Found 372 Results Sorted by Case Date
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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



California – Plastic Surgery – Failure To Manage Hypertension And Hypoxia Perioperatively



In 2013, Plastic Surgeon B was an independent contractor providing facial cosmetic surgery services two days a week for a clinic in California.  A 57-year-old male made an appointment at the clinic for 9/7/2013.  The patient was interested in improving the appearance of his lower face and eyes.

The patient filled out a medical history form, on which he checked, “Yes” to the question, “Are you currently undergoing radiation therapy or chemotherapy for cancer?”  There was no additional explanation.  He did not list the name of the primary care physician (PCP) on the form but indicated that his PCP could be contacted for questions.  He indicated that he was taking no medications and had no allergies.  He listed no prior surgeries.

On 9/13/2013, the patient met with Plastic Surgeon A for a pre-operative visit.  Plastic Surgeon A performed a history and physical examination and wrote prescriptions for diazepam 5 mg #20 tablets, Tylenol with oxycodone 10/325 mg #30, and Keflex 500 mg.  Plastic Surgeon A indicated that the patient had hypertension but was not on any medication.  The patient’s blood pressure was noted to be 152/97.  The patient signed informed consent forms for a face and neck-firming procedure as well as blepharoplasty.  Plastic Surgeon A did not co-sign the forms (which are used to indicate that the plastic surgeon had personally reviewed the risks, benefits, and alternatives of the procedures with the patient and answered all questions).  Plastic Surgeon A noted his surgical plan as “Face & neck.  Upper lids skin only.  Possible fat transfer to cheeks.  Fast absorbing suture.”  Plastic Surgeon A did not sign his surgical plan.

Plastic Surgeon A left his position at the clinic, and the patient’s care was transferred to Plastic Surgeon B.  Surgery was rescheduled for 9/26/2013 with Plastic Surgeon B, and a “Meet the Doctor” date of 9/19/2013 was scheduled.  On 9/16/2013, Plastic Surgeon B filled out and signed a History and Physician Examination form on the patient.  The form documented only the facial examination and surgical plan, including lower lid laser.  There is no documentation of vital signs, particularly no blood pressure reading.  The patient signed new informed consent forms for face and neck firming surgery and blepharoplasty by Plastic Surgeon B.  Plastic Surgeon B did not co-sign the informed consent forms indicating that he had personally reviewed the risks, benefits, and alternatives of the procedures with the patient and answered all questions.  There is no consent form for laser resurfacing.

On 9/25/2013, the patient saw Plastic Surgeon B, and Plastic Surgeon B’s notes indicate “Famvir” and “take BP today.”  There is no documentation in the chart that a prescription for Famvir was written or that the drug was dispensed or used by the patient.  There is also no documentation that the patient’s blood pressure was taken.

The patient presented for surgery on 9/26/2013.  Vital signs were taken, and his blood pressure was documented as 177/116 right and 160/95 left.  At 11:30 a.m., the patient was in the surgical suite and was given oral sedation consisting of diazepam 30 mg; lorazepam 1 mg; acetaminophen with hydrocodone 5/325 mg; promethazine 25 mg; clonidine 0.1 mg; and diphenhydramine 25 mg.  Local anesthesia was infiltrated into the facial skin and subcutaneous tissues one hour and fifteen minutes later at 12:45 p.m.  This consisted of 1% lidocaine with 1:100,000 epinephrine (75 ml); 0.25% bupivacaine with 1:200,000 epinephrine (30 ml); normal saline (60 ml); and approximately 1:150,000 epinephrine with the total being approximately 200 ml of local anesthesia infiltrated.

Surgery commenced sometime after 1:00 p.m. on 9/26/2013.  The patient’s pulse rate, oxygen saturation, and blood pressure were monitored automatically throughout the procedure.  The patient remained hypertensive throughout the procedure, and no additional medications were provided for blood pressure control.  The procedure began with the patient’s oxygen saturation at 98%.  At 1:32 p.m., the oxygen saturation dropped to 58% and remained in the 60-70% range until approximately 3:15 p.m., when it returned to the 90% range.  Additional sedating drugs were given between 4:05 p.m. and 4:30 p.m., and oxygen readings fell again into the 50-70% range until the end of the procedure with only occasional readings in the normal range.

Although not documented in the record, Plastic Surgeon B indicated that sometime after 3:00 p.m., he was called upon to attend a post-operative patient who had presented with incisions on her face that had opened, an emergency.  Plastic Surgeon B left the patient in the surgical suite and, after 20 to 30 minutes attending to the emergency patient, Plastic Surgeon B returned to the surgical suite to complete the patient’s surgery.  Neither his departure from the OR nor the names and qualifications of those attending the patient in his absence are documented in the operative note.  Upon Plastic Surgeon B’s return, the patient was given additional oral sedation, as well as more local anesthesia.  The time of injection of an additional 44 ml of local anesthesia was not documented on the Patient Surgery Information Sheet.  The certified surgical technician administered the anesthesia under Plastic Surgeon B’s supervision and assisted in the procedure; Plastic Surgeon B indicated at his subject interview with the Board on 7/30/2015 that a nurse was also present, but this is not documented in the record.  Surgery was completed at approximately 6:00 p.m.  The patient’s final blood pressure was 186/116.  The patient was discharged home at 6:25 p.m.

The operative report on the patient signed by Plastic Surgeon B is a template document that provided no personal detail on the procedure.  For example, the template stated that skin openings were left behind the patient’s ears for expressing fluid, but the post-operative notes stated that the patient had drainage tubes placed bilaterally.  The operative report stated that a lower lid blepharoplasty was performed, but no such procedure was performed on the patient.

Post-operative photographs of the patient were taken on 9/27/2013, but there is no progress note for this visit.  A note for a visit on 9/28/2013 was signed by a technician and noted that the drainage tubes were being left in place; the patient was apparently not seen by a physician on this visit.  On 9/30/2013, the patient was examined by Plastic Surgeon B (although he did not sign the progress note); at this time, the remaining drainage tube was removed; the patient’s blood pressure was recorded as 187/113; advice given to the patient was to rest and relax.  On 10/2/2013, the patient was seen by staff, and his eyelid sutures were removed; the patient’s blood pressure was recorded as 154/94.  On 10/5/2013, the patient’s blood pressure was recorded as 162/105; there is no progress note for this visit, except that an unsigned addendum to the 10/2/2013 visit indicates that the facelift sutures were removed on 10/5/2013.  Post-operative photographs were taken on 10/21/2013, but there is no accompanying progress note.

The patient was dissatisfied with the results of the procedure and the care he received from Plastic Surgeon B.  The patient filed a consumer complaint, which the Board received on 6/23/2014.

The Board judged Plastic Surgeon B’s conduct to be below the minimum level of competence given failure to address the patient’s hypertension, failure to sufficiently address the patient’s episodes of hypoxia during the procedure, and failure to accurately document his encounters with the patient.

The Board notes that performing surgery on a hypertensive patient adds additional risk to the procedure for excessive bleeding, hematoma formation, and stroke.  Such a risk should be mitigated prior to the initiation of any elective procedure.  Per the Board, if a patient becomes hypertensive during a surgical procedure, medications should be provided to the patient to stabilize the blood pressure.

The Board also notes that if a patient becomes hypoxic during a procedure, it is required to assure the oxygen saturation probe is working correctly and to provide exogenous oxygen for the patient to breathe and return his oxygen saturation to the normal range.  There is no documentation that Plastic Surgeon B responded to the patient’s low oxygen saturation.

The Board expressed concern that the patient’s medical record contained numerous instances of unsigned, incomplete, and absent notes.  Vital signs were at times not documented.  A prescription for Famvir was administered but not documented.  There was no documentation of Plastic Surgeon B’s absence from the surgical suite and no indication of personnel that was left in charge of the patient while Plastic Surgeon B addressed another patient’s emergency.  Operative notes were inadequate and inaccurate.

The Board issued a public reprimand with stipulations that Plastic Surgeon B a medical record keeping course and a continuing medical education course in pre-operative patient evaluation, informed consent, and management of intra-operative hypertension and hypoxia.

State: California


Date: August 2017


Specialty: Plastic Surgery


Symptom: N/A


Diagnosis: N/A


Medical Error: Improper treatment, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



New York – Physician Assistant – Lack Of Lab Work For Routine Visit For A 37-Year-Old Female



On 11/3/2008, a 37-year-old female presented to a physician assistant for a physical and PAP smear.  During the examination, the physician assistant performed a pelvic examination and found normal female genitalia without lesion or discharge.  A PAP smear was obtained without incident.  The physician assistant’s examination of the patient’s abdomen revealed the abdomen was soft and nontender.  The physician assistant’s plan was to reassess the patient in three months unless otherwise indicated.

The physician assistant did not order the patient to undergo any lab work, such as an hCG test.

On 11/12/2008, the patient presented to the hospital with a full-term pregnancy and delivered a baby on the same date.

The Board judged that the physician assistant’s medical care of the patient deviated from accepted standards of care given failure to recognize signs of pregnancy.

State: New York


Date: July 2017


Specialty: Physician Assistant, Family Medicine, Internal Medicine, Obstetrics


Symptom: N/A


Diagnosis: N/A


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


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Nebraska – Family Medicine – Excessive X-Rays And Antibiotics For Sinus Infection And Pneumonia



A family practitioner treated a 32-year-old female, for approximately 10 years.  The patient had a mechanical mitral valve and was on Coumadin therapy.  The family practitioner diagnosed her with sinus infections and pneumonia repeatedly.  He ordered nine sinus x-rays, eight chest x-rays, and 29 prothrombin time tests, the majority of which were subtherapeutic, during a one-year period.  The patient was a chronic smoker, and there was nothing in the chart to indicate smoking cessation counseling was tried.  The patient was treated with Biaxin (from one to four weeks at a time), 13 Rocephin injections, Levaquin for three weeks, Bactrim for one month, Keflex for two days and 10 days and Diflucan, Levaquin and Rocephin treatments simultaneously.

The family practitioner’s use of repeated sinus x-rays for the patient, which have questionable medical value under these circumstances, constituted substandard medical care.

Also, the family practitioner’s use of antibiotic therapy for the patient, there being no evidence that such therapy has a recognized medical benefit under the circumstances, constituted substandard medical care.

Finally, the family practitioner’s failure to refer the patient for pulmonary evaluations, after repeated visits with the same symptoms, constituted substandard of medical care.

For these allegations and others, the Board judged that the family practitioner’s methodology of practice overall and the specific negligent acts of his practice constituted negligence.  The Board ordered that the family practitioner have his license censured, have a practice monitor to review his practice on a quarterly basis for one year, pay a fine, and complete review courses on the following subjects: Eye, Nose, and Throat practice and referral, Endocrinology, Immunology and Immune Systems, indications for the need of radiographs and the appropriate use of radiology consultations.

State: Nebraska


Date: July 2017


Specialty: Family Medicine


Symptom: N/A


Diagnosis: Pneumonia, Infectious Disease


Medical Error: Improper medication management, Unnecessary or excessive diagnostic tests, Failure of communication with other providers, Unnecessary or excessive treatment or surgery


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Urology – Unnecessary Laparoscopic Radical Prostatectomy With Bilateral Pelvic Lymph Node Dissection Performed



On 2/1/2016, a 66-year-old male presented to a urologist for a prostate biopsy.  The urologist or his agents sent the specimens from the patient’s biopsy to pathology.

On 2/10/2016, a pathology report diagnosing the patient with adenocarcinoma of the prostate was issued.

On 2/16/2016 and 2/29/2016, the patient presented to the urologist to review the prostate biopsy pathology.

On 3/16/2016, the urologist performed a robotic assisted laparoscopic radical prostatectomy with bilateral pelvic lymph node dissection on the patient.  The urologist or his agents sent the specimens from the patient’s surgical procedure to pathology.

On 3/25/2016, a pathology report indicating the specimens were “negative for malignancy” was issued.

On 3/25/2016, the urologist or his agents swabbed the patient to obtain a DNA sample to cross-check the DNA profile of the biopsied specimens (from the 2/1/2016 appointment) with the patient’s known DNA sample.

On 4/5/2016, a DNA report was issued, confirming that the DNA profile from the biopsied specimens (from the 2/1/2016 appointment) did not match the DNA profile of the patient.

On 3/16/2016, the urologist performed health care services that were medically unnecessary when he performed the surgical procedure on the patient.

It was requested that the Board order one or more of the following penalties for the urologist: permanent revocation or suspension of his license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Board deemed appropriate.

State: Florida


Date: July 2017


Specialty: Urology


Symptom: N/A


Diagnosis: N/A


Medical Error: Unnecessary or excessive treatment or surgery, False positive


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Physician Assistant – Patient With Animal Bite Wound Treated With Sutures Only



On 7/13/2011, a 47-year-old female presented to a physician assistant with an animal bite wound.  The physician assistant treated the patient’s animal bite wound with sutures.

The physician assistant discussed this wound with an orthopedic specialist, who recommended IV antibiotics and an antibiotic prescription for home.

The physician assistant did not order or administer antibiotics to the patient while the patient was in the hospital.  The physician assistant did not order or administer antibiotics to the patient at the time of discharge.

The Board judged the physician assistant’s conduct to be below the minimal standard of competence given that she failed to prescribe antibiotics when assessing and/or treating a patient with the following presentation.

The Board issued a letter of concern against the physician assistant’s license. The Board ordered that the physician assistant pay a fine of $2,000 against her license and pay reimbursement costs for the case at a minimum of $3,867.71 but not to exceed $5,867.71.  The Board also ordered that the physician assistant complete five hours of continuing medical education in diagnosing and/or treating patients with wounds and five hours of continuing medical education in “risk management.”

State: Florida


Date: July 2017


Specialty: Physician Assistant


Symptom: N/A


Diagnosis: Trauma Injury, Infectious Disease


Medical Error: Improper treatment


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Pathology – Gallbladder Malignancy Confirmed In Wrong Patient



On 5/4/2015, Patient A underwent a laparoscopic gallbladder removal.  Following the procedure, a pathologist reviewed what she thought was the patient’s gallbladder specimen for malignancy.

The gallbladder specimen the pathologist reviewed actually belonged to a different patient, Patient B.

The pathologist determined that the specimen for Patient B was malignant.

The pathologist erroneously reported that Patient A’s gallbladder specimen was cancerous.  The pathologist did not confirm that the specimen belonged to Patient A prior to reporting her diagnosis.

Following the pathologist’s erroneous diagnosis, in July 2015, Patient A underwent two chemotherapy treatments.

On 8/14/2015, the pathologist reviewed Patient A’s actual gallbladder specimen to confirm her prior diagnosis.  At that time the pathologist discovered her error and correctly reported that Patient A’s gallbladder specimen was benign.

The Board judged the pathologist’s conduct to be below the minimum standard of competence given that she failed to confirm that Patient A’s identify matched the gallbladder specimen she reviewed prior to reporting that Patient A’s gallbladder was cancerous.

It was requested that the Board order one or more of the following penalties for the pathologist: permanent revocation or suspension of her license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Board deemed appropriate.

State: Florida


Date: July 2017


Specialty: Pathology


Symptom: N/A


Diagnosis: Cancer


Medical Error: Accidental error, False positive


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



Iowa – Pathology – Squamous Cell Carcinoma Misdiagnosed As Keratoacanthoma



A 49-year-old female underwent a punch biopsy of the left labia on 7/15/2014.  The specimen was delivered to a general pathologist who issued a pathology report diagnosing keratoacanthoma (“KA”).  Under the “COMMENT” portion of the report, the general pathologist noted, “The specimen shows changes of a well-differentiated squamous cell carcinoma.”

The slides examined by the general pathologist were subsequently reread by another pathologist of Iowa Pathology Associates, who confirmed his diagnosis with a dermatopathologist and another pathologist.  The dermatopathologist arrived at a diagnosis of a well-differentiated squamous cell carcinoma with a 0.85 cm depth of invasion.

A senior pathologist reviewed this file and arrived at the opinion that the general pathologist diagnosis of KA, in this case, demonstrated a lack of professional competency and knowledge.  The senior pathologist emphasized the correct diagnosis here was well-differentiated squamous cell carcinoma.  She explained that a KA, as diagnosed by the general pathologist, is a lesion of sun-exposed skin, generally found in the elderly.  It is shaped like a wart and protrudes up from the skin surface, whereas this lesion was not protruding and was located on the vulva.  The senior pathologist acknowledged that some authorities believe a KA is a form of well-differentiated squamous cell carcinoma, but she opined the term should never be used to describe the type of lesion involved in this case.

At the hearing, the senior pathologist further explained that a KA is marked by a dome shape and a keratin core.  The sample in this case did not show those characteristics.  The senior pathologist stated that even more telling was the location of the tumor: KAs are found on skin that is exposed to the sun and the fact that this sample was of vulvar tissue should have led the general pathologist to the conclusion that it was not a KA.  The senior pathologist noted that while vulvar KAs have been reported in the literature, they are extremely rare.

The senior pathologist testified that the misdiagnosis in this case could have resulted in the patient receiving inappropriate treatment.  She explained that KAs do not usually metastasize and excision of the lesion with an adequate margin is the accepted treatment for such a tumor.  Squamous cell carcinoma, on the other hand, may develop lymph node metastasis and the accepted treatment is therefore much more aggressive, and may involve removal of lymph nodes and chemotherapy.  The senior pathologist offered her opinion that the general pathologist’s misuse of terminology demonstrated a lack of substantial knowledge or ability.

A surgical pathologist with Iowa Pathology Associates testified at the hearing.  He was asked to review the patient’s biopsy because of a concern the KA diagnosis provided by the general pathologist was incorrect.  The surgical pathologist noted that while a KA can look quite similar to squamous cell carcinoma, KAs are not found on the vulva.  He testified that he shared this biopsy with colleagues who had 250 years of combined experience and not one of them had ever seen a KA on vulvar tissue.  The surgical pathologist disagreed with the suggestion that this was simply a matter of semantics.  He stated that, while one might use the the terms KA and squamous cell carcinoma interchangeably if one is speaking of skin on the arm or another sun-exposed area, that is simply not the case with vulvar tissue.  The surgical pathologist also emphasized that this was a deeply invasive tumor, 0.85cm, requiring much more aggressive action than would be required for a KA.

A dermatopathologist also testified at the hearing that he reviewed the slides from the patient’s biopsy at the surgical pathologist’s request.  He agreed with the surgical pathologist and the senior pathologist that KAs are not found in vulvar tissue and are restricted to sun-exposed skin.  The dermatopathologist expressed his opinion that this was not a difficult diagnosis to make.

The general pathologist argued that the difference between his diagnosis and that of the Iowa Pathology Associates was only a matter of semantics.  He testified that some authorities use the terms KA and squamous cell carcinoma interchangeably.  He stressed that he used the term “well-differentiated squamous cell carcinoma” in the comment section of his report.  The general pathologist testified that, while KAs are generally found on sun-exposed skin, there have been reports in the literature of vulvar KAs.

In response to questions as to why he did not report the depth of the lesion, the general pathologist explained that he did not do so because the sample was from a punch biopsy.  He noted that he recommended the entire lesion be excised, which would have allowed him to make a concrete diagnosis of the sample and the depth of the tumor.

Another reviewing pathologist agreed with the general pathologist and refused to characterize the general pathologist’s conclusions as a misdiagnosis.  He testified the dispute in this case was involving terminology only and did not rise to a breach of the standard of care. He noted that, in addition to providing the diagnosis of KA, the general pathologist authored a comment in his report stating that the biopsy showed a well-differentiated squamous cell carcinoma.  The reviewing pathologist testified that many authorities consider a KA to be a low grade invasive, well-differentiated squamous cell carcinoma, while others regard it as a unique lesion.  The reviewing pathologist emphasized that even though the general pathologist did not refer to the depth of the lesion, he recommended complete excision.  The reviewing pathologist opined that the general pathologist met the standard of care in this case.

The Board did not accept the general pathologist’s and the reviewing pathologist’s portrayals of the dispute surrounding the patient’s diagnosis as one of semantics only.  The evidence is clear that the lesion in this case was not a KA, which is nearly always found on sun-exposed skin.  The evidence is also clear that, while some authorities believe a KA is a form of well-differentiated squamous cell carcinoma and use of the terms interchangeably when referring to a lesion on sun-exposed skin, the term “KA” is not used to refer to such a lesion in vulvar tissue.  Further, while the literature does contain a few instances of KAs on the vulva, those occurrences are exceedingly rare and happening upon such a case would be remarkable.  The general pathologist’s diagnosis in this case demonstrated an obvious lack of knowledge and departure from the standard of care applicable to the general pathologist.  The Board found that the general pathologist’s actions in this case amounted to professional incompetence and practice harmful and detrimental to the public.

For this allegation and others, the Board judged the general pathologist’s conduct to be below the minimum standard of competence given (his/her) lack of professional competency and practice that was harmful or detrimental to the public.  The pathologist was warned that such practice in the future may result in further disciplinary action against his medical license.

For this allegation and others, the Board ordered the general pathologist to arrange in the auditing of 5% of his cases by outside pathology laboratory approved by the Board and ensure that the auditing entity submits a report to the Board on a quarterly basis.  He was also ordered to obtain consultation with a board-certified dermatopathologist in all suspected melanoma cases and author a paper discussing the diagnostic criteria for well-differentiated squamous cell carcinoma and keratoacanthoma in vulvar tissue.

State: Iowa


Date: June 2017


Specialty: Pathology


Symptom: N/A


Diagnosis: Cancer


Medical Error: Diagnostic error


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



Iowa – Pathology – Intraepithelial Lesion Misdiagnosed As Condyloma Acuminatum



A 70-year-old female underwent a right vulva punch biopsy on 7/1/2014.  The sample was delivered to a general pathologist who noted pigmented cells within the epidermis.  The general pathologist ordered five stains to confirm the diagnosis and rule out Paget’s disease.  All stains were negative and the general pathologist arrived at a diagnosis of condyloma acuminatum with low grade vulvar dysplasia.

A senior pathologist disagreed with the general pathologist’s diagnosis in this case.  She described her findings as “[h]igh grade squamous intraepithelial lesion characterized by severe squamous dysplasia” and noted “[t]his lesion requires complete excision to rule out invasive squamous cell carcinoma.  A wider excision to include negative margins should have been performed.”

The senior pathologist offered her opinion that the general pathologist became sidetracked when he saw pigmented cells in the dermis and dying squamous cells in the epidermis.  The senior pathologist testified she thought those findings led the general pathologist to believe he needed to rule out Paget’s disease and malignant melanoma, which led to the ordering of the five special stains.  She explained that, in her opinion, the dying squamous cells looked nothing like Paget’s cells and the pigmented cells in the epidermis did not appear at all atypical as they would in a malignant melanoma.  The senior pathologist stated both the ordering of the stains and the misdiagnosis showed a deviation from the standard of care on the general pathologist’s part.  She emphasized this was not a benign lesion and the proper diagnosis, high grade squamous dysplasia, requires the excision of additional tissue to rule out invasive squamous cell carcinoma.

In response to questions about his diagnosis and the use of stains, in this case, the general pathologist noted that he saw large epithelial cells with prominent nuclei in the specimen which may be seen in Paget’s disease as well as other diseases.  The general pathologist explained he ordered stains to rule out Paget’s disease and melanoma in-situ.

A reviewing pathologist agreed with the senior pathologist that the general pathologist arrived at a misdiagnosis in this case; however, he did not agree that the misdiagnosis or the use of stains constituted a violation of the standard of care.  The reviewing pathologist opined that the histology warranted the use of stains to rule out Paget’s disease and melanoma and he did not believe the failure to report moderate to severe dysplasia would have resulted in improper management of the patient’s care.

For this allegation and others, the Board judged the general pathologist’s conduct to be below the minimum standard of competence given (his/her) lack of professional competency and practice that was harmful or detrimental to the public.  The general pathologist was warned that such practice in the future may result in further disciplinary action against his medical license.

For this allegation and others, the Board ordered the general pathologist to arrange in the auditing of 5% of his cases by outside pathology laboratory approved by the Board and ensure that the auditing entity submits a report to the Board on a quarterly basis.  He was also ordered to obtain a consultation with a board-certified dermatopathologist in all suspected melanoma cases and author a paper discussing the diagnostic criteria for well-differentiated squamous cell carcinoma and keratoacanthoma in vulvar tissue.

State: Iowa


Date: June 2017


Specialty: Pathology


Symptom: N/A


Diagnosis: Dermatological Issues


Medical Error: Diagnostic error


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Iowa – Pathology – Uncertainty In Diagnosis of Lichen Sclerosus



A 74-year-old female underwent a vulvar punch biopsy on 7/11/2014.  A general pathologist reviewed the specimen and arrived at a diagnosis of lichen sclerosus, a nonmalignant condition.

A senior pathologist arrived at a diagnosis different from that of the general pathologist’s lichen sclerosis diagnosis. She found “[s]kin showing foamy histiocytes, chronic dermal inflammation, and hemosiderin deposition, with a subepidermal vesicle.”  She believed the changes represented a reaction to an injury which could be from a ruptured cyst or gland.  This is also a nonmalignant condition; however, the patient would be managed differently than would a patient with lichen sclerosus.

At the hearing, the senior pathologist emphasized that she saw no features of lichen sclerosus in her review of the slides.  She explained that lichen sclerosus features inflammation running parallel to the epidermis and that was not the case in the patient’s specimen.  She also testified that the pathology report issued by the general pathologist did not contain his microscopic findings so she was unable to determine exactly what features he saw that led him to his diagnosis.  The senior pathologist found the general pathologist did not meet the standard of care in this case.

The general pathologist noted that he found this to be a “rather straight forward case”.  He stated that his diagnosis fits the patient’s age, the clinical information supplied, and the histomorphology.  At the hearing, he pointed out that, even though the senior pathologist criticized his diagnosis, she did not provide a definitive diagnosis herself but only a descriptive diagnosis.  The general pathologist explained that he looks at possible cancer cases, such as this, first thing in the morning when his mind is fresh.  After he is able to rule out malignancy, as in the patient’s case, he waits for the surgical biopsy to correlate his initial diagnosis.  Once again, the general pathologist stressed that the patient did not have a malignant lesion.

Another reviewing pathologist disagreed with the senior pathologist’s diagnosis.  He found the general pathologist’s diagnosis to be more appropriate.  The reviewing pathologist opined that the biopsy “most likely represents a hypertrophic variant of lichen sclerosus et atrophicus, which has some evidence of trauma or irritation in the recent past.”  He stressed that he did not believe the general pathologist arrived at a misdiagnosis in this case or that he failed to meet the standard of care.

There was a divergence in the evidence surrounding the general pathologist’s diagnosis in the patient’s case.  The senior pathologist opined that the general pathologist arrived at an incorrect diagnosis and stressed that she could not even determine how he arrived at his conclusions because he failed to describe his microscopic findings in the pathology report.  The reviewing pathologist, on the other hand, found the general pathologist’s diagnosis to be more appropriate than the senior pathologist’s.

The Board was faced with two equally credible experts who arrived at differing views after reviewing the same slides on which the general pathologist based his diagnosis.  This fact highlights other testimony at the hearing describing pathology as a discipline in which two similarly trained pathologists can disagree on a diagnosis without either violating the standard of care. It leads the Board to the conclusion that the state failed in its burden to prove the general pathologist failed to meet the appropriate standard of care in the patient’s case or that he engaged in practice harmful or detrimental to the public.

The absence of microscopic findings in the patient’s case is concerning. The Board urges the general pathologist to exercise more care and attention in the communication of his findings.

For other various allegations, the Board judged the general pathologist’s conduct to be below the minimum standard of competence given (his/her) lack of professional competency and practice that was harmful or detrimental to the public.  The general pathologist was warned that such practice in the future may result in further disciplinary action against his medical license.

For other various allegations, the Board ordered the general pathologist to arrange in the auditing of 5% of his cases by outside pathology laboratory approved by the Board and ensure that the auditing entity submits a report to the Board on a quarterly basis.  He was also ordered to obtain a consultation with a board-certified dermatopathologist in all suspected melanoma cases and author a paper discussing the diagnostic criteria for well-differentiated squamous cell carcinoma and keratoacanthoma in vulvar tissue.

State: Iowa


Date: June 2017


Specialty: Pathology


Symptom: N/A


Diagnosis: Dermatological Issues


Medical Error: No error found


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



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