Found 372 Results Sorted by Case Date
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California – Obstetrics – Pregnancy And Delivery Complicated With Obesity, Hypertension, Shoulder Dystocia, Variable Decelerations, And Meconium



A 17-year-old obese female first presented to an obstetrician on 11/9/2008.  The patient was pregnant for the first time. Her estimated gestational age was 15 weeks and 4 days.  The patient saw the obstetrician on several occasions during the ensuing 5 months. The patient’s last prenatal visit was on 4/17/2008.  On that day, the patient had a markedly elevated blood pressure of 178/108. The obstetrician did not immediately schedule an induction of labor or otherwise address the patient’s hypertension.

On 4/18/2008, the patient was admitted to the hospital.  There was no documentary evidence that the obstetrician advised the patient to admit herself on that day.  On 4/19/2008, a vacuum assisted vaginal delivery was performed by the obstetrician. The hospital records showed that the head of the patient’s newborn son was delivered in the occiput anterior position at 6:40 p.m.  The patient’s newborn son’s body followed approximately 3 minutes later, concluding 1 hour 13 minutes of second stage of labor. A median episiotomy was cut.

The delivery was complicated by shoulder dystocia, variable decelerations, and meconium.  The patient’s newborn son was admitted to the NICU due to respiratory distress and meconium aspiration syndrome, which required intubation and ventilation.  The applicable standard of care requires that a physician and surgeon, in the course of rendering prenatal care, identify and address all high-risk factors including but not limited to risk factors for shoulder dystocia and the development of gestational hypertension and/or preeclampsia.  The applicable standard of care requires that when considering an operative vaginal delivery, as was done in this case, the physician and surgeon advise the patient of the risks, benefits, and other available options. Also, upon recognizing a shoulder dystocia, the physician and surgeon should institute six different measures rapidly: 1) discontinue oxytocin, 2) cease application of forces, 3) instruct the mother to cease pushing, 4) lower the head of the bed, 5) call for assistance, and 6) start a clock.

The Medical Board of California judged that the obstetrician’s conduct departed from the standard of care because she failed to schedule the patient for immediate induction of labor or otherwise address the patient’s markedly elevated blood pressure on 4/17/2008, address or document that she addressed the high-risk factors, advise the patient of the risks, benefits, and other available options for a successful delivery, assess or document that she assessed the estimated fetal weight, station, position, and the application of negative pressure necessary to carry out a successful operative vaginal delivery, and institute the six measures to be followed upon recognizing a shoulder dystocia.

The Medical Board of California placed the obstetrician on probation for 35 months and ordered the obstetrician to complete a medical record-keeping course and an education course for at least 40 hours for every year of probation.

State: California


Date: November 2016


Specialty: Obstetrics


Symptom: N/A


Diagnosis: Obstetrical Complication


Medical Error: Delay in proper treatment, Failure of communication with patient or patient relations, Failure to follow up, Lack of proper documentation, Procedural error


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Arizona – Obstetrics – Failure To Thoroughly Evaluate Possibility Of Rupture Of Membranes Leads To Birth Complications



The Board was notified of a malpractice settlement involving the treatment of a 33-year-old woman.

On 12/24/2010, a patient presented to determine whether she had experienced a rupture of membranes for 11 hours.  Her history included a positive GBS (Group B Streptococcus) culture.  Nursing staff evaluated her and reported to the obstetrician that she had not experienced a rupture of membranes.

The medical records document that a digital vaginal examination was performed by the nursing staff, but do not indicate that other testing was done.  The obstetrician was in the hospital but did not personally see the patient or examine her.  The obstetrician did not review the fetal tracing at the time.  Upon later review, the respondent noted “variables” along with hyper-variability of which she was not informed.

The patient returned the following morning with chorioamnionitis and was delivered by Cesarean section.  The infant died due to sepsis, hypoxic ischemic encephalopathy, and disseminated intravascular coagulation.

The Board judged obstetrician’s conduct to be below the minimum standard of competence given failure to perform a thorough evaluation and obtain an ultrasound when there was a question of rupture of membranes.

The Board ordered the obstetrician to be reprimanded.

State: Arizona


Date: November 2016


Specialty: Obstetrics


Symptom: N/A


Diagnosis: Obstetrical Complication


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


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



Arizona – Urology – Hepatic Artery, Portal Vein, and Common Bile Duct Transected During Partial Nephrectomy



The Board was notified of a malpractice settlement regarding the treatment of a 76-year-old woman.

On 02/14/2012, a woman was evaluated by a urology regarding a renal lesion that had been found on a CT scan.  The urologist ordered a CT scan which was performed on 11/28/2012 and which revealed no no significant change in size of the 0.9 cm lesion located on the upper pole of the right kidney.  The lesion had a slightly thickened and irregular enhancing wall.  There was a small ventral wall hernia.  The urologist documented the renal lesion as being complex and enhancing with no significant enlargement.  It was around 1 cm in diameter and was not causing the patient any symptoms.  The urologist recommended a biopsy.

On 01/24/2013, the patient underwent a right renal biopsy.  Pathology revealed probable clear cell renal cell carcinoma Fuhrman grade 2.

On 01/30/2013, the urologist documented that he discussed the risks and benefits with the patient regarding surgery.  The urologist offered a hand assisted approach to allow for repair of the patient’s hernia.  The patient gave consent for the procedure.

On 04/17/2013, the patient was admitted for right nephrectomy via hand assisted laparoscopy.  Per the anesthesia record, the anesthesia start time was 1:51 p.m. and surgery start time was 2:26 p.m.  The surgery end time was 5:54 p.m.  The urologist’s operative note documented adhesions and significant bleeding he initially thought was due to injury of the inferior vena cava.  The patient received two packed red blood cell transfusions and the operation was converted to an open procedure.

At 3:00 p.m., the anesthesia record stated that the blood pressure was 60/30.

At 3:47 p.m., a general surgeon was consulted and arrived in the operating room.  The surgeon noted that there was bleeding along the anterolateral edge of the patient’s duodenum and pancreas.  The portal vein, common bile duct, and hepatic artery were transected.  The urologist stated that he proceeded with a radical nephrectomy prior to liver vascular repair to avoid further liver vascular damage.  Per the general surgeon’s note, hepatic warm ischemia time was one hour and fifteen minutes.  After the nephrectomy was completed, the hepatic artery, portal vein, and common bile duct were repaired, including graft replacement.

At 5:30 a.m. on 04/18/2013, the urologist dictated his operative report.

On 04/18/2013, the patient was taken back to surgery after sanguineous fluid was found in the drain output.  The general surgeon’s intraoperative findings included 1500 ml of intra-abdominal blood along with bleeding from a gonadal vessel and from the insertion of the renal vein on the vena cava.  The family requested DNR status for the patient.  The patient subsequently died.

The Board judged urologist’s conduct to be below the minimum standard of competence given failure to use proper surgical technique with correct tissue transection/ligation, failure to timely convert to an open procedure, and failure to consider hepatic artery and portal vein repair prior to proceeding with the performance of the nephrectomy.

The Board ordered the urologist to be reprimanded.

State: Arizona


Date: November 2016


Specialty: Urology, General Surgery, Nephrology, Oncology


Symptom: N/A


Diagnosis: Post-operative/Operative Complication, Cancer


Medical Error: Procedural error


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



Kansas – Obstetrics – Administering Vaccines In A Pregnant Patient Without Consent



On 3/6/2013, a patient presented for a newborn screening. No pregnancy or labor and delivery history were documented.  A family history was documented; however, no detail of family history was documented.  The patient was not seen until eleven days after discharge.

On 7/3/2013, the patient presented to the obstetrician for her four month well exam.  At that appointment, the patient was administered the following vaccines: Hib, PEDIARIX, PCV 13, and Rota.  No consent form for the aforementioned vaccines was found in the record.

On 9/10/2013, the patient presented to the obstetrician for her six-month exam.  The obstetrician electronically signed the record on 9/27/2013, approximately seventeen days later.

The Board judged the obstetrician’s conduct to be below the minimum standard of competence given his failure to describe the services rendered to the patient.

The Board ordered that the obstetrician attend and successfully complete the Medical Record Keeping Seminar at Center for Personalized Education for Physicians (“CPEP”). Also, the Board ordered that the obstetrician hire a medical scribe. Finally, the Board ordered that the obstetrician have another obstetrician monitor his work.

State: Kansas


Date: October 2016


Specialty: Obstetrics


Symptom: N/A


Diagnosis: N/A


Medical Error: Failure of communication with patient or patient relations, Ethics violation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Ophthalmology – Multiple Medical Errors In A Patient With Numerous Ocular Complications



An ophthalmologist treated a 48-year-old female from 2/2/2009 to 10/24/2014.

On 10/29/2013, the ophthalmologist documented a diagnosis of proliferative diabetic retinopathy with diabetic macular edema in both eyes, wet macular degeneration in both eyes, vitreous hemorrhage with posterior vitreous detachment in both eyes, subretinal macular hemorrhage in both eyes, posterior change intraocular lens in the right eye, cataract in the left eye, and dry eye syndrome in both eyes.

From 10/29/2013 to 10/24/2014, the ophthalmologist performed panretinal laser treatment on the patient’s eyes four times; intravitreal Avastin injections in both eyes twelve times; focal laser treatments in the patient’s left eye four times, and the patient’s right eye three times; fluorescein angiography and indocyanine green angiography twenty-six times; ultrasonography five times; and intravitreal injection of antibiotics in the right eye.

The Medical Board of Florida judged the ophthalmologist’s conduct to be below the minimal standard of competence given that the ophthalmologist failed to utilize, or did not create, keep or maintain adequate, legible documentation of utilizing, optical coherence tomography to evaluate the patient.  The ophthalmologist incorrectly or falsely diagnosed the patient with wet macular degeneration.  He performed intravitreal Avastin injections on the patient’s eyes without medical justification on one or more occasions.  He performed focal laser treatments, panretinal laser photocoagulation, fluorescein and indocyanine green angiography, and ultrasounds on the patient’s eyes excessively or without medical justification on one or more occasions.”  He failed to utilize optical coherence tomography to evaluate the patient.  He did not document the lot number or any other identifying information from any of the vials of Lucentis used during his treatment of the patient.

It was requested that the Medical Board of Florida order one or more of the following penalties for the ophthalmologist: 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: October 2016


Specialty: Ophthalmology


Symptom: N/A


Diagnosis: Ocular Disease


Medical Error: Unnecessary or excessive treatment or surgery, Diagnostic error, Failure to order appropriate diagnostic test, Unnecessary or excessive diagnostic tests, Improper medication management, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Neurosurgery – Anterior Cervical Discectomy With Fusion Done At Wrong Level



On 12/21/2015, a 46-year-old male provided informed consent for an anterior cervical discectomy with fusion (ACDF) at the C6-C7 level.

On 12/29/2015, the patient presented to a hospital to undergo an ACDF procedure at the C6-C7 level.

On 12/29/2015, the neurosurgeon performed an ACDF procedure on the patient at the C7-T1 level instead of at C6-C7.

The Board issued a letter of concern against the neurosurgeon.  A fine was paid.  Stipulations included completing five hours of continuing medical education in risk management.  He may complete this requirement by attending a regular meeting of the Board of medicine.  Stipulations also included presenting 1 hour of lecture on wrong site surgeries.

State: California


Date: October 2016


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



Arizona – Maxillofacial Surgery – Administration Of Droperidol, Propofol, Ketamine, And Midazolam For Oral Surgery



On 11/17/2010, a maxillofacial surgeon performed oral surgery on a 68-year-old man.  He administered droperidol, propofol, ketamine, and midazolam for sedation.  While being administered these medications, his blood oxygen saturation level dropped by 50% after being given labetalol.  The patient became asystolic.  The maxillofacial surgeon and his assistants administered cardiopulmonary resuscitation, which included compressions and administration of naloxone and flumazenil.  The patient did not recover and died.

On 07/15/2011, the Dental Board ordered that the maxillofacial surgeon complete 16 hours of CME.  The maxillofacial surgeon appealed, but the Arizona Court of Appeals upheld the Dental Board’s decision.  As of 03/16/2015, the maxillofacial surgeon completed the CME required by the Dental Board.

A medical consultant reviewed the case and judged the maxillofacial surgeon’s conduct to be below the minimum standard of competence by failing to obtain pre-operative clearance from the primary care physician, which would have included an EKG, and by failing to monitor the patient with the use of telemetry and continuous ETCO2 monitoring.  The maxillofacial surgeon also failed to have at least one member of his operative staff to be ACLS certified and failed to document the indication for use of the medications he used during the procedure and the code.

The maxillofacial surgeon testified that he completed six months of residency training in anesthesia.  He testified that his goal with the patient was to place the patient in deep to moderate sedation.  He testified that while he was ACLS certified, his two assistants were not.  During an interview with him, the Board expressed concern with the maxillofacial surgeon’s level of understanding of the different types of anesthesia as well as the anesthesia that was administered to the patient.

The Board ordered the maxillofacial surgeon be reprimanded, be placed on probation for 6 months, and take 15 hours of continuing medical education on sedation and general anesthesia.

State: Arizona


Date: October 2016


Specialty: General Surgery, Anesthesiology


Symptom: N/A


Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Post-operative/Operative Complication


Medical Error: Improper medication management, Failure to properly monitor patient, Lack of proper documentation, Procedural error


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



Washington – Endocrinology – Lack Of Communication Of Blood Test Results With Patient



On 7/16/2014, a patient saw an endocrinologist after being referred by her gynecologist for concerns about “not feeling well” and for questions about whether her hypothyroidism needed additional evaluation and management.

The patient described how the endocrinologist told her to throw out her other medications prescribed by her trusted long-term gynecologist, go on an antidepressant, and see a therapist.  This advice was upsetting to the patient.

At the close of the visit, the patient went to the laboratory and gave a blood sample for testing.  When the patient did not hear of the test results from the clinic after about 10 days, she contacted the clinic and was told that the results could not be found.

In a response to the complaint by the patient that she did not receive timely test results from the endocrinologist, the endocrinologist stated, through her lawyer, that the results were available through a patient electronic record portal called eCare.  However, the patient had not enrolled in eCare and thus did not have access to the test results.  The endocrinologist stated she planned to disclose and review the test results with the patient at a return visit in 3 months.  The patient eventually established care with another endocrinologist.

The endocrinologist’s treatment of the patient fell below the standard of care when the endocrinologist failed to timely communicate the test results which showed the patient’s Hemoglobin A1C was at 6.1%.  This test result is within a range that can be characterized as “prediabetes,” signifying that a patient may develop a diagnosis of diabetes within 10 years.  A diagnosis of diabetes requires a test result of 6.5% or higher.

The Commission stipulated the endocrinologist reimburse costs to the Commission, complete a course on how to maintain and improve communication between physician and patient, and write and submit a paper of at least 1000 words, with annotated bibliography, on the importance of timely communication of laboratory results to patients and others with a need to know.

State: Washington


Date: October 2016


Specialty: Endocrinology


Symptom: N/A


Diagnosis: Diabetes


Medical Error: Failure of communication with patient or patient relations


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Wisconsin – Radiology – Evaluation Of Mediport Placement



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

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

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

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

State: Wisconsin


Date: October 2016


Specialty: Radiology


Symptom: N/A


Diagnosis: Post-operative/Operative Complication


Medical Error: Diagnostic error


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Gastroenterology – Excessive Gastrointestinal Procedures Performed



A gastroenterologist was reprimanded for the treatments of multiple patients given the performance of multiple colonoscopies, gastroscopies, and/or endoscopies without medical indication and documenting the rationale for such procedures.

The gastroenterologist was ordered to undergo 40 hours of continuing medical education.  He was also ordered to enroll in the Physician Assessment and Clinical Education Program (“PACE”) offered at the University of California – San Diego School of Medicine.

State: California


Date: September 2016


Specialty: Gastroenterology


Symptom: N/A


Diagnosis: N/A


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


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



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