Found 1245 Results Sorted by Case Date
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California – Obstetrics – Preeclampsia Pregnancy Complicated By Postpartum Abdominal Pain And Vaginal Discharge



An obstetrician was a physician supervisor for a nurse midwife who was following a patient’s prenatal course through spring and summer 2013.  At the 39 weeks gestation visit, the midwife recorded the patient’s blood pressure as 131/90.  At the next week’s visit, the patient’s blood pressure was measured at 186/101 and her proteinuria was 3+.  The midwife was apparently monitoring the patient for preeclampsia.

There was no indication that the obstetrician was actively supervising the high-risk patient.  The midwife elected to induce labor to address the evolving preeclampsia.  The consequent labor resulted in a vaginal delivery of the patient’s healthy baby in hospital on 8/15/2013.

The obstetrician was called in after the delivery and performed a manual removal of the placenta and a postpartum curettage under general anesthesia.  Over the course of the delivery and postpartum surgery, the patient lost 2-3 liters of blood and her hematocrit level dropped from 41 to 27.  The patient was discharged from the hospital two days after the birth.

Fourteen days later the patient presented with complaints of abdominal pain and vaginal discharge.  The obstetrician treated the patient on an outpatient basis, prescribing oral antibiotics.  The patient’s symptoms did not improve and she was seen in the emergency department, where she was given the first intravenous dose of a long-acting antibiotic.  The patient underwent a diagnostic ultrasound the following day, which was read as revealing “retained products of conception.“

The obstetrician immediately performed another dilation and curettage; the pathology report found “inflamed decidua” but no placental tissue.  The patient was prescribed additional oral antibiotics and discharged from the hospital.  She returned four days later with continuing abdominal pain; physical examination found peritoneal irritation.  She was admitted to the hospital with a diagnosis of peritonitis.  The patient was treated with intravenous antibiotics and improved quickly.  She was released symptom-free from the hospital three days after admission.

The Board judged the obstetrician’s conduct as having fallen below the minimum level of competence given his failure to adequately supervise the midwife’s prenatal monitoring of the patient’s severe preeclampsia and his failure to have a plan of hospital admission if the antibiotics used to treat the patient’s abdominal pain and vaginal discharge two weeks postpartum were unavailing.

For this allegation and others, the Board ordered the obstetrician be placed on probation for a period of three years, complete 40 hours of continuing education per year of probation, enroll in a clinical or educational program equivalent to the Physician Assessment and Clinical Education Program (PACE), be prohibited from supervising any physician assistants, and have a practice monitor assigned to him.

State: California


Date: November 2016


Specialty: Obstetrics


Symptom: Bleeding, Abdominal Pain


Diagnosis: Preeclampsia, Acute Abdomen


Medical Error: Failure to properly monitor patient, Referral failure to hospital or specialist


Significant Outcome: Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



Arizona – Urology – Hepatic Artery, Portal Vein, and Common Bile Duct Transected During Partial Nephrectomy



The Board was notified of a malpractice settlement regarding the treatment of a 76-year-old woman.

On 02/14/2012, a woman was evaluated by a urology regarding a renal lesion that had been found on a CT scan.  The urologist ordered a CT scan which was performed on 11/28/2012 and which revealed no no significant change in size of the 0.9 cm lesion located on the upper pole of the right kidney.  The lesion had a slightly thickened and irregular enhancing wall.  There was a small ventral wall hernia.  The urologist documented the renal lesion as being complex and enhancing with no significant enlargement.  It was around 1 cm in diameter and was not causing the patient any symptoms.  The urologist recommended a biopsy.

On 01/24/2013, the patient underwent a right renal biopsy.  Pathology revealed probable clear cell renal cell carcinoma Fuhrman grade 2.

On 01/30/2013, the urologist documented that he discussed the risks and benefits with the patient regarding surgery.  The urologist offered a hand assisted approach to allow for repair of the patient’s hernia.  The patient gave consent for the procedure.

On 04/17/2013, the patient was admitted for right nephrectomy via hand assisted laparoscopy.  Per the anesthesia record, the anesthesia start time was 1:51 p.m. and surgery start time was 2:26 p.m.  The surgery end time was 5:54 p.m.  The urologist’s operative note documented adhesions and significant bleeding he initially thought was due to injury of the inferior vena cava.  The patient received two packed red blood cell transfusions and the operation was converted to an open procedure.

At 3:00 p.m., the anesthesia record stated that the blood pressure was 60/30.

At 3:47 p.m., a general surgeon was consulted and arrived in the operating room.  The surgeon noted that there was bleeding along the anterolateral edge of the patient’s duodenum and pancreas.  The portal vein, common bile duct, and hepatic artery were transected.  The urologist stated that he proceeded with a radical nephrectomy prior to liver vascular repair to avoid further liver vascular damage.  Per the general surgeon’s note, hepatic warm ischemia time was one hour and fifteen minutes.  After the nephrectomy was completed, the hepatic artery, portal vein, and common bile duct were repaired, including graft replacement.

At 5:30 a.m. on 04/18/2013, the urologist dictated his operative report.

On 04/18/2013, the patient was taken back to surgery after sanguineous fluid was found in the drain output.  The general surgeon’s intraoperative findings included 1500 ml of intra-abdominal blood along with bleeding from a gonadal vessel and from the insertion of the renal vein on the vena cava.  The family requested DNR status for the patient.  The patient subsequently died.

The Board judged urologist’s conduct to be below the minimum standard of competence given failure to use proper surgical technique with correct tissue transection/ligation, failure to timely convert to an open procedure, and failure to consider hepatic artery and portal vein repair prior to proceeding with the performance of the nephrectomy.

The Board ordered the urologist to be reprimanded.

State: Arizona


Date: November 2016


Specialty: Urology, General Surgery, Nephrology, Oncology


Symptom: N/A


Diagnosis: Post-operative/Operative Complication, Cancer


Medical Error: Procedural error


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



Wisconsin – Gynecology – Woman With History Of Breast Cancer, Rectal Cancer, Colorectal Resection, With Post-Menopausal Bleeding



In October 2013, a 62-year-old woman with a history of breast cancer, rectal cancer, colorectal resection, and ileostomy reversal presented to Gynecologist A for post-menopausal bleeding.  Abdominal hysterectomy and bilateral salpingo-oophorectomy was recommended and a consent form was signed.

On 10/29/2013, Gynecologist A noted on the ultrasound the presence of a uterus and ovaries.  Gynecologist A documented that the patient neither had a uterus nor ovaries.

On 11/25/2013, Gynecologist A performed an exploratory laparotomy with lysis of adhesions on the patient.  As documented, Gynecologist A discussed with the patient and the family that she neither had a uterus nor ovaries.

On 3/10/2014, a gynecologist oncologist performed a total abdominal hysterectomy and bilateral salpingo-oophorectomy on the patient.  It is not reported if the patient was eventually diagnosed with cancer.

The Board stated that Gynecologist A engaged in unprofessional conduct by increasing risk of harm to the patient.  She was reprimanded with order for payment of costs.

State: Wisconsin


Date: November 2016


Specialty: Gynecology


Symptom: Gynecological Symptoms


Diagnosis: Gynecological Disease


Medical Error: Diagnostic error, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Wisconsin – Radiology – Chest Wall Pain And Mass With Only Interstitial Lung Disease Reported On CT



In February 2009, a patient presented to his primary care physician with chronic chest pain.  A CT scan was performed.  On 3/9/2009, Radiologist A reviewed the CT scan of the chest and documented interstitial disease.

A high resolution CT scan was performed on 3/19/2009.  Radiologist B reviewed the CT scan of the chest and affirmed findings of interstitial lung disease.

In August 2009, the patient followed up with his primary care physician and complained of a chest mass.  A nurse noted that he had “a large mass in the middle of [his] chest.”

On 8/24/2009, Radiologist C remotely reviewed the patient’s CT scan of the chest.  The 3/5/2009 and 3/9/2009 studies were made available to him.  The clinical history stated “CT Chest Mass in Mid Chest.”  The report stated, “Old granulomatous disease and chronic interstitial lung disease.  Nodular pleural thickening right middle lobe.  Stable findings compared to earlier examination.”

On January 2010, the patient presented to his physician with growing mass.  A biopsy was performed revealing a solitary plasmacytoma of the sternum.

The patient died on 4/25/2010 after radiation treatment.  Radiologist D reviewed all three CT scans and testified that the chest wall mass was present in all three.

Radiologist B and C were reprimanded for engaging in conduct that tends to constitute a danger to the health, welfare, and safety of a patient.

State: Wisconsin


Date: November 2016


Specialty: Radiology


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


Diagnosis: Cancer


Medical Error: False negative


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



North Carolina – General Surgery – Alcohol Based Solution For Surgical Prep And Electrocautery Device Causes Complications During Lipoma Removal



The Board was notified of a professional liability payment made on 7/17/2015.

In preparation for the removal of a lipoma on a patient’s posterior neck, the surgery area and the hairline were treated with an alcohol based antibacterial solution called DuraPrep.  Although the manufacturer’s recommended drying time is two to three minutes, the general surgeon allowed the DuraPrep to dry for approximately ten minutes.  The general surgeon also blotted the patient’s neckline with a sponge.  Seeing no visible residue on the blotting sponge, the patient’s head was covered with a drape.  During the procedure, which was performed using open oxygen under monitored anesthesia care, strands of the patient’s hair covered with DuraPrep solution residue were ignited from the electrocautery.  The oxygen, which had accumulated under the drapes, served as a fire accelerant.  The patient was transferred by air with an endotracheal intubation to a burn center for flash burns to the midface, nose, mouth, eyelids, and right ear.

The Board believed the general surgeon responded appropriately to the intraoperative emergency and noted that the general surgeon sustained second degree burns to his hand trying to extinguish the flame.  The Board also acknowledged the general surgeon and his operating team’s rapid response minimized harm to the patient.

The cause of the fire was multifactorial; however, the Board believed the surgeon was ultimately responsible for the patient’s safety during the operation.  They recommended that in similar cases, the general surgeon should use a non-alcohol based skin prep, allow additional drying time, or use a non-sparking cautery, minimize the use of open oxygen, and use draping techniques that would allow adequate ventilation when open oxygen is used.  The Board acknowledged that the general surgeon received additional training in surgical fire prevention and safety.

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: October 2016


Specialty: General Surgery


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


Diagnosis: Post-operative/Operative Complication


Medical Error: Procedural error


Significant Outcome: N/A


Case Rating: 5


Link to Original Case File: Download PDF



California – Dermatology – Rosacea Treated With Intense Pulsed Light Treatment



On 5/5/2011, a patient presented to a cosmetic laser clinic.  At this initial appointment, a nurse recommended that the patient receive Intense Pulsed Light treatment (“IPL”) utilizing the Lumenis One machine to treat rosacea, redness, and discoloration on his neck and chest.  On 5/5/2011, a dermatologist approved the nurse’s treatment recommendations.  The proposed IPL treatments were to be administered over three clinical visits.  The patient was not informed of the potential risk of severe burn and significant scarring associated with IPL treatment.

On 5/16/2011, the patient underwent his first IPL treatment without any adverse outcome.

On 8/15/2011, the dermatologist performed the second IPL treatment on the patient’s neck and chest using the Lumenis One machine.  At the time that respondent performed the second IPL on the patient, she had not previously reviewed the clinic’s written IPL protocol.  The dermatologist did not adjust the settings on the Lumenis One machine and instead relied on the preset settings.  The patient complained of extreme pain during this administration of the IPL treatment.  The patient asked the dermatologist to stop the IPL treatment at least four times during the course of the treatment.  The dermatologist did not stop the treatment, but only hesitated momentarily to wait for the patient to regain his composure.

The dermatologist continually made comments to coax the patient to proceed with the IPL treatment.  The dermatologist did not adjust the settings on the Lumenis One machine during the course of the IPL treatment.

On 8/15/2011, following the IPL treatment, the patient observed two large purple spots with blistering on his chest.

On 8/19/2011, the patient returned to the clinic for an IPL follow-up appointment with the dermatologist.  During this visit, the dermatologist diagnosed the patient with post-IPL second-degree burns to the neck and chest area.

On 6/7/2012, the patient returned to the clinic for an IPL follow-up appointment with the dermatologist.  The dermatologist noted that the patient had hypopigmented rectangles on his chest.

The dermatologist failed to adequately inform the patient of the potential risks of IPL treatment including burns and scarring.  The dermatologist failed to read the protocol governing the Lumenis One machine prior to treating the patient and failed to adjust the machine to a lower energy prior to treating the patient.

The Board issued a reprimand to the dermatologist and ordered the dermatologist to enroll in a clinical in-service training provided by the vendor of the IPL medical device.

State: California


Date: October 2016


Specialty: Dermatology


Symptom: Dermatological Abnormality


Diagnosis: Dermatological Issues


Medical Error: Procedural error


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Kansas – Pediatrics – Unnecessary Use of Azithromycin In Viral Infection



On 2/27/2013, a 13-year-old female presented to a pediatrician for follow-up five days after a visit to the emergency department where she had complained of chest pain and had an abnormal D-dimer lab value.  No patient education was documented related to the significance of the finding or the risk of a pulmonary embolism.  The patient record appeared to have been signed with a stamp and not dated.

On 4/24/2013, the patient presented with complains of bilateral ear pain and sore throat.  The patient’s past medical history stated “Significant for allergies.”  However, at her previous appointment, it listed only left knee injury. There was no other information contained in her past medical history.  The record was electronically signed by an advanced practice registered nurse (“APRN”) on 5/23/2013.

On 10/21/2013, the patient was seen by the APRN with complaints of vomiting, diarrhea, and abdominal cramping. At this appointment, the patient’s past medical history stated, “Noncontributory.”  The APRN documented putting the patient on Phenergan 25 mg tablets #40 one by mouth every eight hours as needed, Bentyl 20 mg #40 one by mouth every eight hours as needed, and acidophilus tablets #20 one by mouth twice daily for ten days.  The record was electronically signed by the APRN on 11/15/2013.

On 1/28/2014, the patient presented with cough, sore throat, hoarseness, body aches, and headache.  Vitals were taken and documented within normal limits; however, no blood pressure or heart rate was documented.  The patient was positive for cervical lymphadenopathy and flu A, rhonchi and wheezing were noted, and the pediatrician prescribed azithromycin.  Azithromycin is not indicated for a viral infection and not otherwise justified in the absence of a non-current bacterial infection.

The patient record was signed electronically by the APRN on 3/19/2014.

The Board judged the pediatrician’s conduct to be below the minimum standard of competence given his failure to keep written medical records which accurately describe the services rendered to the patient, including patient histories, pertinent findings, examination results and test results.  Also, the pediatrician prescribed, dispensed, and administered or distributed a prescription drug, in an improper or inappropriate manner.

The Board ordered that the pediatrician attend and successfully complete the Medical Record Keeping Seminar at the Center for Personalized Education for Physicians (“CPEP”). Also, the Board ordered that the pediatrician hire a medical scribe. Finally, the Board ordered that the pediatrician have another pediatrician monitor his work.

State: Kansas


Date: October 2016


Specialty: Pediatrics, Emergency Medicine


Symptom: Cough, Headache, Pain


Diagnosis: Infectious Disease


Medical Error: Improper medication management, Failure of communication with patient or patient relations, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Kansas – Obstetrics – Administering Vaccines In A Pregnant Patient Without Consent



On 3/6/2013, a patient presented for a newborn screening. No pregnancy or labor and delivery history were documented.  A family history was documented; however, no detail of family history was documented.  The patient was not seen until eleven days after discharge.

On 7/3/2013, the patient presented to the obstetrician for her four month well exam.  At that appointment, the patient was administered the following vaccines: Hib, PEDIARIX, PCV 13, and Rota.  No consent form for the aforementioned vaccines was found in the record.

On 9/10/2013, the patient presented to the obstetrician for her six-month exam.  The obstetrician electronically signed the record on 9/27/2013, approximately seventeen days later.

The Board judged the obstetrician’s conduct to be below the minimum standard of competence given his failure to describe the services rendered to the patient.

The Board ordered that the obstetrician attend and successfully complete the Medical Record Keeping Seminar at Center for Personalized Education for Physicians (“CPEP”). Also, the Board ordered that the obstetrician hire a medical scribe. Finally, the Board ordered that the obstetrician have another obstetrician monitor his work.

State: Kansas


Date: October 2016


Specialty: Obstetrics


Symptom: N/A


Diagnosis: N/A


Medical Error: Failure of communication with patient or patient relations, Ethics violation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Kansas – Pediatrics – Improper Documentation In A Patient With Cough, Wheezing, and Runny Nose



On 12/5/2012, a newborn patient presented for his two-week check.  No family history, pregnancy, or labor and delivery history were documented.  The patient was not seen until thirty-three days after discharge.

The patient was seen only a total of three times by six months of age.  The medical record did not discuss why immunizations were late.  The plan/treatment section of the record was word-for-word the same information as in other patient records.

On 8/26/2013 a pediatrician saw the patient.  The pediatrician documented the patient had a cough, wheezing, and a runny nose.  No other information regarding an exam was given outside of the patient’s vitals being taken.  The pediatrician administered Microephrine 0.2 ml in the office.  The record appears to have been stamped in the pediatrician’s signature, but there was no corresponding date.

On 9/3/2013, the patient presented to the pediatrician after being admitted to the hospital the week prior with croup, bronchiolitis, and respiratory distress.  No information regarding the patient’s hospital stay was found in the pediatrician’s record.

The Board judged the pediatrician’s conduct to be below the minimum standard of competence given his failure to keep written medical records which accurately describe the services rendered to the patient, including patient histories, pertinent findings, examination results and test results.

The Board ordered that the pediatrician attend and successfully complete the Medical Record Keeping Seminar at Center for Personalized Education for Physicians (“CPEP”). Also, the Board ordered that the pediatrician hire a medical scribe. Finally, the Board ordered that the pediatrician have a pediatrician to monitor his work.

State: Kansas


Date: October 2016


Specialty: Pediatrics


Symptom: Cough


Diagnosis: N/A


Medical Error: Lack of proper documentation, Failure to examine or evaluate patient properly


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Kansas – Pediatrics – Improper Documentation For Reactive Airway Disease And Improper Use of Bactrim



On 2/4/2013 a 7-year-old female presented to a pediatrician and saw the advanced practice registered nurse (“APRN”).  The patient presented with chief complaints of allergies, congestion, and diarrhea.  The patient was prescribed albuterol, Qvar 40 mcg, Bactrim, and triamcinolone.  The Bactrim was prescribed inappropriately for diarrhea.  The pediatrician agreed but thought that he had perhaps forgotten to document otitis media.

On 2/19/2013, the pediatrician saw the patient for a follow-up appointment.  The pediatrician documented that the patient was there for a follow-up for her asthma, even though the patient previously presented with reactive airway disease.  The pediatrician did not document his thought process in how reactive airway disease developed in asthma.  The pediatrician did not electronically sign the record until 4/11/2013.

On 6/11/2013, the patient presented to the pediatrician for a school physical.  The pediatrician failed to document the patient’s asthma.  In the school health examination, the pediatrician stamped signature appears on the form with the date 6/11/2013.  The pediatrician stamped the document “No” to the question, “Is this student subject to any condition which might cause a possible classroom emergency such as seizures, fainting, diarrhea, diabetes, asthma, allergies, etc.”

The Board judged the pediatrician’s conduct to be below the minimum standard of competence given his failure to keep written medical records, and inappropriately prescribing a medication.

The Board ordered that the pediatrician attend and successfully complete the Medical Record Keeping Seminar at Center for Personalized Education for Physicians (“CPEP”). Also, the Board ordered that the pediatrician hire a medical scribe. Finally, the Board ordered that the pediatrician have a pediatrician monitor his work.

State: Kansas


Date: October 2016


Specialty: Pediatrics


Symptom: Allergic Reaction Symptoms, Diarrhea


Diagnosis: Asthma


Medical Error: Lack of proper documentation, Improper medication management


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



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