Found 1245 Results Sorted by Case Date
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Iowa – Pathology – Intraepithelial Lesion Misdiagnosed As Condyloma Acuminatum



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

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

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

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

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

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

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

State: Iowa


Date: June 2017


Specialty: Pathology


Symptom: N/A


Diagnosis: Dermatological Issues


Medical Error: Diagnostic error


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Iowa – Pathology – Uncertainty In Diagnosis of Lichen Sclerosus



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

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

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

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

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

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

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

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

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

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

State: Iowa


Date: June 2017


Specialty: Pathology


Symptom: N/A


Diagnosis: Dermatological Issues


Medical Error: No error found


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



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



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 – 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



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 – Emergency Medicine – Delayed Response In Spine Immobilization And Ordering X-Rays And CT Scan In Patient With Lumbar Spine Fractures



On 6/22/2012 at 12:30 a.m., a patient was an unrestrained back seat passenger of a taxicab when it was involved in a motor vehicle accident.  The patient was intoxicated at the time of the accident.

EMT-Paramedics were dispatched to the scene of the accident and documented that the patient was moving all extremities and had a pulse, motor, and sensation in all four extremities.  The EMT-Paramedics transported the patient to the emergency department without back-board or spinal immobilization precautions.

At 12:58 a.m., the patient arrived at the hospital.

At 1:32 a.m., an ED physician performed an exam of the patient’s back and documented equivocal lumbar back tenderness.  The ED physician performed an exam of the patient’s pelvis and documented equivocal pelvic tenderness.  He also performed a neurologic exam and documented no movement of the patient’s toes or leg muscles.  The ED physician performed a rectal exam and documented that the patient exhibited an absence of anal sphincter tone.

AT 1:48 a.m., the ED physician ordered x-rays of the patient’s lumbosacral spine and pelvis.  The lumbosacral spine x-ray results showed a comminuted fracture dislocation at T12-L1.

At 2:58 a.m., the ED physician ordered a computed tomography scan of the patient’s lumbar spine.  The CT scan of the patient’s lumbar spine also showed a comminuted fracture dislocation at T12-L1.

At 3:17 a.m., the ED physician ordered that the patient be placed on a backboard.

At 4:20 a.m., the patient was transferred by ambulance to a level 1 Trauma Center.

The patient was ultimately diagnosed with paraplegia.  A medical malpractice lawsuit was filed against the physician.

The Board judged the ED physician’s conduct to be below the minimal standard of competence given that he failed to immediately perform a full trauma evaluation, immediately immobilize the patient’s spine, immediately order an x-ray of the patient’s chest, immediately order a CT scan of the patient’s abdomen, and immediately order a CT scan of the patient’s pelvis.

The Board issued a letter of concern against the ED physician’s license.  The Board ordered that the ED physician pay a fine of $5,000 against his license and pay reimbursement costs for the case at a minimum of $6,452.58 and not to exceed $8,452.58.  The Board also ordered that the ED physician complete five hours of continuing medical education of emergency medicine and five hours of continuing medical education in “risk management.”

State: Florida


Date: June 2017


Specialty: Emergency Medicine, Trauma Surgery


Symptom: N/A


Diagnosis: Fracture(s), Spinal Injury Or Disorder


Medical Error: Failure to examine or evaluate patient properly, Delay in proper treatment


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 4


Link to Original Case File: Download PDF



Florida – Radiology – Motor Vehicle Accident With Missed Diagnosis After Review Of The CT Scan



On 8/14/2013, a 63-year-old female patient presented to a hospital with trauma sustained in a car accident.

X-rays of the patient’s chest and ankle were performed.  CT scans of the patient’s head, face, cervical spine, chest, abdomen, and pelvis were performed.  A radiologist read the x-rays and CT scans performed on the patient.  The radiologist recognized several transverse process fractures in the patient’s lumbar spine.  The radiologist failed to diagnose an L4 vertebral body fracture that was present on one or more CT images.  The radiologist failed to order further CT or MRI scans of the patient’s lumbar spine.

The Board judged the radiologist’s standard of care to be below the minimum standard of competence given his failure to recognize and diagnose the L4 vertebral body fracture present on one or more CT images for the patient and order further CT or MRI scans of the lumbar spine.

The Board ordered that the radiologist pay a fine of $7,500 against his license and that the radiologist pay reimbursement costs from a minimum of $3,004.65 to a maximum of $5,004.65.  The Board also ordered that the radiologist complete six hours of continuing medical education in radiological studies/interpretation.

State: Florida


Date: June 2017


Specialty: Radiology


Symptom: N/A


Diagnosis: Fracture(s), Spinal Injury Or Disorder


Medical Error: Diagnostic error, Failure to order appropriate diagnostic test


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Gastroenterology – Patient And Provider Not Notified Of Amended Pathology Biopsy Results From Colonoscopy



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



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