Found 1245 Results Sorted by Case Date
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Iowa – Pathology – Contention In Use Of Slides When Diagnosing Metastatic Melanoma



An 82-year-old female presented with swollen lymph nodes under her right arm. She underwent a core needle biopsy on 8/11/2014.  That biopsy failed to provide a sufficient amount of viable tissue from which to arrive at a definitive diagnosis, but the general pathologist was of the opinion that the sample was “suggestive not diagnostic of metastatic melanoma.”

On 8/26/2014, a right axillary lymph node excisional biopsy was performed on the patient and the sample was sent to the general pathologist. Because of the small amount of viable tissue, the general pathologist prepared a portion of the material for flow cytometry and the remainder in touch preparations, a method by which a thin layer of cells is distributed on a slide for examination.  There was insufficient tissue for a frozen section, which consists of a thin slice of tissue cut from a frozen specimen.  The general pathologist ordered eleven special stains and arrived at a diagnosis of malignant melanoma.

A senior pathologist reviewed this file and expressed no concerns about the general pathologist’s final diagnosis; however, she opined that his use of eleven special stains to rule out other forms of cancer was unnecessary.  The senior pathologist testified that the majority of pathologists are able to diagnose melanoma through touch preparations, although many would prefer a frozen section to rely on.  She opined that the tough preparations, in this case, showed such obvious signs of malignant melanoma that no stains were necessary unless the patient had a history of other cancer.  The senior pathologist testified, if that were the case, a single, inexpensive stain to confirm the diagnosis would have been appropriate.  She stated that the general pathologist’s use of eleven stains suggested a lack of knowledge both as to the appearance of malignant melanoma and as to the appropriate use of special stains.  She emphasized the unnecessary expense added to the patient’s treatment because of the use of these stains.

The general pathologist defended his use of stains in this case.  He stressed that this patient had no clinical history of cancers.  He further noted that he does not have the ability to do stains in his own lab and that specimens must be sent out for staining.  The general pathologist explained that the process involves several days and patients are often anxious to receive a diagnosis.  He noted that he orders all stains he might need when he sends slides out so as to avoid having to send them out a second or third time.  The general pathologist reported he has never had an insurer question his use of stains and that he is of the opinion that the number and type of stains to be used are at the discretion of the physician.  He stressed that his diagnosis of malignant melanoma was correct in this case and that a previous punch biopsy performed by an outside facility on a skin lesion on the patient’s right arm had been misdiagnosed as benign.  After the general pathologist’s diagnosis, the facility that reviewed the specimen from the punch biopsy amended its diagnosis accordingly.

Another pathologist agreed with the general pathologist’s diagnosis.  The other pathologist stressed that it is in the pathologist’s prerogative as to how many stains to order.  He noted that the general pathologist received the patient’s slides without a medical history.  The other pathologists admitted that he might have begun with fewer stains, but he appreciated that the general pathologist might have felt the need to order additional stains in order to rule out other types of malignancies.  The other pathologist was unwilling to deem the order of multiple stains a deviation from the stand of care.

The other pathologist further agreed with the general pathologist that misreading the patient’s previous punch biopsy by an outside facility demonstrates the difficulty of diagnosing melanocytic lesions.

The Board was unconvinced that the evidence presented regarding the general pathologist’s use of special stains met the definitions of either professional incompetence or practice harmful or detrimental to the public.  The state argued that the evidence showed a lack of appropriate knowledge as to when and which special stains to use.

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 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: No error found


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Iowa – Pathology – Using Stains Melan A And HMB 45 To Evaluate Sentinel Lymph Nodes



A 72-year-old male was diagnosed with a malignant melanoma. On 9/24/2014, he underwent an excision of the left forearm skin and removal of the left sentinel lymph nodes.  Intraoperative frozen sections were prepared from the lymph node material and the general pathologist ordered two special stains, Melan A and HMB 45.  The general pathologist issued a report finding the lymph node material negative for metastatic melanoma.

A senior pathologist did not take issue with the diagnosis in this case.  Instead, she expressed her opinion that the general pathologist ordered inappropriate immunohistochemical stains on the lymph node samples.  In her peer review, the senior pathologist wrote: “There is no agreed upon protocol to do HMB-45 and/or Melan-A on sentinel lymph nodes to look for metastatic melanoma cells.”  She called the use of the stains unnecessary and stated: “This just adds cost to the patient.  Melanoma cells are very large and easy to see, therefore making these stains unnecessary.”

At a hearing, the general pathologist again argued that the use of stains is the prerogative of the doctor and that the stains he used were appropriate.  The general pathologist stressed that his diagnosis was not questioned by the senior pathologist.

Another reviewing pathologist supported the general pathologist’s use of stains in the patient’s case.  He noted that, in his own practice, he uses the same strategy employed by the general pathologist to evaluate the presence of microscopic metastases in lymph nodes.  The reviewing pathologist explained that the American Joint Committee on Cancer (AJCC) Staging Handbook recommends the use of stains for the detection of micrometastases and considers it acceptable to classify lymph node positive metastases based solely on staining of melanoma-associated markers.

The senior pathologist countered that both of the special stains ordered by the general pathologist are specific for melanoma.  She noted that the AJCC Melanoma Taskforce has recommended using one specific stain and one sensitive stain.  Stains which are specific for melanoma are useful to avoid false positives, while stains which are sensitive for melanoma are useful to avoid false negatives.  According to the AJCC using only specific markers can lead to missing up to 15% of malignant melanomas.  The senior pathologist remained convinced the general pathologist’s actions in ordering the stains he used violated the standard of care.

The Board was unconvinced that the evidence presented regarding the general pathologist’s use of special stains met the definitions of either professional incompetence or practice harmful or detrimental to the public.  The state argued that the evidence showed a lack of appropriate knowledge as to when and which special stains to use.

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 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: No error found


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Internal Medicine – Daily Dose Of 1200 Milligrams Of Gabapentin For Patient With End Stage Renal Disease



On 5/8/2014, a 74-year-old female presented to an internist for the purpose of establishing care.  The patient had multiple medical problems, including diabetes, end-stage renal disease, and recurrent C. difficile infections.

At all times pertinent to this complaint, the patient was undergoing chronic hemodialysis treatment.

On 6/10/2014, the patient presented to the internist for a follow-up visit.  The internist prescribed 600 mg tablets of gabapentin to the patient to treat her diabetic neuropathy.  The patient’s prescription directed her to take the 600 mg of gabapentin twice daily, totalling 1200 mg of gabapentin per day.

On 6/14/2014, after taking her prescribed dosage of gabapentin, the patient lost control of her leg muscles and fell, resulting in a fracture of the T12 vertebrae in her back.

The prevailing professional standard of care required the internist to prescribe the patient a dosage of gabapentin not to exceed 150 mg per day, due to her end-stage renal disease.  The internist prescribed the patient an inappropriate and/or excessive dosage of gabapentin.

According to the internist, he verbally instructed the patient and/or her family members to modify the gabapentin prescription.

The internist failed to document and/or accurately document the alleged verbal instruction to the patient and/or her family members to modify the patient’s gabapentin prescription.

The Board issued a letter of concern against the internist’s license.  The Board ordered that the internist pay a fine of $5,000 against his license and pay reimbursement costs for the case at a minimum of $30,433.57 and not to exceed $32,433.57.  The Board also ordered that the internist complete a medical records course and complete five hours of continuing medical education in clinical pharmacology and drug dosing.

State: Florida


Date: June 2017


Specialty: Internal Medicine, Nephrology


Symptom: Weakness/Fatigue


Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Diabetes, Neurological Disease, Spinal Injury Or Disorder, Renal Disease, Fracture(s)


Medical Error: Improper medication management, Accidental Medication Error, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Radiology – Epidural Injection With Subsequent Lower Extremity Pain And Sensory And Motor Function Loss



On 1/15/2010, a 61-year-old female underwent an epidural injection.  Following the procedure, she complained of sharp pain in the lower extremities, followed by sensory and motor function loss below the T10 and T11 level.  The patient was transferred by ambulance to the emergency department.

A thoracic and lumbar MRI was performed and interpreted by a radiologist.  The final report for the lumbar spine states “Mild desiccation and degenerative changes of the disc but no disc bulge or herniation is noted.”  His final report of the thoracic spine demonstrates “normal MRI of the thoracic spine…A repeat study of the thoracolumbar spine is recommended without contrast infusion in both projections to better evaluate this area as this is on the edge of the study on the current images both lumbar and thoracic is not well delineated.”  Although the images were suboptimal, the epidural hematoma of the lower thoracic spine was evident in the axial images.

On 1/19/2010, a repeat MRI was performed.  The radiologist interpreted the MRI stating there is “abnormal signal focus demonstrated in the spinal canal from approximately the T10-T11 disc space inferiorly through the T12-L1 disc space located mostly in the posterior and posterolateral aspect of the spinal canal displacing the cords slightly anteriorly and causing a slight mass effect on the cord and subarachnoid sac.  This is consistent with a subdural or epidural hematoma.”

The Board judged the radiologist’s conduct as having fallen below the standard of care given failure to observe and document all pertinent findings on diagnostic imaging studies, failure to discuss findings requiring urgent treatment with the referring physician, failure to diagnose the abnormality found on MRI, and failure to document his discussion with the referring physician regarding the abnormality on MRI.

A public reprimand was issued against the radiologist.

State: California


Date: June 2017


Specialty: Radiology, Emergency Medicine


Symptom: Extremity Pain, Numbness, Weakness/Fatigue


Diagnosis: Spinal Injury Or Disorder


Medical Error: False negative, Failure of communication with other providers, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Pediatrics – Deep Laceration Of The Right Knee Treated With Debridement, Irrigation, And Suturing



On 12/7/2011, an 8-year-old male presented to a medical emergency department with a deep laceration to his right knee.  The laceration was a full thickness cut with visualization of the capsule.  An x-ray revealed air in the knee joint.

A pediatrician examined the patient’s knee and performed debridement, cleaning by irrigation, and suturing of the laceration.  Bacitracin and dressing were applied to the patient’s knee.

On 12/10/2011, the patient returned to the emergency department with complaints of right knee swelling, redness, and pain.  The patient was admitted to the pediatric floor.

Further examination revealed septic arthritis in the patient’s right knee, which required two operations and the introduction of a PICC line for long-term antibiotic therapy.  The patient sustained cartilage damage as a result of the septic arthritis and suffered from significant knee pain.

The Board judged the pediatrician’s conduct to be below the minimal standard of competence given that he failed to refer the patient to an orthopedic surgeon and to fully wash out the patient’s joint by performing an open debridement under anesthesia.

The Board issued a letter of concern against the pediatrician’s license.  The Board ordered the pediatrician to pay a fine of $10,000 against his license and pay reimbursement costs at a minimum of $5,496.59 and not to exceed $7,496.59.  The Board also ordered that the pediatrician complete ten hours continuing medical education in pediatric orthopedic diagnosis and treatment and complete five hours of continuing medical education in “risk management.”

State: Florida


Date: June 2017


Specialty: Pediatrics, Orthopedic Surgery


Symptom: Joint Pain, Swelling


Diagnosis: Trauma Injury, Septic Arthritis


Medical Error: Improper treatment, Referral failure to hospital or specialist


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 4


Link to Original Case File: Download PDF



North Carolina – Orthopedic Surgery – Wrong Site Surgery When Performing Arthrodesis Of The Left Great Toe



The Board was notified of a professional liability payment made on 8/30/16.

A patient presented to an orthopedic surgery for arthrodesis of her left great toe.  In preparing the patient for surgery, the orthopedic surgeon stated that he did not see the markings on the left leg, given that they had been covered by stockings.  The orthopedic surgeon erroneously prepared the patient for surgery on the right toe based on what he believed he saw on the x-ray.  Despite performing appropriate timeout procedures, none of the surgical team appreciated the error until the end of the procedure.

The Board expressed concern that the orthopedic surgeon’s conduct was below the standard of care.  The Board acknowledged that the orthopedic surgeon implemented several practice improvement procedures in response to this event.

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: June 2017


Specialty: Orthopedic Surgery


Symptom: N/A


Diagnosis: Musculoskeletal Disease


Medical Error: Wrong site procedure


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Pain Management – Increase In Dosage Of Nature-Throid In A Patient With Normal TSH And T4 Levels



On 6/3/2013, a 67-year-old female presented to a pain management specialist for treatment of her previously diagnosed hypothyroidism.  The pain management specialist prescribed the patient 65 mg of Nature-Throid daily and drew blood for lab tests.  Each 65 mg Nature-Throid medication consists of 38 mcg of levothyroxine and 9 mcg of liothyronine.  The results of the patient’s blood tests showed normal TSH levels, normal T4 levels, and slightly elevated T3 levels.

On 6/18/2013, the pain management specialist increased the patient’s prescription for Nature-Throid to 130 mg daily.  The results of the patient’s blood tests did not justify increasing the dosage of Nature-Throid prescribed to the patient.  A reasonably prudent physician would only have increased the dosage of Nature-Throid prescribed to the patient with justification.  The pain management specialist did not document justification for increasing the dosage of Nature-Throid prescribed to the patient.  The blood tests did not justify prescribing the 130 mg of Nature-Throid daily.  A reasonably prudent physician would have waited for the patient’s hormone levels to properly balance and reach equilibrium before altering the dosage of Nature-Throid prescribed to the patient.

On 7/16/2013, the pain management specialist increased the patient’s prescription for Nature-Throid to 195 mg daily.  A reasonably prudent physician would not have altered the dosage of Nature-Throid prescribed to the patient without having ordered blood tests for the patient.  The pain management specialist did not document justification for increasing the dosage of Nature-Throid prescribed to the patient.  A reasonably prudent physician would have waited for the patient’s hormone levels to properly balance and reach equilibrium before altering the dosage of Nature-Throid prescribed to the patient.

On 7/16/2013, the pain management specialist informed the patient that he was increasing her dosage of Nature-Throid based on her body temperature.  A reasonably prudent physician would not have increased the dosage of Nature-Throid prescribed to the patient based on the patient’s body temperature.  Also, a reasonably prudent physician would have ordered blood tests for the patient, and he did not order or document ordering any blood tests for the patient.

The Board issued a letter of concern against the pain management specialist’s license.  The Board ordered that he pay a fine of $5,000 against his license and pay reimbursement costs for a minimum of $5,857.09 and not to exceed $7,857.09.  The Board also ordered that he complete a records course and complete ten hours of continuing medical education in endocrinology and complete a course in quality assurance consultation/risk management assessment.

State: Florida


Date: June 2017


Specialty: Pain Management, Endocrinology


Symptom: N/A


Diagnosis: Endocrine Disease


Medical Error: Improper medication management


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Physician Assistant – Cardiac Catheterization Ordered In The Wrong Patient



On 10/11/2015, Patient A, an 89-year-old male presented to the emergency department with complaints of chest congestion, weakness, and chest pressure.

Lab results revealed that Patient A had elevated troponin levels, and he was admitted and referred for a cardiology consultation.

On 10/11/2015, the patient saw a cardiologist for the cardiology consultation.  The cardiologist documented that the patient had an upper respiratory infection and recommended that the patient continue antibiotics, gentle diuresis, and outpatient medical therapy.

At around the same time, on the same date, the cardiologist saw Patient B for a cardiology consultation.  Sometime after the cardiac consultations of Patient A and Patient B, the cardiologist contacted a physician assistant and instructed him to order a cardiac catheterization for Patient B.

The physician assistant placed an entry in Patient A’s medical chart instead of Patient B’s chart, ordering the cardiac catheterization.  The physician assistant failed to review Patient A’s available medical records, including labs, notes, and imaging studies, before placing the cardiac catheterization order in his chart.

The following morning, cardiac catheterization was unnecessarily performed on Patient A.

The Board judged the physician assistant’s conduct to be below the minimal standard of competence given that he failed to review the patient’s available medical records, including labs, notes, and images studies, before placing the cardiac catheterization order in his chart.

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 his license and pay reimbursement costs for the case at a minimum of $2,611.86 and not to exceed $3,111.86.  The Board also ordered that the physician assistant complete five hours of continuing medical education in “risk management.”

State: Florida


Date: June 2017


Specialty: Physician Assistant, Cardiology


Symptom: Weakness/Fatigue


Diagnosis: Infectious Disease


Medical Error: Accidental error, Unnecessary or excessive treatment or surgery


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Interventional Radiology – Kyphoplasty Performed On T11 Instead Of T12 Site For T12 Fracture After A Fall



On 10/13/2015, a 70-year-old male was transported to the emergency department after a fall from a hammock when the rope broke.

A CT scan of the lumbar spine was done and a 20% anterior wedge compression fracture on the T12 section was found.  An MRI of the lumbar spine, on the same day, showed an acute T12 compression fracture.  An MRI of the thoracic spine was done, on the same day, and showed an acute T12 compression fracture with bone marrow edema.

The patient was admitted to the hospital and recommended for T12 kyphoplasty.

On 10/14/2015, an interventional radiologist performed a kyphoplasty on the patient’s T11 vertebrae (wrong site), instead of the T12 vertebrae.

The patient was discharged on 10/19/2015 and began having progressively more pain.

On 10/22/2015, the patient was readmitted to the hospital by ambulance with progressively worsening pain.

On 10/23/2015, a two-view x-ray of the lumbar spine revealed that a T12 compression fracture had remained unchanged despite the 10/12/2015 surgery, and that the T11 vertebrae had been unnecessarily operated upon.

The patient was discharged to a rehabilitation center for two weeks to recover.

The Board issued a letter of concern against the interventional radiologist’s license.  The Board ordered that the interventional radiologist pay a fine of $4,000 against his license and pay reimbursement costs for the case at a minimum of $2,009.04 and not to exceed $4,009.04.  The Board also ordered that the interventional radiologist complete five hours of continuing medical education in “risk management” and complete a one-hour lecture/seminar on wrong site surgeries.

State: Florida


Date: June 2017


Specialty: Interventional Radiology


Symptom: Pain


Diagnosis: Fracture(s), Spinal Injury Or Disorder


Medical Error: Wrong site procedure


Significant Outcome: Hospital Bounce Back


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Internal Medicine – Patient With Suicidal Ideations Referred To A Psychiatrist For The Following Day



On 12/1/2014, a 68-year-old female presented to an internist for a three-month follow-up appointment for hyperlipidemia, anxiety with panic attack, and hypertension.  The patient reported a twenty-year history of untreated depression that was worsening.

The patient reported suicidal ideations, including that the patient had been sitting with a gun to her head.

The internist’s progress note for the patient included a statement that the patient needed to see a psychiatrist that day.  The internist referred the patient to a psychiatrist and scheduled an appointment with the patient with the psychiatrist the following day.

The Board judged the internist’s conduct to be below the minimal standard of competence given that he failed to arrange for the patient to be escorted to a psychiatrist or an emergency department that day.

The Board issued a letter of concern against the internist’s license.  The Board ordered that the internist pay a fine of $5,000 against her license and pay reimbursement costs for the case at a minimum of $1,983.04 and not to exceed $3,983.04.  The Board also ordered that the internist complete five hours of continuing medical education in depression, which shall include the diagnosis and treatment of patients with depression, and complete five hours of continuing medical education in “risk management.”

State: Florida


Date: June 2017


Specialty: Internal Medicine, Psychiatry


Symptom: Psychiatric Symptoms


Diagnosis: Psychiatric Disorder


Medical Error: Delay in proper treatment


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



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