Found 372 Results Sorted by Case Date
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Virginia – Psychiatry – Adjusting Lithium Dosage Based Only On Patient Symptoms



A psychiatrist increased and decrease a patient’s lithium dosage based on the patient’s symptoms.  She did not test the patient’s lithium blood serum level.

On 8/28/2015, the patient was admitted to a hospital for lithium toxicity.  The psychiatrist stated that lithium blood serum levels for long-term lithium patients should be tested at least annually, but also at any time a patient complains of adverse side effects.  The psychiatrist admitted her failure to test the patient’s lithium levels and stated that it “was an inadvertent oversight for which [she] is remorseful.”  The psychiatrist reported that following the patient’s hospitalization for lithium toxicity, she reviewed the charts for her other patients on lithium and determined if they needed testing for lithium blood serum levels.

She provided evidence that she completed 99 hours of CME in psychiatry in 2015 and 58 credit hours of CME in psychiatry in 2017.  She provided a spreadsheet that she created for use in monitoring her patients on lithium.  She was reprimanded by the Virginia Board of Medicine.

State: Virginia


Date: October 2017


Specialty: Psychiatry


Symptom: N/A


Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Psychiatric Disorder


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


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Obstetrics – Excessive And Unindicated Antepartum Testing Performed Over the Course Of A Pregnancy



Between May 2011 and December 2011, an obstetrician provided obstetric services to a 16-year-old female and followed the course of her pregnancy.

The patient had an estimated delivery date of 12/1/2011 and ultimately delivered her baby on 12/1/2011.

On 5/5/2011 and 5/19/2011, the obstetrician performed first-trimester ultrasounds on the patient to monitor the patient’s fetus.

On 6/17/2011, the obstetrician performed a second-trimester ultrasound on the patient to monitor the patient’s fetus.

On 10/11/2011, the obstetrician performed a third-trimester ultrasound on the patient to monitor the patient’s fetus.  The patient’s fetus was in the 29th percentile for growth, which was normal.

On 10/20/2011, the obstetrician performed a third-trimester ultrasound on the patient to monitor the patient’s fetus.  The patient’s fetus was in the 44th percentile for growth, which was normal.

There was no indication for the third-trimester ultrasound that the obstetrician performed on the patient on 10/20/2011.

On 10/28/2011, the obstetrician performed a biophysical profile with ultrasound on the patient and her fetus in order to monitor the patient’s fetus.

The indications documented for the biophysical profile with ultrasound that the obstetrician performed for the patient and her fetus on 10/28/2011 were intrauterine growth restriction and “size less than dates.”  Both intrauterine growth restriction and “size less than dates” were ruled out by the ultrasound conducted on 10/11/2011 and 10/20/2011.

There was no indication for the biophysical profile with ultrasound that the obstetrician performed on the patient and her fetus on 10/28/2011.

On 11/4/2011, the obstetrician performed a biophysical profile with ultrasound on the patient and her fetus in order to monitor the patient’s fetus.  The indications documented for the biophysical profile with ultrasound that the obstetrician performed on the patient and her fetus on were intrauterine growth restriction and “size less than dates.”

Both intrauterine growth restriction and “size less than dates” were ruled out by the ultrasound conducted on 10/11/2011 and 10/20/2011, and the biophysical profile performed on 10/28/2011.

There was no indication for the biophysical profile with ultrasound that the obstetrician performed on the patient and her fetus on 11/4/2011.

On 11/11/2011, the obstetrician performed a third-trimester ultrasound on the patient to monitor the patient’s fetus.  The patient’s fetus was in the 34th percentile for growth, which was normal.  There was no indication for the third-trimester ultrasound the obstetrician performed on the patient on 11/11/2011.

On 11/18/2011, the obstetrician performed a third-trimester ultrasound on the patient to monitor the patient’s fetus.  The patient’s fetus was in the 68th percentile for growth, which was normal.  There was no indication for the third-trimester ultrasound that the obstetrician performed.

The standard of care required that the obstetrician adequately manage the patient’s pregnancy through the use of only indicated antepartum testing and to refrain from performing excessive and unindicated antepartum testing.

It was requested that the Board order one or more of the following penalties for the internist: 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: October 2017


Specialty: Obstetrics


Symptom: N/A


Diagnosis: N/A


Medical Error: Unnecessary or excessive diagnostic tests


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Internal Medicine – Failure To Justify Suboxone Prescribing Practices



From 7/8/2011 to 8/13/2015, an internist treated a 37-year-old female with an opioid dependency for seven years with Suboxone therapy.  During the treatment period, the internist prescribed the controlled substance Suboxone to the patient on one or more occasions.  During the treatment period, the internist failed to substantiate, by test or positive exam, the patient’s history of opiate use to justify the use of Suboxone.

During the treatment period, the internist did not obtain a history of substance abuse, including illicit substances, or a complete medical history from the patient’s prior healthcare provider to support his diagnosis of opioid dependence and opiate withdrawal.

During the treatment period, the internist inappropriately diagnosed the patient, as his physical examination of the patient failed to indicate clinical opiate withdrawal symptoms, to help support his diagnosis of continuous opioid dependence and opiate withdrawal.

During the treatment period, the internist failed to perform tests, including screening for hepatitis B and C, complete metabolic panel, and complete blood count, to completely assess the patient’s condition.

During the treatment period, the internist failed to completely and accurately maintain medical records that justify Suboxone therapy as a proper course of treatment.

During the treatment period, the internist failed to document a clear treatment plan and time frame for detoxification, and/or thoroughly educate the patient about additional recovery.

During the treatment period, the internist failed to perform and/or maintain records of frequent urine toxicology for the patient to prevent noncompliance, dependence, addition, or diversion of controlled substances.

During the treatment period, the internist failed to document, incorporate in the medical records, or comment on all urine toxicology screens performed on the patient on one or more occasions.

During the treatment period, the internist failed to include all logs of prescriptions within his electronic medical record (“EMR”).

During the treatment period, the internist did not pursue, or document pursuing, psychological counseling, prescription drug monitoring (“PDMP”) and follow-up urine toxicology screens to guide optimal therapy.

It was requested that the Board order one or more of the following penalties for the internist: 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: October 2017


Specialty: Internal Medicine


Symptom: N/A


Diagnosis: Drug Overdose, Side Effects, or Withdrawal


Medical Error: Failure to properly monitor patient, Failure to order appropriate diagnostic test, Failure of communication with patient or patient relations, Improper medication management, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Vascular Surgery – Arteriogram Performed On A Patient’s Right Leg Instead Of The Left Leg



On 8/15/2016, a patient presented to a vascular surgeon with peripheral vascular disease, a non-healing ulcer on his left third toe tip, and diminished arterial blood flow in both legs.

Based on his initial evaluation, the vascular surgeon determined that a left leg arteriogram was necessary.

On 8/18/2016, the patient’s family consented to a left leg arteriogram and the vascular surgeon pre-operatively marked the patient’s left and correctly performed a timeout.

After the vascular surgeon performed the timeout, he performed a right leg arteriogram instead of the planned left leg arteriogram.

The Board judged the vascular surgeon’s conduct to be below the minimal standard of competence given that he performed a wrong-site procedure by performing an arteriogram on the patient’s right leg (wrong site) instead of the patient’s left leg (correct site).

It was requested that the Board order one or more of the following penalties for the vascular surgeon: 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: October 2017


Specialty: Vascular Surgery


Symptom: N/A


Diagnosis: Cardiovascular Disease


Medical Error: Wrong site procedure


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Orthopedic Surgery – Damage To Inferior Vena Cava And Other Complications After Guidewire Improperly Placed In Disk Space



On 12/24/2014, a 59-year-old female was admitted to a medical center for a Microscopic Extraforaminal Lumbar Discectomy of L4-L5.  An orthopedic surgeon was assigned to perform the patient’s procedure.  He began the procedure by utilizing image intensification to use a guidewire for initial placement of dilators in the patient’s spine.

After removal of the guidewire, the orthopedic surgeon noted that he felt the guidewire had gone into the disk space slightly.

After sixty percent of the procedure was completed, the orthopedic surgeon was advised by the anesthesiologist that there was a decrease in the patient’s CO2.  It was subsequently noted that the patient’s blood pressure began to drop.

The orthopedic surgeon then placed an OpSite over the patient’s incision, turned the patient to a supine position, and called for assistance from a vascular surgeon.

On 12/24/2014, after becoming hypotensive and then experiencing pulseless electrical activity during the lumbar discectomy, the patient underwent an exploratory laparotomy with repair of inferior vena cava injury.

During the exploratory laparotomy, after approximately one hour of cardiopulmonary resuscitation and advanced cardiac life support protocol, the patient expired on the operating table.

At all times relevant to this case, the prevailing professional standard of care requires that when dealing with patients such as this one, a physician should place instruments into a patient’s body in a manner to do the least possible harm.

The Board judged the orthopedic surgeons conduct to be below the minimal standard of competence given that he allowed an instrument to pass into the patient’s cavity in such a way that injured underlying structures and by failing to recognize the penetration of the guidewire at the time of placement of the initial dilator, which lead to the injury of the patient’s inferior vena cava.

It was requested that the Board order one or more of the following penalties for the orthopedic surgeon: 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: October 2017


Specialty: Orthopedic Surgery


Symptom: N/A


Diagnosis: Post-operative/Operative Complication, Spinal Injury Or Disorder


Medical Error: Procedural error


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



California – Family Practice – Providing Medical Clearance For A Tummy Tuck Procedure



A family practitioner cleared a patient for a tummy tuck procedures.  The patient had a history of sickle cell anemia and a respiratory infection.

The Board judged the family practitioner’s conduct as having fallen below the minimum level of competence given failure to address the status of the patient’s sickle cell anemia and failure to assess the patient’s respiratory infection.

The Board issued a public letter of reprimand.

State: California


Date: October 2017


Specialty: Family Medicine, Internal Medicine


Symptom: N/A


Diagnosis: Hematological Disease, Infectious Disease


Medical Error: Improper treatment


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Gynecology – High Grade Dysplasia Scheduled For Follow Up In 6 Months



On 12/31/2013, a 27-year-old female had a pap smear that showed Atypical Squamous Cells of Undetermined Significance (ASCUS) with a positive showing for HPV.  On 1/30/2014, the patient presented to a gynecologist for colposcopy. Biopsies confirmed Cervical Intraepithelial Neoplasia (CIN) 2 at two biopsy sites, and CIN 1 at a single biopsy site with an insufficient endocervical curettage (ECC).

On 2/10/2014, the patient again presented to the gynecologist for a follow-up examination.  The gynecologist diagnosed the patient with Moderate Cervical Dysplasia, CIN 2, and advised the patient to follow-up in 1 year with a PAP/HPV examination.  On 2/28/2014, after speaking with a colleague, the gynecologist telephoned the patient and advised the patient to return in 6 months for an examination of the abnormal PAP.

The Medical Board of California judged that the gynecologist’s conduct departed from the standard of care because she failed to follow-up with the patient sooner than 6-12 months, and in light of the inadequate ECC, failed to proceed with either a diagnostic excisional procedure or an excision/ablation procedure to treat the high grade dysplasia known to the gynecologist.

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

State: California


Date: August 2017


Specialty: Gynecology


Symptom: N/A


Diagnosis: Gynecological Disease


Medical Error: Delay in diagnosis


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Plastic Surgery – Excessive Use Of Lidocaine During SmartLipo Results In Severe Complications



On 11/2/2012, a 39-year-old female presented to an internist for skin tightening intervention in the lower abdomen under local anesthesia with mild oral and intramuscular sedation, a procedure commonly known as “smart lipo.”

The patient was given 700 to 800 ml of an IV of various medicines, including lidocaine, and then three injections of 1% lidocaine.

Shortly after administration of the IV of various medicines and the lidocaine shots, the patient began to have a grand mal seizure.  The internist treated the patient with IV fluids and Narcan.

The patient reportedly had normal vital signs at the time, but then had another seizure fifteen minutes later.

According to the internist, ten minutes later, on the third seizure, the internist requested an ambulance.

The internist indicated that the patient, upon the third seizure, lost all pulse and respiration.

According to the EMS staff, the internist did not recognize that the patient was in cardiac arrest upon EMS arrival and was not assisting the patient.

The patient was taken to the emergency room in full cardiac arrest, where she died.

The medical examiner listed the patient’s cause of death as acute lidocaine toxicity due to use of lidocaine in a medical procedure.

The internist failed to adequately prepare or maintain medical records in this case in a way that allowed any medical professionals to adequately know the amount of lidocaine administered to the patient.

The Medical Board of Florida judged the internist’s conduct to be below the minimal standard of competence given that he failed to recognize a lack of blood pressure and administer cardiac support (CPR) upon recognition of a lack of blood pressure.  The internist also administered excess lidocaine that caused the patient’s death due to lidocaine toxicity.

The Medical Board of Florida issued a reprimand against the internist’s license.  The Medical Board of Florida ordered that the internist pay of $5,000 for his license and pay reimbursement costs for the case at a minimum of $10,683.65 and not to exceed $12,683.65.  The Medical Board of Florida ordered that the internist complete a records course, complete ten hours of continuing medical education in liposuction procedures and complete five hours of continuing medical education in “risk management.”

State: Florida


Date: August 2017


Specialty: Plastic Surgery, Internal Medicine


Symptom: N/A


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


Medical Error: Improper medication management, Underestimation of likelihood or severity, Lack of proper documentation


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Florida – Physician Assistant – Diflucan For Yeast Infection Given With Tacrolimus



A patient received a heart transplant and was on a long-term tacrolimus regimen.

On 10/7/2011, the patient presented to a physician assistant with complaints of an oral yeast infection.  The physician assistant prescribed the patient a two-week course of Diflucan and advised him to return for follow-up three weeks after the 10/7/2011 appointment.

Diflucan is known to potentiate tacrolimus, which causes the tacrolimus to reach toxic levels.

The standard of care required that the physician assistant perform serial monitoring of the patient’s drug levels to ensure that they did not reach a toxic level, starting immediately after the physician assistant prescribed Diflucan.

The physician assistant did not schedule blood testing to monitor the patient’s drug levels and advised the patient to return for a follow-up appointment three weeks after the initial appointment.

The physician assistant voluntarily relinquished his license.

State: Florida


Date: August 2017


Specialty: Physician Assistant


Symptom: N/A


Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Infectious Disease


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


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Cardiothoracic Surgery – Failure To Follow Up After Pathology Report Shows Abnormal Lymphadenopathy



On 1/25/2013, a 65-year-old male, underwent an artery bypass grafting procedure on his right leg by a cardiothoracic surgeon at a medical center.

During the course of the procedure, the cardiothoracic surgeon took a biopsy of the patient’s right groin lymph node, which was sent off to pathology for analysis.

The patient was never notified by the cardiothoracic surgeon that a biopsy of the right groin lymph node was taken during the procedure.

The cardiothoracic surgeon should have documented the right groin lymph node biopsy as part of the procedure in the operative report for the procedure but failed to do so.

On 1/29/2013, the pathology report for the biopsied tissue revealed a pathologic diagnosis of mantle cell lymphoma.  The pathology report was sent via facsimile to the cardiothoracic surgeon’s office.  The cardiothoracic surgeon should have listed “abnormal lymphadenopathy” as the post-operative diagnosis and failed to do so.

On 1/30/2013, the patient was discharged from the medical center.

The Board judged the cardiothoracic surgeons conduct to be below the minimal standard of competence given that he should have notified the patient of the pathology results and failed to do so.  He also should have obtained oncologic consultation for the patient and failed to do so.  The cardiothoracic surgeon should have provided the patient’s primary care physician and the referring physician with a copy of the pathology report and failed to do so.

The Board issued a letter of concern against the cardiothoracic surgeon’s license.  The Board ordered that the cardiothoracic surgeon pay a fine of $5,000 against his license and pay reimbursement costs for the case for a minimum of $5,063.26 but not to exceed $7,063.26.  The Board ordered that the cardiothoracic surgeon complete a board approved medical records course and complete five hours of continuing medical education in “risk management.”

State: Florida


Date: August 2017


Specialty: Cardiothoracic Surgery, Oncology


Symptom: N/A


Diagnosis: Cancer


Medical Error: Failure to follow up, Failure of communication with other providers, Referral failure to hospital or specialist, Failure of communication with patient or patient relations, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



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