On 11/6/2007, a family practitioner first began treating a patient and continued treating the patient until at least 6/9/2014.

On 12/21/2009, the family practitioner noted in the patient’s medical records that the patient was diabetic, writing “Lab-Spot glucose 242.”  A level of 200 mg/dL or higher often means one has diabetes.

On 1/11/2010, the next exam noted in the patient’s records, the family practitioner noted a refill was needed for glipizide.  However, there is no record that the patient was ever prescribed glipizide prior to this date.

During the course of treatment from the family practitioner, the patient was also prescribed aripiprazole, quetiapine, asenapine, and olanzapine for bipolar disorder.  Aripiprazole, asenapine, and olanzapine can cause or worsen diabetes.  According to medical notes, on 6/13/2011, the family practitioner was treating the patient with both aripiprazole and olanzapine as well as glipizide, which was to control diabetes.

On 7/11/2011, the patient’s blood sugars were noted to be in the 400 range, while 100 to 110 is considered to be the normal range for blood sugars in an individual.  The family practitioner started the patient on insulin glargine to address diabetes on a daily basis.

In an interview that occurred on 10/1/2015, the family practitioner admitted that the family practitioner had no idea if the patient was taking the prescribed medications while under his care.

The Board judged the family practitioner’s conduct as having fallen below the standard of care for multiple patients given failure to record a physical exam in the progress notes, failure to revise and update assessments or plans for those patients, and failure to include a problem list or medication list in his progress notes.  In addition, the family practitioner’s repeated, excessive and/or inappropriate prescribing of large doses of multiple strong antipsychotic medication and antidepressants to the patient with no regard or concern for drug interactions constituted a lack of knowledge and/or unprofessional conduct.

The family practitioner was placed on probation for 5 years with the stipulations of completing 40 hours annually of continuing medical education in the areas of deficient practice, a prescribing practices course at the Physician Assessment and Clinical Education Program, a medical record keeping course, an ethics course, a clinical training program equivalent to the Physician Assessment and Clinical Education Program, and undergo clinical practice monitoring.

State: California

Date: November 2016

Specialty: Family Medicine, Internal Medicine, Psychiatry

Symptom: N/A

Diagnosis: Diabetes, Psychiatric Disorder

Medical Error: Improper medication management, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF