Found 36 Results Sorted by Case Date
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Virginia – Emergency Medicine – Presentation Of Suicidal Thoughts With Missed Incidental Findings



On 1/10/2012, a teenage male presented to the emergency department after being referred for a psychiatric referral by his high school for making a “suicide pact” with his girlfriend.  The patient’s mother accompanied him to the emergency department.  His admitting diagnoses were suicidal thoughts and depression.

An ED nurse conducted a “suicide screening.”  The nurse elicited and documented a history from the patient regarding the suicide pact that he made in September 2011 with his girlfriend who lived in Kansas.  The patient told his friends about the suicide pact, and his friends reported the information to school officials.

The nurse evaluated and documented the patient’s vital signs, including his blood pressure, which was elevated at 182/114 mmHg.

There was no documentation in the patient’s medical record that his blood pressure was repeated.

The nurse started an intravenous line and obtained a urinalysis, drug abuse screen, comprehensive metabolic panel, complete blood count, thyroid stimulating hormone level, and an alcohol level.  The patient’s BUN level was elevated at 33.  His urine creatinine level was elevated at 3.5.  His urine had red blood cells and protein present.  A second nurse documented on a computer-generated form that she had conducted a physical assessment of the patient.

A social worker conducted a 27-minute mental health evaluation and determined that the patient could be discharged from the emergency department.  She notified the ED physician.

The ED physician circled “major depression” on a pre-printed physical examination form and checked off the box stating “cleared medically for psychiatric referral” and discharged the patient home.  The ED physician failed to document any history, physical examination, medical decision-making or any plan for the patient or that he had ordered and/or reviewed any laboratory tests or procedures.

The patient had a history of juvenile rheumatoid arthritis.  He had been treated with methotrexate from 2000 to 2006.  The ED physician failed to document this history.

On 1/4/2013, the patient was evaluated at a clinic for decreasing vision and headaches.  His blood pressure was 200/130.  The staff repeated the reading three times.  He was diagnosed with hypertensive urgency/emergency.  Later that day, he went to an emergency department where he was then transported by helicopter to another hospital, admitted to the intensive care unit, and diagnosed with end-stage renal disease and severe hypertension.

On 2/7/2013, the Board received a complaint from the mother of a patient.  She alleged that the ED physician failed to address her son’s high blood pressure reading and abnormal laboratory results.

In May 2013, the patient received a kidney transplant.

The Board judged the ED physician’s conduct to be below the standard of care given failure to address the abnormal labs and hypertension of the patient.

The Board reprimanded the ED Physician, ordered him to pay a fine, ordered him to complete a course in medical recordkeeping, ordered him to complete a course in pediatric/adolescent emergency medicine, and stipulated that agents may conduct a chart review or peer review of ED physician A’s practice.

State: Virginia


Date: June 2014


Specialty: Emergency Medicine


Symptom: Psychiatric Symptoms, Headache, Vision Problems


Diagnosis: Renal Disease, Hypertensive Emergency, Psychiatric Disorder


Medical Error: Failure to follow up


Significant Outcome: Hospital Bounce Back


Case Rating: 2


Link to Original Case File: Download PDF



Wisconsin – Psychiatry – Unreliable Psychiatric Patient Says He Is Unable To Move After An Unwitnessed Fall



On 10/3/2012, a 25-year-old man was admitted to an inpatient mental health facility for emergency detention.  That morning, the patient had gone to his neighbor’s home in sleepwear, confused, drooling, and unresponsive.  Police were called and observed the patient sliding down a stairwell feet first on his stomach.  Family reported that the patient had been fasting for 4 days.  He refused to cooperate with police, declined to leave, and insisted that he did not require any medical care.  He was “dead weight” when being transported.  Police sent him to the psychiatric crisis unit.

At around 9:07 a.m., Psychiatrist A spoke to the patient’s mother, who reported that since he returned from his neighbor’s house, he refused to get up.  At 10 a.m., Psychiatrist A noted, “Patient refuses transfer to a medical acute care hospital for medical clearance and given patient presentation as healthy, not delirious, seems well-nourished, will defer transfer to ER as patient seems likely to erupt or elope.”

At 10:55 a.m., Psychiatry A performed an Abnormal Involuntary Movement Scale and documented normal movement of the upper and lower extremities.  He stated that the patient would leave if he was sent off site for medical clearance.  He diagnosed psychosis, not otherwise specified.

At 2:45 p.m., the patient was transferred to an inpatient unit.  He was anxious, restless, answered questions appropriately.  He wanted to leave.  The patient walked around the unit to see of the doors were locked.  At 5:30 p.m., a nursing assistant heard someone calling from his room.  There was a cardboard folder stuffed under the base of the door from within the room preventing her from coming into the room.  A registered nurse was able to open the door.  She found the patient lying on the floor prone.  At 5:40 p.m., the report noted that the patient had fallen.  He could not move his legs and asked to be sent to another hospital for evaluation.

Psychiatrist B, a third year resident, documented at 6:25 p.m.: “Pt found by writer in room, Pt states he can’t move, needs to go to hospital…Pt states he hit his head, but when asked where he won’t respond…no trauma noted to head…Pt reports pain.  [Patient A] is noted to turn head…[Patient A] is noted to intermittently move left foot…refused to discuss reason for admission, repeats he wants to go to [a] hospital.”  Psychiatrist B elected not to transfer the patient to a different hospital.  He was concerned that the patient would elope.  He also felt that risk of a traumatic injury was low given how he had behaved with the police, where he did not appear to have sustained any injuries.  No traumatic injuries were noted “on brief exam.”  He ordered a CBC and CMP given that the patient had not eaten and given concern for dehydration with recommendation for follow up with a “medical” team the next day.  While the patient said he could not move and could not feel his legs, no neurological exam was documented.  Subsequent events have not been reported, and it is unknown if the patient experience neurological consequences.

The Board stated that the standard of care is to perform a physical exam in the case of an unwitnessed fall where the patient has hit their head, and where the patient expresses that he “can’t move.”  There was concern that Psychiatrist B exposed the patient to increased risk for injury or death.

Psychiatrist B was ordered to complete Neurological Emergencies: Case Studies in Critical Diagnoses, sponsored by Harvard Medical School and Risk Management Essentials, sponsored by Medical Risk Management.

Of his own accord, Psychiatrist B adjusted his residency schedule to include a rotation on the Neurology Consult Service.

State: Wisconsin


Date: June 2014


Specialty: Psychiatry


Symptom: Psychiatric Symptoms


Diagnosis: Psychiatric Disorder


Medical Error: Failure to examine or evaluate patient properly


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Wisconsin – Psychiatry – Family Practitioner Prescribes Numerous Psychiatric Medications



On 9/17/2010, a 24-year-old woman with a history of chronic back pain after a motor vehicle collision at age 16, presented to Family Practitioner A.  The patient was under the care of a pain specialist.  The pain specialist had been prescribing her morphine 30 mg BID and oxycodone-acetaminophen 10 mg/650 mg, as needed.  The patient had a history of sarcoidosis and was on Advair and albuterol.  The patient reported issues with concentration and focus at school, irritability, and depression.  Family Practitioner A prescribed alprazolam and bupropion.  The alprazolam was helping.  The bupropion was causing insomnia and worsened irritability and was discontinued.  Desvenlafaxine was initiated.

On 11/17/2010, the patient reported that the desvenlafaxine was working.  She wanted to stop smoking.  Varenicline was prescribed.  The patient reported past issues with insomnia on varenicline.  Zolpidem was prescribed in addition to alprazolam and desvenlafaxine.

On 12/21/2010, these prescriptions were continued.  On 3/25/2011, the patient said that she could not concentrate or focus and had lost her job.  She reported concern that she had ADD.  Lisdexamfetamine 30 mg daily was added.  On 4/12/2011, the patient said that the medication was helping, but said she needed a second dose in the afternoon.  Her prescription was increased to 30 mg twice a day.

On 5/13/2011, the patient stated that lisdexamfetamine was making her jittery after the second dose.  The second dose was discontinued, and the morning dose was continued.  In addition, amphetamine/dextroamphetamine IR 10 mg was prescribed for the afternoon.

On 6/13/2011, the patient reported that the amphetamine/dextroamphetamine was ineffective.  On her own, she had started taking lisdexamfetamine twice a day.  On 7/15/2011, the patient reported that the lisdexamfetamine had been effective.  Her prescriptions were renewed.

On 11/29/2011, the patient reported worsening insomnia.  The lisdexamfetamine was stopped and amphetamine/dextroamphetamine IR 20 mg three times a day was prescribed with a new trial of zolpidem.  On 2/28/2012, she reported doing well on amphetamine and dextroamphetamine XR, 20 mg in the morning, and 10 mg IR 3-4 times a day.  The reason for this change was not documented.

On 5/3/2012, the patient again complained of insomnia.  She wondered if she might have obsessive compulsive disorder.  She was referred to psychiatry, and prescribed amphetamine salt combination 10 mg twice a day.  On 6/18/2012, the patient had her last appointment with Family Practitioner A.  She had not yet seen the psychiatrist.  She said that she had stopped amphetamine/dextroamphetamine and desvenlafaxine on her own, after which she had significant difficulty.  She then resumed desvenlafaxine.

Family Practitioner A documented, “2. Psychiatric concerns.  I do think it is time to initiate Lamictal to see if this is helpful as a mood stabilizer.  I do recommend that she keep her appointment with [the psychiatrist].  We will see if we can set her up with a female counselor.  She is otherwise to continue Adderall and Xanax.  Will continue with Pristiq at this time as well.  Pristiq may be kindling her mania.  3.  Insomnia.  Ambien has been helpful.  Will continue this medication.”

Family Practitioner A prescribed lamotrigine 100 mg, #30, one tablet daily.  After inquiry from the Board, Family Practitioner A stated, “[the patient] and I were concerned about the potential for Bipolar Affective Disorder as an explanation for her irritability, reaction to past medications and other psychiatric concerns.  The decision was made to trial lamotrigine as a mood stabilizer until she was able to meet with her psychiatrist.”  There was no documentation on the risks of Lamictal.  The patient took the medication as prescribed and became extremely lethargic.  On 6/19/2012, the patient required hospitalization.

The Board found that Family Practitioner A engaged in unprofessional conduct by engaging in conduct that increased risk of danger to the health, welfare, or safety of the patient.  Concerns including prescribing lamotrigine at high doses, not warning the patient of its side effects, and not deferring the decision to initiate lamotrigine to the psychiatrist.

State: Wisconsin


Date: April 2014


Specialty: Psychiatry, Family Medicine


Symptom: Psychiatric Symptoms


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


Medical Error: Improper medication management, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Kansas – Physician Assistant – Improper Prescribing Practices Involving Alprazolam And Amphetamine



On 12/30/2010, a patient presented to a physician assistant to establish care and with multiple complaints, which included attention deficit hyperactive disorder; however, there was no documentation for this patient visit in the physician assistant’s patient records.

The physician assistant requested the patient’s records from the patient’s previous medical doctor; however, she failed to notice the patient was fired by her prior provider for noncompliance with controlled substances and treatment planning.

On 1/21/2011, the patient called into the physician assistant’s office with Adderall dosage questions and was advised that she could increase the Adderall to 1 tablet twice a day.  She was also told that she would receive a new prescription at the next patient visit.

On 1/24/2011, the physician assistant’s patient record for the patient indicated that she saw the patient for a follow-up. The patient complained of daily headaches and chronic “all over” pain.  The physician assistant diagnosed the patient with anxiety, joint pain, fatigue, and peptic ulcer disease.  The physician assistant documented that she prescribed “Rx Xanax 1 mg [by mouth sublingually] #30. Rx Cymbalta 60 mg 1 [tablet by mouth twice daily] #60 (patient requested double for financial reasons but [would] take 1 [by mouth]).”  The physician assistant also documented that the patient requested pain medications to be prescribed; however, she denied that prescription because there was no etiology found for the pain.

On 1/26/2011, the patient called the physician assistant to inquire about any information the physician assistant had received from her other doctor.  The patient stated that she was willing to come in if necessary.  The physician assistant’s call notes indicated she prescribed the patient clotrimazole 1% cream to be applied to the affected area twice daily.

On 1/31/2011, the patient called the physician assistant requesting a prescription for antibiotics and referenced her colonoscopy.  The physician assistant’s call notes indicated that she prescribed the patient amoxicillin.

On 2/7/2011, the patient called the physician assistant in reference to a prescription for Xanax.  The physician assistant prescribed the patient sixty 1 mg tablets of alprazolam with two refills that were filled by the patient on 2/7/2011, 3/3/2011, and 4/30/2011.

On 2/22/2011, the physician assistant prescribed the patient sixty 15 mg tablets of amphetamine salts with no refills, which was filled by the patient on 2/23/2011.

On 2/23/2011, the physician assistant prescribed the patient thirty 15 mg of amphetamine salts with no refills, which was filled by the patient on 3/21/2011.  On that same day, the physician assistant prescribed the patient an additional sixty 15 mg of amphetamine salts with no refills, which was filled by the patient on 3/7/2011.

On 3/3/2011, the physician assistant saw the patient for complaints of muscle burning, jaw pain, headaches, loss of memory, and lightheadedness.  The physician diagnosed the patient with chronic pain and memory loss.  The physician assistant did not document any prescriptions being prescribed for the patient.  However, she did document speaking with the fiance of the patient and referring the patient to neurology.

On 4/7/2011, the patient called the physician assistant requesting a refill of Adderall because she only filled ½ of the prescription for the previous month.  The physician assistant notated that she checked with the pharmacist and that was correct.  The physician assistant prescribed the patient sixty 15 mg tablets of amphetamine salts with no refills, which was filled by the patient on 4/8/2011.

On 4/26/2011, the physician assistant prescribed the patient ninety 1mg tablets of alprazolam with one refill, which was filled by the patient on 4/28/2011.

On 4/29/2011, the patient presented to the physician assistant for a check-up.  The patient stated she was doing very well and believed all of the problems started when she stopped using Cymbalta.  The patient also reported to the physician assistant that since she restarted the Cymbalta at 60 mg per day, she was doing very well.  The patient also stated to the physician assistant that she was taking Xanax; however she had stopped the Adderall.  Finally, the patient told the physician assistant that she did have joint pain, especially in the knees, and that she was taking a supplement for that.  The physician assistant diagnosed the patient with depression and anxiety.  The physician assistant determined that the patient should continue the Cymbalta and Xanax.

On 6/2/2011, the patient called the physician assistant requesting pain medication and antibiotics.  The physician assistant referred the patient to a dentist and denied her any narcotic prescriptions.

On 6/24/2011, the patient called the physician assistant for a refill of Xanax a day earlier because of car problems.  The physician assistant prescribed the patient ninety 1 mg tablets of alprazolam with two refills, which was filled by the patient only one time on 6/24/2011.  On that same day, the physician assistant also prescribed the patient another ninety 1 mg tablets of alprazolam with an additional refill that was filled by the patient on 7/22/2011 and 8/22/2011.

On 7/8/2011, the physician assistant prescribed the patient thirty 15 mg tablets of amphetamine salts with no refills that was filled by the patient on 7/8/2011.

On 7/22/2011, the physician assistant prescribed sixty 15 mg tablets of amphetamine salts with no refills that was filled by the patient on 7/22/2011.

On 9/20/2011, the physician assistant prescribed the patient ninety 1 mg tablets of alprazolam with two refills, which was filled by the patient on 9/20/2011, 10/17/2011, and 12/2/2011.

The Board judged the physician assistant’s conduct to be below the minimum standard of competence given her excessive, improper, and inappropriate prescribing.  She also failed to require the patient come into the office for a patient visit each time she provided the patient a prescription.

The Board ordered that the physician assistant complete continuing medical education course in controlled substance prescribing, pain, anxiety, and insomnia.

State: Kansas


Date: August 2013


Specialty: Physician Assistant


Symptom: Headache, Pain, Psychiatric Symptoms


Diagnosis: Psychiatric Disorder


Medical Error: Improper medication management


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Washington – Psychiatry – Diazepam Prescribed To Depressed Patient With Suicidal Ideation



A patient was referred to a psychiatrist by her therapist for a psychiatric evaluation due to longstanding depression with periodic thoughts of suicide.  The understanding was that the psychiatrist would manage the patient’s medications while the therapist continued counseling with the patient.

The psychiatrist first saw the patient on 3/24/2008.  The psychiatrist diagnosed the patient as having recurrent major depression and wanted to rule out bipolar disorder.  The psychiatrist examined the patient, took her medical history and assessed the medications she was taking.  These medications were prescribed by previous physicians.  The psychiatrist changed the patient’s depression medication.  He took her off of venlafaxine (Effexor), which the patient felt had previously been helpful but had ceased being effective.  The psychiatrist prescribed lamotrigine (Lamictal).

Over the next five months, the psychiatrist continued the patient on this medication, periodically increasing the dosage up to 200 mg.  In June 2008, the psychiatrist also started the patient on ziprasidone (Geodon), to help reduce anxiety.

The psychiatrist was aware that the patient was taking clonazepam at bedtime.  By August 2008, the psychiatrist had advised the patient to taper off the clonazepam, when the patient reported that she was feeling more depressed and manifesting anxiety.  The psychiatrist noted that the patient’s mental status was despondent and hopeless.  The psychiatrist started the patient on mirtazapine and continued her on Geodon and Lamictal.

On 8/26/2008, the psychiatrist noted that the patient was extremely anxious, depressed, and increasingly suicidal.  The psychiatrist advised the patient to reduce the Lamictal from 200 mg to 100 mg.  The psychiatrist prescribed a quantity of 120 diazepam 10 mg tablets for the patient, one tablet to be taken four times a day as needed.  The psychiatrist note that the patient would return on an as needed basis.

On 9/3/2008, the patient went to a remote wooded recreational area and consumed all of her diazepam.  The patient was found by hikers and taken by ambulance to a hospital for emergency care.  The patient was hospitalized until 9/8/2008.

After the patient’s discharge from the hospital, the psychiatrist saw the patient four times over the following three weeks for anxiety and depression.  The patient subsequently sought out another psychiatrist.

The psychiatrist did not adequately document the rationale for his treatment of the patient’s depression.  The psychiatrist treated the patient for bipolar depression but did not document the factors supporting his decision to treat the patient as having bipolar depression instead of unipolar depression.

On 8/26/2008, despite the patient’s reports of increasing suicidal ideation, the psychiatrist prescribed a large amount of diazepam for the patient.  The quantity and dosage of the psychiatrist’s prescription of diazepam for the patient, in her condition, put the patient at increased risk for an overdose attempt.

The psychiatrist did not provide a well-structured care and monitoring plan for the patient over the nearly six months that he treated her.  In spite of the variety of drugs she was taking and her manifested depression and anxiety, on several occasions, the psychiatrist did not schedule appropriate follow-up visits and instead instructed the patient to return when she felt the need.

The psychiatrist did not establish a crisis plan with the patient during the session on 8/26/2008.  Specifically, there was no mutually-agreed plan for what actions the patient would take in the event that she felt that she was at risk of acting on her suicidal thoughts.

The Commission stipulated the psychiatrist reimburse costs to the Commission, have his license be placed on probation for a period of two years, complete a continuing education course on the topic of outpatient management of the acutely suicidal psychiatric patient, and allow a Commission representative to visit his practice to review patient charts and interview staff.  The representative will focus on  the psychiatrist’s development and documentation of a crisis plan for acutely suicidal patients, the psychiatrist’s documentation of moderation in the amounts of medication prescribed for acutely suicidal patients, the psychiatrist’s documentation for his rationale for his diagnoses for patients, the psychiatrist’s documentation of periodic contact with other mental health providers, and whether the psychiatrist has instituted and documented planned patient follow-ups, instead of follow-ups as needed.

State: Washington


Date: August 2013


Specialty: Psychiatry


Symptom: Psychiatric Symptoms


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


Medical Error: Improper medication management


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Family Medicine – Failure To Examine Patient Properly And Justify Excessive Prescribing Of Medications



On 5/18/2004, a patient presented to a family practitioner for examination and/or treatment. The family practitioner assessed the patient with bipolar disorder, back pain, anxiety, and herniated disc of the neck and back.  He advised the patient to continue her present medications, to have repeat blood tests done in three months, and to come back for a follow-up after one month.

On 6/11/2004, the patient presented to the family practitioner for the follow-up.  He diagnosed the patient with arthritis, hypercholesterolemia, and anxiety.  He prescribed the patient diazepam thirty 5 mg tablets, hydrocodone/acetaminophen sixty 10/650 mg tablets, and Altocor (lovastatin) thirty 60 mg tablets.

On 6/25/2004, the patient again presented to the family practitioner and was diagnosed with lower back pain, left knee pain, and anxiety.  He prescribed the patient Seroquel (quetiapine) sixty 100 mg tablets.

On 7/8/2004, the patient presented to the family practitioner for follow-up on her anxiety and insomnia.  He prescribed the patient diazepam thirty 5 mg tablets and Altocor thirty 60 mg tablets.  He noted in the assessment/plan for the patient that she was to have a lipid panel and a comprehensive metabolic panel, and the office “will have her follow for results.”

On 8/3/2004, the family practitioner prescribed the patient diazepam thirty 5 mg tablets, polymyxin B sulfate – HC Otic, and Seroquel sixty 100 mg tablets.

On 8/4/2004, the family practitioner prescribed the patient Altoprev (lovastatin) thirty 60 mg tablets.  Medical records do not document the basis for this prescription.

On 8/21/2004, the patient presented to the family practitioner for follow-up on her anxiety and insomnia.  He noted in his assessment back pain and anxiety.  His plan for the patient included giving diazepam and indicated she would follow-up after one month.

On 9/2/2014, the family practitioner prescribed the patient Altoprev (lovastatin) thirty 60 mg tablets.  Medical records do not document the basis for this prescription.

On 9/3/2004, the patient presented to the family practitioner with complaints of continued back pain, anxiety, and difficulty sleeping.  He noted in his assessment back pain and anxiety.  His plan for the patient included giving her diazepam and indicated she would follow up after one month.  According to Medicaid records, the family practitioner prescribed the patient diazepam thirty 5 mg tablets and Seroquel sixty 100 mg tablets.

On 9/23/2004, the family practitioner prescribed the patient Seroquel sixty 100 mg tablets.  Medical records do not document the basis for this prescription.

On 10/3/2004, the family practitioner prescribed the patient Altoprev (lovastatin) thirty 60 mg tablets.  Medical records do not document the basis for this prescription.

On 10/6/2004, the family practitioner prescribed the patient diazepam thirty 5 mg tablets, and amoxicillin twenty 500 mg capsules.

The Medical Board of Florida judged the family practitioners conduct to be below the minimal standard of competence given that he failed to perform a complete assessment of the patient.  His assessment of the patient’s complaints and symptoms were non-specific.  He failed to adequately document a complete history and physical in one or more of the patient’s medical records.  Between 5/18/2004 and 10/6/2004, he prescribed medications to the patient inappropriately and excessively.  He also frequently refilled prescriptions without noting an explanation for doing so. The family practitioner failed to accurately and completely document and justify the course of treatment utilized in the care of the patient in one or more of the following ways: by failing to note the past medical history for the patient during one or more of the visits to the general surgeon and/or failing to note records of drugs prescribed.

The Medical Board of Florida reprimanded the license of the family practitioner.  The Medical Board of Florida ordered that he pay a fine of $18,000 against his license and pay reimbursement costs for the case of for a minimum of $19,920.29 and a maximum of $21,920.29.  The Medical Board of Florida also ordered that the family practitioner complete a drug course in “prescribing controlled substances” complete a records course, complete five hours of continuing medical education in ethics and communication, and complete one-hour lecture/seminar on wrong site procedure.

State: Florida


Date: December 2011


Specialty: Family Medicine, Internal Medicine


Symptom: Back Pain


Diagnosis: Psychiatric Disorder, Cardiovascular Disease


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



California – Psychiatry – Improper And Undocumented Evaluation Of Patient With Major Depression And Polysubstance Dependence With Antisocial Personality Traits



A patient had a history of psychiatric interface with previous diagnoses of Major Depression and Polysubstance Dependence with Antisocial Personality Traits.  The records indicated that the patient saw a psychiatrist a total of four occasions on 2/22/2007, 5/8/2007, 6/28/2007, and 10/30/2007 for depressive symptoms.  The psychiatrist diagnosed the patient with a Depressive Disorder and treated the patient with Remeron (an antidepressant) and Benadryl (an allergy medicine) for sleep.

There is no documentation that the psychiatrist appropriately evaluated the patient’s depressive symptoms, including obtaining a history of changes in sleep, decreased interest in unusual activities, feelings of guilt, hopelessness, helplessness, decline in energy, decline in concentration, changes in appetite, changes in psychomotor activity, and thoughts of suicide.

There is no documentation that the psychiatrist documented subjective changes in the patient’s personal, interpersonal, social, and occupational functioning.

Moreover, there is no showing that the psychiatrist performed an objective assessment of the patient’s condition, including conducting a thorough mental status examination and use of other laboratory data, nor did the psychiatrist perform an assessment including a differential diagnosis and a biopsychosocial plan of action.

For this allegation and others, the Board judged that the psychiatrist failed to provide appropriate care and treatment and failed to maintain appropriate medical records.  The Board ordered the psychiatrist to surrender his license.

State: California


Date: July 2011


Specialty: Psychiatry


Symptom: N/A


Diagnosis: Psychiatric Disorder


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


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Psychiatry – Improper And Undocumented Evaluation Of Patient For Psychosis And Depressive Disorder



A patient was evaluated by a psychiatrist a total of nine times between 10/1/2003 and 12/27/2007.  The psychiatrist diagnosed the patient with having psychosis and treated the patient with Risperdal (an antipsychotic drug commonly used to treat schizophrenia and schizoaffective disorder), Benadryl, and Trazadone (an antidepressant).  The patient was later diagnosed with depressive disorder and treated with Zoloft (an antidepressant) and Remeron.

There is no evidence that the psychiatrist evaluated the patient’s psychosis and depressive disorder appropriately by documenting a critical assessment of the patient’s prior psychotic history and interval changes in his current functioning.

There is also no evidence of a critical and thoughtful, or even cursory assessment of prior, current, and intervening symptoms as most of the psychiatrist’s progress notes are essentially identical.

Moreover, the record does not indicate that the psychiatrist comprehensively identified the patient’s previous and current psychiatric symptoms into an appropriate psychiatric diagnosis, nor is there documentation that the psychiatrist considered a differential diagnosis since it is likely that the patient also had schizophrenia and schizoaffective disorder.

Also, the psychiatrist failed to consider other more reasonable and appropriate medications and doses since the records indicate that the psychiatrist generally treated the patient with Zoloft and Risperdal without implementing other antipsychotics and antidepressants which are available and would have been useful to treat this patient.

For this allegation and others, the Board judged that the psychiatrist failed to provide appropriate care and treatment and failed to maintain appropriate medical records.  The Board ordered the psychiatrist to surrender his license.

State: California


Date: July 2011


Specialty: Psychiatry


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



California – Psychiatry – Improper Evaluation Of Patient With Psychiatric Disorder And Subtherapeutic Depakote Dosing



A psychiatrist saw a patient on 12/4/2007 and 6/6/2008.  The psychiatrist diagnosed the patient with having schizoaffective disorder and prescribed Depakote, mirtazapine, ziprasidone (an antipsychotic used in treating schizophrenia and bipolar disorder), and hydroxyzine (an antihistamine for treatment of allergies).

There is no documentation that the psychiatrist assessed the patient’s prior psychiatric functioning, any response to previous psychiatric treatment, nor did the psychiatrist conduct a comprehensive current assessment of the patient’s personal, interpersonal, social, and occupational functioning. The psychiatrist did not consider a differential diagnosis, which would include schizophrenia and mood disorder.

Although the psychiatrist did order appropriate chemistries on 12/4/2007, it does not appear that labs were drawn until five months later, on 5/29/2008.  The Depakote level at that time was 2.9, significantly subtherapeutic.  On the psychiatrist’s follow-up appointment with the patient on 6/6/2008, the Depakote level was not documented as being reviewed and the patient was kept on a significantly subtherapeutic dose.

For this allegation and others, the Board judged that the psychiatrist failed to provide appropriate care and treatment and failed to maintain appropriate medical records.  The Board ordered the psychiatrist to surrender his license.

State: California


Date: July 2011


Specialty: Psychiatry


Symptom: N/A


Diagnosis: Psychiatric Disorder


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


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Psychiatry – Incomplete And Inadequate Mental Status Examination With Failure To Properly Prescribe Lithium



A psychiatrist evaluated a patient on one occasion on 10/13/2004.  The patient’s medications include Lithium Carbonate (used to treat mania and bipolar disorder), olanzapine (an antipsychotic drug used for treating schizophrenia and bipolar disorder), and fluoxetine (an antidepressant).  The patient died while in custody on 10/22/2004.

The psychiatrist’s 10/13/2004 progress note included a cursory summary of the patient’s subjective complaints, as well as an incomplete and inadequate mental status examination.  The psychiatrist also doubled the patient’s Lithium dose/level from 450 mg twice daily to 900 mg twice daily without knowing the patient’s prior Lithium dose/level.

There is also no documentation that the psychiatrist questioned the patient regarding side effects, assessed the patient’s subjective symptoms and level of psychosocial functioning, considered a possible differential diagnosis, a plan for psychiatric care, including medication adjustment as required, and appropriate ancillary services.

For this allegation and others, the Board judged that the psychiatrist failed to provide appropriate care and treatment and failed to maintain appropriate medical records.  The Board ordered the psychiatrist to surrender his license.

State: California


Date: July 2011


Specialty: Psychiatry


Symptom: N/A


Diagnosis: Psychiatric Disorder


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


Significant Outcome: Death


Case Rating: 1


Link to Original Case File: Download PDF



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