Risk Management Tools & Resources


CASE STUDY: Electrolysis Treatment Removes Unwanted Hair but Causes Another Unsightly Outcome

Laura M. Cascella, MA, CPHRM


Case Details

The patient, a female in her mid-thirties, presented to a dermatology practice for consultation regarding hair removal on both sides of her chin. The patient met with an esthetician employed by the practice, who requested that the patient fill out a skin care questionnaire. The patient complied, and described her skin's complexion as olive and noted that she rarely burns.

The patient was scheduled for her first electrolysis treatment approximately 10 days later. At that appointment, the patient was not assessed by a physician prior to the esthetician beginning treatment. During the electrolysis, the patient reported pain. The procedure was briefly stopped so the esthetician could "fan" the skin to cool it, and then the treatment resumed. Following the first electrolysis appointment, the patient called the dermatology practice to report chin swelling. The esthetician reassured the patient that it was fine. The swelling eventually resolved, but the area remained red.

About a month later, the patient returned for a second electrolysis treatment. At that time, the esthetician told the patient that she would turn down the laser settings, which would prevent swelling and further redness. Following the second treatment, the patient called to report that her skin had blistered and an "indent" had appeared on her chin.

It was ultimately determined that the patient had suffered a deep tissue injury to her chin as a result of inappropriate laser settings, which resulted in a permanent divot. The patient filed a malpractice lawsuit against the physician owner of the dermatology practice alleging improper supervision and vicarious liability for the esthetician's actions. The case was settled with a payment in the midrange and defense costs in the low range.


Numerous common risk factors that lead to medical errors and subsequent malpractice claims occurred in this case. Two related risk factors — practicing beyond scope and credentialing issues — paved the way for the patient's adverse outcome.

Scope of practice refers to the functions that healthcare providers are permitted to perform as licensed professionals — such as diagnosing, treating, and prescribing. Scope of practice for a given profession is determined by state laws and regulations as well as standards and competencies set forth by professional associations and organizational policies.

In this case, the esthetician who performed the electrolysis had a cosmetology license, but the state where the dermatology practice was located required a master esthetician license to perform laser treatments. Thus, the esthetician was practicing beyond the legal scope of practice for her state, and her license was suspended as result of this case. This deviation from the legal scope of practice also called into question the dermatology practice's credentialing and privileging procedures.

Credentialing and privileging are the processes by which a healthcare organization assesses and confirms the qualifications of a practitioner and authorizes the provision of specific services. The dermatology practice's credentialing and privileging processes should have included verification of the type of license that the esthetician held, and any privileges granted to her should have been consistent with state regulations for that type of license.

The state where the dermatology practice was located also required that laser treatments must be performed under the supervision of a physician, who must first assess the patient and review the laser settings. Neither occurred in this case, and the practice did not have any written policies or protocols related to supervision requirements. Together, these risk issues resulted in liability exposure for the physician owner of the dermatology practice.

A final issue in this case was documentation. The most egregious documentation issue occurred following the patient's second treatment and subsequent complaint of the blistering and indent on her chin. The esthetician altered the patient's health record with an entry that was back-dated to the time of the patient's initial consultation. In that entry, the esthetician alleged that the patient initially sought treatment because she already had the divot in her chin from previous laser treatment. The entry also noted that the patient was initially happy with the treatment that the esthetician provided, but then claimed the treatment resulted in the injury.

Inadequate documentation also was problematic in this case. Aside from the back-dated entry, the esthetician's documentation about the patient's consultation and treatment was scant, and — without appropriate supervision — the lack of documentation was never addressed. Further, the skin assessment questionnaire that the patient completed was not included in her health record, and it's not clear whether the esthetician reviewed the form in preparation for selecting the appropriate treatment and laser settings for the patient.

When combined with all of the other issues in this case, the documentation issues eroded the credibility of the dermatology practice and made the case difficult to defend.

In Summary

Healthcare practices of all types, including those that offer cosmetic services, must be knowledgeable about state laws that regulate licensing, scope of practice, and supervision requirements for the types of providers they employ.

Practices should have formal credentialing and privileging processes as well as ongoing competency evaluation to ensure the safety of patients and reduce liability exposure. Further, written policies and protocols should guide supervisory requirements and expectations for documentation in health records, and practice leaders should monitor for compliance with these policies.

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