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Florida – Psychiatry – Lithium Administration With Lisinopril And Hydrochlorothiazide
On 12/7/2016, a 30-year-old female was admitted to University Behavioral Center (“UBC”) while suffering from acute psychotic symptoms and was placed under a psychiatrist’s care. The patient remained under the psychiatrist’s care at UBC for approximately eleven days.
On the day of the patient’s admission, the psychiatrist began treating the patient with lithium. The psychiatrist continued treating the patient with lithium until 12/17/2016.
The patient had previously been prescribed lisinopril (an ACE inhibitor) and hydrochlorothiazide (a thiazide diuretic) for hypertension. The psychiatrist continued treating the patient with hydrochlorothiazide until 12/16/2016. The psychiatrist continued treating the patient with lisinopril for the duration of her stay at UBC.
During the course of the patient’s confinement at UBC, her condition worsened, and she experienced incontinence and increasing levels of confusion. After falling in the shower on 12/18/2016, the patient was transferred to a hospital for medical treatment, where it was determined that the patient was experiencing lithium toxicity. As a result of the lithium toxicity, the patient suffered kidney failure, which required dialysis.
The Board judged the psychiatrist’s conduct to be below the minimum standard of competence given that she should have been aware of the potential drug interactions with lithium and to prescribe alternative antipsychotic drug to a patient taking both a thiazide diuretic and an ACE inhibitor, as each of these drugs has a known interaction with lithium which presents risk of lithium toxicity. The psychiatrist also failed to monitor the patient for signs of lithium toxicity, and she failed to immediately discontinue treatment with lithium when the patient began experiencing symptoms of lithium toxicity.
It was requested that the Board order one or more of the following penalties for the psychiatrist: permanent revocation or suspension of her license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Board deemed appropriate.
State: Florida
Date: December 2017
Specialty: Psychiatry
Symptom: Psychiatric Symptoms, Confusion, Urinary Problems
Diagnosis: Drug Overdose, Side Effects, or Withdrawal
Medical Error: Improper medication management, Failure to properly monitor patient
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
Virginia – Psychiatry – Adjusting Lithium Dosage Based Only On Patient Symptoms
A psychiatrist increased and decrease a patient’s lithium dosage based on the patient’s symptoms. She did not test the patient’s lithium blood serum level.
On 8/28/2015, the patient was admitted to a hospital for lithium toxicity. The psychiatrist stated that lithium blood serum levels for long-term lithium patients should be tested at least annually, but also at any time a patient complains of adverse side effects. The psychiatrist admitted her failure to test the patient’s lithium levels and stated that it “was an inadvertent oversight for which [she] is remorseful.” The psychiatrist reported that following the patient’s hospitalization for lithium toxicity, she reviewed the charts for her other patients on lithium and determined if they needed testing for lithium blood serum levels.
She provided evidence that she completed 99 hours of CME in psychiatry in 2015 and 58 credit hours of CME in psychiatry in 2017. She provided a spreadsheet that she created for use in monitoring her patients on lithium. She was reprimanded by the Virginia Board of Medicine.
State: Virginia
Date: October 2017
Specialty: Psychiatry
Symptom: N/A
Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Psychiatric Disorder
Medical Error: Improper medication management, Failure to properly monitor patient
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
Florida – Psychiatry – Female Admitted With Depression And Psychosis Started On Quetiapine 200 mg Nightly
On 3/27/2013, a 44-year-old female presented to a behavioral health center after being “Baker Acted,” or involuntarily institutionalized, for depression and psychosis.
Upon the patient’s admission to the behavioral health center, a psychiatrist was called to place medication orders.
The psychiatrist called back one hour later and ordered Seroquel 200 mg at bedtime, among other medication orders.
Shortly after administration of the Seroquel, the patient experienced an episode of syncope and fell forward, sustaining a loss of consciousness, lacerations to her face, and a broken jaw.
The Board judged the psychiatrist’s conduct to be below the minimal standard of competence given that she failed to order an initial dose of 50 mg or less of Seroquel and titrate the dosage up as needed.
It was requested that the Board order one or more of the following penalties for the psychiatrist: permanent revocation or suspension of his license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Board deemed appropriate.
State: Florida
Date: October 2017
Specialty: Psychiatry
Symptom: Psychiatric Symptoms
Diagnosis: Drug Overdose, Side Effects, or Withdrawal
Medical Error: Improper medication management
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
Vermont – Family Practice – Oversight In Anorexia Nervosa Monitoring
A patient was treated by a family practitioner from May 2012 to September 2012.
On the first office visit, the patient presented with symptoms and behaviors that met the DSM-IV criteria of anorexia nervosa, as well as the National Institute for Mental Health criteria of Pediatric Acute Neuropsychiatric Syndrome (PANS). The patient’s medical records from the patient’s prior primary care physician included a diagnosis of anorexia nervosa and a prior recommendation for inpatient mental health treatment for anorexia.
The family practitioner made the following diagnoses: systemic inflammatory syndrome with multi-systemic symptoms and marked neuropsychiatric dysfunction with probable underlying infectious triggers; PANS (Pediatric Acute Neuropsychiatric Syndrome); and probable PITANDs (Pediatric Infection-Triggered Autoimmune Neuropsychiatric Disorders). Anorexia nervosa was not documented as a primary or differential diagnosis. The family practitioner indicated that he considered the possibility of a purely behavioral syndrome like anorexia nervosa, but felt that the patient’s anorexia was “part of a more complex multi-system picture.”
The family practitioner based his diagnosis on the patient’s history and symptoms meeting the diagnostic criteria for PANS, testing positive to three infectious agents, and an initial response positive response to PITANDs treatment, in addition to a lack of positive response to anorexia nervosa focused management with the patient’s prior primary care physician and other consultants.
The family practitioner saw the patient on three occasions over a four month period, which the Board believes is inadequate for management of anorexia for an adolescent. The family practitioner relied on his nurse to call the patient on weekly updates and weight checks.
In addition to three office visits, the family practitioner’s treatment included ordering numerous blood tests, and the prescribing of medications, antibiotics, herbal supplements, and vitamins for the infection etiologies and the inflammatory conditions. However, he did not prescribe any medications for the treatment of anorexia nervosa. While the family practitioner believed that the patient was being treated by his primary care physician, this was not confirmed with any other provider, and the family practitioner did not communicate directly with any other provider beyond sending his initial office visit note and lab results to the patient’s primary care physician.
The Board judged the family practitioner’s medical records and communication with the patient’s primary care physician concerning his treatment of the patient were inadequate. The family practitioner’s office notes did not document past surgical and family history, temperature, height, BMI calculation, and growth curve charting.
Based on review of the family practitioner’s medical records concerning his treatment of the patient and the documentation of his communication with the patient’s parents, it appears that the family practitioner did not clearly explain his role in the patient’s care to the patient’s parents until the end of his treatment. Is it possible that the patient’s parents believed that the family practitioner had taken over the role as the primary care physician and was actively managing the patient’s care.
The family practitioner’s position was that he believed that he was participating in the care of the patient in the role as a consultant to his primary care physician and that the patient’s primary care physician was concurrently monitoring the patient. With the exception of the provision of his initial office note and lab results, the family practitioner did not communicate with the patient’s primary care provider during the course of his treatment. After sending his initial note and lab results, the family practitioner did not communicate with the patient’s primary care provider or any other medical professionals until the patient had an acute worsening of the condition on 9/13/2012.
The Board judged that the family practitioner failed to appropriately monitor, manage, and maintain comprehensive medical records on a juvenile patient with a severe eating disorder.
The Board ordered that the family practitioner be reprimanded, complete one hour of continuing medical education on cognitive bias, and that he shall only practice medicine in a structured, group setting for a period of three years.
State: Vermont
Date: September 2017
Specialty: Family Medicine, Psychiatry
Symptom: Weight Loss
Diagnosis: Psychiatric Disorder
Medical Error: Improper treatment, Failure of communication with other providers, Failure of communication with patient or patient relations, Failure to properly monitor patient, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
Vermont – Psychiatry – Pediatrician Prescribes A Combination Of An SSRI And A Benzodiazepine
A pediatrician first met a patient in 2010 when conducting a routine college physical. In 2011, the pediatrician started the patient on Prozac (fluoxetine) 10 mg daily after the patient started reporting that he was having problems with depression. After a month, the patient indicated that the medication was working “a little” and denied any side effects, the pediatrician prescribed another 30 tablets of Prozac 20 mg with no refills.
The pediatrician did not see the patient again until 1/30/2014 when the patient came in for a physical exam. The pediatrician documented that the patient was doing well and was off Prozac.
On 1/22/2015, the patient again came in to see the pediatrician for a physical exam. The patient was experiencing decreased energy levels, sleeping well, having some difficulty with depression and occasional panic attacks. The patient was noted as stating that the Prozac he had taken previously did not really help. The notes document that education and counseling were done, but there was no comment on suicidality.
The pediatrician started the patient on Prozac 40 mg once a day, 30 tablets with no refills, because he had tolerated the 20 mg dose in the past with no side effects. The patient was also prescribed Xanax (alprazolam), 0.25 mg, 5 tablets with no refills, and was told to take one as needed.
On 1/29/2015, the patient was seen by the pediatrician to follow up on his anxiety and depression. The patient reported that he was still having panic attacks, for which he took 2 of the 0.25 mg Xanax, and that overall his depression was worse, but that he was dealing more with anxiety than depression. The patient indicated that he was tolerating the Prozac well. The patient denied any suicidal ideation or planning. The pediatrician prescribed the patient Klonopin (clonazepam) 1.0 mg, two times a day, 60 tablets with no refills and increased his Xanax prescription to 0.5 mg as needed, five tablets with no refills. The pediatrician documented that he provided education and counseling and referred the patient to psychiatry, although the patient indicated that he did not want to go.
On 1/31/2015, the patient reported losing most of his Xanax at work. The pediatrician advised the patient to stay on Prozac and Klonopin and to save the few Xanax he had for severe panic attacks. The pediatrician advised the patient that he would look into getting the patient to see a psychiatrist and that he would figure out what to do with the Xanax the following week, but in the meantime, the patient could go to the emergency department or call the pediatrician if he had a panic attack. The patient agreed to this plan.
During this time, the mother observed changes in the patient’s behavior, including slurring of words, wobbling on his feet, and sleepiness and the patient also became erratic and volatile. This was not brought to the attention of the pediatrician.
On the morning of 2/2/2015, the patient called his mother from work and advised they were sending him home because his behavior was similar to someone who was intoxicated. It was also claimed the patient met with a pharmacist at work, who allegedly told him that the dose of Klonopin was too high and he should cut the dose in half.
The patient returned home and continued to exhibit erratic, volatile, and irrational behavior. The patient also advised his mother that he tried to cut his wrist and glued it shut. None of these events were told to the pediatrician and the patient did not show the cut to the pediatrician during the appointment on 1/29/2015 appointment. The patient made an appointment with another doctor, but could not get in until 2/6/2015. The patient’s mother asked the patient if he wanted to go to the emergency department but the patient declined, indicating that he had a plan (to cut the dose of Klonopin in half). That evening the patient had an argument with his girlfriend and committed suicide.
Prozac (fluoxetine) packaging contains a “Black Box” warning for patients up to 21 years of age that indicates there is a very small chance of an adverse reaction that can make the patient more agitated and prone to increased suicidal thoughts. The patient’s medical chart does not indicate whether the pediatrician explained the Black Box warning to the patient.
The pediatrician retired from the practice of medicine in Fall 2016 as previously planned and for reasons totally unrelated to the allegations in this matter. He is not currently practicing medicine in the State of Vermont.
The Board judged the pediatrician’s conduct to be below the minimum standard of competence given his failure to maintain adequate and comprehensive medical records, his improper prescribing of an unusually high dose of Prozac, Xanax, and Klonopin, and his failure to conform to the essential standards of acceptable and prevailing practice.
The Board ordered that the pediatrician be reprimanded, pay a fine, and if he applies for a license renewal, he must take a continuing education course on psychotropic medications and retain the services of a practice monitor for a minimum of two years.
State: Vermont
Date: July 2017
Specialty: Psychiatry, Pediatrics
Symptom: Psychiatric Symptoms
Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Psychiatric Disorder
Medical Error: Improper medication management, Lack of proper documentation
Significant Outcome: Death
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Internal Medicine – Patient With Suicidal Ideations Referred To A Psychiatrist For The Following Day
On 12/1/2014, a 68-year-old female presented to an internist for a three-month follow-up appointment for hyperlipidemia, anxiety with panic attack, and hypertension. The patient reported a twenty-year history of untreated depression that was worsening.
The patient reported suicidal ideations, including that the patient had been sitting with a gun to her head.
The internist’s progress note for the patient included a statement that the patient needed to see a psychiatrist that day. The internist referred the patient to a psychiatrist and scheduled an appointment with the patient with the psychiatrist the following day.
The Board judged the internist’s conduct to be below the minimal standard of competence given that he failed to arrange for the patient to be escorted to a psychiatrist or an emergency department that day.
The Board issued a letter of concern against the internist’s license. The Board ordered that the internist pay a fine of $5,000 against her license and pay reimbursement costs for the case at a minimum of $1,983.04 and not to exceed $3,983.04. The Board also ordered that the internist complete five hours of continuing medical education in depression, which shall include the diagnosis and treatment of patients with depression, and complete five hours of continuing medical education in “risk management.”
State: Florida
Date: June 2017
Specialty: Internal Medicine, Psychiatry
Symptom: Psychiatric Symptoms
Diagnosis: Psychiatric Disorder
Medical Error: Delay in proper treatment
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
California – Family Practice – Patient With Multiple Psychiatric Conditions And A Low Platelet Count Placed On Enbrel For Rheumatoid Arthritis
On 11/17/2008, a family practitioner first began treating the patient. The family practitioner treated the patient for anxiety, panic disorder, neuropathic pain from an old left thigh stab wound, post-traumatic stress disorder, bipolar disorder, chronic insomnia, obesity, and hypothyroidism.
On 7/18/2013, the patient was seen in an emergency department. The laboratory results from that visit indicated that the patient had a very low platelet count of 63,000 versus a normal platelet count of 140,000 to 150,000. The laboratory results also stated that the mean corpuscular volume (MCV) was found to be 106.6. The MCV is the average volume of red cells in a specimen.
On 7/19/2013, the patient was treated by the family practitioner. The medical notes for that visit state that the patient “returns for follow up on an ER visit yesterday for abdominal pain.” The notes also state, “Labs reveal macrocytic RBC indices.”
Red blood cell (RBC) indices are part of the complete blood count (CBC) test. The indices also include MCV, hemoglobin amount per red blood cell (MCH), and the amount of hemoglobin relative to the size of the cell (hemoglobin concentration) per red blood cell (MCHC).
The MCV, MCH, and MCHC were all recorded in the patient’s laboratory results from the 7/18/2013 emergency department visit.
On 8/9/2013, the patient commenced treatment for rheumatoid arthritis by using the drug Enbrel, which was prescribed by the family practitioner, even though Enbrel can cause a low platelet count and even though the family practitioner knew or should have known that as of 7/19/2013, the patient’s platelet count was low.
On 10/8/2013, the patient informed the family practitioner that another clinic treating the patient noted that the patient’s platelet count was dropping and advised the patient to go directly to the hospital for a blood draw. The family practitioner then discontinued the patient’s use of Enbrel, writing, “discussed fact that thrombocytopenia is a rare but recognized adverse side effect of Enbrel treatment.”
Additionally, any patient treated with Enbrel should have a Tuberculosis (TB) skin test prior to commencing therapy in order to confirm the absence of disease.
Contrary to standards, the family practitioner provided no documentation for the required pretreatment negative tuberculin skin test prior to the commencement of treatment with Enbrel. In fact, not until 9/17/2014, more than one month after treatment with Enbrel commenced, was a negative TB skin test noted in the patient’s medical record.
On 10/18/2011, the family practitioner noted in the patient’s medical records that the patient was positive for hepatitis C. Yet, the family practitioner never referred the patient to a liver specialist for hepatitis C.
The family practitioner allowed the patient to dictate the treatment by prescribing, on multiple occasions, medications that the patient had requested.
On 7/8/2009, the family practitioner prescribed clonidine for the patient for insomnia. Clonidine is a drug normally used to treat hypertension, but it has been effectively used in low doses to treat insomnia in children on ADHD medications. At that time, the patient’s blood pressure was charted as 110/60.
On 7/15/2009, the family practitioner discontinued the patient’s use of clonidine when the patient reported that the medicine was not effective for sleep and that it caused dizziness. On that same date, the patient’s blood pressure was charted as 80/60.
Between 7/8/2009 and 7/15/2009, the patient was using the following medications with the family practitioner’s knowledge: fluoxetine, diphenhydramine, clonidine, and olanzapine.
On 8/16/2011, the family practitioner prescribed Saphris for the patient for insomnia, even though insomnia is a known side effect of Saphris. By 9/9/2011, the patient stopped taking Saphris after claiming to have developed a tolerance for the medication.
The Board judged the family practitioner’s conduct as having fallen below the standard of care for multiple patients given failure to record a physical exam in the progress notes, failure to revise and update assessments or plans for those patients, and failure to include a problem list or medication list in his progress notes.
The family practitioner was placed on probation for 5 years with the stipulations of completing 40 hours annually of continuing medical education in the areas of deficient practice, a prescribing practices course at the Physician Assessment and Clinical Education Program, a medical record keeping course, an ethics course, a clinical training program equivalent to the Physician Assessment and Clinical Education Program, and undergo clinical practice monitoring.
State: California
Date: November 2016
Specialty: Family Medicine, Internal Medicine, Psychiatry
Symptom: Psychiatric Symptoms, Dizziness
Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Psychiatric Disorder
Medical Error: Improper medication management
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
California – Family Practice – Elevated Glucose Levels In A Patient On Aripiprazole, Asenapine, Quetiapine, And Olanzapine
On 11/6/2007, a family practitioner first began treating a patient and continued treating the patient until at least 6/9/2014.
On 12/21/2009, the family practitioner noted in the patient’s medical records that the patient was diabetic, writing “Lab-Spot glucose 242.” A level of 200 mg/dL or higher often means one has diabetes.
On 1/11/2010, the next exam noted in the patient’s records, the family practitioner noted a refill was needed for glipizide. However, there is no record that the patient was ever prescribed glipizide prior to this date.
During the course of treatment from the family practitioner, the patient was also prescribed aripiprazole, quetiapine, asenapine, and olanzapine for bipolar disorder. Aripiprazole, asenapine, and olanzapine can cause or worsen diabetes. According to medical notes, on 6/13/2011, the family practitioner was treating the patient with both aripiprazole and olanzapine as well as glipizide, which was to control diabetes.
On 7/11/2011, the patient’s blood sugars were noted to be in the 400 range, while 100 to 110 is considered to be the normal range for blood sugars in an individual. The family practitioner started the patient on insulin glargine to address diabetes on a daily basis.
In an interview that occurred on 10/1/2015, the family practitioner admitted that the family practitioner had no idea if the patient was taking the prescribed medications while under his care.
The Board judged the family practitioner’s conduct as having fallen below the standard of care for multiple patients given failure to record a physical exam in the progress notes, failure to revise and update assessments or plans for those patients, and failure to include a problem list or medication list in his progress notes. In addition, the family practitioner’s repeated, excessive and/or inappropriate prescribing of large doses of multiple strong antipsychotic medication and antidepressants to the patient with no regard or concern for drug interactions constituted a lack of knowledge and/or unprofessional conduct.
The family practitioner was placed on probation for 5 years with the stipulations of completing 40 hours annually of continuing medical education in the areas of deficient practice, a prescribing practices course at the Physician Assessment and Clinical Education Program, a medical record keeping course, an ethics course, a clinical training program equivalent to the Physician Assessment and Clinical Education Program, and undergo clinical practice monitoring.
State: California
Date: November 2016
Specialty: Family Medicine, Internal Medicine, Psychiatry
Symptom: N/A
Diagnosis: Diabetes, Psychiatric Disorder
Medical Error: Improper medication management, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
California – Psychiatry – Improper Prescribing Practices Of Quetiapine, Venlafaxine, Lamotrigine, Lorazepam, Zolpidem, Fluoxetine, And Alprazolam
On 8/7/2012 continuing through 9/13/2013, a patient received psychiatric treatment from a psychiatrist over eight appointments. The patient presented as a 54-year-old 135-pound female patient seeking treatment for the management of bipolar disorder. During each of these appointments, the patient was at the hospital while the psychiatrist provided treatment remotely from his home via telepsychiatry. The initial assessment noted that the patient was normal for mood, affect, memory, depression, and anxiety with no suicidal ideation. Per the Board, the psychiatrist’s medical records for the patient failed to contain an adequate history of the patient and lacked adequate documentation to support a bipolar diagnosis.
Over the course of his treatment of the patient, the psychiatrist consistently prescribed large quantities and high doses of psychiatric medications to be taken simultaneously, including the following: quetiapine, venlafaxine, lamotrigine, lorazepam, zolpidem, fluoxetine, and alprazolam.
The psychiatrist prescribed the patient 10 mg of zolpidem despite the advisory from the FDA that women should receive no more than 5 mg due to the potential for cognitive and memory impairment and the psychiatrist’s medical records for the patient fail to reflect a consideration or discussion of the risks versus benefits of treatment with this medication. The psychiatrist prescribed the patient daily doses of quetiapine and venlafaxine at the maximum recommended dose. The psychiatrist prescribed the patient lamotrigine at twice the recommended dose for bipolar disorder and the psychiatrist’s medical records for the patient fail to reflect why he chose to prescribe the medication at these doses.
Per the Board, the psychiatrist diagnosed the patient with depression; however, he failed to adequately document the history, extent, degree or other information regarding the patient’s depression or include any identifiable symptoms that might support a diagnosis of depression. The psychiatrist failed to recognize and/or document the possibility that the patient’s flat affect could be caused by overprescribing and polypharmacy given the extraordinarily high doses of quetiapine and benzodiazepines he prescribed.
The psychiatrist diagnosed the patient with insomnia; however, he failed to adequately document the patient’s difficulty sleeping or include any identifiable symptoms that might support a diagnosis of insomnia. The psychiatrist failed to recognize and/or document the possibility that the patient’s insomnia could be caused by overprescribing and polypharmacy given the extraordinarily high doses of antidepressants (venlafaxine, mirtazepine, and fluoxetine) he prescribed, which are known to produce insomnia in patients.
The psychiatrist failed to discuss and/or document a discussion of the risk of metabolic syndrome with the patient. The psychiatrist failed to monitor and/or order labs to check the lipids, blood sugar, or weight of the patient, all of which are known risk factors with high dosages of quetiapine.
The psychiatrist’s records for the care and treatment of the patient mostly consisted of identical information copied from one appointment to the next. Per the Board, the psychiatrist’s notes failed to contain any useful information that is unique to the patient and instead contained only conclusions without facts to support them. The mental status examination, interval history, and diagnosis portions of the medical records were identical in wording and formatting throughout all eight appointments with the psychiatrist. In contrast to the boilerplate language copied from prior visits, the limited number of original entries by the psychiatrist were short, telegraphic informational, and appeared in short lines with abbreviation and misspellings. The psychiatrist’s medical records for the patient failed to document prescriptions of Percocet from another medical provider.
On 2/14/2013, the patient presented to the hospital emergency department with a “possible accidental overdose of benzodiazepines.” The patient was treated but was not admitted to the hospital. The psychiatrist saw the patient several days later and attributed the overdose to an accidental overdose due to taking the incorrect medication in the dark. The psychiatrist prescribed multiple psychiatric medications without reducing the dose or quantity of medications available to the patient to prevent a future overdose due to noncompliance with the medication regimen. The psychiatrist failed to document the potential for a repeated overdose event in the patient’s medical records.
On 6/17/2013, the patient presented to the hospital emergency department unconscious with a CPK over 3000 and elevated BUN and creatinine levels. The patient was admitted and with a diagnosis of acute rhabdomyolysis, dehydration, and benzodiazepine overdose. Toxicology tests were negative for substances of abuse, but revealed high levels of the byproducts of venlafaxine, fluoxetine, mirtazapine, alprazolam, and nortriptyline. The patient became septic with multiple organ failure, went into a coma, and was intubated on 6/22/2013 and subsequently transferred to another hospital.
The Board judged the psychiatrist’s conduct as having fallen below the minimum level of competence given his unnecessary prescription of multiple simultaneous prescriptions of two short-acting benzodiazepines to be taken concurrently with zolpidem, his prescription of numerous dangerous drugs and controlled substances in the absence of a discussion over the risks of treatment, his prescription of excessive doses of zolpidem, his failure to obtain a second opinion, his failure to assess the patient’s suicide risk, and his overall failure to appropriately manage the patient’s medications.
The Board ordered that the psychiatrist be placed on probation for a period of three years, complete 40 hours of continuing medical education for each year of probation, enroll in a prescribing practices course, enroll in a medical record keeping course, be prohibited from supervising physician assistants, and be assigned a practice monitor.
State: California
Date: November 2016
Specialty: Psychiatry
Symptom: Psychiatric Symptoms
Diagnosis: Psychiatric Disorder, Drug Overdose, Side Effects, or Withdrawal
Medical Error: Improper medication management, Failure of communication with patient or patient relations, Failure to properly monitor patient, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
Virginia – Family Medicine – Long History Of Narcotic Seeking Behavior And Pattern Of Abuse
From 12/01/2010-12/03/2010, a 31-year-old-man with schizophrenia and bipolar disorder was hospitalized. During the hospitalization, a psychiatric consultation revealed that the patient had a significant history of “drug seeking behavior (primarily opiates) and significant paranoid thinking.” It was noted that since July 2010, the patient had presented to the emergency department at least 11 times, “most all of which where he is complaining of pain and seeking some type of medication.”
He had stuck a nail in his ankle and stabbed himself in the thigh in two separate instances, which the mother believed were performed to obtain more pain medications. He had obtained pain medications from other family members. The mother confirmed that he had a “severe drug problem.”
It was also documented that the patient had at least 10 prior psychiatric hospitalizations for the diagnosis of mixed personality disorder (mainly paranoid) and severe opioid dependence. It was noted that the patient was unlikely to take his prescribed psychotropic medications.
On 6/27/2011, the patient’s PCP stated that another physician, who was managing the patient’s pain, refused to prescribe him further narcotics given that his urine drug screen was negative for hydrocodone, which the physician had been prescribing him.
On 7/24/2011, the patient presented to an emergency department for treatment of a re-opened gunshot wound in his right calf. It was documented that the patient had recently been hospitalized at another hospital for an overdose of barbiturates and opiates (which required intubation).
On 10/17/2011, a pain management specialist declined to accept the patient given the patient’s “PMP and UDS results, as well as his record including violent behavior and 2 self-inflicted gunshot wounds…These results and behaviors are highly suggestive of a substance abuse disorder. I would recommend that he be evaluated and treated for addiction…He also likely has rebound headaches given his multiple daily doses of controlled substances. Weaning of the controlled substances would address the rebound headache issue…[and] would be safer from a potential overdose perspective…[F]rom my review of the record, I am very concerned that treatment for his pain would be unsuccessful without first addressing the addiction issue.”
From 2/09/2012 to 2/25/2012, the patient was hospitalized was treated for recurrent infection of his right leg gunshot wound. It was documented that “[u]ltimately, it was felt he had a significant component of pain [medication] seeking behavior…Ultimately, we have recommended to him that he taper and stop all of his pain meds over time. If he cannot do that, I have recommended to him that he seek treatment for substance abuse.”
On 1/6/2012, the surgeon treating the patient’s non-healing gunshot wound was contacted by a pharmacist who reported that the patient was receiving prescriptions for oxycodone/acetaminophen from his PCP at the same time the surgeon was prescribing the medication for him. On 1/25/2012, the patient’s PCP refused to see him anymore after he caused a scene in the waiting room and broke his crutches when his PCP would not write for further narcotics.
The patient reported to the surgeon that his pain medications had been stolen on 2/01/2012 and again on 3/21/2012.
On 3/23/2012, the patient first visited the family practitioner, who subsequently prescribed large quantities of narcotics despite his prior history. The family practitioner testified that she initially did not know of the patient’s prior history. When she knew of his history, she testified that she wanted to gain the patient’s trust first and then she planned to taper the patient off of narcotics.
From March 2012 to August 2015, the family practitioner prescribed fentanyl patches, oxycontin, hydromorphone, Fioricet, and alprazolam for chronic pain from the self-inflicted gunshot wound to the right lower leg, neuropathic pain of the right leg, chronic headaches, chronic left ankle pain, and anxiety.
On 03/29/2013, the family practitioner entered into a controlled substance agreement with the patient. Once executed, the patient failed to enforce provisions of the agreement, such as performing urine drug screens or performing pill counts consistently.
On numerous occasions, the family practitioner documented that the patient reported that his brother, sister, roommate, friends, or others had stolen his pain medications. The family practitioner failed to require a police report proving these alleged thefts and routinely replaced the prescriptions for these stolen medications.
On 4/11/2012, the patient reported that he had run out of his hydromorphone early because he was carrying it with him in the car when the pills fell out of his coat pocket into the back seat. In other instances, he reported that he had lost his pill bottles.
On 6/15/2012, his bottle of hydromorphone again went missing. The patient asserted that his roommate (who allegedly suffered from AIDS) was in possession of the pain medications with blood covering the roommate’s hands as well as several of the pill bottles. He said he could not find the bloody bottle of hydromorphone. When the family practitioner refused to prescribe hydromorphone, he reported that even if he could find the bottle of hydromorphone, he would be afraid to take it, given the risk of HIV exposure.
On 7/5/2012, the pharmacist called the family practitioner stating that the patient had consumed 40 tablets of hydromorphone in just three days. The patient complained that the pharmacist had only given him 40 out of 180 prescribed on 06/29/2012 and requested that the family practitioner provide him with another script. The family practitioner’s nurse practitioner then provided the patient with a prescription for 50 tablets of hydromorphone.
On 10/25/2012, another physician in the family practitioner’s practice saw the patient and noted that the patient was being prescribed “unbelievable doses of opiates along with benzos.”
On 6/12/2013, a blood serum drug test was negative for hydromorphone. On 7/22/2013, the patient explained that he had stopped the hydromorphone 1-2 days prior to the blood test done on 06/12/2013. He stated that he failed to inform the family practitioner of this at his last visit because he thought the medication would still show up in his blood and he did not want the family practitioner to be mad at him for not taking his hydromorphone exactly as prescribed.
On 7/19/2013, he reported that he had run out of a month’s supply of hydromorphone and alprazolam prescribed to him on 06/12/2013 with fill dates of 06/30/2013. Despite the evidence, the family practitioner noted that she would “give him the benefit of doubt and am refilling his meds. for 1 month.”
On 8/1/2013, the patient’s mother told the family practitioner that the patient believed others were stealing his medications secondary to his schizophrenia. The family practitioner and mother agreed that the mother would dispense medications to the patient. On 01/10/2014, the patient reported to the family practitioner that his mother had given back his medications to manage himself.
On 8/16/2013, the family practitioner authorized an early refill given that the patient said his fentanyl patches were falling off, requiring him to increase his hydromorphone usage.
On 11/14/2013, the family practitioner watched a video where the patient secretly recorded his sister stealing a pain patch off of his desk. The patient declined to call the police as recommended by the family practitioner and said her sister had gone into treatment.
On 5/1/2014, the patient received hydrocodone/acetaminophen from his dentist. The family practitioner prescribed the patient more of the same and gave him early scripts for hydromorphone and fentanyl.
On 6/4/2014, the patient reported that he had been hospitalized at a psychiatric facility. His mother admitted that she did not want to manage his medications because the patient kept pestering her for them.
On 6/4/2014, the patient was hurting more than usual and could not take extra medication given that his mother had taken back control.
On 7/9/2014, the patient informed the family practitioner that her mother had not given him any fentanyl patches and he was taking extra hydromorphone in response. The mother had left a message if her son could take an extra hydromorphone pill per day. The family practitioner responded by admonishing the patient not take take an extra hydromorphone per day and prescribed him more fentanyl patches.
On 8/25/2014, the patient was taken to the emergency department after the family practitioner had written prescriptions for hydromorphone (#540), Fioricet (#360), and fentanyl patches (#45) and after the patient had misused these medications.
On 09/25/2014, the family practitioner prescribed further narcotic medications, noting that “this will be [the patient’s] last chance to show his responsibility.”
Despite a pattern of abuse, the family practitioner continued to prescribe narcotics to the patient and in response to the patient’s self-titration upward due to increased pain, she increased the daily dosage of hydromorphone.
On 6/18/2015, the patient reported that he had increased his consumption of hydromorphone to two pills every 6 hours. He justified this increase, saying he would experience suicidal ideation and hallucinations if he failed to do so. In response, the family practitioner noted that she did “not believe that he is abusing the meds. I believe that his pain is uncontrolled.”
On 7/2/2014, the patient reported acute withdrawal symptoms and suicidal thoughts due to being out of hydromorphone for 12 days. The pharmacy had refused to fill the early hydromorphone prescription the family practitioner had given him on 06/28/2015.
The family practitioner testified that she took over care of the patient’s pain management given that other physicians would not and the surgeon did not know what to do with him.
She testified that the patient absolutely refused to see mental health providers during the treatment period. She said that the reason she did not threaten to cut the patient off from his narcotic regime was that she wanted him to buy into the treatment plan.
Based on her treatment of this patient and another, the family practitioner was reprimanded. She was prohibited from treating any patients with chronic pain starting 30 days after the order. Within twelve months of the order, she was to provide proof of completing 15 credit hours in the subject of pain management and 8 hours in the subject of recognizing addiction.
State: Virginia
Date: September 2016
Specialty: Family Medicine, Pain Management, Psychiatry
Symptom: Pain, Psychiatric Symptoms
Diagnosis: Drug Addiction, Drug Overdose, Side Effects, or Withdrawal
Medical Error: Improper medication management
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF