Found 372 Results Sorted by Case Date
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California – Plastic Surgery – Liposuction And Touch-Ups Of Abdomen And Arms



On 9/2/2010, a physician assistant, under the supervision of a plastic surgeon, performed abdominal liposuction utilizing local anesthesia on a patient.  Before the procedure, it had been made clear to the patient that if she was not happy with the procedure and required touch-ups, these would be done at no extra charge.

Pre-operative photos of the patient’s abdomen showed an infra-umbilical hanging “pouch” of skin.  The patient was, in fact, not a candidate for liposuction, but should have had an infra-umbilical dermolipectomy.  Photos taken post-operatively showed dents and waviness in the patient’s abdominal skin.

After the first procedure, the patient felt that not enough fat had been taken from her abdomen and made a follow-up appointment with the plastic surgeon’s practice.  When she arrived for her follow-up appointment, she discovered that the physician assistant no longer worked at the plastic surgeon’s practice and was no longer supervised by the plastic surgeon.  The plastic surgeon agreed to perform a touch-up procedure on the patient, but would not do it free of charge since, as he explained, he did not regard himself responsible for the work performed by his physician assistant.  The plastic surgeon agreed to perform the touch-up procedure on the patient’s abdomen for half the original fee.

On 11/11/2010, the plastic surgeon performed touch-up liposuction on the patient’s abdomen and also performed liposuction on the patient’s arms at the customary full price.  Subsequently, the patient was unhappy with the results of this second procedure, particularly with regards to her arms and was informed by the plastic surgeon that he could perform revision surgery at an additional fee.  When the patient called the plastic surgeon’s practice for a follow-up appointment, she was informed that they had moved offices. The patient had not been notified of the move.

Standard tumescent fluid contains a mixture of Lactated Ringer’s solution, epinephrine, and lidocaine.  Tumescent fluid is more toxic if epinephrine is not used. The plastic surgeon’s “Tumescence Calculation Worksheet,” dated 11/11/2010, in the patient medical chart incorrectly listed a maximum safe lidocaine dose for the patient as 2,981 mg.  For the patient, weighing 54 kg, it would be safe to use tumescent fluid containing epinephrine and up to 1,890 mg lidocaine.

A note, which does not bear the name of any patient, but is reportedly a report on the patient’s second procedure, stated that 1,450 ml of tumescent fluid was infiltrated during the procedure and 2% lidocaine was used.  The note did not state what volume of lidocaine was mixed in the tumescent fluid bag or whether epinephrine was added. The note, purportedly electronically signed by the plastic surgeon on 11/20/2010, the day before the surgery was performed, consisted largely of “check boxes” with no narrative explaining what was done, to which exact body area (stating only “arms” and “full abdomen”), on what date or at what time, to whom and/or by whom.  The note had only the following comment: “patient tolerated well.” There was no indication that the patient’s vital signs were monitored during the second procedure.

There was no documentation in the patient’s medical records from which the plastic surgeon’s opinion of the results of the liposuction of the patient’s arms can be determined, or whether any remediation would be considered.  Between 1/4/2011 and 1/7/2011, the patient repeatedly asked the plastic surgeon and/or his employees for a copy of her medical records, but never received anything in response to her requests.

The Medical Board of California judged that the plastic surgeon’s conduct departed from the standard of care because he failed to maintain adequate and accurate medical records, failed to provide the patient with a copy of her medical records, performed abdominal liposuction on the patient when dermolipectomy was indicated, and performed revision surgery on the patient’s abdomen approximately 10 weeks after the initial surgery.

The Medical Board of California placed the plastic surgeon on probation for 4 years and ordered the plastic surgeon to complete a medical record keeping course, an education course, and a professionalism program (ethics course).  The plastic surgeon wasprohibited from solo practice, performing any and all cosmetic and/or aesthetic surgical procedures of any kind, and supervising physician assistants.

State: California


Date: June 2015


Specialty: Plastic Surgery


Symptom: N/A


Diagnosis: N/A


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


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Plastic Surgery – Liposuction And “Venus Freeze” Treatments



After a consultation with a plastic surgeon on 3/9/2012, a patient underwent liposuction with the plastic surgeon on 3/13/2012.  The patient’s medical chart contained no documentation of the consultation on 3/9/2012 or of a history and physical exam. The location of the incisions made and exact areas worked on by the plastic surgeon were not documented anywhere in the patient’s medical chart.  Post-operative photos showed dents and waviness on the abdomen with stab incisions visible in the mid-lower abdomen above the panty line.

The patient was unhappy with the results of the liposuction, but was assured by the plastic surgeon that her concerns would be resolved over time and that healing would not be complete for 6 months.  She was further told by the plastic surgeon that if, after 6 months, she was still not satisfied with the results of her liposuction, the plastic surgeon would take further steps to rectify the situation.

Postoperatively, the patient visited the plastic surgeon’s practice on 11 occasions including for a follow-up consultation, an examination and photographs, and 7 “Venus Freeze” treatments.  No documentation can be found in the patient’s medical chart for approximately 7 of her post-operative visits to the plastic surgeon’s practice. At least 2 clinical notes in the patient’s medical chart reflected treatment and/or visits by her to the plastic surgeon’s practice on dates on which she had neither visited the plastic surgeon’s practice nor received any treatment.  Other clinical notes for visits by the patient to the plastic surgeon’s practice were unsigned, leaving it unclear by whom she was seen and/or treated on a particular day.

Standard tumescent fluid contains a mixture of Lactated Ringer’s solution, epinephrine, and lidocaine.  Tumescent fluid is more toxic if epinephrine is not used. The plastic surgeon’s “Tumescence Calculation Worksheet” in the patient’s medical chart incorrectly listed a maximum safe lidocaine dose for the patient as 3,245 mg.  For the patient, weighing 59 kg, it would be safe to use tumescent fluid containing epinephrine and up to 2,065 mg lidocaine.

A note, which did not bear the name of any patient, but was apparently a report on the patient’s procedure, stated that 2,000 ml of tumescent fluid was infiltrated during the procedure, and 2% lidocaine was used.  The note did not state what volume of lidocaine was mixed in the tumescent fluid bag or whether epinephrine was added. The note, purportedly electronically signed by the plastic surgeon on 3/13/ 2012, consisted largely of “check boxes” and contained no narrative explaining what was done, on what date or at what time, to whom and/or by whom.  Th note bore only the following comment: “patient tolerated well.” There was no indication that the patient’s vital signs were monitored during the procedure.

Around May 2012, the patient asked the plastic surgeon for copies of the photos taken of her preoperatively and postoperatively.  She received her pre-operative photos in May 2012, but was never given copies of her post-operative photographs.

The patient’s final “Venus Freeze” treatment at the plastic surgeon’s practice was on 6/19/2012.  Her next scheduled visit was for her 6 month post-operative follow-up visit, on 9/13/2012. When the patient arrived at the Clairemont office, she found it closed.  By making enquiries, the patient subsequently ascertained that the plastic surgeon’s practice had closed approximately one week earlier. There was no notice posted regarding the closure or any forwarding address or telephone number for enquiries.  The patient had received no notice of the closure nor any referral to any other physician or medical practice. The plastic surgeon made no arrangements for the patient’s follow-up care or for the promised revision surgery.

The Medical Board of California judged that the plastic surgeon’s conduct departed from the standard of care because he failed to maintain adequate and accurate medical records, made incisions for abdominal liposuction too high on the patient’s abdomen and/or not within the umbilicus or just above the pubic hair area and beneath the panty line, abandoned the patient, and failed to provide the patient with a copy of her post-operative photographs.

The Medical Board of California placed the plastic surgeon on probation for 4 years and ordered the plastic surgeon to complete a medical record keeping course, an education course, and a professionalism program (ethics course).  The plastic surgeon was prohibited from solo practice, performing any and all cosmetic and/or aesthetic surgical procedures of any kind, and supervising physician assistants.

State: California


Date: June 2015


Specialty: Plastic Surgery


Symptom: N/A


Diagnosis: N/A


Medical Error: Lack of proper documentation, Failure of communication with patient or patient relations, Failure to follow up, Improper medication management, Lack of proper documentation, Procedural error


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Washington – General Surgery – Resection Of Large Retroperitoneal Sarcoma And Blood Loss



A general surgeon indicated poor judgment in the resection of a large retroperitoneal sarcoma on 8/11/2011.  Bleeding began at the beginning of the procedure.  The general surgeon persevered in the surgery despite inadequate assistance, inadequate blood availability, and recommendations to modify his approach.  The patient died within twenty-four hours following the procedure due to blood loss.  The medical record significantly misstated the timing, source, and amount of the patient’s blood loss.

The general surgeon’s license is currently expired and he is not practicing medicine in Washington.  The Commission stipulated that the general surgeon not perform any future surgical procedures in Washington and must inform the Commission if he intends to practice again in Washington.

State: Washington


Date: June 2015


Specialty: General Surgery


Symptom: N/A


Diagnosis: Cancer


Medical Error: Procedural error, Lack of proper documentation


Significant Outcome: Death


Case Rating: 2


Link to Original Case File: Download PDF



Washington – Urology – Prostatitis And Prolonged Elevated PSA



On 7/18/2012, a 57-year-old male patient was treated by a urologist for a urinary tract infection and an elevated prostate-specific antigen (PSA) of 22.  The patient’s primary care provider had started antibiotic therapy but he still had signs of infection.  On 7/27/2012, the urologist noted that the patient’s infection had resolved and he planned to re-check PSA in about 6 weeks.  The urologist also noted that he performed a digital rectal examination (DRE) that showed a rubbery prostate without palpable enlargement.

On 9/7/2012, the urologist noted that the patient had no symptoms of infection and his PSA remained elevated at 14.75.

On 12/5/2012, the urologist noted that the patient’s infection had returned and his PSA had elevated at 17.43.  The urologist planned to repeat the patient’s PSA in two weeks after completing antibiotics.

On 2/13/2013, the urologist noted that the patient’s infection had resolved and that his PSA remained elevated at 17.8

On 6/27/2013, the urologist noted that the patient’s infection had returned and his PSA had elevated at 27.5.  The urologist planned to repeat the patient’s PSA in two weeks after completing antibiotics.  On 7/24/2013, the urologist noted that the patient’s infection had resolved and that his PSA had been persistently elevated; however, no repeat PSA test was performed on that day.

On 8/21/2013, the urologist noted that the patient’s infection had not returned and that his PSA remained significantly elevated at 22.4.  The urologist noted that a DRE showed a normal feeling prostate.

On 11/21/2013, the urologist noted that the patient’s infection had not returned and that his PSA remained significantly elevated at 22.8.  The urologist noted that a repeat DRE was unremarkable.  The urologist noted that a biopsy may be necessary if the patient’s PSA remained elevated for another three months.

In January 2014, the patient decided to consult with another urologist who performed a DRE and noted that the prostate felt firm “on right apex and mid.”  A biopsy was performed several weeks later and adenocarcinoma was detected in nine of twelve cores with a Gleason’s score of 7.  The patient underwent successful surgery in June 2014 and his PSA subsequently resolved at 0.007.

The patient’s PSA levels were significantly elevated at all times while being treated by the urologist.  The urologist chose not to initiate antibiotic therapy for an extended period of time in order to obtain a reliable PSA test result and/or perform a biopsy while the patient was on antibiotics.  The urologist’s delay in advising the patient regarding the risks and benefits of treatment options did not cause actual harm, but the delay increased the risk that the patient’s adenocarcinoma could metastasize prior to detection and effective treatment.

The Commission stipulated that the urologist reimburse costs to the Commission, complete 4 hours of continuing education on the management of prostatitis caused by chronic bacterial infection with prolonged elevated PSA, and write and submit a paper of at least 1000 words, with bibliography, on the continuing education completed.

State: Washington


Date: May 2015


Specialty: Urology


Symptom: N/A


Diagnosis: Prostate Cancer


Medical Error: Delay in proper treatment, Underestimation of likelihood or severity


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Wisconsin – Obstetrics – Second Pregnancy Scheduled For Elective Induction Given Concern For Macrosomia



In 2013, a patient had seen a family practitioner for the delivery of her first child.  She delivered at 38 weeks gestation.  The fetus was in breech position, which was corrected.  The patient had extra bleeding, and no further complications.  The infant was 9 pounds.

On 10/9/2014, the family practitioner started providing prenatal care to the patient for her second pregnancy with an expected due date of 5/4/2015.  At 28 weeks on 2/10/2015, glucose level was noted to be elevated.  The family practitioner scheduled the patient for an elective induction of labor on 4/28/2015 given expectation that the second child would be large.  Induction began at 10:30 a.m. on the scheduled date.  At around 1:30 p.m., the patient was dilated to 3 cm and underwent rupture of membranes.  At around 2 p.m., the patient requested medication for pain.  The family practitioner instructed the nurse to administer IV fentanyl.  Afterwards, the patient became nauseated, lost consciousness, and stopped breathing.  After 30-60 seconds, the patient turned dusky bluish.  Nasal cannula with high flow oxygen was inserted.  The patient failed to respond.  The family practitioner left the room to instruct staff to call 911.  The family practitioner administered naloxone to the patient.  Bag valve mask was administered to establish artificial ventilation.  The heart rate of the fetus was slowly dropping.  EMS arrived at around 2:15 p.m.  The nurse was ventilating the patient with a bag valve mask.  Oropharyngeal airway was not in place, no one was performing chest compressions, and patient was pulseless.  The family practitioner was unable to tell EMS how much fentanyl or naloxone was administered.  EMS initiated CPR.  At around 2:30 pm, fire and rescue personnel arrived and intubated the patient, started an IV, and continued chest compressions.  The patient was transported to the ED where she arrived pulseless without respirations.  The patient expired.

A post mortem C-section was performed and a 9 pound male infant was delivered.  Upon delivery, the infant expired.  The cause of death was discovered to be amniotic fluid embolism.  The pathologist noted “The Decedent’s cause of death is attributed to amniotic fluid embolism experienced during childbirth.  This process is relatively rare occurring in approximately 1 out of 50,000 pregnancies although has a reported mortality in excess of 80%.  This reportedly accounts for approximately 10% of all maternal deaths.  An associated or contributing additional visceral or toxicologic disease is not identified.”

The recommendation was that the family practitioner complete Advance Trauma Life Support training and complete a course on safe opioid prescribing.  The family practitioner was prohibited from managing obstetrics patients during labor and delivery.

State: Wisconsin


Date: May 2015


Specialty: Obstetrics, Family Medicine


Symptom: N/A


Diagnosis: Obstetrical Complication


Medical Error: Diagnostic error, Improper treatment, Improper medication management


Significant Outcome: Death


Case Rating: 5


Link to Original Case File: Download PDF



California – Pathology – Incorrect Differentiation Between Myeloblasts And Basophilis On Flow Cytometry Analysis In Chronic Myelogenous Leukemia



On 5/18/2011, a hematopathologist reported on his review of a patient’s peripheral blood that was sent for flow cytometry in a case of chronic myelogenous leukemia (CML).  In his final diagnosis, the hematopathologist reported “Approximately 15-20% myeloblasts. Together with high leukocyte count, basophilia, and eosinophilia, circulating blasts are consistent with chronic myelogenous leukemia in accelerated phase, tending to myeloid blast crisis. Recommend bone marrow study including cytogenetics for confirmation of diagnosis.”  The hematopathologist found that there were two abnormal populations and each represented myeloblasts: population (a) comprising 6-7% of the total cells, and population (b) comprising 11-12% of the total cells.  However, a review of the flow cytometric histograms revealed that while population (a) represented true myeloblasts, which were positive for CD34, population (b), in fact, represented basophils.  Population (b) had all the characteristics of basophils including level of CD45 expression (at a level between the lymphocytes and true blasts), low side scatter, CD11b expression, and negativity for HLA-DR.  The hematopathologist erroneously grouped this population of basophils with myeloblasts.  Based upon this error, the reporting of the number of blasts was incorrect, 15-20% instead of the correct range of 6-7%.

Chronic myelogenous leukemia has three phases: the chronic phase, the accelerated phase, and the blast phase (blast crisis).  The flow cytometric studies showed 6-7% blasts, and the correct classification of disease was the chronic phase.  The hematopathologist incorrectly classified the disease as being in the accelerated phase tending to blast.  The hematopathologist failed to recognize basophils in the flow cytometric study and confused the basophil population with blast population.  In his report, he counted basophils as a second population of blasts, and consequently, he reported the number of blasts at 15-20%, which was significantly higher than the correct number of 6-7%.  This resulted in the hematopathologist incorrectly classifying the disease.  Based upon this incorrect classification of the disease as aggressive tending to blast crisis, more aggressive treatment was incorrectly indicated for the patient.

The hematopathologist’s failure to recognize basophils by flow cytometric analysis in the case of the patient represented incompetence and/or inadequate and/or inaccurate record-keeping for a hematopathologist.

For this case and others, the Medical Board of California issued a public reprimand and ordered the hematopathologist to complete a medical record-keeping course.

State: California


Date: April 2015


Specialty: Pathology, Hematology


Symptom: N/A


Diagnosis: N/A


Medical Error: Diagnostic error


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Pathology – Interpreting Immunohistochemical Stains To Diagnose Either Classical Hodgkin’s Lymphoma Or EBV-Positive DLBCL



A hematopathologist incorrectly interpreted a patient’s disease (in the biopsy of the patient’s right neck lymph node) as classical Hodgkin lymphoma, when in fact, the patient had EBV-positive diffuse large B-cell lymphoma (DLBCL).

On 3/12/2011, another physician originally diagnosed the patient with EBV-positive DLBCL.  Then, on 4/11/2011, the hematopathologist re-evaluated the patient, and he believed the patient’s condition to be classical Hodgkin lymphoma, but pending outside consultation.  On 5/16/2011, the case was sent to another consulting physician, who diagnosed the patient with EBV-positive DLBCL.  The hematopathologist then issued an addendum after expert consultation.

However, the hematopathologist’s original report made on 4/11/2011 exhibited incompetence and/or inadequate and/or inaccurate record-keeping in its morphologic assessment and interpretation of the immunohistochemical stains in this case.  His interpretation of the immunohistochemical stains was incorrect with respect to certain key stains including CD15 and CD30 leading to the wrong diagnosis of classical Hodgkin lymphoma.  The hematopathologist disregarded sheets of CD20 large lymphoid cells in this case.  A few of the large cells were CD30 positive, which was an activation marker, but the majority of the neoplastic cells were negative for CD30.  CD15 was negative in neoplastic cells while scattered benign histiocytes were positive for Cd15.  Yet, the hematopathologist reported both stains (CD15 and CD30) as strongly positive in neoplastic cells.  The hematopathologist dismissed significant morphologic findings and instead concentrated on a few less important ones.  The hematopathologist’s report demonstrated that he had put too much emphasis on scattered and few CD30+ activated large B-cells and interpreted benign histocytes as CD15+ neoplastic cells.  At the same time, the hematopathologist failed to pay enough attention to numerous CD20+ large B-cells seen in sheets.

For this case and others, the Medical Board of California issued a public reprimand and ordered the hematopathologist to complete a medical record-keeping course.

State: California


Date: April 2015


Specialty: Pathology, Hematology


Symptom: N/A


Diagnosis: Cancer


Medical Error: Diagnostic error


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Plastic Surgery – 18 mg Of Hydromorphone, 20 mg Of Oxycodone, 20 mg Of Valium, And 25 mg Of Phenergan Administered For Anesthesia



On 5/13/2008, a patient presented to a plastic surgeon at a rejuvenation and aesthetics institute.  The patient consented to having rhytidectomy and blepharoplasty surgical procedures performed on her.  Rhytidectomy is the technical term for what is commonly referred to as a face lift, a type of cosmetic surgery used to give a more youthful appearance.  Blepharoplasty is the surgical modification of the eyelid.  The patient also consented to liposuction and a neck lift.

On 6/20/2008, the patient underwent a face and neck lift and blepharoplasty.  The plastic surgeon personally prescribed and administered anesthesia to the patient and did not utilize the services of a qualified physician assistant, anesthesiologist, or registered nurse anesthetist.  Anesthesia was prescribed by the plastic surgeon and, according to the plastic surgeon’s operative report, consisted of 0.5 percent xylocaine with epinephrine injected locally, supplemented with 14 mg of Dilaudid (trade name for hydromorphone, a schedule II controlled substance) p.o. (by mouth), 20 mg of Percocet (which contains oxycodone, a schedule II controlled substance) p.o., 20 mg of Valium (trade name for diazepam, a schedule IV controlled substance) p.o., and 25 mg of Phenergan p.o.

The pre-op checklist indicated that the amount of Dilaudid administered to the patient was 18 mg.  The amounts of opiates were excessive at 14 to 18 mg of Dilaudid and the polypharmacy that results when Dilaudid is combined with Valium and Percocet produces a mixture of drugs that can have tremendous potentiating effect on one another.  Polypharmacy refers to the use of too many forms of medication by a patient, when more drugs are prescribed than is clinically warranted.  Potentiation occurs when two or more drugs are taken and one of them intensifies the action of another, thereby cutting down on the amount of the narcotic needed.

The plastic surgeon’s Intra-Op Record indicated that the procedures commenced at 11:00 a.m., ended at 1:32 p.m., and that the patient was moved to recovery at 1:44 p.m.  The plastic surgeon’s Operative Report indicated that the surgery was completed without complications and that the patient tolerated the procedure well.

At an unspecified time, while the patient was in recovery, the patient’s oxygen saturation was measured at 65%, a significantly lower level than normal.  This level is consistent with a lack of oxygen being supplied to the vital organs and tissues of the patient which, if left untreated, would result in her eventual death from oxygen deprivation.

The plastic surgeon was notified of the low oxygen saturation and at 2:10 p.m. the patient was given an ampule of Narcan by the nurse.  Narcan is a narcotic antagonist.  It works by blocking opiate receptor sites, which reverses or prevents toxic effects of narcotic (opioid) analgesics, such as Dilaudid and Percocet.  Narcan, however, has a very short period of effectiveness whereas the Dilaudid and Percocet have a much longer lasting effect.  Narcan, therefore, provides, only a short-lived counter effect to an overdose of Dilaudid and/or Percocet.  Narcan, temporarily, would mask the effect of an overdose of Dilaudid and/or Percocet.

The patient was discharged from the rejuvenation and aesthetics institute the same afternoon.

On 6/21/2008, early in the morning the patient was found in bed, unresponsive and cool, and emergency medical services was called.  The patient arrived by emergency transport at 2:00 a.m. at a medical center dead.

The medical examiner determined that the manner of death was accidental and the cause of death was combined drug toxicity.  The toxicology report from the medical examiner’s office indicated the presence of a lethal level of hydromorphone (Dilaudid); a level of concentration fully attributable to the dosage administered to the patient the previous day by the plastic surgeon.

All the opioids found the the patient’s post-mortem blood and urine were fully attributable to the dosages administered and/or prescribed to the patient the previous day by the plastic surgeon.

The Board judged the plastic surgeon’s conduct to be below the minimum standard of competence given that he failed to keep adequate medical records to make clear how much Dilaudid was administered to the patient,  administered an excessive quantity and/or improper combination of drugs for anesthesia, failed to realize that Narcan’s short-acting nature and palliative affect would be long outlasted by the narcotic medications, failed to diagnose the patient was overdosed on narcotics, and allowed her to be discharged before this condition was alleviated.

The Board ordered the plastic surgeon to pay an administrative fine of $20,000 and suspended his license.

State: Florida


Date: April 2015


Specialty: Plastic Surgery


Symptom: N/A


Diagnosis: Drug Overdose, Side Effects, or Withdrawal


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


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



North Carolina – Obstetrics – Complications Of Shoulder Dystocia And Nuchal Cord



The Board was notified of a professional liability payment.

In October 2011, a 23-year-old woman 39 weeks and 4 days pregnant in her first pregnancy was admitted to the hospital for induction of labor.  Pitocin was started and fetal monitoring was initiated.  At some point during labor, fetal monitoring strips revealed evidence suggestive of fetal distress.  The birth was complicated by shoulder dystocia and nuchal cord.  The baby was born in distress and later died secondary to respiratory failure and hypoxic encephalopathy.

An independent medical expert reviewed the obstetrician’s care and judged his conduct to be below the standard of care due to failure to immediately report to the delivery room after being called by the delivery room nurse, the decision to increase the Pitocin when it should have been stopped, and delay in delivering the baby when there were signs of fetal distress.

The Board issued a public letter of concern, which was reported to the Federation of State Medical Boards and may have been reported to the National Practitioner Data Bank.

State: North Carolina


Date: April 2015


Specialty: Obstetrics


Symptom: N/A


Diagnosis: Obstetrical Complication


Medical Error: Procedural error, Improper medication management


Significant Outcome: Death


Case Rating: 1


Link to Original Case File: Download PDF



California – Obstetrics – Hyperglycemia During Pregnancy With Elevated Hemoglobin A1c



On 5/13/2009, a patient registered for obstetrical care at a medical group and had an expected delivery date of 12/3/2009.  On 7/22/2009, a physician assistant found the patient to have an abnormal glucose in her urine. The patient was transferred to another facility for diabetes self-management.  The physician assistant prescribed glyburide to control the patient’s blood sugar and referred her to see an obstetrician.

The patient first saw the obstetrician on 9/30/2009, at which time the patient’s glucose was well controlled. On 10/15/2009, the patient’s glycosylated hemoglobin A1c was found to have an elevated value.  The obstetrician did not change the management of the patient’s diabetes, either to increase the amount of glyburide or to begin treatment with insulin. On 10/19/2009, the first and only fetal monitor and documentation of a fetal non-stress test (NST) appears in the patient’s records and suggested that the fetus was not acidotic at the time.

On 11/23/2009, the patient made an unscheduled visit to see the obstetrician, complaining of decreased fetal motion.  Except for noting positive fetal motion, there was no record of the patient’s complaint, and there was no documentation of an NST or a Biophysical Profile (BPP) to ensure fetal well being.  After 10/19/2009, the obstetrician did not document the patient’s blood sugar values and failed to provide the fetal strips for or the record results from any NST assessment of fetal welfare.

On 11/25/2009, the patient went to the hospital complaining of not having felt fetal movement since that morning, where it was determined that there had been an intra-uterine fetal demise.  A urine dip-stick test, taken upon the patient’s admission, revealed a greater than 1000 mg/dL of glucose. Finger-stick glucose was elevated to 250 mg/dL. Labor was induced, and the patient required an insulin infusion to control her blood sugar.  The delivery of the demised fetus took place at 1:25 p.m. on 11/26/2009. A subsequent pathological evaluation of the placenta and the autopsy of the fetus produced a finding of reactive erythroblastosis, associated with diabetes mellitus, and showed a postmortem interval of less than 48 hours.

The Medical Board of California judged that the obstetrician’s conduct departed from the standard of care because she failed to treat the patient’s hyperglycemia with insulin when glyburide was having an inadequate effect controlling the patient’s glucose, recognize that the patient manifested a blood sugar profile diagnostic of pregestational diabetes, treat her overt diabetes, ensure that the patient had a regular program of fetal testing with fetal NTS performed, provide an appropriate evaluation of the patient’s report of decreased fetal motion in November 2009, and create and maintain adequate medical records.  The obstetrician also lacked knowledge to control the patient’s glucose levels and lacked understanding that the patient manifested a blood sugar profile diagnostic of pregestational diabetes.

The Medical Board of California placed the obstetrician on probation for 35 months and ordered her to complete a medical record-keeping course 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.

State: California


Date: April 2015


Specialty: Obstetrics


Symptom: N/A


Diagnosis: Obstetrical Complication


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


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



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