Found 372 Results Sorted by Case Date
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Florida – Gastroenterologist – Staff Does Not Relay To Gastroenterologist A Pathology Report Of Polyps Removed During A Colonoscopy



On 10/5/2009, a patient presented to a gastroenterologist for evaluation for a colonoscopy screening.  Following the evaluation, the patient was scheduled for a colonoscopy.

On 10/21/2009, the patient presented to the gastroenterologist for a scheduled colonoscopy.

During the procedure, the gastroenterologist removed several polyps, which were sent to a pathologist for evaluation.

The gastroenterologist advised the patient that the pathology results would be available in three to four days and to schedule a follow-up colonoscopy with the gastroenterologist in three months to check for residual tissue.

On 10/23/2009, the pathologist faxed a report containing the results of his evaluation of the polyps removed from the patient’s bowel to the gastroenterologist’s office.

The pathology report was received by the gastroenterologist’s staff who forwarded the results to the patient’s primary care physician.

On 10/23/2009, the gastroenterologist was not informed that the pathology report for the patient had been received.

The gastroenterologist should have followed-up on the status of the pathology evaluation following the colonoscopy performed on 10/21/2009.

The gastroenterologist did not inquire as to the status of the pathology evaluation following the colonoscopy performed on 10/21/2009.

The gastroenterologist should have reviewed the pathology report and communicated the pathologist’s findings to the patient.

The gastroenterologist did not review the pathology report or communicate the pathologist’s findings to the patient.

The pathology report revealed that at least one of the polyps removed from the patient contained an invasive adenocarcinoma.

On 1/22/2010, the patient’s primary care physician contacted the gastroenterologist to inform him that the patient was due for a follow-up colonoscopy.

On 2/10/2010, the patient presented to the gastroenterologist for a scheduled colonoscopy.

Prior to the procedure, the gastroenterologist should have reviewed the pathology report from the colonoscopy performed on 10/21/2009.

The gastroenterologist did not review the pathology report from the colonoscopy performed on 10/21/2009 prior to performing the second colonoscopy on 2/10/2010.

The gastroenterologist performed the colonoscopy.  The pathology report from the procedure performed on 2/10/2010 showed a benign hyperplastic polyp.

On 2/11/2010, the pathology report from the 2/10/2010 colonoscopy was faxed to the gastroenterologist’s office.  In light of the pathology results, the gastroenterologist informed the patient to schedule a follow-up colonoscopy in three years.

On July 2013, the patient was diagnosed with metastatic adenocarcinoma.

The Medical Board of Florida judged the gastroenterologist’s conduct to be below the minimal standard of competence given that he failed to review the pathology report from the colonoscopy performed on 10/21/2009 and communicate the pathologist’s findings to the patient.  He also failed to review the pathology report from the colonoscopy performed on the 10/21/2009, prior to performing the colonoscopy on 2/10/2010.

The Medical Board of Florida issued a letter of concern against the gastroenterologist’s license.  The Medical Board of Florida ordered that the gastroenterologist pay a fine of $5,000 against his license and pay reimbursement costs for the case at a minimum of $2,131.75 and not to exceed $4,131,75.  The Medical Board of Florida also ordered that the gastroenterologist complete five hours of continuing medical education in “risk management.”

State: Florida


Date: December 2016


Specialty: Internal Medicine


Symptom: N/A


Diagnosis: Cancer


Medical Error: Failure to follow up


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Radiology – Radiologist Reports Negative Findings On A CT Scan For A Pediatric Patient Who Fell Down A Flight Of Stairs



A 30-month-old boy presented to the emergency department on 8/29/2011, after falling down a flight of stairs.

Following his presentation to the emergency department, a CT scan of the patient’s brain and neck was performed, and a radiologist interpreted the results of the scan as negative.

On 9/1/2011, the patient presented to his pediatrician with significant neurological problems.  Based on the patient’s symptoms, the patient’s pediatrician contacted the radiologist to discuss the case.

As part of his discussion with the patient’s pediatrician, the radiologist re-reviewed the patient’s CT scan and determined that his previous negative findings were incorrect.  The radiologist noted that a “subtle but focal increased density within the spinal cord” was evident on the patient’s CT scan.

Based on this finding, the radiologist coordinated with the patient’s pediatrician to have the patient returned to the emergency department for evaluation and treatment.

In preparation for the patient’s return to the emergency department, the radiologist attached an addendum to his previous report that explained that he failed to identify a hematoma within the patient’s spinal cord.

Upon the patient’s return to the emergency department, the patient was given additional imaging studies.  These studies revealed that the hematoma within the patient’s spinal cord had grown since the original CT scan.

Based on this finding, the patient underwent surgical evacuation of the hematoma.  The patient’s hematoma was successfully evacuated, but the patient ultimately left functionally quadriplegic as a result of damage already caused by the bleed.

The Medical Board of Florida judged the radiologist’s conduct to be below the minimal standard of competence given that he failed to correctly interpret the patient’s CT scan and identify the hematoma within the patient’s spinal cord.  The radiologist was unable to correctly interpret the patient’s CT scan, and the standard of care required him to refer the patient’s CT scan results to a pediatric radiologist or a neuroradiologist for review.

The Medical Board of Florida issued a letter of concern against the radiologist’s license.  The Medical Board of Florida ordered that the radiologist pay a fine of $5,500 against his license and pay reimbursement costs for the case at a minimum of $3,190.96 and not to exceed $5,190.96.  The Medical Board of Florida also ordered that the radiologist complete five hours of continuing medical education in the area of “pediatric radiology” and complete five hours of continuing medical education in the area of “diagnosis and treatment of hematoma.”

State: Florida


Date: December 2016


Specialty: Radiology, Pediatrics


Symptom: N/A


Diagnosis: Hemorrhage, Spinal Injury Or Disorder


Medical Error: False negative, Referral failure to hospital or specialist


Significant Outcome: Permanent Loss Of Functional Status Or Organ, Hospital Bounce Back


Case Rating: 4


Link to Original Case File: Download PDF



Florida – Pediatrics – Newborn With Occipitofrontal Circumference In The 97th Percentile



A child was born on 3/5/2010.

From 3/15/2010 to 5/10/2013, the mother of the minor child, presented the child to a pediatrician at least ten times for check-ups and/or sick visits.

On 3/22/2010, the child presented to the pediatrician for a 2-week check-up.  The pediatrician documented the child’s occipitofrontal circumference (OFC) to be in the 75th percentile.

On 5/5/2010, the child presented to the pediatrician for a 2-month check-up.  The pediatrician documented the child’s OFC to be in the 90th percentile.

On 7/12/2010, the child presented to the pediatrician for a 4-month check-up.  The pediatrician documented the child’s OFC to be in the 97th percentile.

ON 9/13/2010, the child presented to the pediatrician for a 6-month check-up.  The pediatrician documented the child’s OFC to be in the 97th percentile.

On 12/6/2010, the patient presented to the pediatrician for a 9-month check-up.  The pediatrician documented the child’s OFC to be in the 97th percentile.

The pediatrician documented that the child had developmental delays in crawling on all fours, pincer grasping, and language development.

On 3/6/2011, the patient presented to the pediatrician for a 12-month check-up.  The pediatrician documented that the child had developmental delays in waving and pointing.  The pediatrician documented that the development was discussed with the parent.

On 6/15/2011, the child presented to the pediatrician for a 15-month check-up.  The pediatrician documented the child’s OFC to be in the 97th percentile.  The pediatrician documented that the child had developmental delays in walking alone, stooping, and recovering.

On 9/14/2011, the child presented to the pediatrician for an 18-month check-up.  The pediatrician documented that the child’s OFC was in the 90th percentile.  The pediatrician documented that the child had developmental delays in walking backward and kicking a ball.

On 3/7/2012, the child presented to the pediatrician for a two-year check-up.  The pediatrician documented that the child’s OFC was in the 97th percentile.  The pediatrician documented that the child had developmental delays in language development, specifically, the child had “very limited vocabulary.”

On 5/31/2012, the pediatrician referred the child to an ear, nose, throat doctor (ENT) to consider frenulectomy for a tied tongue.

On 6/4/2012, the pediatrician referred the child to pediatric orthopedics for falling, stumbling, and inability to jump.

On 6/12/2012, the pediatrician referred the child to a speech therapist prior to the frenulectomy.

The speech therapist suggested that the child have his hearing checked.

On 7/12/2012, the pediatrician referred the child to audiology prior to the frenulectomy.

On 12/5/2012, the pediatrician referred the child to an occupational therapist for low motor skills.

The pediatrician did not refer the child for a workup, to include an MRI of the head and neck or a pediatric neurology evaluation, to diagnose OFC enlargement and developmental delays at any of these previous appointments.

On 3/11/2013, the child presented to the pediatrician for a three-year check-up.  The pediatrician documented that the child had developmental delays in language development.  The pediatrician documented concerns with the child’s motor skills and speech.

On 3/13/2013, the pediatrician referred the child for a pediatric neurology evaluation with an MRI.

On 5/10/2013, the child was diagnosed with hydrocephalus and arachnoid cysts.

The Medical Board of Florida judged the pediatrician’s conduct to be below the minimal standard of competence given that she failed to have the child evaluated for excessive OFC and developmental delays at least when the child was nine months old.  She also failed to perform a complete workup on the child, including an MRI of the head and neck or a pediatric neurology evaluation, at least when the child was nine months old since the OFC was in the 97th percentile and developmental delays were evident.  The pediatrician also failed to refer the child to a pediatric neurologist or developmental pediatrician to diagnose the reason for the child’s OFC enlargement and developmental delays at least nine months old.  She also failed to refer the child for a complete workup at either the 12-month, 15-month, 18-month, or 2-year check-up due to the child’s OFC enlargement.

It was requested that the Medical Board of Florida order one or more of the following penalties for the pediatrician: 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 Medical Board of Florida deemed appropriate.

State: Florida


Date: December 2016


Specialty: Pediatrics


Symptom: N/A


Diagnosis: Neurological Disease


Medical Error: Delay in proper treatment, Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Referral failure to hospital or specialist


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



North Carolina – General Surgery – Laparoscopic Nissen Fundoplication Complicated By Hypotension



On 10/18/2012, a general surgeon performed a laparoscopic nissen fundoplication procedure on a patient for gastroesophageal reflux disease and a large hiatal hernia.

During the operation, an EGD was performed, during which the patient suffered perforation of the upper esophagus/posterior pharynx.  Subsequently, following completion of the initial laparoscopic repair, the patient developed hypotension and was found to have a laceration of the infrarenal aorta.

Multiple attempts were made to control the bleeding.  Efforts to resuscitate the patient were unsuccessful, and the patient died.

The Board obtained the patient’s records and sent them to a qualified independent medical expert for review.  The independent medical expert judged the general surgeon’s conduct to be below the minimum standard of competence given failure to terminate the procedure when the patient suffered perforation of the upper esophagus/posterior pharynx.  The expert also expressed concern regarding the general surgeon’s use of a bladed trocar and the adequacy of the general surgeon’s documentation of the operation.  Documentation lacked information regarding the decision to proceed after the perforation of the upper esophagus/posterior pharynx; information about the trocar placement; and information about anatomic findings, details of gastric mobilization, or what type of retraction was used on the liver.

The Board ordered general surgeon to be reprimanded.

The Consent Order was reported to the Federation of State Medical Boards and the National Practitioner Data Bank.

State: North Carolina


Date: December 2016


Specialty: General Surgery


Symptom: N/A


Diagnosis: Gastrointestinal Disease


Medical Error: Procedural error, Lack of proper documentation


Significant Outcome: Death


Case Rating: 1


Link to Original Case File: Download PDF



Virginia – Family Practice – Prescription Of Narcotics Despite Patient’s Long Abuse History



A family practitioner was managing a patient’s medications.

Although the family practitioner was aware of the patient’s drug abuse, she prescribed the patient oxycodone, Opana, hydrocodone, meperidine, Oxycontin, diazepam, alprazolam, clonazepam, Lunesta, and Ambien on a consistent basis.  She failed to check the Prescription Monitoring Program or perform any random urine/serum drug screening to ascertain whether the patient was taking her medications appropriately.

On 12/28/2008, when the patient was informed that the family practitioner was referring her for chronic pain management and detox and that her appointment was before Christmas, she immediately called the family practitioner and reminded her that she had “promised” to continue seeing the patient through the holidays.

The patient also stated that she had no way to get to the pain clinic for the appointment and so she could not go before Christmas.

In spite of the patient’s efforts to avoid detox, the family practitioner instructed her staff to reschedule the appointment for after 1/1/2008 and continued to prescribe the patient Opana.

On 1/5/2009, the patient again reported that she had a problem getting to the pain clinic for her appointment.  She would “prefer” to stay with the family practitioner rather than go to the pain clinic.  The patient reported that she and her husband had entered marriage counseling and as part of said counseling, she had “agreed” to wean off opiates.

Although the family practitioner had previously documented the patient’s inability to wean off of opiates and in spite of the patient’s manipulative behavior, the family practitioner agreed to continue treating the patient.

From approximately September through November 2009, although the family practitioner was prescribing the patient oxycodone, oxymorphone, diazepam, alprazolam, zolpidem, Lunesta, butorphanol, Fentanyl, methadone, and meperidine at different times and in various combinations and dosages, she failed to take action in response to reports from her own staff suggesting that the patient was over-medicated.

On 9/21/2009, staff reported to the family practitioner that the patient sounded groggy when she called the office seeking a medication refill.  The family practitioner nonetheless prescribed oxycodone 15 mg, 60 pills, that day.

On 9/30/2009, staff reported to the family practitioner that the patient had called the office seeking more pain medication.  She was told that the patient “sounds like she is in another world.”  The family practitioner nonetheless prescribed oxycodone 20 mg, 60 pills, that day.

On 10/23/2009, the patient filled a prescription for oxycontin 10 mg, 28 pills.

On 10/29/2009, the patient filled a prescription for hydrocodone/homatropine 5 mg/5 ml, 120 ml.

On 11/6/2017, the patient filled a prescription for diazepam 10 mg, 120 pills.

On 11/7/2017, the patient filled a prescription for zolpidem 12.5 mg, 30 pills.

On 11/10/2017, staff informed the family practitioner that the patient “sounded like she was taking too much medication and her voice was very slurred.”

From November 2009 to 2/2/2010, the family practitioner continued to prescribe opiates and other controlled substances to the patient.

In November 2009, the family practitioner learned that the patient attempted suicide and was admitted for detox.

On 12/2/2009, the patient told the family practitioner that she left detox two weeks early because it “was not working for her” and reported that the detox facility had stopped her opiates and benzodiazepines.  The family practitioner nonetheless resumed the patient’s diazepam and meperidine.

On 12/4/2009, the patient presented to the family practitioner’s office complaining of knee pain and asked for some pain medications to “help” her while she was doing Christmas shopping. Despite being aware of the patient’s lengthy history of drug addiction and even though the patient had decreased her use of controlled substances after detox, the family practitioner prescribed Opana 10 mg, 40 pills, and wrote that she would “let” the patient have a few short-acting Opana to use when she needs to walk somewhere but “not for comfort at home.”

On 1/6/2010, to “improve” the patient’s daily activity, the family practitioner agreed to continue opiates and prescribed Opana 10 mg, 60 pills, a larger quantity than the prior prescription.  The patient drove her car into a brick wall later that day.

On 2/2/2010, the patient claimed that the car accident was due to an accelerator malfunction in her car.  In explaining why she was seeking an Opana refill a week early, the patient stated that the pain was still as bad as it was immediately after the accident.  For this reason, she had been taking the Opana more frequently than prescribed.  The family practitioner subsequently prescribed her an even larger quantity of Opana than before.  She prescribed her Opana 10 mg, 90 pills.

On 2/2/2010, the patient died secondary to acute drug toxicity from Opana.

The Board issued the family practitioner a reprimand.  She was ordered to read the Board of Medicine’s Guidance Document on the Use of Opioid Analgesics in the Treatment of Chronic Pain.  She was ordered to complete 15 hours of continuing education on the subject of proper prescribing of opioids.

State: Virginia


Date: December 2016


Specialty: Family Medicine, Internal Medicine


Symptom: N/A


Diagnosis: Drug Addiction, Drug Overdose, Side Effects, or Withdrawal


Medical Error: Improper medication management


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



California – Otolaryngologist – Flonase, Afrin Spray, and Endoscopic Sinus Surgery To Treat Chronic Sinusitis, Septal Deviation, and Allergic Rhinitis



On 9/19/2011, a patient presented to an otolaryngologist on referral from another physician for an evaluation of eye tearing for 8 months.  The otolaryngologist documented a history suggestive of sinus disease.  The otolaryngologist diagnosed chronic sinusitis, septal deviation, and allergic rhinitis.  The otolaryngologist ordered hypertonic saline solution and Claritin for treatment of the patient’s diagnosis of chronic sinusitis and allergic rhinitis.

On 2/23/2012, the patient presented to the otolaryngologist with continuing symptoms.  The otolaryngologist ordered a CT scan that showed some sinus disease in the left maxillary sinus and ordered the use of Flonase and Afrin spray every other day as well as recommended endoscopic sinus surgery.  On 8/1/2012, the otolaryngologist performed an endoscopic sinus surgery on the patient.  During the 6-month post-operative period, the otolaryngologist saw the patient several times.  Initially, the otolaryngologist noted “fairly heavy” polyps in the bilateral nasal cavities.  The otolaryngologist noted the polyps improved during the 6-month post-operative period.

The Medical Board of California judged that the otolaryngologist committed gross negligence in his care and treatment of the patient given that he performed endoscopic sinus surgery on the patient without an appropriate medical indication and recommended the chronic use of Afrin spray.  The otolaryngologist also failed to properly diagnose and/or treat the patient’s tearing complaints.

For allegations in this case and others, the Medical Board of California requested a hearing be held for the otolaryngologist and issue a decision on: permanent revocation or suspension of his license, revoking or denying approval of his authority to supervise physician assistants, placing him on probation, or taking other and further action as deemed necessary and proper.

State: California


Date: December 2016


Specialty: Otolaryngology


Symptom: N/A


Diagnosis: Ear, Nose, or Throat Disease, Post-operative/Operative Complication


Medical Error: Unnecessary or excessive treatment or surgery, Diagnostic error, Improper treatment, Improper medication management


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



North Carolina – Obstetrics – Delay In The Management Of Progressive Proteinuria And Hypertension



The Board reviewed the care rendered by an obstetrician who submitted an application to the North Carolina Medical Board.

The Board obtained patient records regarding a specific patient and sent them to a qualified independent medical expert for review.

The independent medical expert judged the obstetrician’s conduct to be below the minimum standard of competence.  The expert raised concern that the delivery should have occurred sooner in light of the patient’s progressive proteinuria and hypertension.  Patient monitoring was deficient and abnormal labs were not addressed.  The management of the patient’s hypertension was deficient.  The neurological assessments following delivery were inadequate.  Lastly, the use of NSAID for pain control was inappropriate.  The expert believed that the seriousness of the patient’s situation was not recognized.

The Board issued a public letter of concern, which was reported to the Federation of State Medical Boards.  It was not reported to the National Practitioner Data Bank.

State: North Carolina


Date: December 2016


Specialty: Obstetrics


Symptom: N/A


Diagnosis: Obstetrical Complication


Medical Error: Delay in proper treatment, Failure to properly monitor patient


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – General Surgery – Five Vulvar Surgeries And Breast Tattoo Removals Conducted For Cosmetic Alteration



In December 2008, a 30-year-old female presented to a general surgeon for removal of breast tattoos.  A 12/1/2008 document entitled “comprehensive examination” does not include an adequate history of the present illness, obstetrical history, gynecological history, or past surgical history.  The patient presented to the general surgeon for three tattoo removal visits.  The last of those presentations was on 1/27/2009.

On 1/27/2009, at her visit with the general surgeon, the patient made complaints related to the fullness and asymmetry in the area above the pudendal cleft of her left vulva as well as a pudendal flap and excessive skin.  At this time, the patient had a history of eight vaginal deliveries.

The patient returned one day later on 1/28/2009 to have the first of what would ultimately be five vulvar surgeries to remove the areas identified above.  The surgery was documented with an operative note and included a surgical consent.  The surgery did not include a complete history and physical.  No record of the patient’s last menstrual cycle, method of contraception, or whether the general surgeon performed a pregnancy test preoperatively, was documented.  There was no documentation of a discussion related to the known risks of scarring and dyspareunia.

Following the first surgery, the general surgery referred to the patient’s skin as “mucosal skin tags” and he believed them to be from trauma “from multiple deliveries.”

On 2/24/2009, a second surgery was performed.  The surgery was documented with an operative note and included a surgical consent.  The surgery did not include a complete history and physical.  No record of the patient’s last menstrual cycle, method of contraception, or whether the general surgeon performed a pregnancy test preoperatively, was documented.  There was no discussion related to the function of the vulva.  The surgery appeared to be for cosmetic reasons alone.  There was no documentation of a discussion related to the known risks of scarring and dyspareunia.

Three additional surgeries were performed on 4/2/2010, 5/6/2011, and 5/17/2011.  Like the two before, each was documented with an operative note and included a surgical consent.  The surgery did not include a complete history and physical.  No record of the patient’s last menstrual cycle method of contraception, or whether the general surgeon performed a pregnancy test preoperatively was documented.  There was no discussion related to the function of the vulva.  The surgery appeared to be for cosmetic reasons alone.  There was no documentation of a discussion related to the known risks of scarring and dyspareunia.

During each of the five surgeries, the general surgeon removed varying portions of the patient’s labia minora, labia majora, and clitoral hood.  The end result was complete removal of the labia minora and almost complete removal of the clitoral hood.

As a result of the multiple procedures, the patient was left with excessive scar tissue and complete exposure of the clitoris.  This led to vulvar pain, dryness, bleeding, inability to have sexual intercourse, difficulty urinating, and urine that did not flow in a continuous stream.  The patient presented to a plastic surgeon and gynecologist for repair.

The Board judged the general surgeon’s conduct as having fallen below the standard of care given the performance of procedures with disregard of normal anatomy and physiology, disregard of the scar tissue that would form around the introitus and that would leave the clitoris exposed with complete removal of the clitoral hood, and failure to refer the patient to a specialist.

The Board issued a public reprimand with the stipulation to complete at least 20 hours of continuing medical education in correcting areas of deficiency.

State: California


Date: November 2016


Specialty: General Surgery, Gynecology, Plastic Surgery


Symptom: N/A


Diagnosis: N/A


Medical Error: Procedural error, Failure to examine or evaluate patient properly, Referral failure to hospital or specialist, Improper treatment


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 4


Link to Original Case File: Download PDF



California – Family Practice – Elevated Glucose Levels In A Patient On Aripiprazole, Asenapine, Quetiapine, And Olanzapine



On 11/6/2007, a family practitioner first began treating a patient and continued treating the patient until at least 6/9/2014.

On 12/21/2009, the family practitioner noted in the patient’s medical records that the patient was diabetic, writing “Lab-Spot glucose 242.”  A level of 200 mg/dL or higher often means one has diabetes.

On 1/11/2010, the next exam noted in the patient’s records, the family practitioner noted a refill was needed for glipizide.  However, there is no record that the patient was ever prescribed glipizide prior to this date.

During the course of treatment from the family practitioner, the patient was also prescribed aripiprazole, quetiapine, asenapine, and olanzapine for bipolar disorder.  Aripiprazole, asenapine, and olanzapine can cause or worsen diabetes.  According to medical notes, on 6/13/2011, the family practitioner was treating the patient with both aripiprazole and olanzapine as well as glipizide, which was to control diabetes.

On 7/11/2011, the patient’s blood sugars were noted to be in the 400 range, while 100 to 110 is considered to be the normal range for blood sugars in an individual.  The family practitioner started the patient on insulin glargine to address diabetes on a daily basis.

In an interview that occurred on 10/1/2015, the family practitioner admitted that the family practitioner had no idea if the patient was taking the prescribed medications while under his care.

The Board judged the family practitioner’s conduct as having fallen below the standard of care for multiple patients given failure to record a physical exam in the progress notes, failure to revise and update assessments or plans for those patients, and failure to include a problem list or medication list in his progress notes.  In addition, the family practitioner’s repeated, excessive and/or inappropriate prescribing of large doses of multiple strong antipsychotic medication and antidepressants to the patient with no regard or concern for drug interactions constituted a lack of knowledge and/or unprofessional conduct.

The family practitioner was placed on probation for 5 years with the stipulations of completing 40 hours annually of continuing medical education in the areas of deficient practice, a prescribing practices course at the Physician Assessment and Clinical Education Program, a medical record keeping course, an ethics course, a clinical training program equivalent to the Physician Assessment and Clinical Education Program, and undergo clinical practice monitoring.

State: California


Date: November 2016


Specialty: Family Medicine, Internal Medicine, Psychiatry


Symptom: N/A


Diagnosis: Diabetes, Psychiatric Disorder


Medical Error: Improper medication management, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Obstetrics – Pregnancy And Delivery Complicated With Obesity, Hypertension, Shoulder Dystocia, Variable Decelerations, And Meconium



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

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

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

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

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

State: California


Date: November 2016


Specialty: Obstetrics


Symptom: N/A


Diagnosis: Obstetrical Complication


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


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



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