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A 56-year-old woman’s annual mammogram showed a lesion in her right breast.  A needle core biopsy of the lesion was obtained on 4/28/2014.  A general pathologist reviewed the patient’s slides and diagnosed the patient with an invasive well-differentiated ductal carcinoma of the right breast.  Based on his diagnosis, the general pathologist ordered immunohistochemical stains for estrogen and progesterone receptors and other tests.  A surgical follow up was recommended.

The patient was referred to a surgeon who informed her she would undergo an immediate lumpectomy.  The patient sought further consultation from a general surgeon and plastic surgeon for evaluation and treatment of the cancer and reconstructive surgery.  The patient met with both on 5/6/2014, at which time she elected to proceed with a bilateral mastectomy, followed by breast reconstructive surgery. The general surgeon’s records show he ordered a consultation with the John Stoddard Cancer Tumor Board for another opinion. The general surgeon contacted the general pathologist and informed him of the findings.  On that same day, the general pathologist sent the slides to Mayo Clinic to be re-read.  The general pathologist also scheduled the case to be discussed at the Marshalltown Medical and Surgical Center’s Tumor Board on 5/19/2014.

The Mayo Clinic issued its report on 5/20/2014, diagnosing a complex sclerosing lesion with unusual ductal hyperplasia and microcalcifications.  On that same date, the general pathologist authored an addendum to his pathology report amending the diagnosis to conform with that of the Mayo Clinic and adding the following comment:

“The case is reviewed for tumor board.  After reviewing the case, the case was sent to Mayo Clinic for a second opinion and the [sic] diagnosis is changed from invasive ductal cell carcinoma to complex sclerosing lesion.  The changes in the diagnosis are communicated with the general surgeon.  Results of the correct report will be discussed with the patient by the general surgeon”.

The patient underwent a lumpectomy performed by the general surgeon on 5/22/2014.  Iowa Pathology Associates reviewed the slides from the lumpectomy and issued a histopathology report confirming the diagnosis of a complex sclerosing lesion.  The report stated, “there is no evidence of atypicality or malignancy.”

An audio recording made by the patient’s husband of a discussion he and the patient had with the general pathologist regarding the misdiagnosis was admitted into evidence.  In response to an inquiry regarding why the second opinion was not obtained prior to making an initial diagnosis, the general pathologist cited to the cost of a consultation.

A senior pathologist at the Iowa clinic reviewed the patient’s slides at the Board’s request and, in contrast to the general pathologist’s carcinoma diagnosis, arrived at a diagnosis of “radial scar” which term is often used interchangeably with “complex sclerosing lesion”.  The senior pathologist testified that she found the diagnosis to be an easy one and that an “average pathologist” would have been able to make it.  However, in her written report the senior pathologist relied on a textbook, which contained the following passage: “The importance of recognizing various patterns of adenosis and sclerosing lesions, and the reason why they are considered together in this chapter, is that they may be mistaken for invasive carcinoma…”  The senior pathologist noted that the condition she diagnosed is benign, although complete excision of the lesion is generally recommended if the diagnosis has been made on a needle biopsy because of the risk of associated malignancy which can be identified only after surgical excision.

The senior pathologist also questioned the general pathologist’s use of special stains in this case.  She explained that myoepithelial cells are not present in invasive cancers and, therefore, stains can be used to look for those cells.  If a stain is used and it shows that myoepithelial cells are present, the sample would not be consistent with invasive cancer.  The senior pathologist emphasized that had the general pathologist ordered the appropriate stains, such as P63, to confirm or rule out cancer in the patient’s case, he might not have misdiagnosed cancer.  On the other hand, the senior pathologist argued that the stains the general pathologist ordered were for breast cancer receptors (estrogen and progesterone) and for human epidermal growth factor receptor 2 (“HER2”) status and that the HER2 was sent for fluorescent in-situ hybridization (“FISH”) analysis, all of which were unnecessary because the patient did not have breast cancer.  The senior pathologist noted that these unnecessary steps added substantial costs to the patient’s care.

The senior pathologist emphasized that this patient might have undergone an unnecessary lumpectomy or mastectomy had her case not been reviewed further.  The senior pathologist found that the general pathologist failed to meet the standard of care when he misdiagnosed the patient because of a substantial lack of knowledge or ability to discharge the professional obligations within the scope of pathology practice.  She also determined that the general pathologist’s actions, in this case, showed a failure to possess and exercise the degree of skill, learning, and care expected of a reasonable, prudent physician acting in the same or similar circumstances.

In response to the Board’s inquiry regarding this patient, the general pathologist admitted his initial diagnosis was incorrect.  He stated, however, that he read the patient’s slides a few days later while preparing to present the case at a Tumor Board and began to have second thoughts about the diagnosis.  According to the general pathologist, he “mentally” amended the diagnosis at that time to being “suspicious of cancer”.  The general pathologist stressed that he discussed the case with the patient’s clinician and also sent it to the Mayo Clinic for a second opinion.  He explained that complex sclerosing lesions are very difficult to evaluate and are subject to misdiagnosis.  The general pathologist testified that when he received the pathology report from the Mayo Clinic on 5/20/2014, he authored a correction to his original report, amending the diagnosis to complex sclerosing lesion with unusual ductal hyperplasia and microcalcifications.

The general pathologist further testified at a hearing that the HER2 test and FISH analysis were requested by the patient’s clinician and were obtained due to that request.

The general pathologist emphasized that he learned from his error in this case and now requests additional immunostains and/or second opinions in these types of cases.

Another pathologist reviewed the case and while agreeing that the general pathologist reached an incorrect diagnosis at the outset, disagreed with the senior pathologist’s determinations that the misdiagnosis and use of stains demonstrated any lack of professional knowledge or a deviation from the standard of care from the general pathologist’s part.  He opined that this type of lesion can be difficult to evaluate, especially when the general pathologist has only a small amount of tissue provided by a needle core biopsy as opposed to a completely excised lesion.  The reviewing pathologist also emphasized that, while the senior pathologist opined the general pathologist ordered unnecessary stains, the pathologists at Mayo Clinic ordered additional stains when they re-read the slides involved.

The other reviewing pathologist offered his opinion that the general pathologist did not display professional incompetence or any behavior harmful or detrimental to the public in his review of the patient’s case.

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

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

State: Iowa

Date: June 2017

Specialty: Pathology

Symptom: N/A

Diagnosis: Dermatological Issues

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

Significant Outcome: N/A

Case Rating: 4

Link to Original Case File: Download PDF

In April 2013, a nurse practitioner collected a skin biopsy from a 20-year-old patient’s back.  That biopsy was reviewed by a general pathologist, who diagnosed superficial spreading of malignant melanoma (“SSMM”).  He did not consult with any other pathologist or dermatopathologist prior to providing the nurse practitioner with the SSMM diagnosis.

The patient was referred for treatment and a surgical consult was requested by her treating physician.  The same biopsy material reviewed by the general pathologist was also read by two pathologists, at the surgeon’s request.  Those pathologists agreed with the general pathologist’s diagnosis of SSMM.

After the patient underwent an excision, she was referred to a dermatologic surgeon, for annual skin examinations. The dermatologic surgeon noted the patient’s surgical scar and a few irregular moles during his 2013 exam.  During the 2014 examination, the dermatologic surgeon noted one irritated nevus, which was removed but saw nothing atypical.

Subsequently, in July 2014, the nurse practitioner collected a new shave biopsy from the patient’s back, near the site of the former biopsy.  The general pathologist discussed the proximity of the lesions with the nurse practitioner and the two agreed that, upon gross examination, the present biopsy material was similar in appearance to the first.  Upon microscopic examination, the general pathologist again arrived at a diagnosis of SSMM.  Once again he did not consult any other pathologist or dermatopathologist prior to providing the diagnosis to the nurse practitioner.

The nurse practitioner contacted the dermatologic surgeon with the patient’s diagnosis.  The dermatologic surgeon questioned the diagnosis because he examined the patient only two months earlier.  The dermatologic surgeon requested and received the slide on which the general pathologist based his SSMM diagnosis.  When he reviewed the slide, the dermatologic surgeon believed it showed an irritated nevus and not SSMM.

The dermatologic surgeon sent the slide from the patient’s latest biopsy to Iowa Pathology Associates, to be re-read.  A dermatopathologist reviewed the patient’s slide.  He found nothing in the sample which would point to melanoma.  He determined the slide showed an inflamed compound nevus.  Because his diagnosis conflicted with the general pathologist’s diagnosis, the dermatopathologist consulted with four of his colleagues, each of whom agreed the slide was not SSMM but an inflamed nevus.

The dermatopathologist then reported his findings to the dermatologic surgeon, who then began to question the patient’s SSMM diagnosis in 2013 SSMM.  The dermatologic surgeon obtained slides from the 2013 biopsy which looked to him to be identical to the slide from the 2014 biopsy.  The dermatologic surgeon then sent these slides to the dermatopathologist for review as well.

The dermatopathologist reviewed the slides from the 2013 biopsy and, once again, arrived at a diagnosis of inflamed compound nevus.  He shared these slides with the same four colleagues previously consulted, and once again, each concluded that the SSMM diagnosis was incorrect and that the slides showed an inflamed compound nevus.

Based on the dermatopathologist’s  diagnosis, the dermatologic surgeon alerted the patient’s mother that the patient did not have melanoma and the patient avoided a second surgery.

At the hearing, the dermatopathologist expressed his concerns with the general pathologist’s misdiagnosis in the patient’s case.  The dermatopathologist explained that a diagnosis of melanoma often makes it difficult for the patient to obtain health insurance and often he or she cannot obtain life insurance.  The dermatopathologist also explained that people diagnosed with melanoma are prohibited from donating tissue or blood.  Finally, the dermatopathologist testified to his fear that if the general pathologist misdiagnosed an inflamed compound nevus as malignant melanoma, that he might also be misdiagnosing malignant melanomas as inflamed compound nevi, thereby potentially exposing patients to the risk of developing metastatic melanoma.

A senior pathologist testified that neither of the biopsy specimens collected from the patient showed features of malignant melanoma.  She noted that there was no upward migration of atypical melanocytes or Pagetoid spread of atypical melanocytes. The senior pathologist explained the melanocytes in the patient’s biopsies showed no evidence of cytological atypia.  The senior pathologist also took issue with the fact that the general pathologist ordered a Melan-A stain, which, while it might have been appropriate had the biopsies shown malignant melanoma, was unnecessary since the correct diagnosis was inflamed compound nevus.

The senior pathologist emphasized the emotional strain placed on a patient once given a diagnosis of malignant melanoma.  She also noted that such a diagnosis might well result in a wider excision of the biopsy site, a regional lymph node excision, and chemotherapy; all unnecessary for an inflamed compound nevus.

The senior pathologist, dermatopathologist, and dermatologic surgeon all testified to the difficulty of making a diagnosis of malignant myeloma.  The senior pathologist wrote in her peer review to the Board:

“In my practice, EVERY case I think is malignant melanoma goes out for second (and sometimes third) opinion; regardless of how certain I am that the lesion is indeed a malignant melanoma. I feel that the practice of skin pathology (dermatopathology) is very difficult when it comes to accurately classifying atypical melanocytic proliferations, such as malignant melanoma and dysplastic nevi. Without special training, I believe it’s best to get second opinions on these cases; however that is my opinion and may not be shared by all pathologists”.

Likewise, while the dermatologic surgeon testified he was not an expert in pathology, he asserted that the diagnosis of an inflamed nevus is not a difficult one to make. He did admit, however, that the subspecialty of dermatopathology was developed specifically because of the difficulty in diagnosing melanomas.  He noted that, in his practice, he sees “problem after problem” with the diagnoses provided by general pathologists and that, as a result, he will not accept a diagnosis from a general pathologist without confirmation by a specialist.

The dermatopathologist noted that the practice of pathology involves, at best, the subjective interpretation of objective data and, at times, less than objective data. He stated that malignant melanoma is a particularly difficult diagnosis and urged that confirmation of that diagnosis could and should be had through consultation with a pathology group with subspecialty expertise such as the pathology group at Mayo Clinic.

In response to the complaint regarding this patient, the general pathologist noted that his 2013 diagnosis of SSMM was confirmed by the Ames Pathology Group who reviewed the biopsy at that time at the request of the patient’s surgeon. He stressed that he read the 2014 biopsy with the knowledge that this patient had been diagnosed with SSMM and that the diagnosis had been confirmed the previous year. He also noted that the 2014 biopsy was taken very close to the site of the 2013 biopsy.  The general pathologist noted that this information caused him to lean towards an SSMM diagnosis.  He also explained that, since the biopsy was from the patient’s back, an excision with a wider margin would not lead to any cosmetic defects.  He noted he was aggressive in this case because he did not want the patient to come back with metastatic melanoma.  He stressed the difficulty of diagnosing pigmented skin lesions.

At the hearing, the general pathologist testified that he remained convinced the patient’s 2014 biopsy showed SSMM.

Another reviewing pathologist expressed a different opinion in the patient’s case.  He stressed that the 2013 SSMM diagnosis had been confirmed after the slides were reread by the Ames Pathology Group and that fact, along with histology of the 2014 biopsy, would have led him to classify the latter specimen as, at the very least, an atypical compound melanocytic proliferation which would not rule out melanoma. The other reviewing pathologist stated that his review of the specimen revealed extensive lymphocytic reaction in the dermis which, in some cases, can mask an infiltrating tumor, He noted that in his practice, this sample would have been sent out for a consultation with a dermatopathologist.  However, once again the reviewing pathologist found no professional incompetency or harm to the public in the general pathologist’s action with regard to this case

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

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

State: Iowa

Date: June 2017

Specialty: Pathology

Symptom: N/A

Diagnosis: Dermatological Issues

Medical Error: Diagnostic error

Significant Outcome: N/A

Case Rating: 4

Link to Original Case File: Download PDF

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

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

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

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

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

On 5/6/2013, a 55-year-old female presented to a digestive health center for a colonoscopy with biopsy.  During the colonoscopy, a gastroenterologist found a mass in the patient’s rectosigmoid region.  He obtained multiple biopsies of the mass and sent the specimens for in-house pathologic evaluation.  The colonoscopy was completed without complication and the patient was brought to recovery in stable condition.

On 5/7/2013, an in-house pathologist rendered a preliminary gastrointestinal pathology report which reported that the specimen was highly suspicious for a signet ring adenocarcinoma.  The initial pathology report indicated that the case was sent to a second pathologist for another opinion.

The gastroenterologist received and reviewed the initial pathology report.  He referred the patient to a colorectal surgeon for surgical intervention.

On 5/8/2013, the second pathologist issued a pathology report which stated that the specimen was negative for signet cells and adenocarcinoma and recommended a re-biopsy to completely rule out malignancy.  The gastroenterologist received and reviewed the copy of the report by the second pathologist.

On 5/16/2013, the in-house pathologist issued an amended gastrointestinal pathology report which stated that the specimen was negative for signet ring cells.  The gastroenterologist received and reviewed the amended pathology report.

Despite receiving and reviewing the pathology report from both the pathologists, the gastroenterologist failed to notify the patient of the change in the reading of the specimen.  The gastroenterologist also failed to ensure that the colorectal surgeon was notified of the change in the reading of the specimen.

On 6/11/2013, the patient underwent a low anterior resection, mobilization of splenic flexure, and diverting loop ileostomy with colonic J pouch.

The Board judged the gastroenterologists conduct to be below the minimal standard of competence given that he failed to notify the patient of the change in the reading of the specimen and ensure that the colorectal surgeon was notified of the change in the reading of the specimen.

The Board issued a letter of concern against the gastroenterologist’s license.  The Board ordered that the gastroenterologist pay a fine of $10,000 against his license and pay reimbursement costs of a minimum of $3,008.71 and not to exceed $5,008.71.  The Board also ordered that the gastroenterologist complete five hours of continuing medical education in “risk management.”

State: Florida

Date: June 2017

Specialty: Gastroenterology

Symptom: Mass (Breast Mass, Lump, etc.)

Diagnosis: Cancer

Medical Error: Failure of communication with patient or patient relations, False positive, Failure of communication with other providers

Significant Outcome: N/A

Case Rating: 5

Link to Original Case File: Download PDF

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

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