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North Carolina – Vascular Surgery – Abdominal Aortic Aneurysm 8.3 cm In Size With Large Type I Endoleak
On 3/31/12, a 76-year-old male with a history of heart disease, chronic obstructive pulmonary disease (COPD), prior endovascular repair of a large abdominal aortic aneurysm (AAA) in 2010 at an outside hospital (OSH) presented to the VA Medical Center emergency department with complaints of back, flank, and hip pain.
On 4/1/12 in the early morning, the patient had a CT scan with contrast which revealed an 8.3 cm AAA with large Type I endoleak. There was retroperitoneal stranding consistent with an aneurysm rupture. At 7:45 a.m., these findings were communicated to the emergency department physician.
At 8:00 a.m., the patient was evaluated by a vascular surgeon. Based on the vascular surgeon’s interpretation of the CT films and the patient’s clinical presentation, the vascular surgeon recommended admission for observation with a follow-up consultation with orthopedic surgery and interventional radiology.
The patient was admitted to the medical ward for the next three days during which he continued to have severe ongoing pain that was managed with pain medications.
On 4/4/12, the patient had a precipitous decline in his clinical status with severe hemodynamic compromise. A repeat CT scan demonstrated a ruptured AAA with aortocaval fistula. The patient was taken to the operation room where the vascular surgeon performed an open repair of the aortocaval fistula and ruptured AAA. However, the patient suffered extensive operative blood loss, perioperative myocardial infarction, and neurological injury.
The patient survived the procedure but remained critically ill. Over the next several days, the patient improved to a certain degree, but it was felt that the patient had suffered brain injury with little chance for meaningful recovery.
On 4/9/12, supportive measures were withdrawn, and the patient died.
In January 2017, the Board received information regarding a medical malpractice lawsuit settlement payment related to the care provided by the vascular surgeon to the patient.
The Board obtained the patient’s records and sent them to a qualified independent medical expert for review. The independent medical expert judged the vascular surgeon’s conduct to be below the minimum standard of competence given failure to adequately diagnose and aggressively treat the patient’s symptomatic, ruptured AAA despite evidence of the patient’s life-threatening condition.
The vascular surgeon was reprimanded.
The Board reported the Consent Order to the Federation of State Medical Boards.and the National Practitioner Data Bank.
State: North Carolina
Date: July 2017
Specialty: Vascular Surgery, Emergency Medicine
Symptom: Back Pain, Pelvic/Groin Pain
Diagnosis: Aneurysm, Post-operative/Operative Complication
Medical Error: Delay in proper treatment
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF
Florida – Pain Management – Contrast And Steroid Injected Into The Intrathecal Space Instead Of The Epidural Space
Between February 2006 and September 2012, a patient presented to a pain specialist with complaints of chronic low back pain.
On one or more occasions between February 2006 and September 2012, the pain specialist assessed the patient with, among other things, low back pain, lumbago, osteoarthritis, lumbar failed back surgery syndrome, lumbar radiculopathy, and lumbar muscle spasms.
On 9/28/2012, the patient presented to the pain specialist in order for him to perform a lumbar transforaminal epidural steroid injection with catheter and fluoroscopy. Epidural administration is a medical route of administration in which a drug or contrast agent is injected into the epidural space of the spinal cord.
During the procedure, the pain specialist inserted the tip of the catheter through the patient’s epidural space and into the patient’s intrathecal space. Intrathecal administration is a medical route of administration in which a drug or contrast agent is injected into the spinal canal, or into the subarachnoid space so that it reaches the cerebrospinal fluid.
During the procedure, the pain specialist injected contrast and injectate into the patient’s intrathecal space instead of the patient’s epidural space.
The pain specialist did not obtain an intra-injection lateral view epidurogram to confirm the location of the catheter tip and/or the dispersal pattern of the contrast and injectate.
The pain specialist did not obtain a post-injection lateral view epidurogram to confirm the location of the catheter tip and/or the dispersal pattern of the contrast and injectate.
The pain specialist did not recognize that he had performed an intrathecal injection instead of an epidural injection.
After the procedure, the patient complained of bilateral hip and leg pain, numbness, and paralysis.
The patient was transferred to a hospital where she was ultimately diagnosed with conus medullaris syndrome.
It was requested that the Medical Board of Florida order one or more of the following penalties for the pain specialist: permanent revocation or suspension of his license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Medical Board of Florida deemed appropriate.
State: Florida
Date: June 2017
Specialty: Pain Management, Anesthesiology
Symptom: Back Pain, Numbness, Extremity Pain, Pelvic/Groin Pain, Weakness/Fatigue
Diagnosis: Post-operative/Operative Complication, Spinal Injury Or Disorder
Medical Error: Wrong site procedure, Lack of proper documentation, Procedural error
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Emergency Medicine – Pelvic Pain And Vaginal Bleeding With Urinalysis Revealing A Glucose Level >1000
On 8/21/2014, a patient presented with complaints of pelvic pain and vaginal bleeding. The patient was examined by a physician assistant supervised by an ED physician.
The physician assistant ordered laboratory evaluation for the patient, which included bloodwork, cervical/vaginal swabs, pelvic ultrasound, and urinalysis.
The urinalysis revealed the patient’s glucose level to be >1000, which was so high that it could not be measured.
The physician assistant gave the patient a prescription for Flagyl, an antibiotic, gave her education materials on uterine bleeding, bacterial vaginosis, dehydration, and ovarian cysts, and instructed her to follow up with her primary care physician and gynecologist. The physician assistant discussed the patient’s case with the ED physician and the ED physician agreed with the plan of care.
The ED physician did not perform or order a finger stick glucose test or a basic metabolic panel.
The ED physician did not discuss and/or did not order the physician assistant to discuss the patient’s glucose level in relation to her possible new onset of diabetes and did not recommend or order the physician assistant to recommend further evaluation and treatment of her elevated glucose levels.
The ED physician did not administer or order the administration of intravenous fluid and insulin.
On 8/26/2014, the patient expired due to diabetic ketoacidosis.
The Medical Board of Florida judged the ED physician’s conduct to be below the minimal standard of competence give that she failed to administer or order the administration of a finger stick glucose test or basic metabolic panel, discuss or instruct the physician assistant to discuss the patient’s glucose levels in relation to her possible new onset of diabetes and recommend further evaluation and/or treatment of her elevated glucose levels, and failed to administer or order the administration of intravenous fluid and insulin.
It was requested that the Medical Board of Florida order one or more of the following penalties for the ED physician: 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: April 2017
Specialty: Emergency Medicine, Endocrinology, Physician Assistant
Symptom: Pelvic/Groin Pain, Abnormal Vaginal Bleeding
Diagnosis: Diabetes
Medical Error: Failure to follow up, Failure to order appropriate diagnostic test, Failure of communication with other providers, Improper supervision, Improper medication management
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF
Wisconsin – Radiology – CT Scan Showing Wedged-Shaped Splenic Infarct After Motor Vehicle Accident
On 7/13/2015, a 50-year-old woman was involved in a motor vehicle accident. She was transported by helicopter to Hospital A.
The ED physician ordered a CT of the chest, abdomen, and pelvis with IV contrast. Radiologist A performed a preliminary reading of the CT scan having been provided with “50 years old, female, Chest, abdominal, and pelvis pain post mvc.”
Radiologist A interpreted the CT scan as showing a “probable anterior wedged shaped splenic infarct.” The patient was discharged from Hospital A.
The CT scan was subsequently reviewed by Radiologist B, who read the scan as revealing splenic lacerations and hemorrhage.
Hospital A staff attempted to reach the patient regarding these findings. The patient then presented to Hospital B, where additional diagnostic imaging confirmed bleeding. The patient underwent emergent evacuation of a massive hemoperitoneum, lysis of adhesions, and splenectomy. She died on 7/13/2015.
Radiologist A was deemed to have fallen below the standard of care and it was recommended that he complete a course on emergent CT interpretation in an emergency/trauma setting.
State: Wisconsin
Date: January 2017
Specialty: Radiology, Emergency Medicine
Symptom: Chest Pain, Abdominal Pain, Pelvic/Groin Pain
Diagnosis: Trauma Injury
Medical Error: Diagnostic error, False negative
Significant Outcome: Death, Hospital Bounce Back
Case Rating: 3
Link to Original Case File: Download PDF
Florida – General Surgery – Lump And Pain After Procedure To Strip Greater Saphenous Vein And Ligate Saphenofemoral Junction
On 9/9/2011, a general surgeon performed a greater saphenous vein stripping, a ligation of the saphenofemoral junction, and phlebectomies on a patient’s right leg.
On 9/12/2011, the third post-operative day, the patient reported pain and redness.
The next day, on 9/13/2011, the patient called the general surgeon’s office and complained of throbbing pain in her right leg and groin. The patient was instructed to use a heating pad, to elevate her leg as much as possible, and to call if symptoms escalate.
The next day, on 9/14/2011, at a follow-up appointment with the general surgeon, the patient reported increased pain secondary to a hematoma. The patient was instructed to follow up in one week.
Six days later, on 9/19/2011. The patient called the general surgeon’s and complained of increased pain in her right leg and a lump in her right groin area. The patient was instructed to go to a radiology center for a stat right leg ultrasound.
The patient presented for a venogram, which revealed total occlusion of the right common femoral vein with extravasation.
The patient was transferred to a medical center on 9/23/2011. A physician performed a right groin evacuation of the hematoma and exploration of the right common femoral vein. The physician found that during the original surgery, the general surgeon had ligated and transected the common femoral vein instead of the greater saphenous vein.
As a result of the injury, the patient continues to experience pain and swelling to her right leg.
The Medical Board of Florida judged the general surgeon’s conduct to be below the minimum standard of competence given that he failed to clearly identify the saphenofemoral junction and then ligate, transect, and strip the greater saphenous vein. The general surgeon also failed to further investigate the patient’s pain and hematoma at the time of her complaints, including ordering a venous ultrasound of the leg. The general surgeon did not correctly identify and ligate the greater saphenous vein. Instead, he ligated and transected the common femoral vein. The general surgeon did not adequately investigate and evaluate the patient’s post-operative pain and hematoma. Instead, he waited seven days before advising the patient to obtain a venous ultrasound.
The Medical Board of Florida issued a letter of concern against the general surgeon’s license. The Medical Board of Florida ordered that the general surgeon pay a fine of $10,000 against his license and pay reimbursement costs for the case at a minimum of $8,070.79 and not to exceed $10,070.79. The Medical Board of Florida also ordered that the general surgeon complete a medical records course, complete five hours of continuing medical education in vascular surgery, and complete five hours of continuing medical education in “risk management.”
State: Florida
Date: November 2016
Specialty: General Surgery
Symptom: Pelvic/Groin Pain, Mass (Breast Mass, Lump, etc.), Extremity Pain, Swelling
Diagnosis: Post-operative/Operative Complication, Cardiovascular Disease
Medical Error: Wrong site procedure, Delay in proper treatment, Failure to order appropriate diagnostic test
Significant Outcome: N/A
Case Rating: 4
Link to Original Case File: Download PDF
California – Gynecology – Complications After Hysterectomy For Patient With Simple Hyperplasia Without Atypia And A History Of Infraumbilical Midline Incision
A 46-year-old female presented to a gynecologist in July 2011 complaining of vaginal bleeding. The patient had a history of ulcerative colitis and an infraumbilical midline incision. The patient next presented about one month later. The laboratory results included small fibroids, a small polyp, and a small ovarian cyst. Based on these findings, the gynecologist recommended and performed an endometrial biopsy. The result of the endometrial biopsy was simple hyperplasia without atypia. The gynecologist discussed the options for treatment with the patient and offered her medical treatment with repeat endometrial biopsy, dilation, and curettage with ablation, or hysterectomy.
The patient requested a hysterectomy with removal of both ovaries for definitive treatment. The gynecologist obtained consent for a robotic hysterectomy and discussed the risks of the procedure, which included the possibility of finding extensive adhesions that would require an open abdominal hysterectomy as opposed to the laparoscopic approach.
On 10/19/2011, the patient was taken to the operating room, where she underwent a diagnostic laparoscopy and a total abdominal hysterectomy and bilateral salpingo-oophorectomy. The findings at the time of surgery included an enlarged uterus with several small fibroids, normal ovaries, and normal fallopian tubes. There were excessive thick adhesions from the small bowel and omentum to the anterior abdominal wall and the left pelvic sidewall. There were also adhesions in the right upper quadrant from the omentum to the abdominal wall. The gynecologist used a closed technique to enter the abdominal cavity with a Veress needle. The gynecologist placed the patient in maximum Trendelenburg position and then made a small incision in the umbilicus and inserted the Veress needle. After removing the Veress needle, the gynecologist placed a 5 mm trocar and was able to visualize the adhesions. She then placed a second 5 mm trocar under direct visualization in the area clear of adhesions and used monopolar scissors for approximately 5 minutes in the attempt to lyse the adhesions. The gynecologist noted that the adhesions were very thick and extensive and included the bowel. She did not feel as though it was safe to proceed with the robot. The gynecologist removed the instruments and proceeded with an uneventful total abdominal hysterectomy and bilateral salpingo-oophorectomy through a Pfannenstiel incision.
The patient’s post-operative course was eventful. On the first post-operative day, she was noted to have a pulse of 130 bpm. She was in moderate pain despite IV pain medication. A CBC was drawn, which showed a normal WBC count of 3.5, but it showed 50% bands. The bandemia was not noted in the post-operative note. On the second post-operative day, the gynecologist saw the patient again at 2 p.m. and noted that the patient remained on oxygen. Her pulse also remained at 130. The gynecologist ordered an EKG and a chest x-ray, increased the pain medication, and advised the patient to ambulate. A CBC drawn that day was not mentioned in the post-operative note, but it showed a normal WBC count at 4.7 and again showed bandemia of 18%. The gynecologist wrote a discharge order at 2:20 p.m. on that day without any parameters.
Tachycardia persisted, and the patient developed shortness of breath, pain with breathing, and an oxygen saturation level of 82% for which the nursing staff called the Rapid Response Team. The patient was transferred to a critical care bed with the diagnosis of acute hypoxic respiratory failure and peritonitis, and the gynecologist on-call was notified. The gynecologist had signed out to the on-call gynecologist for the weekend. During that weekend, the patient’s condition continued to worsen. A CT scan performed on the evening of 10/22/2011 showed multiple fluid and air collections in the abdomen, mesentery, and abdominal wall. Various medical specialists as well as the gynecologist on-call evaluated the patient throughout the weekend. On the fifth post-operative day, a general surgeon was consulted, who immediately made the diagnosis of a bowel perforation and took the patient to the operating room for a bowel resection. The patient remained in the hospital and was discharged o 11/9/2011.
During the gynecologist’s care, treatment and management of the patient, the gynecologist obtained informed consent and, on multiple occasions, discussed the risks, benefits, and alternatives to the surgery and included the additional risks due to the patient’s earlier bowel surgery. As part of the alternatives to surgery, the gynecologist offered the patient an endometrial ablation, which is contraindicated in the presence of endometrial hyperplasia, as this is considered a precancerous condition. During an interview with representatives of the Medical Board of California, the gynecologist explained that she would no longer operate on this patient, but would refer her to the new gynecologic oncologist at another hospital.
At the time of the interview, the gynecologist was aware that the patient’s condition was precancerous since she would now refer the patient to an oncologist. Simple hyperplasia does not require referral to an oncologist, but, given that the pathology of simple hyperplasia is considered a precancerous condition, the offering of endometrial ablation as an alternative was not appropriate.
Bowel injury is a known complication during the performance of a hysterectomy, whether it is performed laparoscopically or as an open procedure. The risk of bowel injury is increased in a patient who, like this patient, had undergone a previous abdominal or bowel surgery and in a patient with a vertical midline incision.
The standard of care dictates that when the patient is at high risk for bowel injury, the surgeon must take all available precautions in order to avoid this complication and have a high index of suspicion of bowel injury if the patient’s post-operative course is complicated. The gynecologist was well aware of the patient’s higher risk for pelvic adhesions. The patient had a vertical midline incision from a previous colectomy, and on multiple occasions, the gynecologist discussed the high likelihood of adhesions with the patient.
The Medical Board of California judged that the gynecologist’s conduct departed from the standard of care because she did not use a safer technique when inserting the Veress needle, offered her the alternative of endometrial ablation, and failed to recognize in a timely manner that the patient had sustained a bowel injury.
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 education course for at least 40 hours for every year of probation.
State: California
Date: November 2016
Specialty: Gynecology
Symptom: Abnormal Vaginal Bleeding, Pelvic/Groin Pain, Shortness of Breath
Diagnosis: Post-operative/Operative Complication, Gynecological Disease
Medical Error: Procedural error, Diagnostic error, Improper treatment
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
California – Gynecology – Laparotomy And Bilateral Cystectomy For Removal Of Benign Cysts With Subsequent Complication
During February and March of 2010, a patient was seen by her primary care nurse practitioner and was directed to conduct blood work to evaluate various physical symptoms. On 3/24/2010, the patient was seen by her nurse practitioner for evaluation of lab results. During the appointment, the nurse practitioner reviewed blood work results and ordered a pelvic ultrasound. The ultrasound revealed that the patient had very large cysts on both ovaries, measuring approximately 13 cm and 17 cm. The patient was referred to Gynecologist A for treatment of the large cysts and pelvic pain.
On 4/7/2010, the patient emailed Gynecologist A to inform her of the ultrasound results and seek treatment as needed. Gynecologist A recommended surgery to remove the cysts. The surgery was scheduled to take place on 6/2/2010. During a pre-operative appointment with Gynecologist A on 5/19/2010, the patient provided consent for the surgical procedure. The consent form indicated that the patient consented to a bilateral cystectomy, possibly by laparotomy, and the possible need for an oophorectomy. The patient was informed of risks of surgery, including the risk of damage to nearby organs.
On 5/23/2010, the patient presented to the emergency department with acute pelvic pain. She was seen the next day by Gynecologist B, who was aware that the patient’s Gynecologist A was in the operating room that day performing procedures. Gynecologist B telephoned Gynecologist A in the operating room to determine if the patient could be added to the surgical schedule on that day. The patient reported to the emergency department for evaluation and possible surgery.
On the same day, 5/24/2010, Gynecologist A performed surgery on the patient. Gynecologist A performed a laparotomy and a bilateral cystectomy. Gynecologist A sent two specimens of excised tissue to the laboratory for analysis and pathology report. On 5/25/2010, Gynecologist A reported that she conducted an examination under anesthesia, a bilateral ovarian cystectomy, and exploratory laparotomy. Gynecologist A described making a midline incision and removing large cysts from both ovaries. Gynecologist A described the ovaries, fallopian tubes, and uterus as unremarkable.
On 5/26/2010, two days later, a pathologist filed a report of the two specimens Gynecologist A obtained during the surgery. It showed that the first specimen comprised a right ovarian cyst with a fallopian tube densely adherent to the cyst, and the second specimen comprised a left ovarian cyst with a fallopian tube densely adherent to the cyst. The report further indicated all samples were found to be benign.
On 6/7/2010, the patient saw Gynecologist A for a post-operative appointment. Gynecologist A charted and informed the patient that the pathology report and laboratory findings showed that the cysts removed during the surgery had been benign. Gynecologist A did not inform the patient of the pathology report findings that portions of both fallopian tubes had been removed during the surgery.
On 5/14/2013, the patient was seen by a nurse practitioner in the Department of Obstetrics and Gynecology for complaints of pelvic pain and for a referral for infertility evaluation. During this appointment, the nurse practitioner reviewed the reports from the 5/25/2010 surgery and noticed that the surgical specimens obtained during surgery contained the fimbriated ends of both fallopian tubes, likely rendering the patient infertile.
On 6/13/2013, the patient underwent a hysterosalpingogram, which confirmed that her fallopian tubes were abnormal. On 6/25/2013, the nurse practitioner explained to the patient the results of the abnormal hysterosalpingogram, and the laboratory findings that her fallopian tubes had been removed during the 5/24/2010 surgery, which had not been previously disclosed to her.
The Medical Board of California judged that Gynecologist A’s conduct departed from the standard of care because she failed to adequately review and communicate the results of the pathology report showing the patient’s fallopian tubes had been removed during surgery.
The Medical Board of California placed Gynecologist A on probation for 35 months and ordered Gynecologist A to complete a medical record-keeping course, a professionalism program (ethics course), and an education course.
State: California
Date: November 2016
Specialty: Gynecology
Symptom: Pelvic/Groin Pain
Diagnosis: Gynecological Disease
Medical Error: Procedural error, Ethics violation, Failure of communication with patient or patient relations
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 3
Link to Original Case File: Download PDF
Arizona – Emergency Medicine – Recent Cardiac Catheterization With Subsequent Presentation Of Right Groin Pain
The Board received notification of a malpractice settlement.
On 07/20/2011, a 66-year-old male presented to the emergency department. He reported bleeding of his right groin status post cardiac catheterization performed 2 days prior. The patient was evaluated by ED physician A, who noted that the bleeding had improved and that the right groin swelling had not gotten worse. The patient reported taking enoxaparin and warfarin for his mechanical aortic valve. The remainder of the examination was unremarkable with the exception of some noted bruising to the right groin. The patient was discharged home after prolonged observation in the ED.
On 07/23/2011, the patient returned to the same ED and was evaluated by a resident. The patient complained of right groin pain that radiated into the right lower back and was associated with numbness and tingling of his anterior right thigh. ED physician B was supervising the resident. The resident noted that the patient had developed a “knot” over the insertion site the night before, which was followed by increased pain into the right back. At the time of the second ED visit, the patient reported that the pain was more persistent, and he was having difficulty walking.
The resident noted that the patient was taking blood thinners and that he “bruises/bleeds easily” secondary to the blood thinning medications. Tenderness to palpation of the right groin was noted as well as a 3 x 6 cm oval area of ecchymosis with a small palpable round mass underneath and a 3 cm long longitudinal mass that was extremely tender.
There was no documentation of a back examination. The neurologic portion of the examination was limited to the patient’s mental status. A blood analysis and a CT scan were ordered. The CT scan revealed a small to moderate retroperitoneal bleed on the right side consistent with right psoas hematoma as well as enhancement of the right common femoral artery and vein concerning for an aneurysm.
The reading radiologist recommended an ultrasound and the findings were discussed with the resident. No ultrasound was available at that time. The patient was subsequently discharged home with instructions to return with any worsening pain, fevers, chest pain, or shortness of breath, and to follow up with his cardiologist. The ED physician submitted an addendum to the medical record noting that he examined the patient with the resident and agreed with the care plan.
Later that same day, the patient was taken to a different ED by ambulance complaining of shortness of breath. The patient was noted to be in significant respiratory distress and was subsequently intubated for pending respiratory failure. A blood analysis showed a hemoglobin of 4.2, creatinine of 3.4, potassium of 6.6, and an INR of 2.2. The patient was severely anemic with hyperkalemia from acute renal failure. When treatment was initiated to correct hyperkalemia, the patient went into cardiac arrest.
At 5:45 a.m. on 07/24/2011 and despite aggressive treatment efforts, the patient was pronounced dead.
An autopsy performed revealed the immediate cause of death was a massive right-sided retroperitoneal hematoma likely resulting from an intimal tear in the right femoral artery with dissection and adventitial hemorrhage.
The Board judged the ED physician’s conduct to be below the minimum standard of competence given failure to obtain an ultrasound to determine if an aneurysm was present. He also failed to appreciate the risks of sending a patient home who has a bleed and who is on blood thinners.
The ED physician testified that the recommendation to obtain further ultrasound imaging was not communicated to him. The ED physician expressed deep remorse for the error in judgment and stated that it would never be repeated.
The Board ordered the ED physician be reprimanded.
State: Arizona
Date: June 2016
Specialty: Emergency Medicine, Cardiology, Internal Medicine
Symptom: Bleeding, Numbness, Back Pain, Pelvic/Groin Pain, Swelling
Diagnosis: Hemorrhage
Medical Error: Failure to order appropriate diagnostic test, Underestimation of likelihood or severity, Failure of communication with other providers, Failure to follow up, Improper supervision
Significant Outcome: Death, Hospital Bounce Back
Case Rating: 5
Link to Original Case File: Download PDF
Florida – Radiology – Incorrect Interpretation Of CT Scan In A Patient With Groin and Abdominal Pain
On 3/5/2013, a patient presented to the emergency department with pain in his groin and in the left lower quadrant of his abdomen.
Following the patient’s presentation to the emergency department, a computerized tomography scan (CT scan) of the patient’s abdomen and pelvis was ordered.
A radiologist interpreted the patient’s 3/5/2013 CT scan. He failed to correctly interpret the patient’s scan and failed to report one or more abnormalities evident in the patient’s scan including: a large mass in the patient’s lower abdomen, discoid atelectasis and fibrosis at the patient’s lung bases, significant coronary artery calcification, severe aortoiliac atherosclerotic disease, and fluid in the patient’s pelvis.
In August 2013, a follow-up CT scan was performed that revealed a malignant mass in the patient’s lower abdomen.
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 $7,000 against his license and pay reimbursement costs for the case at a minimum of $3,396.68 and not to exceed $5,396.68. The Medical Board of Florida also ordered that the radiologist complete ten hours of continuing medical education in the diagnosis of abdominal cancer and complete five hours of continuing medical education in “risk management.”
State: Florida
Date: April 2016
Specialty: Radiology
Symptom: Pelvic/Groin Pain, Abdominal Pain
Diagnosis: Cancer
Medical Error: False negative
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
North Carolina – Pediatrics – Testicular Pain, Tenderness, And Swelling With Ultrasound Scheduled In 2 Days
In June 2015, the Board received report of a malpractice settlement payment.
On 08/27/2011, a 14-year-old male presented with pain, tenderness, and swelling of the right testicle for two days. The internist’s diagnosis was “testicular swelling, rule out hydrocele.” He prescribed ibuprofen and Augmentin.
The internist scheduled an ultrasound for 08/29/2011, at which time the patient was diagnosed with testicular torsion. The testicle had become necrotic and was surgically removed on that day.
The independent medical expert judged the internist’s conduct to be below the minimum standard of competence given failure to order an ultrasound to be done immediately or failure to refer the patient to a urologist on an emergency basis and failure to document a suspicion for testicular torsion.
The Board ordered the internist to be reprimanded and pay a $1,000.00 disciplinary fine.
State: North Carolina
Date: March 2016
Specialty: Pediatrics, Internal Medicine
Symptom: Pelvic/Groin Pain
Diagnosis: Testicular Torsion
Medical Error: Delay in proper treatment, Diagnostic error
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF