Found 1245 Results Sorted by Case Date
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Arizona – Anesthesiology – Right Toe Amputation With A Medical HIstory Of Pulmonary Hypertension, Morbid Obesity, End Stage Renal Disease, And Severe Mitral Regurgitation



The Board received notice of a malpractice settlement.

On 08/07/2013, a 62-year-old female was scheduled to undergo a first right toe amputation due to gangrene.  The patient had a prior history of coronary artery bypass graft, end stage renal disease on dialysis, diabetes mellitus type II requiring insulin therapy, morbid obesity, hypertension, and anemia with a hematocrit under 30%.  She also had a medical history of pulmonary hypertension and severe mitral regurgitation, but this medical history was not obtained by the anesthesiologist.

The anesthesiologist assessed the patient as an ASA IV.  During the procedure, the patient’s heart rate decreased to 40 beats per minute, then increased to about 60 beats per minute with oxygen saturation of 93%.  The patient’s pulse oximetry tracing flatlined with a heart rate between 40 and 60 beats per minute and a normal sinus rhythm.  It is unclear what happened next.  There was report that he was unable to obtain blood pressures given malfunctioning equipment.  At the end of surgery, it appears that the patient went into cardiac arrest.  While compressions were performed for five to ten minutes, the patient suffered an anoxic brain injury.  She did not regain consciousness and remained ventilator dependent until she died two months later.

The Board judged the anesthesiologist’s conduct to be below the minimum standard of competence given failure to timely recognize a life-threatening condition of the patient and initiate resuscitation.  He failed to obtain a complete past medical history for a non-emergency surgery.

The anesthesiologist testified that he was unaware that the patient had pulmonary hypertension and severe mitral valve regurgitation.  If he was aware, he would have canceled the surgery.  He testified that even though the malfunctioning blood pressure cuff caused difficulty with direct monitoring of the patient’s blood pressure, he was reassured by the readings of the plethysmograph tracing, despite not having a blood pressure reading that could be charted.

He also testified that he had never previously had a patient that required up to seven doses of a pressor such as phenylephrine or epinephrine in concurrence with the inability to obtain a blood pressure.  He believed that allowing the surgery to continue would keep the patient’s natural catecholamines elevated and would keep the blood pressure up.  He stated that it was only after the surgery stopped that the patient experienced a sudden cessation of circulation.

He testified that the anesthesia record was filled out in the ICU after the surgery was over.  He stated that just before he left and transported the patient to the ICU, he took basic data with blood pressure, pulse rates off the recording that was present in the anesthesia monitor, but he forgot to make recordings of the CO2 and forgot to put that in the record.

The Board ordered the anesthesiologist be reprimanded, given that they found it troubling that a full past medical history was not obtained.

State: Arizona


Date: June 2016


Specialty: Anesthesiology, Internal Medicine


Symptom: N/A


Diagnosis: Post-operative/Operative Complication


Medical Error: Improper treatment, Failure of communication with patient or patient relations


Significant Outcome: Death


Case Rating: 1


Link to Original Case File: Download PDF



California – General Surgery – Fallopian Tube Removed Instead Of Appendix For Presumed Appendicitis And Other Complications



A 40-year-old female was admitted to a hospital on 5/4/2009 with lower abdominal pain with some localization in the right lower quadrant, presumed to be appendicitis.

On 5/5/2009, the general surgeon performed an open exploratory operation and removed an abdominal structure, presumed to be the patient’s appendix.  Per the Board, the general surgeon had suspected appendicitis but failed to carry out proper operative diagnostic tests.  Even using an open approach in his surgery, the general surgeon failed to establish anatomical identification of the appendix as the structure arising from the cecum (bowel).  Instead, the general surgeon assumed that the longitudinal structure was the appendix, and he removed it.  Pathology proved the general surgeon’s assumption to be inaccurate and showed the removed structure to be a fallopian tube with pyosalpinx.  The patient was discharged from the hospital on 5/8/2009.  The general surgeon failed to advise the patient that he had removed a fallopian tube, not her appendix.

On 2/6/2010, shortly after midnight, the patient returned to the hospital complaining of abdominal pain.  An abdominal pelvic CT scan was performed.  A preliminary report by the radiologist suggested a large ventral abdominal hernia in the right lower quadrant measuring approximately 11 cm and containing small bowel loops.  Another CT scan was performed at 5:03 a.m.  It indicated a large abdominal wall hernia in the anterolateral aspect of the upper right pelvis, containing numerous loops of non-dilated small bowel.  Stranding in the mesentery in the region of the hernia suggested vascular congestion or mild incarceration.  Additionally, it suggested a 4.3 cm cyst on the patient’s right ovary.

Later on 2/6/2010, the general surgeon performed an open ventral hernia repair.  It is unclear from his operative report whether he intended to treat a single hernia or double hernias.  Enterotomies were made, (which can occur during lysis of adhesions) altering the sterility of the wound.  The wound was contaminated.  The general surgeon used a synthetic non-absorbable mesh.  The use of mesh in a contaminated wound is controversial as the risk of infection to the mesh is high, especially when using a synthetic non-absorbable material as was used here.  Furthermore, the general surgeon failed to employ an adequately-sized mesh.  The mesh the general surgeon used was only 1/2 inch wide, whereas the standard of care requires that mesh overlap the hernia by 3 centimeters on each side.  Six days later, a ventral hernia was noted on x-rays, suggesting an early recurrence due to inadequate repair, or a missed hernia not diagnosed at surgery.

By 2/19/2010, a CT scan of the abdomen showed a large right-sided Spigelian hernia with dilated loops of small bowel, subtle inflammatory changes surrounding the distal small bowel, and some subcutaneous gas laterally.

The general surgeon noted that on 2/19/2010, he performed an open ventral hernia repair via a midline incision, as well as a small bowel resection with a side-to-side functional end-to-end distal small bowel anastomosis, and “attempted repair of recurrent ventral hernia.”  He had no assistant.  The general surgeon’s operative description that he performed a small bowel resection and reanastomosis had no resemblance to the surgery performed.

On 2/20/2010, the general surgeon performed another exploratory laparotomy on the patient.  The general surgeon documented that he performed a small bowel resection and reanastomosis.  Specifically, the small bowel in the hernia sac was considered non-viable so it was resected and a side-to-side functional end-to-side small bowel reanastomosis was performed.  Additionally, the general surgeon described that a small area of the bowel was adherent to the abdominal wall anterolaterally, and he was unable to safely dissect it off.  He, therefore, performed an entero-ascending colostomy in a side-to-side functional end-to-end anastomosis.  The general surgeon placed a drain into the space of the hernia sac and closed the midline wound.

In the operative report, the “Pre-operative Diagnosis” was “Hemoperitoneum.”  The “Post-operative Diagnosis” was “Intestinal torsion secondary to ventral hernia with reincarceration.”  The “Operation” was “Exploratory laparotomy, small bowel resection, enterocolotomy, or anastomosis, between distal small bowel and the ascending colon, and placement of drain in the hernia sac.”

The operative report stated that after the previous laparotomy incision was opened, “[an] area of torsion of small intestine was found in the old hernia space which had been disrupted and transudative fluid was removed with pool suction, the area of torsed small bowel was reduced from the hernia sac and then it was resected as it was felt to be nonviable and a side-to-side functional end-to-end anastomosis. (sic) A small area of the bowel was adherent to the abdominal wall anterolaterally and was unable to be safely dissected off.  The decision was made to perform an enteroascending colotomy (sic) which was done with 55 GIAs in a side-to-side functional end-to-end fashion.  All these anastomoses were then reinforced with a 3-0 silk on a pop-off needle in a Lembert fashion.  After this was done, the drain 10 mm Jackson-Pratt was placed into the space of the hernia sac and attention became directed towards closure.”

The general surgeon’s operative description that he resected more small bowel and created an “enteroascending colostomy” as a “small bowel was adherent to the anterior abdominal wall anterolaterally” had no resemblance to the surgery performed.

On 2/20/2010, the general surgeon operated on the patient again, suspecting abdominal compartment syndrome due to blood loss.  He performed two mini-laparotomies to exclude this possibility.  Per the Board, the general surgeon ineffectively performed laparotomies away from the source of suspected bleeding.  The general surgeon suspected high intra-abdominal pressure.  Per the Board, in that circumstance, the midline wound should have been re-opened and a temporary closure allowing abdominal wall expansion should have been performed.  Such reoperation could have been a good opportunity to inspect the prior surgeries.  Following the surgery, the patient remained in the intensive care unit in critical condition.

By 2/23/2010, a CT scan of the abdomen revealed a ventral hernia with small bowel within it.  By 2/26/2010, a CT scan showed a right anterolateral defect with multiple loops of small bowel and contrast present within the loops of small bowel in and out of the hernia sac.  Multiple foci of gas appeared extraluminally.  In essence, the general surgeon had left a portion of the patient’s intestine unconnected to the rest of her intestine, and created an environment, which allowed infection to occur.

By 3/2/2010, the patient’s care was transferred to another surgeon who performed yet another laparotomy with the general surgeon as an assistant describing what he had done, which did not make sense to the primary surgeon.  After extensive separation of adhesions, a leaking distal intestinal loop was resected, a colonic anastomosis was taken down, and a mesh was removed from the abdominal wall.  An end ileostomy was performed, and a gastrostomy was placed.  The primary surgeon documented that no appendix was identified.

The Board judged the general surgeon’s conduct as having fallen below the standard of care given failure to clearly and correctly identify the anatomy, failure to provide accurate descriptions of the operation in his operative reports, misidentification of the transverse colon as the ascending colon, misidentification of the fallopian tube as the appendix, and performed reanastamosis of the small bowel to itself rather than to its distal segment.

In managing the patient’s ventral hernia, he failed to clarify if he was treating a single hernia or double hernias.  He made enterotomies during lysis of adhesions, altering the sterility of the wound.  He used a synthetic non-absorbable material mesh in a contaminated wound and used an inadequate size of the mesh measuring only 1/2 inch wide.

In managing the patient’s abdominal compartment syndrome, he performed two mini-laparotomies to exclude bleeding but performed them away from the suspected source of the bleeding.  He was negligent when he suspected high intra-abdominal pressure but failed to re-open the midline wound and perform a temporary closure allowing abdominal wall expansion, using the re-operation as an opportunity to inspect the prior surgeries.

He failed to keep timely, accurate, and legible medical records.  Handwritten notes were illegible, precluding interdisciplinary communication with other physicians and medical staff.

On 9/5/2013, the general surgeon executed a Stipulation and Agreement for Voluntary Surrender of Medical License to resolve an investigation into his conduct with respect to the erroneous removal of a healthy kidney from a patient.  He was suspended by the hospital where the surgery was performed.  He was permanently barred from practicing medicine in Louisiana.

The Board ordered that the general surgeon’s license be surrendered.

State: California


Date: June 2016


Specialty: General Surgery


Symptom: Abdominal Pain


Diagnosis: Acute Abdomen


Medical Error: Wrong site procedure, Improper treatment, Lack of proper documentation, Procedural error


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



Washington – Emergency Medicine – Elevated INR Level, Hypertension, And Administration Of Ketorolac



On 1/20/2012, a 54-year-old male with a history of chronic hypertension had right knee replacement surgery.  He was discharged on 1/21/2012 and Coumadin was prescribed to prevent deep vein thrombosis (DVT).   The patient was apparently confused about his Coumadin dosages and may have taken too much.  On 1/26/2012, his INR level was elevated at 3.2, when 2.0 to 3.0 is normal.  It is unclear whether the Coumadin dosage confusion was ever resolved.

On 2/1/2012, the patient was seen in the emergency department for severe post-operative knee pain.  His knee was evaluated and his symptoms were reviewed.  He had no stroke or seizure symptoms but did have a headache behind his right eye.  His blood pressure was elevated at 180/102.  The patient was given pain and anti-nausea medication, and a number of lab tests were done.  At 1:01 a.m. on 2/1/2012, his INR level was significantly elevated at 5.2.  The lab called the elevated INR results into the patient’s nurse who documented that she notified the ED physician immediately.

A dose of hydromorphone only slightly reduced the patient’s pain, so the ED physician ordered ketorolac (an intravenous NSAID with known risks of bleeding and hypertension complications).  The first dose of ketorolac was given approximately 19 minutes after the ED physician was notified of the elevated INR.  Approximately 45 minutes later, the ED physician ordered a second dose of hydromorphone.  At about the same time, the ED physician ordered a second dose of ketorolac, just 48 minutes after his first dose.  At 3:20 a.m., the patient’s blood pressure was noted at 178/102, and he was discharged at 3:25 a.m. with his knee pain improved.

On 2/2/2012, the patient returned home in the early morning hours and stayed up to perform some knee exercises in his living room.  He was hard to arouse when his teenage daughter found him there.  911 responded and obtained his history from the hospital.  The paramedics concluded the patient had been over-medicated and told his family that he would recover with time.  Three hours later another 911 call was made as the patient’s condition had worsened, and he was transported to the hospital. Upon arrival at the hospital, the patient was unresponsive.  His blood pressure was 178/106, his INR was 5.5, and his right pupil was unresponsive.  His head CT showed a large brain hemorrhage in the right temporal-parietal lobe.  The patient died at 1 p.m. and the cause of death was catastrophic intraparenchymal hemorrhage.

The ED physician’s treatment of the patient fell below the standard of care and may have caused or contributed to the patient’s brain hemorrhage and death in the following ways:

1)     The ED physician gave the patient an initial 30 mg IV dose of ketorolac (which may only be given with caution for patients with hypertension and coagulation disorder) after he knew the patient had chronic hypertension and had critically elevated blood pressure and INR levels.

2)     The ED physician gave the patient a second 30 mg IV dose of ketorolac less than an hour later when the recommended dose is 30 mg every six hours for a healthy individual.

The Commission stipulated the ED physician reimburse costs to the Commission, permit a representative of the Commission to make semiannual review visits, maintain a patient log with the name, date, and time he treats any patient with an elevated INR, complete 6 hours of continuing education covering the subject of risk factors involved in evaluating, prescribing, and managing post-operative emergency department patients with complications including impaired coagulation, hypertension, and elevated INR comorbidities, and write and submit a paper of at least 1000 words, with references, on what the ED physician learned from the courses above, discussing and analyzing the patient’s case, and explaining how he will incorporate what he learned into his practice.

State: Washington


Date: June 2016


Specialty: Emergency Medicine, Internal Medicine


Symptom: Extremity Pain, Headache


Diagnosis: Intracranial Hemorrhage


Medical Error: Improper medication management


Significant Outcome: Death, Hospital Bounce Back


Case Rating: 4


Link to Original Case File: Download PDF



Washington – Family Practice – Accidental Fall With Pain In Hands, Twitching In Extremities, And Muscle Spasms In Legs Months Later



On 2/15/2012, a woman in her late forties met with her family practitioner to address pain in her right knee two days after slipping on the kitchen floor.  The patient reported her knee hurt when bearing weight on it and when turning to the right.  Upon examining the patient’s knee, the family practitioner instructed the patient to wait over the next month for the inflammation to subside and to see if she was able to function as she did before the fall.

On 3/6/2012, the patient sent the family practitioner a secure message requesting a massage prescription, as she had been receiving intermittent massage treatment for many years and felt it helped her with her shoulder pain.  The patient clearly stated the pain was caused by bruxism and caused or increased her tinnitus.  A referral was placed that afternoon by a physician covering for the family practitioner.  The patient responded on 3/12/2012 requesting a prescription, instead of a referral, for insurance purposes.  On 3/13/2012, the family practitioner issued the requested document.  In a subsequent correspondence, the patient also brought up feeling tension in her shoulders when she went down the stairs, feeling nerve pain in her hands and elbows when she sneezed, and walking with numbness in her hands.  The family practitioner did not comment on the patient’s newer symptoms and did not ask her to make an appointment to be seen by the family practitioner.  The family practitioner failed to appreciate the significance of hand numbness and sneeze-induced pain described by the patient.

In May 2012, the patient saw an orthopedic surgeon to further examine her knee.  The orthopedic surgeon’s formal assessment was patellofemoral syndrome.  After the appointment, the patient wrote to the orthopedic surgeon seeking a clear answer regarding the muscle spasms in her legs she was experiencing in about 10-20 times a day and sometimes in her arms.  The orthopedic surgeon told her this issue is not common for someone with her condition and could be a result of a number of things including electrolyte imbalances, dehydration, or neurologic causes and to talk to her primary care provider for further work up.  The orthopedic surgeon provided a report to the family practitioner.

On 6/27/2012, the family practitioner saw the patient to address concerns of increased pain in her hands and how she still felt she had not fully recovered from her fall earlier that year.  She also felt increased pain during exercise and twitching in her extremities.  The patient reported a history of carpal tunnel.  The family practitioner performed an examination of the patient’s wrists and found symptoms consistent with carpal tunnel in the patient’s left wrist.  The family practitioner also noted the patient gained 17 pounds in approximately a year and a half and discussed the long-term importance of staying active.  The family practitioner suspected the patient could be diabetic (as both her parents were diabetic, increasing her risk) and that her possibly having diabetes could be contributing to her neurologic symptoms.  The family practitioner ordered testing for diabetes.  Although diabetes may have been a concern, the symptoms and history are not compatible with a diagnosis of diabetic neuropathy.  Through a secure message two days after the appointment, the family practitioner told the patient that while not yet diabetic, her sugars were higher than before, and that she wanted her to find ways to increase her activity and reduce her weight, and offered to refer her to another provider for a steroid injection in her knee.

On 7/6/2012, the patient sent the family practitioner a secure message in which she described the pain in her hands as “incredible” and when she bent her head down, her left arm went numb.  This symptom is a clear sign of origin in the spinal cord and should have resulted in urgent patient evaluation and prompt referral to neurology or neurosurgery.  The patient reported she wanted to wait six to eight more weeks to see if the pain resolved.  The family practitioner said that six weeks is an appropriate time to wait, and if it was not improving, she would refer the patient for nerve conduction testing and a neurosurgery referral.

On 7/20/2012, after the patient’s pain did not resolve, the family practitioner referred the patient for nerve conduction studies and a neurosurgery referral.  In August 2012, the patient met with a neurologist who confirmed the patient had left-sided carpal tunnel as well as myelopathic symptoms.  Magnetic resonance imaging (MRI) revealed the patient had suffered damage to her spinal cord at C4-C5, C5-C6, and C6-C7 from her fall earlier that year and required surgery.  The patient underwent surgery in late September.

The family practitioner failed to provide an appropriate and timely referral to a specialist.  The patient experiences ongoing symptoms.

The Commission stipulated the family practitioner reimburse costs to the Commission, complete 6 hours of continuing education in the areas of diagnosis and management of spinal cord and nerve root injuries and long-term complications of glucose intolerance and diabetes mellitus, and write and submit a paper of at least 1000 words on the subjects of her continuing education courses and the ways her practice will change based on the experience.

State: Washington


Date: June 2016


Specialty: Family Medicine, Internal Medicine, Neurology


Symptom: Extremity Pain, Numbness


Diagnosis: Spinal Injury Or Disorder


Medical Error: Delay in proper treatment


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 4


Link to Original Case File: Download PDF



Wisconsin – Radiology – CT Scan Interpretation For Unrelenting Postprandial Abdominal Pain



A patient presented with postprandial abdominal pain at an ER in Virginia.  The abdominal pain was described as “unrelenting” and diffuse.

A CT abdomen/pelvis was ordered.  The radiologist interpreted the CT scan by tele-radiology.  The history provided included “right upper quadrant and epigastric pain, vomiting, and WBC of 14.9.”

2 days later after presentation in the evening, an MRA was performed and interpreted by Radiologist B.  It revealed superior mesenteric, celiac, and inferior mesenteric artery occlusions. The patient was taken to surgery.  The next day, he died.

The radiologist acknowledged the findings of superior mesenteric and celiac artery occlusions and acknowledged that he did not report them, either from not observing them or given that there were no other findings to suggest acute ischemia.

Further education on CT scan reading was recommended.

State: Wisconsin


Date: June 2016


Specialty: Radiology, Emergency Medicine


Symptom: Abdominal Pain, Nausea Or Vomiting


Diagnosis: Acute Abdomen


Medical Error: False negative


Significant Outcome: Death


Case Rating: 5


Link to Original Case File: Download PDF



Washington – Gynecology – Endometrial Biopsy Results Reveal Cancer And Difficulty Contacting Patient



A patient began seeing a gynecologist in April 2014, after being informed she may have an ovarian cyst.

On 5/12/2014, an ultrasound showed possible ovarian cysts, as well as changes in the lining of the uterus (endometrium) potentially consistent with cancer.  Approximately one week later, the patient contacted the gynecologist’s office to inquire about the ultrasound results.  The gynecologist’s staff told the patient she had a cyst and instructed her to schedule another appointment with the gynecologist.

On 6/24/2013, the gynecologist performed an endometrial biopsy.  The next day, the gynecologist received a pathology report showing the patient had Grade I (of III) endometrial carcinoma.

The gynecologist made an outside oncology referral.  The patient alleges that the gynecologist did not contact the patient upon receipt of the biopsy results.  The patient had alleged that she learned of the results from the oncology clinic, more than two weeks after the biopsy, when they called her to schedule an appointment.  The patient alleged that when she contacted the gynecologist’s office to ask why they had not informed her of the biopsy results, she was told they had been unable to find her phone number.

On 7/16/2014, the patient contacted the gynecologist’s office again. An ARNP explained the biopsy results and made a copy of the pathology report for the patient.

The patient terminated her relationship with the gynecologist and later underwent a hysterectomy. Her diagnosis was Stage I, Grade II endometrial carcinoma.

The Commission stipulated the gynecologist reimburse costs to the Commission and permit a representative of the Commission to make visits to the gynecologist’s office and review office and medical records and interview the gynecologist and office staff.  Upon request, the gynecologist will also provide the Commission with documentation related to patient information protocol, including the number and types of tests ordered, the methods for relaying the test results, and the timeliness with which results were relayed.

State: Washington


Date: June 2016


Specialty: Gynecology, Oncology


Symptom: N/A


Diagnosis: Gynecological (Endometrial, Ovarian, Cervical) Cancer


Medical Error: Failure of communication with patient or patient relations


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



North Carolina – Family Practice – Ultrasound Shows 6 cm Solid Mass Of The Right Kidney



The Board was notified of a professional liability payment on 08/27/2015.

A 2003 ultrasound report indicated that a patient had a possible 6 cm solid mass on his right kidney.  The written report from the radiologist recommended further evaluation utilizing a CT scan of the kidneys, and specifically noted that “these findings were discussed with the referring physician.”  No follow-up evaluation was obtained.  Several years later, the patient was diagnosed with renal cell cancer.

The Board expressed concern that the family practitioner’s conduct fell below the minimum standard of competence given that he failed to follow up properly on the radiological study.

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: May 2016


Specialty: Family Medicine, Internal Medicine


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


Diagnosis: Cancer


Medical Error: Failure to follow up


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Gynecology – Pathology Showing Serous Cystadenoma, Hydrosalpinx, and Endometrium With Fragments Of Inactive Atrophic Endometrium, Fragments Of Myometrium, And Mature Fibroadipose Tissues



On 4/23/2009, the patient saw a gynecologist to establish herself as a patient for gynecological care.  During this initial visit, the patient reported lower abdominal pain, shifting from left to right over the previous 2 weeks.  A pelvic ultrasound performed 3 weeks before the visit showed a thickened endometrium of 1.2 cm, a small anterior fibroid, and a minimally complex follicle in the right ovary, 1.8 cm.  The gynecologist scheduled the patient for the following surgical procedures: a dilation and curettage, hysteroscopy, laparoscopy, and possible removal of fallopian tube and ovary. The gynecologist did not include any notation in the chart that he discussed alternatives to the surgery to treat the patient, such as repeat ultrasound, endometrial biopsy, or blood work monitoring.  This failure to document that alternatives to surgery were offering or discussed constituted a simple departure from the standard of care.

The patient completed standard consent forms for these procedures, which did not make reference to any unique risk factors due to her specific physical condition.  The patient was morbidly obese when she saw the gynecologist on 4/23/2009. She weighed 321 pounds and had undergone 2 previous abdominal surgeries, an appendectomy, and a cholecystectomy.  Obesity causes additional risks for abdominal surgery, including but not limited to, an increased risk of infection, pneumonia, pulmonary embolism, or other thromboembolic complications, as well as reducing the ability to successfully enter the abdomen and complete the procedure.  Previous abdominal surgeries increase the risk of adhesions, particularly of the bowel to the anterior abdominal wall, which can increase the risk of bowel perforation and its complications. The gynecologist’s failure to provide informed consent on the specific risks of the proposed surgeries to the patient, given her size and previous surgeries, constituted a simple departure from the standard of care.

On 5/5/2009, the gynecologist performed surgery on the patient.  During the surgery, the gynecologist noted that the patient had adhesions of the omentum and bowel to the anterior abdominal wall with only a small window on the right side extending to the pelvis.  The uterus was retroverted and the left tube, ovary, and uterus could not be visualized because of adhesions. The gynecologist removed the right tube and ovary and performed a dilation and curettage and hysteroscopy.  The gynecologist was unable to visualize the tubal ostia. Due to the patient’s large size and adhesions discovered during surgery, the surgery was prolonged. Although it would not be discovered until 6 days later, during the corrective surgery, the gynecologist had perforated the patient’s uterus during the 5/5/2009 surgery and failed to recognize that he had done so.  Although uterine perforation is a known complication of the surgical procedure, the gynecologist’s failure to recognize the complication was poor practice and constituted a simple departure from the standard of care.

On 5/6/2009, the gynecologist received a telephone call from the pathology department indicating that the results of the patient’s pathology showed serous cystadenoma with focal serous adhesions.  The right tube showed hydrosalpinx. The endometrium revealed fragments of inactive atrophic endometrium and fragments of myometrium and finally mature fibroadipose tissues. These findings were suggestive of uterine perforation.  The gynecologist stated that he called the patient on 5/6/2009 to inform her of this finding and set up an office appointment, but that the patient reported she was feeling fine and would keep her appointment of 5/8/2009. The gynecologist did not chart that phone call in the medical record.  The gynecologist did not include a notation in the patient’s chart that he had the telephone call with the patient to inform her of the pathologist’s findings. On 5/8/2009, the gynecologist saw the patient in his office with complaints of bleeding, but no report of fever or abdominal pain other than around the incision.  The gynecologist charted that he performed bimanual examination, which was negative. The gynecologist stated that he offered a CT scan during the appointment on 5/8/2009, which the patient declined. The gynecologist’s failure to place a note in the patient’s medical record indicating that he had a telephone call with her on 5/6/2009 to inform her of the pathologist report, or that he offered a CT scan on 5/8/2009, constituted a simple departure from the standard of care.

On 5/9/2009, the patient called to report continued bleeding.  A group physician took the call on behalf of the gynecologist and directed the patient to report any serious pain, hemorrhage, or fever, but otherwise to follow-up with the gynecologist for an appointment in 2 days.

Two days later, on 5/11/2009, the patient kept her appointment with the gynecologist.  At that appointment, the patient’s condition had deteriorated. The gynecologist diagnosed her with uterine perforation and gastritis and sent her directly to the hospital.  At the hospital, the patient underwent immediate surgery revealing a rectal perforation and multiple pockets of infection throughout the abdomen. The patient had corrective surgery including colostomy.  Postoperatively, the patient had a difficult hospital course, including pulmonary insufficiency, pneumonia, sepsis due to E. Coli, transfusion, and wound care complications. The patient required subsequent, additional corrective surgery.

The Medical Board of California judged that the gynecologist’s conduct departed from the standard of care because he failed to provide specific informed consent, chart that he had advised the patient of surgical alternatives, recognize that he perforated the uterus, and chart the 5/6/2009 telephone call and 5/8/209 offer of a CT scan.

For this case and others, the Medical Board of California ordered the gynecologist to surrender his license.

State: California


Date: May 2016


Specialty: Gynecology


Symptom: Abdominal Pain, Bleeding


Diagnosis: Post-operative/Operative Complication, Sepsis


Medical Error: Procedural error, Delay in diagnosis, Failure of communication with patient or patient relations, Lack of proper documentation


Significant Outcome: Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



California – Anesthesiology – Attempted Intubation On Patient With Abscess At The Right Mandibular Angle



On 3/1/2014, a patient arrived at the hospital by air ambulance.  The patient presented with intermittent respiratory difficulties, and his throat was constricted.  The patient could only open his mouth 1 cm. CT scans of the patient’s neck showed a 6.8 x 4.8 cm abscess at the right mandibular angle.  The CT scans indicated that there were severe edema and tracheal narrowing. The patient complained of respiratory difficulty when lying down.  The patient was prepped for the surgical drainage of the neck abscess. The anesthesiologist assigned to the procedure noted that he performed an assessment at 4:15 p.m.  The patient entered the operating room at 4:23 p.m.

The anesthesiologist documented a compromised airway and noted a CT scan that showed a left shift of pharyngeal tissues.  The anesthesiologist noted the need to perform awake intubation if the airway was compromised. The anesthesiologist administered IV sedation, providing 1 mg x 2 of midazolam and 100 mcg of fentanyl, to the patient.  The anesthesiologist had the patient lay down in a supine position. At 4:30 p.m., the anesthesiologist administered general anesthesia consisting of oxygen and sevoflurane. He then provided the patient with a dose of 80 mg of succinylcholine.

The anesthesiologist attempted to obtain endotracheal intubation while the patient was sedated.  The anesthesiologist repeatedly used a trachlight, also known as a light wand, in an attempt to transilluminate the soft tissues of the patient’s neck for placement of the endotracheal tube.  The anesthesiologist attempted to use different pieces of equipment as he repeatedly tried to intubate the patient. Additional airway equipment was not immediately available and had to be brought to the operating room.  The anesthesiologist did not attempt to wake the patient to try an awake intubation. The anesthesiologist’s multiple attempts at intubation were unsuccessful, and surgical intervention was required. At 5:10 p.m., a surgeon performed a tracheostomy.  The patient’s preoperative note was written at 5:42 p.m., and he signed the note at 5:53 p.m.

The Medical Board of California judged that the anesthesiologist’s conduct departed from the standard of care because he failed to appreciate the degree of airway difficulty in preparation for the administration of general anesthesia despite documenting swelling, a restricted mouth opening, a CT scan showing severe edema and tracheal narrowing, and a complaint of respiratory difficulty when lying down.  The anesthesiologist also failed to prepare for and manage a known difficult airway by inadequately documenting the case before attempts at intubation began, failing to use proper equipment, and failing to have the necessary intubation equipment available in case initial intubation attempts were unsuccessful.

The Medical Board of California placed the anesthesiologist on probation for 4 years and ordered him to complete a medical record-keeping course, education course for at least 20 hours for the first year of probation, and clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California


Date: May 2016


Specialty: Anesthesiology


Symptom: Shortness of Breath, Swelling


Diagnosis: Ear, Nose, or Throat Disease


Medical Error: Procedural error, Underestimation of likelihood or severity, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Anesthesiology – Arteriovenous Fistulogram On Obese Patient With Renal Disease, Asthma, Cardiovascular Disease, Diabetes, And Sleep Apnea



On 3/5/2014, a 55-year-old, 5’3”, and 109 kg (BMI 44.2) female was scheduled for a left arm arteriovenous fistulogram and possible revision of her dialysis fistula to prevent re-bleeding.  An anesthesiologist assumed the anesthesia care of this patient prior to the start of surgery. The patient suffered from a history of end-stage renal disease, had been on dialysis for 15 years, suffered from obesity, asthma, rheumatoid arthritis, diabetes, and sleep apnea, and used home oxygen at night.  The patient also had a history of atrial fibrillation, cardiomyopathy with an ejection fraction of 28%, moderate-severe aortic insufficiency and stenosis, coronary artery disease with stents placed in 2013, and chronic congestive heart failure. The patient had begun to experience bleeding from the AV fistula five days prior to admission.

In his pre-operative note, the anesthesiologist documented that the patient was 100 kg, had chronic renal failure, had coronary disease with stents, had a left bundle branch block, and suffered from occasional gastric reflux.  The anesthesiologist did not note that the patient suffered from sleep apnea, cardiomyopathy, chronic heart failure, atrial fibrillation, aortic valve disease, or diabetes. The anesthesiologist’s note did not document the last time the patient had received dialysis.   The anesthesiologist’s pre-operative note showed that he saw the patient at 3:40 p.m. Anesthesia start time was noted at 3:49 p.m. The note was filed at 4:24 p.m. and signed at 5:18 p.m.

The patient’s vital signs were charted at 3:55 p.m. and were listed as followed: blood pressure of 160/70, pulse of 78/min sinus rhythm, respiratory rate of 20, and 100% oxygen saturation on the 10 L mask.  At 3:50 p.m., the anesthesiologist administered 1 mg of midazolam and 50 mcg of fentanyl and began a propofol infusion. The dose of propofol was not charted. At 4:05 p.m., the anesthesiologist administered 1 mg of midazolam and 50 mcg of fentanyl.  Just prior to the surgeon injecting local anesthetic, the anesthesiologist administered 30 mg propofol, but did not chart the dosage. The anesthesiologist attached the pulse oximeter trace distal to the blood pressure cuff on the same limb. The anesthesiologist also had the patient wear a non-rebreathing oxygen mask.  At 4:20 p.m., the surgery began. During the surgery, the surgeon noticed the patient’s blood had turned dark and that the patient was cyanotic. At 4:28 p.m., it was noted that the surgeon could not feel a pulse, and a code was called.

The anesthesiologist provided 0.4 mg of atropine and 1 mg of epinephrine.  The patient’s blood pressure was 90/40. The anesthesiologist provided a second dose of epinephrine.  The code blue team note began at 4:28 p.m. The patient was intubated at 4:29 p.m. Compressions began at 4:31 p.m.  The code blue team provided one amp of bicarbonate. The patient’s pulse was obtained. Then the patient’s pulse could not be felt a second time.  A second code was called at 4:50 p.m. Further work was done of the patient. The patient was transferred to the ICU, where she remained unresponsive.  She was converted to comfort care and expired that evening.

The Medical Board of California judged that the anesthesiologist departed from the standard of care because he administered doses of sedation to an obese patient with a history of sleep apnea, who was sensitive to the effects of respiratory depressants.  The anesthesiologist was not vigilant during the time that she developed hypoventilation and obstruction. Prior to the surgeon realizing that the patient had no pulse, the anesthesiologist failed to promptly and adequately rescue her.  Once the code was called, the anesthesiologist failed to take an active role in the resuscitation of the patient. The anesthesiologist also failed to recognize and treat respiratory depression, bradycardia, and pulseless arrest. The anesthesiologist’s failure to recognize the patient’s condition led to intubation and airway rescue being delayed, only occurring after the code team had arrived.  The pre-operative note was written and submitted after the patient received IV sedation and signed after she coded a second time. The anesthesiologist did not create a summary note of the code blue events that occurred in the operating room or of the patient’s subsequent death. The anesthesiologist failed to document this intraoperative sentinel event.

The Medical Board of California placed the anesthesiologist on probation for 4 years and ordered him to complete a medical record-keeping course, an education course for at least 20 hours for the first year of probation, and a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California


Date: May 2016


Specialty: Anesthesiology


Symptom: Bleeding


Diagnosis: Cardiovascular Disease, Asthma, Pulmonary Disease


Medical Error: Failure to examine or evaluate patient properly, Improper treatment, Improper medication management, Lack of proper documentation


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



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