Found 36 Results Sorted by Case Date
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Arizona – Psychiatry – Care Of A Patient Over 10 Years Starting At Age 5



In September 1996, a 5-year-old girl presented to a psychiatrist with the assessment of Attention Deficit Hyperactivity Disorder and possible depression.  The psychiatrist’s nurse practitioner documented that she had excessive anger, difficulty following direction, excessive worry, and impulsivity.  The nurse practitioner diagnosed the girl with depression not otherwise specified.  She prescribed fluoxetine and set up follow-up in a month.

At the second visit, the girl reported that she had been hearing voices.  The nurse practitioner changed her diagnosis to bipolar disorder and initiated divalproex sodium.  The psychiatrist was not present during the initial assessment, but he co-signed the nurse practitioner’s note and ordered refills of fluoxetine.

In December of 1996, the psychiatrist first saw the patient for a medication review and documented that the patient was still hearing voices.  Fluoxetine was discontinued.  A follow-up was scheduled for 2-6 weeks with the nurse practitioner and for 8-10 weeks with the psychiatrist.

On 01/01/1997, a colleague of the psychiatrist ordered admission of the patient to a hospital given that she had brandished a knife at home.

On 01/06/1997, the psychiatrist gave a telephone order to discharge the patient home to her mother.  The discharge summary was not completed until 01/28/1997.

On 01/24/1997, the patient was seen by the nurse practitioner, who documented that the girl was still hearing voices, but only at home and not at school.  The nurse practitioner increased the dose of thioridazine (unclear if started in the hospital), and the psychiatrist signed the note.  The psychiatrist did not see the patient until more than 8 months after her discharge from the hospital.

The psychiatrist continued to treat the patient for the next ten years.  He saw the patient fourteen times and documented her behaviors as “nasty,” “belligerent,” “hostile,” and “irritable.”  During that time, her diagnosis remained unchanged.  The interval between visits varied between two weeks and eighteen months.  The psychiatrist continued to prescribe, change, and refill medications without seeing the patient in person or documenting a rationale for the changes.

In 02/2005, the patient was admitted to a hospital after threatening her mother.  The treating physician noted that the patient’s admission was a consequence of mood disorder due to medications that were inconsistent and variable.

In 03/2005, the patient was discharged.  The psychiatrist did not see the patient until almost one month after her discharge.

Over the next two years, the psychiatrist saw the patient six times, but continued to write prescriptions for several classes of medications.

The Board deemed the physician’s conduct to have fallen below the standard of care in several respects:

1) He failed to conduct a comprehensive psychiatric evaluation prior to establishing a diagnosis or initiating treatment.

2) He engaged in polypharmacy by prescribing thioridazine in addition to other antipsychotics and mood stabilizers without documenting psychosis or cyclical mood disturbance.

3)  He failed to obtain an EKG prior to the initiation of thioridazine.

4) He prescribed a tranquilizing medication to a non-psychotic child as a chemical restraint.

5) He failed to administer the Abnormal Involuntary Movement Scale test at least every 6 months to assess for drug-induced movement disorders.

6) He failed to conduct timely follow-up visits with the patient.

7) He failed to attend to the patient within 24 hours of admission.

8) He failed to timely dictate a discharge summary.

9) He failed to make his own assessment of the patient and instead relied on the parent to assess the patient’s symptoms.

10) He allowed the patient’s parent to dictate medication changes.

11) He failed to coordinate care with the patient’s therapist.

12) He failed to reconsider diagnoses when the patient failed to improve.

13) He failed to assess the patient for substance abuse.

The Board initiated a case after notification of a medical malpractice settlement that occurred in the treatment of a 20-year-old woman who was misdiagnosed as bipolar disorder and developed tardive dyskinesia and a memory disorder secondary to psychiatric medications.

The Board ordered the psychiatrist to be reprimanded, pay the costs of the proceeding, and take 15 hours of continuing medication education on medical record keeping, 5 hours on child psychiatry risk management, and 5 hours on medical ethics.

State: Arizona


Date: June 2016


Specialty: Psychiatry


Symptom: Psychiatric Symptoms


Diagnosis: Psychiatric Disorder


Medical Error: Improper medication management, Diagnostic error, Failure of communication with other providers, Failure to follow up, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Virginia – Psychiatry – Suicide Attempt With 100 Risperidone And/Or Olanzapine Pills



On 08/28/2015, while serving as the psychiatrist on call at a mental health facility, the psychiatrist was notified by the nursing staff that a patient, who had a documented history of multiple suicide attempts, reported taking approximately 100 risperidone and/or olanzapine pills she had been hoarding.  The psychiatrist told the nursing staff that he would not examine the patient; instead, he gave telephonic orders to perform checks of the patient every 15 minutes, vital signs every hour, and remove all items from the room that could pose a danger to the patient.

After several calls from the nursing staff and the nursing supervisor requesting that the psychiatrist examine the patient and informing him that the patient had refused the hourly vital sign checks, the psychiatrist arrived on the ward approximately two hours after he was notified of the reported overdose.  Instead of examining the patient, he reported that he observed her from the doorway of her room and then left the ward.  The psychiatrist did not give any additional orders for the care or monitoring of the patient and did not make any entries into the patient’s medical record about his observations.

The psychiatrist acknowledged that he made an error in judgment in not immediately examining the patient and that this episode is not indicative of the way he practices medicine.  He stated that when he went to the ward, he determined that the patient’s vital signs were stable, she was sitting up in bed awake, and he did not want to reinforce her behavior by entering her room and engaging.

The Board issued the psychiatrist a reprimand.

State: Virginia


Date: May 2016


Specialty: Psychiatry


Symptom: Psychiatric Symptoms


Diagnosis: Psychiatric Disorder


Medical Error: Failure to examine or evaluate patient properly


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Virginia – Internal Medicine – Unusual Dosing Of Adderall For Medical Student



In 2006, an internist diagnosed a fourth-year medical student with attention deficit hyperactivity disorder and prescribed her Adderall.  She reported that she was having problems focusing and paying attention in medical school.   The Board expressed concern there was a lack of testing and a lack of an independent, adequate work up to establish the diagnosis.

From July 2010 to September 2010, the internist treated the patient.  On 7/2/2010, the internist resumed treatment with the patient, now a physician in a fellowship program, when she returned to the Charlottesville area after a four-year absence from his practice.

During this office visit, based solely upon the patient’s representations that she had been treated for ADHD with up to 160 mg per day of Adderall by her psychiatrist in Norfolk, the internist prescribed Adderall (90 dosage units, 30 mg tid) and Adderall XR (40 dosage units, 20 mg po bid) to the patient.  Per the Board, the dosage that was prescribed is more than three times the maximum recommended dose to treat adult ADHD.

Prior to prescribing Adderall, the internist did not obtain records of testing and/or documentation from any other treatment provider and did not perform any independent work up to establish the ADHD diagnosis and/or the need for Adderall.  Throughout the course of treatment, the internist allowed the patient to self-titrate her dosages and failed to properly monitor and manage the patient’s use of Adderall when he repeatedly escalated his prescribing to coincide with the patient’s medication decisions and self-determined doses, which resulted in the prescription of 1074 dosage units of Adderall in 71 days.

Specifically, on 7/14/2010, just 12 days after receiving a 30-day prescription, the patient informed the nurse practitioner under the internist’s supervision that she had stopped taking Adderall XR because it kept her awake and that already she had taken all 90 pills of her short-acting Adderall.  Despite noting concerns in the patient’s treatment record that the patient was “taking too much Adderall,” the nurse practitioner prescribed an additional 54 dosage units of Adderall (20 mg tid) to last until the patient could see the internist.

When the internist saw the patient on 7/19/2010, he increased her dosage of Adderall from 30 mg tid to 30 mg qid.

On 7/30/2010, without documenting any reason for another change in dosage, the internist increased the patient’s Adderall dosage to 30 mg q4h (max 5 tabs in 24 hrs) while also noting that the patient’s symptoms of distractibility were “fairly stable.”

The internist prescribed another 150 dosage units of Adderall (30 mg q4h with a max of 5 tablets in 24 hours) for the patient.

On 9/9/2010, after the patient telephoned him requesting an early prescription because she had “upped” the Adderall to 1.5 tablets every four hours, the internist prescribed 210 dosage units of Adderall (30 mg q4h with a max of 5 tablets in 24 hours.

Despite the foregoing evidence that the patient was misusing or abusing her medications, the internist failed to address these concerns or refer her for substance abuse evaluation and treatment.

In a letter to the Board dated 9/14/2015, the internist stated that he recognized that the patient was taking an unusually high dose of Adderall in 2010, but he believed the treatment was effective for her.  He stated that he was concerned about drug-seeking behavior and discussed the issue with the patient, but she assured him that she sought additional medication only because she lost her medications and because it had gotten wet on at least one occasion.  (This discussion with the patient is not documented in the internist’s records.)

The internist stated “looking back,” he wished he had obtained the records of her prior treating psychiatrist and that it had been his “consistent practice to…obtain treatment records from any previous treaters who prescribed Adderall” for his patients.  He explained that he did not attempt to obtain prior treatment records for the patient because he “knew her from the time [he] treated her as a patient in 2006.”  He stated that only a few of his patients are treated with Adderall.

The internist was issued a reprimand.  He was to complete 15 hours of continuing medical education in the subject of the proper prescribing of controlled substances and recognizing the signs of abuse/misuse of prescription medication.

State: Virginia


Date: May 2016


Specialty: Internal Medicine, Family Medicine


Symptom: Psychiatric Symptoms


Diagnosis: Psychiatric Disorder


Medical Error: Improper medication management, Failure of communication with other providers, Physician concern overridden, Failure to properly monitor patient


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Arizona – Psychiatry – Management Of High Dose Olanzapine And Lamotrigine In A Pediatric Patient



On 05/11/2011, an 11-year-old male was admitted to the Children’s Hospital where the psychiatrist held privileges for violent behaviors and auditory hallucinations.  The patient presented with established diagnoses of attention deficit hyperactivity disorder (ADHD) combined type, oppositional defiant disorder (ODD), and mood disorder not otherwise specified according to his outpatient psychiatrist.  His psychotropic medications prior to admission were aripiprazole and guanfacine.  The patient had two prior psychiatric admissions in 2010 for aggression, auditory hallucinations, and a suicide attempt, and was previously taking mirtazapine, dexmethylphenidate, and valproic acid, all of which caused increased violent behavior.

During the hospitalization, the psychiatrist’s diagnosis for the patient was bipolar disorder vs mood disorder psychosis not otherwise specified, and ODD.  The psychiatrist discontinued the aripiprazole and guanfacine and replaced them with olanzapine, titrated to 10 mg at 3 p.m., and lithium.

The psychiatrist also added amantadine, due to the patient’s report of a significantly increased appetite, and benztropine, due to drooling and lip-smacking.  The psychiatrist’s progress notes and discharge summary state that the patient subjectively reported improvement in his mood and auditory hallucinations, though he complained of morning sedation on discharge.  The psychiatrist adjusted the patient’s olanzapine dosage and schedule of dosing during the inpatient stay due to this complaint.  The patient’s discharge dose and schedule was 10 mg at 3 p.m. and 7 p.m.

Between 06/02/2011 and 05/08/2013, the psychiatrist saw the patient 9 times.

In November 2012, the psychiatrist treated the patient during a hospital admission.

There were numerous telephone calls from the patient’s mother to the psychiatrist’s office between office visits and on an emergency department visit for abdominal pain in August 2011.

The patient and his family were later involved with Child Protective Services due to an allegation that his mother hit him with a broom, which was substantiated.

The psychiatrist changed the patient’s medications and dosages frequently throughout this period, depending on the patient’s reported side effects.

Specifically, on 06/02/2011, the psychiatrist initiated lamotrigine with a written titration schedule starting with 25 mg in the evening and increasing the dose every two weeks to a final dose of 200 mg every evening.  The psychiatrist also increased the patient’s dose of benztropine due to extrapyramidal symptoms, changed the patient’s lithium dose to 600 mg in the morning and 300 mg in the evening, and kept the patient’s olanzapine dose the same.  He advised a follow-up appointment in 5-6 months.

On 08/29/2011, the patient was admitted to the emergency department with abdominal pain and was diagnosed with constipation.  His weight had increased from 34 kg to 43.5 kg.  His mother complained that he was eating too much.

On 10/06/2011, the patient was seen at the psychiatrist’s office by another physician.  The patient’s father noted that the patient complained of auditory and visual hallucinations, and paranoia.  The physician added risperidone 0.5 mg at bedtime and decreased his lamotrigine by 50 mg per day due to concern that it may increase agitation and anxiety.  The physician further recommended a follow-up with the psychiatrist in 1-2 weeks.

On 12/02/2011, the psychiatrist saw the patient in follow up.  Full labs were completed and the patient’s lithium level was 0.9 on 900 mg per day.  The patient’s weight was 44.77 kg.  The psychiatrist’s note stated that the risperidone helped with the patient’s aggression and moodiness, but that the patient was giddy and laughing uncontrollably during the examination.  The psychiatrist increased the patient’s amantadine to a total of 300 mg per day, and increased the patient’s lamotrigine back to 200 mg per day and advised titration to 300 mg total daily dose, taken in the morning.  The psychiatrist also advised the patient’s mother to call the nurse in one month for a clinical update and to discuss discontinuation of risperidone.  The psychiatrist recommended a follow-up in 5-6 months.

On 01/05/2012, the patient’s mother reported that the patient was still taking risperidone and that the patient was talking in his sleep with increased irritability and tearfulness over small things.  The patient’s mother was advised to consider trileptal at 300 mg twice a day.

On 01/19/2012, the patient’s mother again phoned to report that the patient was having difficulty sleeping and bad dreams.  She was advised to try melatonin or diphenhydramine.

On 03/12/2012, the patient’s mother phoned to report that the patient was complaining of intermittent hand tremors that were worse with stress.  The mother also expressed concern about the possibility that the patient might develop diabetes, as it ran in the family.  The psychiatrist reassured the mother that the tremors were likely due to anxiety.

On 05/05/2012, the patient’s mother again called with concern that the patient was having bad dreams.  She was advised to increase the patient’s olanzapine by 5 mg per day for a total daily dose of 25 mg per day and a same day office visit was scheduled.  The patient’s weight had decreased 2 pounds since his December 2011 visit, but his triglycerides were elevated.

On 08/03/2012, the patient’s mother called and reported that the patient was experiencing an increase in paranoia and aggression.  The psychiatrist advised that the patient should start trileptal 300 mg twice a day with a one month prescription and two refills called into the pharmacy.

On 08/06/2012, the patient’s mother called again to report that she had discontinued the trileptal because the patient was crying for no reason, biting his lower lip, and feeling the urge to harm others.  The psychiatrist advised the patient’s mother to add olanzapine 2.5 to 5 mg at 3 p.m. and a prescription for 5 mg at 3 p.m. was called into the pharmacy on 08/10/2012 with 5 refills.

On 10/11/2012, the patient’s mother called to report that the patient was hitting, kicking, and throwing things, and that he was easily agitated.  As a result, the patient’s follow-up appointment was moved up and the psychiatrist saw the patient on 10/31/2012.  The patient’s weight was recorded as having increased 13 pounds.  The patient’s mother reported that he had increased eating, along with increased visual hallucinations of a man, increased aggression, decreased hygiene, and self-picking at scabs.  The psychiatrist again advised trileptal, despite the previously unsuccessful trial, and discussed relaxation techniques and coping skills.  The psychiatrist also advised the patient’s mother to consider asenapine (Saphris).

On 11/02/2012, the patient’s mother called to inform the psychiatrist that she could not afford asenapine.  The psychiatrist increased the patient’s olanzapine and advised the patient’s mother to consider metformin.  He called in a six month prescription for metformin to the pharmacy.

From 11/25/2012 to 11/29/2012, the patient was hospitalized after becoming increasingly aggressive and self-injurious over the prior few weeks.  The patient reported multiple familial stressors.  Mild tongue fasciculations were noted.  The benztropine and lamotrigine were increased during his stay.

On 12/03/2012, the patient had a follow-up visit with the psychiatrist, who increased his olanzapine dose.  He also increased his benztropine dose to assist with side effects that could be caused by an increased olanzapine dose.

On 12/07/2012, the psychiatrist’s notes indicate that the patient’s olanzapine dose had not been increased as previously ordered on 12/03/2012.  The psychiatrist again ordered that the olanzapine dose be increased and advised follow-up in 3-4 months.

On 02/13/2013, the patient had a follow-up visit with the psychiatrist, who noted a diagnosis of bipolar disorder and ordered labs in one month.  He advised the patient to schedule a follow-up visit in 3-4 months.

On 04/05/2013, the psychiatrist had a follow up visit with the patient along with both his mother and father.  The psychiatrist changed the olanzapine dose to 5 mg in the morning, 10 mg at midday, and 15 mg at bedtime.

On 05/08/2013, the patient had a follow-up visit with the psychiatrist.  The patient complained of daytime sleepiness and an intermittent hand tremor.  The psychiatrist prescribed cetirizine and decreased the patient’s olanzapine dose to 2.5 mg in the morning with the afternoon and evening dose staying the same.

After May 2013, another physician assumed care.  The diagnoses were updated to ADHD, ODD, and PTSD.  The new physician decreased the patient’s psychotropic medications significantly.  The patient appeared to be tolerating the changes well and had not been demonstrating physical aggression, self-harm, or suicidal ideation.  He had resolution of the tachycardia and started to lose weight.

The Board judged psychiatrist’s conduct to be below the minimum standard of competence.  The Board noted that the standard of care requires that the psychiatrist explain the risks, benefits, and alternatives of treatment.  He deviated from the standard of care by prescribing high-dose olanzapine and lamotrigine despite apparent side effects.  He failed to consider a treatment plan to include both pharmacological and psychosocial interventions.

The Board ordered the psychiatrist be reprimanded.

State: Arizona


Date: February 2016


Specialty: Psychiatry, Pediatrics


Symptom: Psychiatric Symptoms


Diagnosis: Psychiatric Disorder


Medical Error: Improper medication management, Improper treatment


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Indiana – Gynecology – Gynecologist Practices Psychiatric In-Home Counseling Outside Of His Capabilities



A gynecologist had been a patient’s provider since approximately 2006.  He was also the obstetrician for the prenatal care for the patient’s three children, delivery of two of the patient’s children, and postpartum depression following the birth of her third child.

The patient gave birth to her third child on 9/6/2013, and following the birth, the gynecologist treated her for postpartum depression.  The gynecologist had previously treated the patient for anxiety and depression for several years prior.

In late October 2013, out of concern for the patient’s mental and physical health resulting from her continued postpartum depression, the patient’s husband contacted the gynecologist to notify him of the patient’s concerning behavior in that she refused to get out of bed and was showing signs of increased depression.

During that same time, the patient’s husband sought medical advice and assistance from the gynecologist, which resulted in the gynecologist coming over to the patient’s house to assess the patient’s medical condition on at least two occasions.

Following these visits, the gynecologist recommended to the patient’s husband that he provide in-home counseling to the patient to treat her depression and anxiety.

From November 2013 through spring of 2014, the gynecologist visited the patient in her home and provided in-home counseling to the patient and frequently communicated with the patient via text message. The patient’s husband was present during several of the counseling sessions between the patient and the gynecologist.  The patient’s husband described the sessions with the gynecologist as typical counseling sessions based upon his attendance at previous counseling sessions with the patient and other providers.

The gynecologist failed to keep documentation regarding these sessions and did not bill the patient and the patient’s husband for these services.  Also the gynecologist was not qualified by training or experience to provide mental health counseling.

A typical OB/GYN practitioner, in handling patients suffering from postpartum depression, would question the patient in his office to determine whether mental health services were needed, and then refer the patient to a mental health provider, if necessary. They would only remain involved in the care of a patient’s postpartum depression by providing prescriptive support if the mental health provider he referred the patient to did not have prescriptive authority and medications were recommended by the mental health provider.

The gynecologist was not qualified by training or experience to provide mental health counseling.

In late 2013, the gynecologist referred the patient to a psychiatrist;  however, the gynecologist continued to provide in-home counseling sessions and medical care to the patient.

The patient received prescription medication from the psychiatrist after she was referred by the gynecologist to the psychiatrist.

The gynecologist and the patient discussed terminating the physician-patient relationship;  however, no letter was written formalizing the termination of the physician-patient relationship and the patient was not referred to another gynecologist by the gynecologist.

The gynecologist began a sexual relationship with the patient in early February 2014.

In November 2013, the gynecologist prescribed the patient Prestiz, a medication to treat depression.  The patient filled that medication from the gynecologist on 2/3/2014.

The gynecologist wrote the patient a prescription for birth control in November 2013.  The patient received monthly refills of that prescription, with the last refill dated on 2/14/2014.

On 12/30/2013, the gynecologist continued to provide medical care and treatment to the patient when he wrote a prescription for the patient for zolpidem (Ambien) 10 mg.  The gynecologist prescribed the patient refills of Ambien, one of which the patient filled on 3/26/2014.  On at least one occasion the gynecologist exchanged two of his tablets of Ambien 5 mg for one of the patient’s Ambien 10 mg tablets with her consent.

On 2/24/2014, the patient received a blood lab draw ordered by the psychiatrist.  The results of the blood draw indicated that the gynecologist was still the patient’s physician.

In May 2014, the gynecologist admitted to two physicians practicing at an OB/GYN clinic that he had an inappropriate and sexual relationship with the patient.

The patient also admitted that she had an affair with the gynecologist to her husband, her father, her sister, and several of her friends on approximately May 2014, after initially denying the affair.

In the spring of 2014, the patient recommended that her brother-in-law meet with the gynecologist to ask him questions regarding symptoms he was experiencing from a medication prescribed by another practitioner.

On 4/27/2014, the gynecologist prescribed Ambien to the brother-in-law during an in-home counseling session that took place in the brother-in law’s home.

The gynecologist provided in-home counseling sessions to the patient’s brother-in-law on a second occasion.  During this session, the gynecologist told the brother-in-law that he was depressed and at times was suicidal and that the patient was the only person who could help him deal with his depression.

The gynecologist failed to maintain necessary patient records for the counseling sessions and the prescription that he provided to the patient’s brother-in-law.

The Board judged the gynecologist’s conduct to be below the minimum standard of competence given his failure to keep medical records and his ability to practice within his own specialty.

The Board ordered that the gynecologist’s license be suspended and ordered him to complete forty hours of continuing medical education divided into the following: eight hours on record keeping, eight hours on ethics, eight hours on confidentiality, eight hours on patient boundaries, and eight hours on controlled substance prescribing. Also, the gynecologist must have a course on psychiatric and psychological care. Finally, the Board ordered that the gynecologist pay a fine of $5,500.

State: Indiana


Date: October 2015


Specialty: Gynecology, Obstetrics, Psychiatry


Symptom: N/A


Diagnosis: Psychiatric Disorder


Medical Error: Failure of communication with other providers, Ethics violation, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Virginia – Psychiatry – Vascular Surgeon Attempts To Manage Adolescent Patient With Disruptive Behavior And Suicidal Ideation



A vascular surgeon took on the psychiatric care of an 11-year-old female from 4/13/2013 to June 2013.

On 4/13/2013, he prescribed fluoxetine to treat the patient’s depression.  On 4/19/2013, he prescribed amitriptyline to treat her pain and sleeplessness.

From 4/25/2013 to 4/29/2013, the patient was hospitalized and she became “suicidal, grabbing knives, threatening to jump off [the] balcony, refusing to sleep, [experiencing] anxiety…screaming, [and] crying.”  The patient was discharged from the hospital against medical advice with the diagnoses of mood disorder, not otherwise specified, and attention deficit hyperactivity disorder, combined type, along with the recommendation that she begin treatment with quetiapine.

When the patient’s parents disagreed with the hospital’s diagnosis and recommended treatment, the vascular surgeon again prescribed fluoxetine and amitriptyline, but her “episodes of disruptive behavior and agitation” increased during his treatment regimen until the patient experienced another crisis episode of extreme agitation on 5/6/2013.

The vascular surgeon told the Committee that he prescribed those medications again because the parents were unhappy that pain medications, such as hydromorphone, had been prescribed for their daughter.  The parents believed that the patient’s condition worsened on the regimen administered by the hospital.  They expected the vascular surgeon’s treatment plan to bring the patient “back to baseline.”  The vascular surgeon agreed with the parents and testified that amitriptyline had been effective in controlling the patient’s nighttime pain.

On 5/6/2013, when the patient was in a crisis, the vascular surgeon did not refer her to a mental health specialist, to the emergency department, or to an inpatient psychiatric unit.

He initially administered intramuscular diazepam 15 mg when the patient was in his office.

When the symptoms escalated, he treated her with four doses of haloperidol 5 mg and four doses of diphenhydramine 25 mg.  She developed extrapyramidal side effects of drooling and biting on the inside of her cheeks, and ultimately required hospitalization.

On 5/18/2013, the vascular surgeon attempted to treat what he described as the patient’s “highly agitated and combative state” by sedating her using a combination of intravenous lorazepam, diphenhydramine, diazepam, and propofol administered in her home.

The vascular surgeon said that he treated the child psychiatrically due to a personal experience he had had with an adolescent psychiatric case.  He explained that he was a close personal friend of the patient.  The parents did not want their child to go to a hospital unless necessary, and when it was necessary, there were not any hospitals available that would accept their insurance.

The vascular surgeon said that in retrospect he would have found a hospital the family would find acceptable.  The patient is unfortunately still experiencing problems and has gone through multiple therapists and psychiatrists.

The Board issued a reprimand.

State: Virginia


Date: April 2015


Specialty: Psychiatry, Pediatrics


Symptom: Psychiatric Symptoms


Diagnosis: Psychiatric Disorder


Medical Error: Improper medication management, Failure of communication with other providers


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Psychiatry – Patient With A Long History Of Depression Suicides 24 Hours After Discharge



A 65-year-old male Jehovah’s Witness had a long history of outpatient treatment for depression.

In 2012, he was admitted twice to an acute facility, secondary to assessment of active suicidality.  He was first admitted on 2/1/2012 and discharged on 2/14/2012.  He continued with outpatient care after his discharge.  At the time of discharge, the patient was complaining of continuing depressive symptoms and was prescribed fluoxetine 10 mg in addition to bupropion.

Between February 2012 and the end of March 2012, the patient gave away his firearms because he was concerned that he might use it on himself.  The patient saw Psychiatrist A and was admitted on 3/28/2012 due to worsening depression and suicidal ideation.  He was placed on a 5150 hold.

The progress notes on the date of admission of 3/28/2012 provide that the patient was transferred by ambulance from the Kaiser emergency department on a 5150 status to Community Behavioral Health Center (CBHC) in Fresno due to potential danger to self.  The patient reported increased depression, saying that he wanted to jump off a bridge and, “I want to get rid of the pain inside.”  The patient denied any stressors and reported that he stopped taking his antidepressants 3 months ago and that he began decompensating and could not get control of his depression.  He denied previous suicide attempts but had continued suicidal thoughts stating that he got rid of all his guns.  The patient was described as “hopeless, depressed, and at risk for self harm.”

On 3/30/2012, the patient was seen by Psychiatrist B.  The psychiatrist noted that “[the patient] reported that this is his fourth episode of depression and this was the first time he actually had intent to end his life stating ‘scary’.  [The patient] is hopeless, depressed, and at risk for self harm.”  Psychiatrist B diagnosed the patient with a severe recurrent major depression and prescribed Wellbutrin SR 150 mg twice a day, Seroquel 25 mg nightly, and maintained his Synthroid dose.  Shortly after admission, Psychiatrist B increased the patient’s fluoxetine form 10 mg to 20 mg.  He noted that the patient had overwhelming feelings of guilt.

The documentation in the care plan showed that the patient’s condition remained unchanged while he was confined from 3/30/2012 to the time of discharge.

On 4/2/2012, the nurse noted in the care plan that the patient was soft spoken with flat and depressed affect.  She also described the patient as guarded with minimal disclosure.  She also noted, “he felt like losing control of impulses and feeling the sense of futility in thought but not action.”  She goes on to assess him, noting, “he still feels helpless and hopeless.”  She indicated he could not verbalize a plan for self-care.  Finally, she writes, “no harm to self since on unit, but remains a danger to self as evident by withdrawn and guarded behavior.  Remained depressed width (sic) minimal change.”

On 4/2/2012, Psychiatrist B discharged the patient.  Psychiatrist B documented: “Hospital course remarkable for good improvement.  [The patient] was provided with ward milieu therapy, medication adjusted.  [The patient] made good progress toward the end of hospitalization.  His mood improved, suicidal ideation resolved.  [The patient] denies any homicidal ideations or psychotic symptoms.  [The patient] was discharged today in stable condition.  Follow up with Kaiser IOP.”  Psychiatrist B documented that the patient was feeling better and not suicidal and felt that the patient was ready for discharge on 4/2/2012, despite the fact that on the same day, the care plan notes reflected the fact that the patient felt no change in his condition.  Psychiatrist B failed to address and document collateral sources such as the nurse’s notes that reflected that the patient’s condition was unchanged.

On 4/3/2012, immediately after discharge, the patient told his wife that he was planning to go out to obtain a prescription at a local pharmacy.  She apparently went out to a Bible study class.  He did not go to the pharmacy but went instead to the farm of a neighbor.  He went in and removed a rifle from the neighbor’s home, drove down the road, and died from a self-inflicted gunshot wound to the skull.  Sheriff’s deputies were dispatched to the scene, discovered the body, and notified the patient’s wife.

After a hearing involving experts from both parties, the Board judged Psychiatrist B’s treatment and discharge of the patient within the standard of care.  The Board judged Psychiatrist B’s documentation of the hospitalization below the standard of care given failure to clarify the patient’s medication history in light of contradictory entries in the medical records.  The Board issued a public letter of reprimand with the stipulation that he take a medical record keeping course through the Physician Assessment and Clinical Education Program.

State: California


Date: February 2015


Specialty: Psychiatry


Symptom: Psychiatric Symptoms


Diagnosis: Psychiatric Disorder


Medical Error: Lack of proper documentation


Significant Outcome: Death


Case Rating: 1


Link to Original Case File: Download PDF



California – Psychiatry – Patient With History Of Bipolar Disorder Placed On Topiramate, Quetiapine, Aripiprazole, Temazepam, And Cyproheptadine



On 10/2/2012, a patient filed a complaint against a psychiatrist stating the following:

“On November 11, 2011 [the psychiatrist] used Topamax [to] help me lose weight.  I start to lose memorial [sic] not lose weight, and I keep teller [sic] her, but she ignore and keep increasing it till I can’t play piano and cannot function.  I have to stop take it by myself.  I was doing good on my bipolar meds, but she told me psych meds are poison needs to change, so she change it, then I went into a spending madness loss all my money.”

The patient was a 62-year-old woman seen by the psychiatrist at a medical group from 10/7/2011 to 6/22/2012.  Her presenting complaint was being “extremely happy” and having “too many ideas in her head.”  She used to be an addict but was now sober for 25 years.  She had prior thoughts of wanting to kill her husband.  The psychiatrist diagnosed her with “drug dependence excluding opioid type drug” and “bipolar I disorder most recent episode manic.”  The psychiatrist’s initial plan was to continue quetiapine 800 mg daily, aripiprazole 2 mg daily, temazepam 30 mg “with tapering down,” and to add cyproheptadine 4 mg at bedtime.

On 10/24/2011, aripiprazole was increased to 10 mg at bedtime, temazepam decreased to 15 mg, and cyproheptadine increased to 8 mg at bedtime.

On 11/7/2011, there was no order for topiramate, but on 12/16/2011, the psychiatrist continued to prescribe cyproheptadine 8 mg, temazepam 15 mg, aripiprazole 15 mg at night, and quetiapine 600 mg daily.  (The Board reports that the quetiapine situation was confusing since there were two prescriptions noted).

On 12/30/2011, there was an order for topiramate 450 mg daily.  By the end of December, the patient was taking topiramate 450 mg daily.  There was an ambiguous doctor’s note on the medical record, dated 12/30/2011, stating that the patient was confused, necessitating decreasing the dose of topiramate from 300 to 200 mg daily.  The Board reported that the doctor’s notes were ambiguous.  On 12/30/2011, thyroid medication was initiated at 50 mcg daily.

On 1/6/2012, 1/13/2012, 1/16/2012, 1/27/2012, 2/17/2012, 2/24/2012, 3/23/2012, and 4/13/2012, the patient continued to receive topiramate 650 mg daily.

On 5/18/2012, this dose was reduced to 500 mg daily and was reduced further on 6/22/2012.

The Board judged the psychiatrist’s care of the patient as having fallen below the standard of care given the inappropriate use of topiramate at double the maximum indicated dose in a patient with bipolar disorder, given failure of maintaining a medical record that clearly documents the clinical course of a patient, and given plagiarism of notes written by her colleague.

The Board noted that the risks of using topiramate outweigh the benefits in a patient with bipolar disorder.  Topiramate’s side effects are noted to include “sedation, asthenia, dizziness, ataxia, paresthesia, nervousness, nystagmus [and] tremor.”  In addition, it is noted that topiramate is used adjunctively for bipolar disorder and only certain patients may respond to topiramate after several weeks or months of treatment.  It is noted that topiramate is not indicated for mania.

The Board also expressed concern over polypharmacy, given that topiramate can cause sedation at high doses and given that the patient was also on quetiapine, cyproheptadine, aripiprazole, and temazepam.

The Board also madenote that the psychiatrist called 911 with false accusations that the physician owner of the clinic (where she previously worked before her position at the clinic was terminated) had sexually assaulted patients.  She also made repetitive phone calls to a patient attempting to bribe her with medications to make false accusations of sexual assault against the physician owner of the clinic.

The psychiatrist was placed on probation for 3 years with stipulations to complete 40 hours annually of continuing medical education in areas of deficient practice, a prescribing practices course, a medical record keeping course, an ethics course, a professional boundaries program, 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.  She was ordered to undergo clinical monitoring and was prohibited from engaging in the solo practice of medicine.

State: California


Date: January 2015


Specialty: Psychiatry


Symptom: Psychiatric Symptoms


Diagnosis: Psychiatric Disorder


Medical Error: Improper medication management, Ethics violation, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Kansas – Physician Assistant – Lack Of Evaluation While Managing Risperidone And Citalopram Regimes



On 8/10/2010, a 34-year-old male patient was incarcerated at a county jail.  The patient was incarcerated at the jail until 12/23/2010.

The patient’s medical record for the time he spent incarcerated at the county jail consisted of a single “medical progress note.”  That note indicates that a physician assistant reviewed the patient’s medical record on 12/8/2010.  There was no documentation of the patient’s medical record that indicated that the physician assistant saw or evaluated the patient.

The physician assistant has alleged that he was called by an officer at the county jail during the patient’s intake and that the officer advised the physician assistant of the patient’s history of depression or possibly bipolar psychiatric history.  Based upon that history, the physician assistant prescribed the patient risperidone 1 mg daily and citalopram 20 mg daily.  According to the county jail inmate medication log, this prescription was first taken by the patient on 8/26/2010.

The county jail medication log for the patient had documentation indicating that the physician assistant changed the administration time of the patient’s medication to being administered by jail personnel to after 6:00 p.m.

The county jail medication log for the patient had documentation indicating that the physician assistant changed the administration of the patient’s medication to twice a day on 9/28/2010.  It also had documentation indicating that the physician assistant decreased the medication dosages for the patient back to once a day on 10/30/2010.

The Board judged the physician assistants conduct to be below the minimum standard of competence given his failure to document performing an assessment of the patient, his reason for prescribing the medications, the medication effectiveness, or the reasons for increasing or decreasing the medications he prescribed to the patient.

The Board ordered the physician assistant license to be placed on probation until he completes a continuing medical education course entitled “Intensive Course in Medical Record Keeping with Individual Preceptorships.”

State: Kansas


Date: December 2014


Specialty: Physician Assistant


Symptom: N/A


Diagnosis: Psychiatric Disorder


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


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Indiana – Family Medicine – ALCAT Ordered With Ambiguity On Patient’s Consent And Insurance Coverage



On 5/15/2012, an osteopathic medicine practitioner began treating a patient.  On 5/15/2012, the patient specifically sought treatment for ankle and back injuries following a fall down a flight of stairs, and he asked to be screened for Attention Deficit Disorder (ADD).  The patient was diagnosed with depression, anxiety, and ADD, in addition to the lower back injury (with spina bifida occulta noted on the x-ray) and left ankle sprain.  The osteopathic medicine practitioner prescribed Adderall and Pristiq, with a follow-up scheduled in a month.  The patient presented an insurance card and paid his copayment at the time of the office visit.

On 5/16/2012, the osteopathic medicine practitioner’s office staff verified the patient’s insurance coverage.

On 6/5/2012, the patient presented for a follow-up appointment.  The patient did not request a treatment for any new symptoms at this time, but requested spinal manipulation for back pain and a refill of his Adderall prescription.  The patient’s insurance coverage was verified by the osteopathic medicine practitioner’s office staff.  During the patient’s physical examination, the osteopathic medicine practitioner noted a right thyroid nodule, and recommended a thyroid ultrasound.  In addition to other diagnostic laboratory tests (e.g., CBC, lipid panel, and TSH), the osteopathic medicine practitioner also recommended an antigen leukocyte cellular antibody test (“ALCAT”) to determine if the patient suffered from certain food intolerances or sensitivities in order to then work with the patient on a diet plan for adjunctive treatment of ADD, depression, anxiety, and joint pain.  The osteopathic medicine practitioner claimed this plan of treatment was discussed with the patient, although he did not discuss the cost.  The osteopathic medicine practitioner claimed that he informed the patient that the patient’s insurance would cover the cost of the ALCAT.  The patient claimed no discussion of the treatment took place.  No discussion of the treatment plan was documented in the medical records.  While the osteopathic medicine practitioner had the patient sign a generic consent form agreeing to “any necessary medical diagnosis or treatment,” he did not have the patient fill out forms explaining any of the specific tests the osteopathic medicine practitioner had ordered.  The patient went to the lab to have the blood work performed and did not object to any of the tests.

On 6/11/2012, the osteopathic medicine practitioner’s office staff learned that the patient’s insurance coverage had lapsed as of 5/31/2012, despite verification from the insurance company on 6/5/2012.  The osteopathic medicine practitioner’s office stated and documented that it contacted the patient on 5/12/2012 to discuss payment options and mailed monthly invoices to the patient, but no payment was ever received for the services rendered on 6/5/2012.

On 2/10/2013, the patient filed a consumer complaint stating that he was not informed of the cost of the ALCAT, and that the ALCAT was experimental and not covered by insurance companies.  The patient stated that he was billed for the full cost of the ALCAT, was not informed of the cost in advance, and that he had not requested an allergy test.

Certain commercial insurers’ coverage determinations state that the ALCAT is deemed to be “experimental” or “investigational” with respect to food allergy testing.  The osteopathic medicine practitioner depended on scientific studies and white papers provided by Cell Science Systems (the manufacturer of the ALCAT) which confirm that the ALCAT is a diagnostic tool to determine food sensitivities and intolerances.  Certain commercial insurers will pay for ALCAT testing for purposes of food sensitivity/intolerance testing.  The literature on the use of the ALCAT was present in the patient waiting area in the office of the osteopathic medicine practitioner.  Because the patient’s insurance covered the cost of the ALCAT test for food sensitivity/intolerance testing, and the osteopathic medicine practitioner’s office accepted insurance payment as payment in full for the test, he believed no payment would be owed by the patient for the ALCAT testing.

The Board judged the osteopathic medicine practitioners conduct to be below the minimum standard of competence given his failure to sufficiently document the patient’s treatment plan, the purpose for utilizing the diagnostic test at issue, and the patient’s understanding and consent to such testing.

The Board ordered that the osteopathic medicine practitioner complete 10 hours of continuing medical education related to documentation and the informed consent process, update his written policies and consent forms, and pay a fine of $5.00.

State: Indiana


Date: September 2014


Specialty: Family Medicine


Symptom: Back Pain


Diagnosis: Psychiatric Disorder, Spinal Injury Or Disorder


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


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



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