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Florida – Plastic Surgery – Intra-operative Anemia During Blepharoplasty And Lipoplasty
On 02/06/1997, a 33-year-old woman presented to a plastic surgeon to discuss blepharoplasty and lipoplasty. The patient was scheduled for a pre-operative autologous blood donation, but cancelled the donation appointment.
On 02/21/1997, the plastic surgeon performed blepharoplasty and lipoplasty of the thighs, buttocks, and abdomen, extracting around 6,300 ml of material. The estimated blood loss was 500 ml. The patient received no blood transfusion before and during the procedure. The plastic surgeon did not perform pre-operative blood tests to determine the patient’s blood clotting status, hemoglobin level, and hematocrit.
The plastic surgeon performed an intra-operative test which revealed the patient’s hemoglobin level to be 8.2 and hematocrit to be 23.6. Despite these findings, the plastic surgeon continued with surgery.
During her overnight postoperative stay, the patient had two episodes of hypotension. The plastic surgeon did not order or perform any post-operative laboratory tests. The patient received no blood and was discharged the following morning on 02/22/1997.
On 02/25/1997, the patient presented to an emergency department with weakness and swollen knees. She was diagnosed with a blood loss of approximately 3,000 ml as a result of the prior surgery. Her hemoglobin/hematocrit was noted to be critically low at 3.7/11. She underwent blood transfusions to treat her acute anemia.
The Board judged that the plastic surgeon’s conduct fell below the minimum standard of competence by failing to order blood clotting factors, hemoglobin, and hematocrit prior to surgery, failing to stop the surgery upon discovering her anemia during surgery, failing to perform the surgery in a hospital as opposed to in an office setting, failing to perform follow up lab studies given the anemia found during surgery, and failing to adequately document the patient’s post-operative recovery.
The Board ordered that the plastic surgeon complete 30 hours of continuing medical education in the relevant field of pre-operative and post-operative testing. The Board ordered that the license be placed on probation for one year and six months. During probation, the plastic surgeon was to be monitored to ensure he is practicing competently. Surgical restrictions included that the plastic surgeon should obtain pre-operative blood work-up, including hemoglobin, hematocrit, basic metabolic panel, and urinalysis on every prospective surgical patient who is to undergo anesthesia as well as ordering a hemoglobin and hematocrit post-operatively. The plastic surgeon was ordered to take a Special Purpose Examination (SPEX) if recommended by the evaluator within six months of the Final Order.
State: Florida
Date: August 1998
Specialty: Plastic Surgery
Symptom: Swelling, Weakness/Fatigue
Diagnosis: Post-operative/Operative Complication
Medical Error: Improper treatment, Failure to order appropriate diagnostic test
Significant Outcome: Hospital Bounce Back
Case Rating: 3
Link to Original Case File: Download PDF
Wisconsin – General Surgeon – Lung Infiltrates On X-Ray Thought To Be From Radiation Done After Lumpectomy For Breast Carcinoma
A general surgeon provided medical care to a female patient from 1962 until her death in 1991. The patient’s date of birth was 10/3/1922, and she was around 68-years-old at time of death.
In July of 1980, the general surgeon diagnosed right breast carcinoma and performed a lumpectomy followed by radiation therapy.
X-rays taken after radiation therapy revealed infiltrates in the lungs thought related to the radiation treatment. Enlarging nodules in the right lung were also noted.
Board certified radiologists compared the x-rays made yearly between 1981 and 1991 and interpreted the x-rays as revealing gradually enlarging nodules of the right lung consistent with extremely slow growing metastases.
The general surgeon noted the findings and believed the patient to be clinically stable. For this reason, he did not obtain pulmonary or oncology consultations to address the findings.
The Board ordered the general surgeon complete 20 hours of continuing medical education in the treatment of breast cancer.
State: Wisconsin
Date: October 1997
Specialty: General Surgery, Oncology
Symptom: N/A
Diagnosis: Breast Cancer
Medical Error: Underestimation of likelihood or severity
Significant Outcome: Death
Case Rating: 3
Link to Original Case File: Download PDF
Virginia – Emergency Medicine – Fracture Of The Second Metacarpal Of The Left Hand
On 9/19/1992, a 32-year-old female presented to an ED physician with a fracture of the second metacarpal of the left hand. There was rotation of the distal fragment and malalignment. The ED physician neither performed reduction of the fracture nor referred the patient for such a procedure. He applied a short arm cast.
On 10/6/1992, the patient had her cast removed. The ED physician reapplied the cast. The patient subsequently had malunion with overlapping of the index finger over the middle finger, and limitation of movement at the metacarpophalangeal joint, and required open reduction and internal fixation with correction of the malunion.
The patient’s x-rays were reviewed with the ED physician, who admitted that he had accepted as clinically adequate an inadequate reduction of the fracture.
The patient sustained permanent shortening and deformity of her finger. A lawsuit was commenced, and the patient received a medical malpractice payment of $30,000 after settlement.
The ED physician had petitioned for reinstatement of his license and was denied not only given the above case but also due to multiple other reasons.
State: Virginia
Date: September 1997
Specialty: Emergency Medicine
Symptom: Extremity Pain
Diagnosis: Fracture(s)
Medical Error: Improper treatment
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
Wisconsin – Family Practice – Dexamethasone For Patient With Weakness And Numbness After A Fall
On 11/12/1979, a patient made an appointment to see a family practitioner. He was able to see the family practitioner on the same day. It was the first time the patient saw this family practitioner. He told the family practitioner that he had fallen down some steps at a construction site where he was working 2 days before. He had landed on his back, but was able to get up and walk away from the fall. The patient complained of numbness and weakness in both hands and legs. In addition, he reported difficulties with his balance.
The family practitioner did not document the patient’s medical history. An adequate physical examination was not documented. However, a physical exam was performed, which revealed weakness in the right hand. Weakness or numbness of the other extremities was not documented.
The family practitioner ordered cervical spine x-rays for the patient, but did not document the results. The family practitioner did not conduct any other diagnostic studies. There was soft tissue swelling (location unclear), for which the family practitioner prescribed dexamethasone.
The family practitioner did not document a follow-up plan. No instructions for physical restrictions were given.
On 11/27/1979, the patient returned to the family practitioner’s office. The family practitioner performed a physical examination of the patient and noted that the patient had developed ataxia and had developed weakness of the right arm. The family practitioner’s complete notes stated:
“No improvement from above symptoms. Medscreen basic and hemogram. Sed. rate to hospital. Objective – as above. Assessment – etiology unknown. Plan – outpatient work-up. SMA-12, CBC and sed. rate. Refer to neurologist. Send report. Appointment to see [a neurologist], December 10, 10:45 a.m.”
On 12/10/1979, a neurologist performed a neurological examination and documented that the patient likely had a cervical disc problem at the C5 level.
On 12/16/1979, the patient was admitted to the hospital by the neurologist.
On 12/21/1979, a neurosurgeon performed cervical hemilaminectomy. The final diagnosis of the patient was noted to be cervical spondylosis with cervical myelopathy.
The Board judged the family practitioner’s conduct to be below the standard of care given failure to document findings of the cervical x-ray and failure to adequately assess the patient’s symptoms for a neurological cause.
He was ordered to complete a continuing medical education in neuroanatomy and neurophysiology at the University of Wisconsin Medical School. He was ordered to adopt office procedures to ensure every patient of his has a medical history taken and an appropriate physical examination documented. A reviewing physician was to be monitoring the family practitioner and reviewing his medical records every three months to ensure compliance. The reviewing physician was to submit written reports.
State: Wisconsin
Date: March 1989
Specialty: Family Medicine, Internal Medicine, Neurology
Symptom: Weakness/Fatigue, Numbness, Swelling
Diagnosis: Spinal Injury Or Disorder
Medical Error: Diagnostic error, Delay in proper treatment, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 4
Link to Original Case File: Download PDF
Wisconsin – Family Practice – Pseudoephedrine For Dizziness, Plugged Ears, Nausea, And Difficulty Walking
On 06/11/1980, a patient presented to a family practitioner with dizziness, plugged ears, nausea, and difficulty walking. The family practitioner did not document the patient’s medical history and his family history. He did not conduct a physical examination of the patient other than his ears. The family practitioner flushed the patient’s right ear canal, but did not document the results. The family practitioner did not take his blood pressure. He did not conduct further studies or order any lab tests. He prescribed pseudoephedrine. There was no plan for a follow-up.
The patient worsened, developed slurred speech, began favoring his left hand over his right hand (despite being right-handed), and had even more difficulty walking.
On 06/14/1980, the patient’s wife called the family practitioner’s office, given that the patient had not improved. The family practitioner was not in the office that day. The family practitioner’s partner told the patient’s wife to bring the patient to the emergency department.
On 06/14/1980, the patient presented to the emergency department. At 11 a.m., his blood pressure was 250/178. At 11:20 a.m., his blood pressure had increased to 290/190.
On 07/07/1980 despite continued medical treatment, the patient eventually succumbed to his illness and died. The final pathologic diagnoses included thrombosis of bilateral vertebral arteries with infarction of the right cerebellum and thrombosis of the right coronary artery. The patient had been treated for hypertension in 1971 and 1972, but was not taking any medication for hypertension when he was treated by the family practitioner in 1980.
The Board judged the family practitioner’s conduct to be below the standard of care given failure to check the patient’s blood pressure prior to administering pseudoephedrine and failure to diagnose cerebellar stroke in a patient with difficulty walking.
He was ordered to complete a continuing medical education in neuroanatomy and neurophysiology at the University of Wisconsin Medical School. He was ordered to adopt office procedures to ensure every patient of his has a medical history taken and an appropriate physical examination documented. A reviewing physician was to be monitoring the family practitioner and reviewing his medical records every three months to ensure compliance. The reviewing physician was to submit written reports.
State: Wisconsin
Date: March 1989
Specialty: Family Medicine, Internal Medicine, Neurology
Symptom: Dizziness, Nausea Or Vomiting
Diagnosis: Ischemic Stroke, Acute Myocardial Infarction
Medical Error: Failure to examine or evaluate patient properly, Diagnostic error, Improper medication management
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF