Found 36 Results Sorted by Case Date
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California – Neurology – Lamictal, Depakote, And Topamax For Seizures



A 14-year-old girl was referred by her pediatrician to a child neurologist for seizures.  The child neurologist first saw the patient on 8/10/2009. The patient’s first seizure occurred at age 10, early morning on 2/21/2006, and a second episode occurred in the early morning sometimes around December 2008.  At the time the patient saw the child neurologist, her medication included Klonopin 0.5 mg p.m., Depakote at 750 b.i.d., and Vistaril 10 mg p.m. The patient’s MRI on October 2008 was normal. The patient’s EEG performed on October 2007 noted 3-13 seizures.  The child neurologist’s assessment was “juvenile myoclonic epilepsy; rule out adverse effect of med correctly given; insomnia unspecified; depressive disorder; and cafe au lait spots x 2.” The child neurologist ordered a video EEG “to rule out any epileptogenic foci.”

On 8/12/2009, the video EEG was performed.  The technician reported sharp and slow waves left F3-C3.  The child neurologist read it as normal. A BAER was performed on the same day even though it was not ordered by the child neurologist.  The BAER was not indicated, and the referring diagnosis for the BAER was not in the record and was used only for billing.

The child neurologist next saw the patient on 8/21/2009 for a follow-up visit.  The child neurologist noted that the patient was tolerating Depakote well. The Depakote level was 101.  The child neurologist diagnosed breakthrough seizures despite the fact that no seizures were reported. The child neurologist added Topamax Sprinkles 25 mg to increase to 50 mg b.i.d.  She stopped the Klonopin and Vistaril.

On 11/2/2009, the child neurologist saw the patient for a follow-up visit.  She noted that patient was gaining weight with Topamax and wanted to stop Depakote, though it was well tolerated.  The patient had no seizures and no myoclonic jerks. The child neurologist ordered another video EEG without medical indication.  The result of the second video EEG was normal. The child neurologist’s reading of the video EEG followed a template and was the same with all of her video EG reports except for the first paragraph regarding time of sleep, wake, and meals.

The child neurologist next saw the patient on 5/3/2010.  The patient reported no auras or seizures. The child neurologist noted under past medical history that the patient had suicidal thoughts.  The child neurologist did not address this issue during this visit. The child neurologist continued Topamax 50 mg b.i.d., even though there was a note of memory problems.  The child neurologist reduced Depakote to 500 b.i.d. She ordered labs and a 4-day ambulatory EEG without any medical indication. The 2 previous video EEGs were normal, and the patient did not have any seizures.  The patient underwent a third video EEG on this visit, which was not ordered nor medically indicated.

On 6/8/2010, the child neurologist saw the patient for a follow-up visit.  The patient was taken off Topamax. Her memory improved, but her headaches recurred.  The child neurologist diagnosed migraines without asking sufficient questions to make that diagnosis.  She added amitriptyline 10 mg, Imitrex 100 mg, and continued Depakote 500 b.i.d.

The 4-day ambulatory EEG ordered on 5/3/2010 was performed on 7/6/2010.  It was completed despite the fact that the patient just underwent a third video EEG on 5/3/2010.  There was no medical indication for the 3 previous EEGs and the 4-day ambulatory EEG. The 4-day ambulatory EEG was read as normal.

On 8/23/2010, the child neurologist saw the patient for 2 back-to-back seizures that occurred on 8/11/2010.  The patient was taken to the emergency room with a history of early morning twitching since the seizures. The child neurologist’s assessment was breakthrough seizures.  The child neurologist added Lamictal 100 mg b.i.d. and raised Depakote from 500 mg b.i.d. to 1000 mg b.i.d. The child neurologist failed to recognize that on 7/29/2010, the patient was having myoclonic jerks, which were described as twitches.  The patient had been on 750 mg b.i.d. with a level of 100 and had been seizure free for 2 years. The child neurologist failed to recognize the important interaction between Lamictal and Depakote. The child neurologist failed to consider that it was very likely that the patient had toxic levels of both Depakote and Lamictal.  The child neurologist did not check the patient’s blood levels. The child neurologist ordered another video EEG and another ambulatory EEG. The video EEG was performed on September 2010 and was normal. The child neurologist used the same template on her report.

The child neurologist next saw the patient on 11/4/2010.  The patient was unable to sleep, had difficulties with coordination and balance, was forgetful; all symptoms consistent with medication toxicity.  The child neurologist failed to recognize it as such. The patient was on Depakote 500 mg b.i.d. and Lamictal 100 mg b.i.d. Suicidal ideation was noted in the child neurologist’s previous notes, but the child neurologist failed to address this issue.  The child neurologist added Prozac 20 mg, which had a black box warning for suicidal ideation.

The Medical Board of California judged that the child neurologist’s conduct departed from the standard of care because she ordered 4-5 video EEGs and an ambulatory EEG without medical indication, ordered a BAER with no medical indication, lacked knowledge and/or did not consider the important interaction between Depakote and Lamictal.  The child neurologist diagnosed migraines without establishing diagnostic criteria, diagnosed circadian sleep disorder without asking any questions regarding symptoms and adding the polysomnogram report in the chart, and prescribed Prozac to patient with a history of suicidal thoughts despite the black box warning.

For this case and others, the Medical Board of California placed the child neurologist on probation and ordered the child neurologist to complete a medical record keeping course, a professionalism program (ethics course), an education course (at least 40 hours per year for each 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.  The child neurologist was assigned a practice monitor and was prohibited from supervising physician assistants and advanced practice nurses.

State: California


Date: January 2018


Specialty: Neurology, Pediatrics


Symptom: Headache


Diagnosis: Neurological Disease, Drug Overdose, Side Effects, or Withdrawal, Psychiatric Disorder


Medical Error: Improper medication management, Diagnostic error, Failure to examine or evaluate patient properly, Unnecessary or excessive diagnostic tests


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Virginia – Psychiatry – Adjusting Lithium Dosage Based Only On Patient Symptoms



A psychiatrist increased and decrease a patient’s lithium dosage based on the patient’s symptoms.  She did not test the patient’s lithium blood serum level.

On 8/28/2015, the patient was admitted to a hospital for lithium toxicity.  The psychiatrist stated that lithium blood serum levels for long-term lithium patients should be tested at least annually, but also at any time a patient complains of adverse side effects.  The psychiatrist admitted her failure to test the patient’s lithium levels and stated that it “was an inadvertent oversight for which [she] is remorseful.”  The psychiatrist reported that following the patient’s hospitalization for lithium toxicity, she reviewed the charts for her other patients on lithium and determined if they needed testing for lithium blood serum levels.

She provided evidence that she completed 99 hours of CME in psychiatry in 2015 and 58 credit hours of CME in psychiatry in 2017.  She provided a spreadsheet that she created for use in monitoring her patients on lithium.  She was reprimanded by the Virginia Board of Medicine.

State: Virginia


Date: October 2017


Specialty: Psychiatry


Symptom: N/A


Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Psychiatric Disorder


Medical Error: Improper medication management, Failure to properly monitor patient


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Vermont – Family Practice – Oversight In Anorexia Nervosa Monitoring



A patient was treated by a family practitioner from May 2012 to September 2012.

On the first office visit, the patient presented with symptoms and behaviors that met the DSM-IV criteria of anorexia nervosa, as well as the National Institute for Mental Health criteria of Pediatric Acute Neuropsychiatric Syndrome (PANS).  The patient’s medical records from the patient’s prior primary care physician included a diagnosis of anorexia nervosa and a prior recommendation for inpatient mental health treatment for anorexia.

The family practitioner made the following diagnoses:  systemic inflammatory syndrome with multi-systemic symptoms and marked neuropsychiatric dysfunction with probable underlying infectious triggers; PANS (Pediatric Acute Neuropsychiatric Syndrome); and probable PITANDs (Pediatric Infection-Triggered Autoimmune Neuropsychiatric Disorders).  Anorexia nervosa was not documented as a primary or differential diagnosis.  The family practitioner indicated that he considered the possibility of a purely behavioral syndrome like anorexia nervosa, but felt that the patient’s anorexia was “part of a more complex multi-system picture.”

The family practitioner based his diagnosis on the patient’s history and symptoms meeting the diagnostic criteria for PANS, testing positive to three infectious agents, and an initial response positive response to PITANDs treatment, in addition to a lack of positive response to anorexia nervosa focused management with the patient’s prior primary care physician and other consultants.

The family practitioner saw the patient on three occasions over a four month period, which the Board believes is inadequate for management of anorexia for an adolescent.  The family practitioner relied on his nurse to call the patient on weekly updates and weight checks.

In addition to three office visits, the family practitioner’s treatment included ordering numerous blood tests, and the prescribing of medications, antibiotics, herbal supplements, and vitamins for the infection etiologies and the inflammatory conditions.  However, he did not prescribe any medications for the treatment of anorexia nervosa. While the family practitioner believed that the patient was being treated by his primary care physician, this was not confirmed with any other provider, and the family practitioner did not communicate directly with any other provider beyond sending his initial office visit note and lab results to the patient’s primary care physician.

The Board judged the family practitioner’s medical records and communication with the patient’s primary care physician concerning his treatment of the patient were inadequate. The family practitioner’s office notes did not document past surgical and family history, temperature, height, BMI calculation, and growth curve charting.

Based on review of the family practitioner’s medical records concerning his treatment of the patient and the documentation of his communication with the patient’s parents, it appears that the family practitioner did not clearly explain his role in the patient’s care to the patient’s parents until the end of his treatment.  Is it possible that the patient’s parents believed that the family practitioner had taken over the role as the primary care physician and was actively managing the patient’s care.

The family practitioner’s position was that he believed that he was participating in the care of the patient in the role as a consultant to his primary care physician and that the patient’s primary care physician was concurrently monitoring the patient.  With the exception of the provision of his initial office note and lab results, the family practitioner did not communicate with the patient’s primary care provider during the course of his treatment.  After sending his initial note and lab results, the family practitioner did not communicate with the patient’s primary care provider or any other medical professionals until the patient had an acute worsening of the condition on 9/13/2012.

The Board judged that the family practitioner failed to appropriately monitor, manage, and maintain comprehensive medical records on a juvenile patient with a severe eating disorder.

The Board ordered that the family practitioner be reprimanded, complete one hour of continuing medical education on cognitive bias, and that he shall only practice medicine in a structured, group setting for a period of three years.

State: Vermont


Date: September 2017


Specialty: Family Medicine, Psychiatry


Symptom: Weight Loss


Diagnosis: Psychiatric Disorder


Medical Error: Improper treatment, Failure of communication with other providers, Failure of communication with patient or patient relations, Failure to properly monitor patient, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Vermont – Psychiatry – Pediatrician Prescribes A Combination Of An SSRI And A Benzodiazepine



A pediatrician first met a patient in 2010 when conducting a routine college physical.  In 2011, the pediatrician started the patient on Prozac (fluoxetine) 10 mg daily after the patient started reporting that he was having problems with depression.  After a month, the patient indicated that the medication was working “a little” and denied any side effects, the pediatrician prescribed another 30 tablets of Prozac 20 mg with no refills.

The pediatrician did not see the patient again until 1/30/2014 when the patient came in for a physical exam.  The pediatrician documented that the patient was doing well and was off Prozac.

On 1/22/2015, the patient again came in to see the pediatrician for a physical exam.  The patient was experiencing decreased energy levels, sleeping well, having some difficulty with depression and occasional panic attacks.  The patient was noted as stating that the Prozac he had taken previously did not really help.  The notes document that education and counseling were done, but there was no comment on suicidality.

The pediatrician started the patient on Prozac 40 mg once a day, 30 tablets with no refills, because he had tolerated the 20 mg dose in the past with no side effects.  The patient was also prescribed Xanax (alprazolam), 0.25 mg, 5 tablets with no refills, and was told to take one as needed.

On 1/29/2015, the patient was seen by the pediatrician to follow up on his anxiety and depression.  The patient reported that he was still having panic attacks, for which he took 2 of the 0.25 mg Xanax, and that overall his depression was worse, but that he was dealing more with anxiety than depression.  The patient indicated that he was tolerating the Prozac well.  The patient denied any suicidal ideation or planning.  The pediatrician prescribed the patient Klonopin (clonazepam) 1.0 mg, two times a day, 60 tablets with no refills and increased his Xanax prescription to 0.5 mg as needed, five tablets with no refills.  The pediatrician documented that he provided education and counseling and referred the patient to psychiatry, although the patient indicated that he did not want to go.

On 1/31/2015, the patient reported losing most of his Xanax at work.  The pediatrician advised the patient to stay on Prozac and Klonopin and to save the few Xanax he had for severe panic attacks.  The pediatrician advised the patient that he would look into getting the patient to see a psychiatrist and that he would figure out what to do with the Xanax the following week, but in the meantime, the patient could go to the emergency department or call the pediatrician if he had a panic attack.  The patient agreed to this plan.

During this time, the mother observed changes in the patient’s behavior, including slurring of words, wobbling on his feet, and sleepiness and the patient also became erratic and volatile.  This was not brought to the attention of the pediatrician.

On the morning of 2/2/2015,  the patient called his mother from work and advised they were sending him home because his behavior was similar to someone who was intoxicated.  It was also claimed the patient met with a pharmacist at work, who allegedly told him that the dose of Klonopin was too high and he should cut the dose in half.

The patient returned home and continued to exhibit erratic, volatile, and irrational behavior.  The patient also advised his mother that he tried to cut his wrist and glued it shut.  None of these events were told to the pediatrician and the patient did not show the cut to the pediatrician during the appointment on 1/29/2015 appointment.  The patient made an appointment with another doctor, but could not get in until 2/6/2015.  The patient’s mother asked the patient if he wanted to go to the emergency department but the patient declined, indicating that he had a plan (to cut the dose of Klonopin in half).  That evening the patient had an argument with his girlfriend and committed suicide.

Prozac (fluoxetine) packaging contains a “Black Box” warning for patients up to 21 years of age that indicates there is a very small chance of an adverse reaction that can make the patient more agitated and prone to increased suicidal thoughts.  The patient’s medical chart does not indicate whether the pediatrician explained the Black Box warning to the patient.

The pediatrician retired from the practice of medicine in Fall 2016 as previously planned and for reasons totally unrelated to the allegations in this matter.  He is not currently practicing medicine in the State of Vermont.

The Board judged the pediatrician’s conduct to be below the minimum standard of competence given his failure to maintain adequate and comprehensive medical records, his improper prescribing of an unusually high dose of Prozac, Xanax, and Klonopin, and his failure to conform to the essential standards of acceptable and prevailing practice.

The Board ordered that the pediatrician be reprimanded, pay a fine, and if he applies for a license renewal, he must take a continuing education course on psychotropic medications and retain the services of a practice monitor for a minimum of two years.

State: Vermont


Date: July 2017


Specialty: Psychiatry, Pediatrics


Symptom: Psychiatric Symptoms


Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Psychiatric Disorder


Medical Error: Improper medication management, Lack of proper documentation


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Internal Medicine – Patient With Suicidal Ideations Referred To A Psychiatrist For The Following Day



On 12/1/2014, a 68-year-old female presented to an internist for a three-month follow-up appointment for hyperlipidemia, anxiety with panic attack, and hypertension.  The patient reported a twenty-year history of untreated depression that was worsening.

The patient reported suicidal ideations, including that the patient had been sitting with a gun to her head.

The internist’s progress note for the patient included a statement that the patient needed to see a psychiatrist that day.  The internist referred the patient to a psychiatrist and scheduled an appointment with the patient with the psychiatrist the following day.

The Board judged the internist’s conduct to be below the minimal standard of competence given that he failed to arrange for the patient to be escorted to a psychiatrist or an emergency department that day.

The Board issued a letter of concern against the internist’s license.  The Board ordered that the internist pay a fine of $5,000 against her license and pay reimbursement costs for the case at a minimum of $1,983.04 and not to exceed $3,983.04.  The Board also ordered that the internist complete five hours of continuing medical education in depression, which shall include the diagnosis and treatment of patients with depression, and complete five hours of continuing medical education in “risk management.”

State: Florida


Date: June 2017


Specialty: Internal Medicine, Psychiatry


Symptom: Psychiatric Symptoms


Diagnosis: Psychiatric Disorder


Medical Error: Delay in proper treatment


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Family Practice – Elevated Glucose Levels In A Patient On Aripiprazole, Asenapine, Quetiapine, And Olanzapine



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



California – Family Practice – Patient With Multiple Psychiatric Conditions And A Low Platelet Count Placed On Enbrel For Rheumatoid Arthritis



On 11/17/2008, a family practitioner first began treating the patient.  The family practitioner treated the patient for anxiety, panic disorder, neuropathic pain from an old left thigh stab wound, post-traumatic stress disorder, bipolar disorder, chronic insomnia, obesity, and hypothyroidism.

On 7/18/2013, the patient was seen in an emergency department.  The laboratory results from that visit indicated that the patient had a very low platelet count of 63,000 versus a normal platelet count of 140,000 to 150,000.  The laboratory results also stated that the mean corpuscular volume (MCV) was found to be 106.6.  The MCV is the average volume of red cells in a specimen.

On 7/19/2013, the patient was treated by the family practitioner.  The medical notes for that visit state that the patient “returns for follow up on an ER visit yesterday for abdominal pain.”  The notes also state, “Labs reveal macrocytic RBC indices.”

Red blood cell (RBC) indices are part of the complete blood count (CBC) test.  The indices also include MCV, hemoglobin amount per red blood cell (MCH), and the amount of hemoglobin relative to the size of the cell (hemoglobin concentration) per red blood cell (MCHC).

The MCV, MCH, and MCHC were all recorded in the patient’s laboratory results from the 7/18/2013 emergency department visit.

On 8/9/2013, the patient commenced treatment for rheumatoid arthritis by using the drug Enbrel, which was prescribed by the family practitioner, even though Enbrel can cause a low platelet count and even though the family practitioner knew or should have known that as of 7/19/2013, the patient’s platelet count was low.

On 10/8/2013, the patient informed the family practitioner that another clinic treating the patient noted that the patient’s platelet count was dropping and advised the patient to go directly to the hospital for a blood draw.  The family practitioner then discontinued the patient’s use of Enbrel, writing, “discussed fact that thrombocytopenia is a rare but recognized adverse side effect of Enbrel treatment.”

Additionally, any patient treated with Enbrel should have a Tuberculosis (TB) skin test prior to commencing therapy in order to confirm the absence of disease.

Contrary to standards, the family practitioner provided no documentation for the required pretreatment negative tuberculin skin test prior to the commencement of treatment with Enbrel.  In fact, not until 9/17/2014, more than one month after treatment with Enbrel commenced, was a negative TB skin test noted in the patient’s medical record.

On 10/18/2011, the family practitioner noted in the patient’s medical records that the patient was positive for hepatitis C.  Yet, the family practitioner never referred the patient to a liver specialist for hepatitis C.

The family practitioner allowed the patient to dictate the treatment by prescribing, on multiple occasions, medications that the patient had requested.

On 7/8/2009, the family practitioner prescribed clonidine for the patient for insomnia.  Clonidine is a drug normally used to treat hypertension, but it has been effectively used in low doses to treat insomnia in children on ADHD medications.  At that time, the patient’s blood pressure was charted as 110/60.

On 7/15/2009, the family practitioner discontinued the patient’s use of clonidine when the patient reported that the medicine was not effective for sleep and that it caused dizziness.  On that same date, the patient’s blood pressure was charted as 80/60.

Between 7/8/2009 and 7/15/2009, the patient was using the following medications with the family practitioner’s knowledge: fluoxetine, diphenhydramine, clonidine, and olanzapine.

On 8/16/2011, the family practitioner prescribed Saphris for the patient for insomnia, even though insomnia is a known side effect of Saphris.  By 9/9/2011, the patient stopped taking Saphris after claiming to have developed a tolerance for the medication.

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.

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: Psychiatric Symptoms, Dizziness


Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Psychiatric Disorder


Medical Error: Improper medication management


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Psychiatry – Improper Prescribing Practices Of Quetiapine, Venlafaxine, Lamotrigine, Lorazepam, Zolpidem, Fluoxetine, And Alprazolam



On 8/7/2012 continuing through 9/13/2013, a patient received psychiatric treatment from a psychiatrist over eight appointments.  The patient presented as a 54-year-old 135-pound female patient seeking treatment for the management of bipolar disorder.  During each of these appointments, the patient was at the hospital while the psychiatrist provided treatment remotely from his home via telepsychiatry.  The initial assessment noted that the patient was normal for mood, affect, memory, depression, and anxiety with no suicidal ideation.  Per the Board, the psychiatrist’s medical records for the patient failed to contain an adequate history of the patient and lacked adequate documentation to support a bipolar diagnosis.

Over the course of his treatment of the patient, the psychiatrist consistently prescribed large quantities and high doses of psychiatric medications to be taken simultaneously, including the following: quetiapine, venlafaxine, lamotrigine, lorazepam, zolpidem, fluoxetine, and alprazolam.

The psychiatrist prescribed the patient 10 mg of zolpidem despite the advisory from the FDA that women should receive no more than 5 mg due to the potential for cognitive and memory impairment and the psychiatrist’s medical records for the patient fail to reflect a consideration or discussion of the risks versus benefits of treatment with this medication.  The psychiatrist prescribed the patient daily doses of quetiapine and venlafaxine at the maximum recommended dose.  The psychiatrist prescribed the patient lamotrigine at twice the recommended dose for bipolar disorder and the psychiatrist’s medical records for the patient fail to reflect why he chose to prescribe the medication at these doses.

Per the Board, the psychiatrist diagnosed the patient with depression; however, he failed to adequately document the history, extent, degree or other information regarding the patient’s depression or include any identifiable symptoms that might support a diagnosis of depression.  The psychiatrist failed to recognize and/or document the possibility that the patient’s flat affect could be caused by overprescribing and polypharmacy given the extraordinarily high doses of quetiapine and benzodiazepines he prescribed.

The psychiatrist diagnosed the patient with insomnia; however, he failed to adequately document the patient’s difficulty sleeping or include any identifiable symptoms that might support a diagnosis of insomnia.  The psychiatrist failed to recognize and/or document the possibility that the patient’s insomnia could be caused by overprescribing and polypharmacy given the extraordinarily high doses of antidepressants (venlafaxine, mirtazepine, and fluoxetine) he prescribed, which are known to produce insomnia in patients.

The psychiatrist failed to discuss and/or document a discussion of the risk of metabolic syndrome with the patient.  The psychiatrist failed to monitor and/or order labs to check the lipids, blood sugar, or weight of the patient, all of which are known risk factors with high dosages of quetiapine.

The psychiatrist’s records for the care and treatment of the patient mostly consisted of identical information copied from one appointment to the next.  Per the Board, the psychiatrist’s notes failed to contain any useful information that is unique to the patient and instead contained only conclusions without facts to support them.  The mental status examination, interval history, and diagnosis portions of the medical records were identical in wording and formatting throughout all eight appointments with the psychiatrist.  In contrast to the boilerplate language copied from prior visits, the limited number of original entries by the psychiatrist were short, telegraphic informational, and appeared in short lines with abbreviation and misspellings.  The psychiatrist’s medical records for the patient failed to document prescriptions of Percocet from another medical provider.

On 2/14/2013, the patient presented to the hospital emergency department with a “possible accidental overdose of benzodiazepines.”  The patient was treated but was not admitted to the hospital.  The psychiatrist saw the patient several days later and attributed the overdose to an accidental overdose due to taking the incorrect medication in the dark.  The psychiatrist prescribed multiple psychiatric medications without reducing the dose or quantity of medications available to the patient to prevent a future overdose due to noncompliance with the medication regimen.  The psychiatrist failed to document the potential for a repeated overdose event in the patient’s medical records.

On 6/17/2013, the patient presented to the hospital emergency department unconscious with a CPK over 3000 and elevated BUN and creatinine levels.  The patient was admitted and with a diagnosis of acute rhabdomyolysis, dehydration, and benzodiazepine overdose.  Toxicology tests were negative for substances of abuse, but revealed high levels of the byproducts of venlafaxine, fluoxetine, mirtazapine, alprazolam, and nortriptyline.  The patient became septic with multiple organ failure, went into a coma, and was intubated on 6/22/2013 and subsequently transferred to another hospital.

The Board judged the psychiatrist’s conduct as having fallen below the minimum level of competence given his unnecessary prescription of multiple simultaneous prescriptions of two short-acting benzodiazepines to be taken concurrently with zolpidem, his prescription of numerous dangerous drugs and controlled substances in the absence of a discussion over the risks of treatment, his prescription of excessive doses of zolpidem, his failure to obtain a second opinion, his failure to assess the patient’s suicide risk, and his overall failure to appropriately manage the patient’s medications.

The Board ordered that the psychiatrist be placed on probation for a period of three years, complete 40 hours of continuing medical education for each year of probation, enroll in a prescribing practices course, enroll in a medical record keeping course, be prohibited from supervising physician assistants, and be assigned a practice monitor.

State: California


Date: November 2016


Specialty: Psychiatry


Symptom: Psychiatric Symptoms


Diagnosis: Psychiatric Disorder, Drug Overdose, Side Effects, or Withdrawal


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


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Washington – Psychiatry – Ingestion Of A Large Dose Of Zoloft In A Suicide Attempt



On 1/25/2016, a patient reported to the emergency department for treatment of the ingestion of a large dose of Zoloft in an apparent suicide attempt.  The patient reported that she took the medication approximately four hours prior to her arrival to the emergency department.  The patient indicated she had a twenty-seven-year history of depression.

The emergency department notes indicated that the patient suffered nausea, vomiting, and tachycardia.  After successful treatment of the patient’s drug ingestion, she was still deemed to be at risk for suicide, and inpatient treatment was recommended.  The patient was stabilized after a course of inpatient treatment and subsequently discharged.

On 3/21/2016, the physician that had prescribed the Zoloft told the Commission that the patient had received a consistent dose of Zoloft from primary care providers for approximately eight to ten years for treatment of depression.  The physician indicated that he provided the patient with prescriptions for Zoloft on two or three occasions since 2010 to avoid interruptions in her ongoing regimen, due to difficulties establishing timely medical appointments and changes with insurance provider procedures.  When writing the patient’s prescription for Zoloft, the physician used his typical prescription language allowing renewals to be refilled for up to one year.  The physician did not document the prescriptions or physical assessment of the patient in the medical record.

The physician failed to meet the standard of care in prescribing Zoloft for the patient when he provided her, a patient with a twenty-seven-year history of depression, with a year supply of medication on several occasions without proper evaluation or follow-up of her condition.

The Commission stipulated the physician reimburse costs to the Commission, complete a live/in-person course on prescribing medications, and write and submit a paper of at least one thousand words, plus bibliography, addressing the risks of prescribing medications without appropriate clinical oversight and recordkeeping.

State: Washington


Date: August 2016


Specialty: Psychiatry


Symptom: Nausea Or Vomiting, Palpitations


Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Psychiatric Disorder


Medical Error: Improper medication management


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



North Carolina – Psychiatry – Patient Expresses Suicidal Intent If He Were To Be Arrested



The North Carolina Medical Board was notified of an action taken by the Florida Board of Medicine against a psychiatrist’s medical license.

On 09/20/2012, a patient was arrested and charged with indecent exposure.  The patient indicated that if he were to be arrested, he would commit suicide.  The patient was involuntarily brought to the hospital where an ED physician was employed.

The psychiatrist admitted the patient for overnight observation and the following morning determined that the patient was not a suicide risk and discharged him back to the police.  The next day, the patient committed suicide.

On 03/13/2015, as a result of the patient’s suicide and information provided to the Florida Board, an administrative complaint was filed against the psychiatrist alleging that the psychiatrist had not performed a thorough examination of the patient.

On 08/18/2015, the complaint was resolved by a Final Order and Settlement Agreement.  In this agreement, it was noted that the psychiatrist was issued a letter of concern, ordered the psychiatrist to complete continuing medical education in risk management, and ordered to pay a fine.

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: June 2016


Specialty: Psychiatry


Symptom: Psychiatric Symptoms


Diagnosis: Psychiatric Disorder


Medical Error: Underestimation of likelihood or severity


Significant Outcome: Death


Case Rating: 2


Link to Original Case File: Download PDF



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