Found 65 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



California – Neurology – Three EEGs Ordered Without Indication And Diagnosis Of Epilepsy



A 9-year-old girl was referred by her pediatrician to a child neurologist for headaches.  The child neurologist first saw the patient on 9/10/2009. The patient’s mother stated that the patient’s headaches started in 7/20/2009.  The patient had no episodes of loss of consciousness of any type. The child neurologist’s review of systems revealed headaches, neck pain, and back pain.  The child neurologist noted headaches following a viral infection in July 2009 described as constant tension and pressure with nausea, photophobia, and difficulty concentration.  The child neurologist’s diagnosis was childhood migraine and prescribed 10 mg amitriptyline. The child neurologist ordered an MRI to rule out neoplasm and aneurysms. The child neurologist also ordered an EEG, which was not indicated for headaches.

On 9/18/2009, the EEG was performed.  The technician described the EEG with “sharp and slow waves.” On 9/30/2009, the child neurologist saw the patient for an office visit.  The child neurologist read the EEG as showing “generalized polyspike and wave which was synchronous bilaterally over both hemispheres which is highly suggestive of a generalized seizure disorder.”  The child neurologist stopped the amitriptyline 10 mg she prescribed at the last visit because of “seizures on EEG.” She ordered a neurosurgery consult and planned a separate meeting with the mother.

The child neurologist next saw the patient on 11/4/2009.  The child neurologist prescribed Depakote at 250 b.i.d. The patient’s Depakote level was at 72.  The patient reported no seizures or auras, but the child neurologist in her diagnosis documented “seizures, breakthrough.”  The child neurologist ordered a second video EEG with computer analysis without medical indication. The EEG was performed on 11/25/2009.  The technician report showed no abnormality. The child neurologist’s report was of generalized polyspike and slow waves bilaterally, “highly suggestive of generalized epilepsy,” with localized slowing in the left temporal area.

On 2/11/2010, the child neurologist saw the patient for a follow-up visit.  The chief complaint was learning difficulty. The Depakote level was 53. The patient denied experiencing any auras and/or any seizures.  On the next visit, on 5/11/2010, the patient still did not report any auras or seizures. The child neurologist’s diagnoses were generalized epilepsy, childhood headaches, adverse effect of medication, and learning disability.  The child neurologist ordered a third video EEG with computer analysis to rule out seizures and BAER (brainstem auditory evoked response) to rule out hearing loss, despite no medical indication. The video EEG was performed on 6/28/2010 and was normal.  On 7/12/2010, the child neurologist saw the patient for a follow-up visit. The patient denied having headaches and seizures. The child neurologist ordered a 72-hour ambulatory EEG despite the normal EEG.

The child neurologist next saw the patient on 1/19/2011 for a follow-up visit.  The patient’s mother complained that the patient’s math and history test results were still low.  The patient had no witnessed seizures and was tolerating Keppra well. Despite the negative findings, the child neurologist diagnosed “seizures, breakthrough, rule out.”  The child neurologist ordered another video EEG. At this point in time, the 72-hour video EEG she previous ordered on 7/12/2010 had not been performed.

On 2/18/2011, a 72-hour ambulatory EEG was performed.  The child neurologist’s last visit with the patient was on 3/14/2011.  On the last visit, the child neurologist noted that the 72-hour ambulatory EEG was normal.  She discontinued Keppra. She diagnosed the patient with “arachnoid cyst, middle cranial fossa; generalized epilepsy; learning disability; and adverse effect of medication given correctly.”

The Medical Board of California judged that the child neurologist’s conduct departed from the standard of care because she ordered 3 video EEGs and an ambulatory EEG without medical indication, ordered a BAER with no medical indication, misdiagnosed epilepsy on a patient with no medical history of seizures of any type, and made diagnoses of breaththrough seizures with no basis, contrary to her own findings that were no auras or seizures reported.

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, Nausea Or Vomiting, Back Pain, Head/Neck Pain


Diagnosis: N/A


Medical Error: Unnecessary or excessive diagnostic tests, False positive


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Pediatrics – Cough, Post-Tussive Emesis, Fever, Elevated Heart Rate, And Elevated Respiratory Rate



On 6/8/2012, a 16-year-old female presented with complaints of tactile fever for the previous four days, coughing, and one incident of post-tussive emesis.

A pediatrician performed an examination and documented that the patient’s temperature was 98.3, her heart rate was 98, and her respiratory rate was 22.  The patient’s weight was also documented to be 209 pounds.

The pediatrician assessed the patient was suffering from an upper respiratory infection (URI) and recommended that she continue over-the-counter medication to manage her symptoms.

On 6/9/2012, the patient again presented to the pediatrician.  She presented with the same complaints of fever and coughing, but additionally complained of a sore throat.

The pediatrician performed an examination and documented that the patient’s heart rate was 106 and her respiratory rate was 32.  She was also running a temperature of 100.8.

The pediatrician assessed that the patient had a URI and pharyngitis.  The pediatrician provided the patient with respiratory instruction and advised that she should return in two days if her temperature persisted.

Despite the increase in the patient’s heart rate and respiratory rate from the 6/8/2012 and 6/9/2012 visit, the pediatrician did not order a STAT chest x-ray for the patient. Despite the increase in the patient’s heart rate and respiratory rate from the 6/8/2012 and 6/9/2012 visit, the pediatrician did not check the patient’s oxygen saturation.

On 6/10/2012, the patient expired in her home.  The medical examiner documented the patient’s cause of death as pneumonia with sepsis due to haemophilus influenzae.

The Medical Board of Florida judged the obstetrician’s conduct to be below the minimal standard of competence given that he failed to order a STAT chest x-ray and check the patient’s oxygen saturation.

The Medical Board of Florida issued a letter of concern against the pediatrician’s license.  The Medical Board of Florida ordered that the pediatrician pay a fine of $5,000 against his license and pay reimbursement cost at a minimum of $1,408.03 and a maximum of $3,408.03.  The Medical Board of Florida ordered that the pediatrician complete five hours of continuing medical education in pediatric medicine and complete three hours of continuing medical education in diagnosis and treatment of pneumonia.

State: Florida


Date: August 2017


Specialty: Pediatrics, Emergency Medicine, Family Medicine, Internal Medicine


Symptom: Fever, Cough, Nausea Or Vomiting


Diagnosis: Pneumonia


Medical Error: Failure to order appropriate diagnostic test


Significant Outcome: Death


Case Rating: 4


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 – Pediatrics – Deep Laceration Of The Right Knee Treated With Debridement, Irrigation, And Suturing



On 12/7/2011, an 8-year-old male presented to a medical emergency department with a deep laceration to his right knee.  The laceration was a full thickness cut with visualization of the capsule.  An x-ray revealed air in the knee joint.

A pediatrician examined the patient’s knee and performed debridement, cleaning by irrigation, and suturing of the laceration.  Bacitracin and dressing were applied to the patient’s knee.

On 12/10/2011, the patient returned to the emergency department with complaints of right knee swelling, redness, and pain.  The patient was admitted to the pediatric floor.

Further examination revealed septic arthritis in the patient’s right knee, which required two operations and the introduction of a PICC line for long-term antibiotic therapy.  The patient sustained cartilage damage as a result of the septic arthritis and suffered from significant knee pain.

The Board judged the pediatrician’s conduct to be below the minimal standard of competence given that he failed to refer the patient to an orthopedic surgeon and to fully wash out the patient’s joint by performing an open debridement under anesthesia.

The Board issued a letter of concern against the pediatrician’s license.  The Board ordered the pediatrician to pay a fine of $10,000 against his license and pay reimbursement costs at a minimum of $5,496.59 and not to exceed $7,496.59.  The Board also ordered that the pediatrician complete ten hours continuing medical education in pediatric orthopedic diagnosis and treatment and complete five hours of continuing medical education in “risk management.”

State: Florida


Date: June 2017


Specialty: Pediatrics, Orthopedic Surgery


Symptom: Joint Pain, Swelling


Diagnosis: Trauma Injury, Septic Arthritis


Medical Error: Improper treatment, Referral failure to hospital or specialist


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 4


Link to Original Case File: Download PDF



California – Pediatrics – Long Term Regimen Of Compounded Dexamethasone Cough Syrup For Pneumonia And Asthma



On 1/13/2015, a pediatrician saw a child just short of her second birthday.  She had been diagnosed with asthma and was maintained on corticosteroid and albuterol inhalers.  The patient presented with fever, coughing, and loss of appetite.  Although she had taken an antibiotic prior to this visit, it is not noted in the pediatrician’s chart notes.  The pediatrician diagnosed pneumonia, laryngotracheobronchitis (croup), and asthma and prescribed a different antibiotic for her.

The pediatrician stated that she followed up with the patient by telephone on 1/14/2015 and 1/15/2015.  Based on these follow-up calls, the pediatrician prescribed compounded cough syrup at a daily dose containing 0.55 mg dexamethasone, a corticosteroid.  She prescribed a sufficient amount of the medication to last a month and when the patient’s mother said that she was afraid that the patient would begin to cough again because her entire family had caught the cold, the pediatrician called in a partial refill for the medication.  None of this information was included in the pediatrician’s chart notes for the patient.

The pediatrician’s chart notes for the patient’s follow-up visits on 1/20/2015 and 2/20/2015 did not make reference to the compounded cough medication, instructions on how to take the medication, or to the advice she gave the patient’s mother concerning weaning the patient off the medication.  Although the pediatrician stated that she was concerned about the patient’s reduced “immunity” and recommended an over the counter immune pediatric supplement for the patient on 2/20/2015, this concern was not documented in the patient’s chart notes.

The Board judged the pediatrician’s conduct to have fallen below the standard of care given failure to appropriately prescribe dexamethasone to the patient and given failure to document the follow-up telephone calls, the fact that she had prescribed the compounded cough medication to the patient, instructions for the patient to wean off the dexamethasone, concern for the patient’s reduced “immunity,” and the fact that the patient had taken antibiotics prior to her first visit with the patient.

A public reprimand was issued against the patient with stipulations to take a medical record keeping course.

State: California


Date: May 2017


Specialty: Pediatrics


Symptom: Cough, Fever


Diagnosis: Pneumonia, Asthma


Medical Error: Improper medication management, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Pediatrics – Fourteen-Year-Old Male With A Hemoglobin Of 8.2



On 7/30/2013, a 14-year-old male was seen by a pediatrician for a well-child assessment.  The pediatrician reviewed the patient’s height, weight, temperature, and blood pressure and administered hearing and vision tests.  She reviewed the patient’s development, including body image, home situation, education, school progress, risk-taking behaviors, sexuality, and mental health.  A complete physical examination was performed.

On 7/30/2013, the patient received a routine HPV immunization.  Routine diagnostic laboratory tests were ordered, including urinalysis.  A hemoglobin test by finger stick was performed.  The patient’s urinalysis test result was normal, but his hemoglobin result of 8.2 was significantly lower than normal.  The pediatrician repeated the hemoglobin test by finger stick but did not order a complete blood count by venipuncture.  The patient’s hemoglobin result was again 8.2.  The pediatrician started the patient on iron supplement therapy and instructed him to follow up in three months.  No additional diagnostic tests were done during this visit.

On 8/18/2013, the clinic received a report that the patient was experiencing shortness of breath and chest pain.  The patient was instructed to go to an emergency room.

At the emergency room, the patient experienced a full cardiac arrest.  His complete blood count revealed severe anemia, with a hemoglobin result of 7.5, a hematocrit of 21, 99 atypical lymphocytes, and a critically low platelet count of 39,000.  The patient’s cause of death was acute lymphoblastic leukemia/lymphoma.

The Board deemed the pediatrician’s level of conduct to be below the standard of care given failure to order a complete blood count by venipuncture for the follow-up blood test, failure to schedule a visit and lab check at an earlier date, and failure to consider other diagnoses in addition to iron deficiency anemia.

The Board issued a public reprimand against the pediatrician.  Stipulations included performing sixty hours of free services to a community or a non-profit organization, conducting 40 hours of continuing medical education, enrolling in a professionalism program, and undergoing a clinical competency assessment program.

State: California


Date: May 2017


Specialty: Pediatrics, Hematology


Symptom: Shortness of Breath, Chest Pain


Diagnosis: Cancer, Hematological Disease


Medical Error: Failure to order appropriate diagnostic test, Delay in proper treatment


Significant Outcome: Death


Case Rating: 5


Link to Original Case File: Download PDF



North Carolina – Physician Assistant – 10-Year-Old With Cough, Fever, High Blood Pressure, and Sore Throat Diagnosed With Strep Throat



The Board was notified of a professional liability payment made on 1/28/2016.

A 10-year-old presented to a physician assistant with a chief complaint of cough, headache, sore throat, and fever.  The patient’s blood pressure was elevated, 140/190, and she had a fever of 103.2 degrees F.  According to the history, the patient denied nausea, vomiting, or diarrhea.  In the physical examination, it was documented a normal respiratory assessment.  The patient was diagnosed with strep throat, prescribed amoxicillin, and the patient was discharged home.

The patient died two days later from pneumonia secondary to influenza infection, which was not listed in the differential diagnosis.

The Board expressed concern that the physician assistant did not consider influenza in the differential diagnosis, prescribed an antibiotic without identifying the pathogen responsible for the infection, and did not perform a blood pressure recheck for the patient’s hypertension.  The Board noted a failure to document providing adequate follow up instructions to the patient’s family enumerating red flag signs and symptoms which would prompt the family to return the child to a health care facility.

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: April 2017


Specialty: Physician Assistant, Emergency Medicine, Pediatrics


Symptom: Fever, Cough, Headache


Diagnosis: Pneumonia


Medical Error: Diagnostic error, Lack of proper documentation


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



Arizona – Pediatrics – Pediatrician Suddenly Resigns And Leaves Without Prior Arrangements Or Warning



A pediatrician held the position of Chief Medical Officer.

On 10/22/2014, the pediatrician was scheduled to see patients, but informed his Chief Operating Officer that morning that he was resigning effective immediately.  The pediatrician was asked to stay 48 hours to allow the employer to seek a locum tenens to replace him, but he declined, and provided a letter of resignation for himself and another physician employed by his Employer.

Consequently, the Employer’s clinic did not have any physicians to see the patients scheduled that day.  The Employer was ultimately unable to secure a locum tenens for 10 days following the resignations and appointments for pediatric patients had to be cancelled, rescheduled, or the patients were referred elsewhere during that time period.  The pediatrician did provide prescription refills for established patients for a period of time following his resignation.

The standard of care requires a physician to give a reasonable amount of time before resigning from a practice to assure seamless care of the patients in that practice setting.

The Board judged the pediatrician’s conduct to be below the minimum standard of competence given failure to allow for a seamless transition of patient care, which ultimately increased the risk of patient harm.

The Board ordered the pediatrician be reprimanded.

State: Arizona


Date: April 2017


Specialty: Pediatrics


Symptom: N/A


Diagnosis: N/A


Medical Error: Ethics violation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Kansas – Physician Assistant – High Dosing Regimen Of Amitriptyline For A Pediatric Patient With Headache, Vomiting, And Incontinence



On 11/19/2015, a patient presented to a physician assistant at a family care clinic with chief complaints of headache, vomiting, and incontinence since 11/17/2015.  The patient’s father reported, in addition to the severe headache, the patient was experiencing involuntary arm jerking.  Furthermore, the night prior, the patient experienced hearing voices.

The patient had a history of respiratory problems, was noted to have “poor” functional status, and was noted to be in preschool.

The physician assistant did not complete a neurological examination; however, he diagnosed the patient with pediatric migraine and ordered thirty 10 mg tablets of amitriptyline with instructions for the patient to take one tablet three times daily and the patient was to have one refill.  The physician assistant did not perform a thorough workup to include additional studies or tests prior to prescribing amitriptyline.

On 2/3/2016, the Board received a response from the physician assistant wherein he indicated, “I recall little about the episode, except possibly after reviewing his chart and the nurses [sic] report, in investigating his headache and cyclic vomiting and physical exam in UpToDate that the treatment I initiated would have been per the UpToDate recommendations.”

UpToDate is an online website claiming to be an evidence-based, physician-authored clinical decision support resource.

The physician assistant inappropriately prescribed amitriptyline due to the excessive dose and age of the patient.

The Board judged the physician assistant’s conduct to be below the minimum standard of competence given his inappropriate prescribing of amitriptyline.

For this allegation and others, the Board ordered the physician assistant to contact The Center for Personalized Education for Physicians, (“CPEP”) for a competence assessment, follow all recommendations of the CPEP assessment, and complete a medical record keeping seminar.

State: Kansas


Date: April 2017


Specialty: Physician Assistant, Family Medicine, Pediatrics


Symptom: Headache, Nausea Or Vomiting, Psychiatric Symptoms, Urinary Problems


Diagnosis: Neurological Disease


Medical Error: Improper medication management, Accidental Medication Error, Failure to examine or evaluate patient properly


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



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