.m. that evening. The patient was allowed to rest, and the next morning, on 7/30/2009 at 7:30 a.m., Pitocin was started again. During this time, it was noted that she had “reactive” fetal heart tracings. The nurses did not place an order for an internal fetal monitor. When the fetal heart tones were low, the Pitocin should be turned off. If the mother keeps having contractions, the baby gets no rest, which is what likely occurred in this case.
At 8:18 p.m., she was only dilated 4-5 cm. The patient had spontaneous rupture of the membranes with thick meconium noticed. At 8:50 p.m., the patient was dilated to 8 cm, 0 station. There was no mention of a possible Cesarean section in the notes. On 7/31/2009, a female infant weighing 9 lbs 5 oz was delivered using a vacuum because a shoulder dystocia was encountered. Unfortunately, the baby was deceased.
The Medical Board of California judged that the obstetrician’s conduct departed from the standard of care because he failed to estimate the fetal size, fetal lie, and pelvic adequacy. The obstetrician also did not mention the application of a fetal electrode. This is important because the obstetrician did not know if the heart rate was coming from the mother or the baby; thus, an internal electrode would have been an accurate way to measure the baby’s heart rate. Review of the fetal monitor strips showed back to back contractions and inadequate recordings. During labor and delivery, Pitocin should have been stopped in the contractions showed a low fetal heart rate and tachysystole (no rest between contractions). This patient was also a poor candidate for induction because she had a Bishop score of 4. When the membranes were ruptured with 3+ meconium, this should have alerted the obstetrician that the baby was somehow compromised and action by the obstetrician was required. Also, the patient was a transfer patient, but the obstetrician did not order lab studies or an ultrasound. There were many errors which lead to the untimely demise of this baby. Had there been an estimate of fetal weight, or an ultrasound performed within 6 weeks of induction of labor, the obstetrician would have known the patient was having a big baby, and the obstetrician might have performed a Cesarean section.
The Medical Board of California issued a public reprimand and ordered the obstetrician to complete a clinical competence assessment program.
State: California
Date: November 2017
Specialty: Obstetrics
Symptom: N/A
Diagnosis: Obstetrical Complication
Medical Error: Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Failure to properly monitor patient, Improper treatment, Improper medication management
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF