Found 35 Results Sorted by Case Date
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Washington – Psychiatry – Ingestion Of A Large Dose Of Zoloft In A Suicide Attempt



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

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

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

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

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

State: Washington


Date: August 2016


Specialty: Psychiatry


Symptom: Nausea Or Vomiting, Palpitations


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


Medical Error: Improper medication management


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



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



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

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

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

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

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

The Board issued a public letter of concern, which was reported to the Federation of State Medical Boards.  It was not reported to the National Practitioner Data Bank.

State: North Carolina


Date: June 2016


Specialty: Psychiatry


Symptom: Psychiatric Symptoms


Diagnosis: Psychiatric Disorder


Medical Error: Underestimation of likelihood or severity


Significant Outcome: Death


Case Rating: 2


Link to Original Case File: Download PDF



Arizona – Psychiatry – Care Of A Patient Over 10 Years Starting At Age 5



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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

8) He failed to timely dictate a discharge summary.

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

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

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

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

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

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

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

State: Arizona


Date: June 2016


Specialty: Psychiatry


Symptom: Psychiatric Symptoms


Diagnosis: Psychiatric Disorder


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


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



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



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

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

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

The Board issued the psychiatrist a reprimand.

State: Virginia


Date: May 2016


Specialty: Psychiatry


Symptom: Psychiatric Symptoms


Diagnosis: Psychiatric Disorder


Medical Error: Failure to examine or evaluate patient properly


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



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



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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Board ordered the psychiatrist be reprimanded.

State: Arizona


Date: February 2016


Specialty: Psychiatry, Pediatrics


Symptom: Psychiatric Symptoms


Diagnosis: Psychiatric Disorder


Medical Error: Improper medication management, Improper treatment


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



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



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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

State: Indiana


Date: October 2015


Specialty: Gynecology, Obstetrics, Psychiatry


Symptom: N/A


Diagnosis: Psychiatric Disorder


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


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



North Carolina – Psychiatry – Dosing Of Psychiatric Medications For A Three Year Old



On 05/14/2014, a three-year-old patient presented to a psychiatrist for an evaluation.  The patient’s mother complained of problems with attention, erratic sleep schedule, and aggression towards the patient’s younger sibling.

The psychiatrist diagnosed the patient with attention deficit hyperactivity disorder (ADHD) and prescribed two psychostimulant medications with a recommendation for a follow-up within a month.

On 09/16/2014, the psychiatrist saw the patient, who presented with complaints of trouble sleeping, diminished appetite, and diminished energy level.  The patient’s mother had consulted another physician, who discontinued one of the ADHD medications, because the dosage was considered too high for the patient.  The psychiatrist then discontinued both of the medications that the psychiatrist had initially prescribed for the patient and started the patient on a third psychostimulant medication for ADHD.

On 10/28/2014, the patient returned to the psychiatrist, who discontinued the third medication he had prescribed and prescribed a fourth psychostimulant medication for ADHD.  The psychiatrist also prescribed two new antidepressant medications at dosages recommended for an adult.  Within 48 hours of taking these three prescriptions, the patient became ill and was hospitalized due to an altered mental status.

In November 2014, the Board received complaints regarding the care provided by the psychiatrist.  The complaints were from two of the patient’s treating physicians.  The patient’s medical records were sent to an independent medical expert who specializes in child psychiatry.  This independent medical expert opined that all aspects of the psychiatrist’s care for the patient were below the acceptable and prevailing standard of care in North Carolina.

The medical expert opined that the psychiatrist did not conduct a complete and thorough evaluation of the patient.  The diagnosis of ADHD in a three year old requires collateral information which was not obtained.  The expert opined that the medication choices for the patient were below the standard of practice.  Stopping one medication and starting a combination of three medications at adult dosage levels in a three year old lead to serious iatrogenic side effects requiring hospitalization.

The Board required that the psychiatrist complete 15 hours of Category 1 CME in the diagnosis and treatment of ADHD with a 6 month time limit.

State: North Carolina


Date: May 2015


Specialty: Psychiatry


Symptom: Allergic Reaction Symptoms


Diagnosis: Autoimmune Disease


Medical Error: Improper medication management


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



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



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

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

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

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

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

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

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

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

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

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

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

The Board issued a reprimand.

State: Virginia


Date: April 2015


Specialty: Psychiatry, Pediatrics


Symptom: Psychiatric Symptoms


Diagnosis: Psychiatric Disorder


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


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Family Medicine – Treating Lyme Disease And Babesia With Improperly Managed Medications And Unaddressed Psychiatric Symptoms Leads To Complications



On 2/28/2011, a 58-year-old male visited a family practitioner.  The patient had traveled from his home to consult with the family practitioner in order to “confirm a diagnosis of Lyme disease.”  The patient completed a Questionnaire and a Symptoms Checklist during the visit. On the Questionnaire, the patient checked the “Yes” boxes for the following questions regarding his psychological status: “sudden, abrupt mood swings” (daily), “unusual depression” (weekly), “feeling as if you are losing your mind” (daily), “paranoia” and “obsessive/compulsive” (weekly), “decreased frustration tolerance” (constant), and “generalized anxiety” (weekly).  The patient also checked the “Yes” boxes for “sleeping too much,” “difficulty falling or staying asleep,” “decreased social functioning,” and “decreased job performance.”

For the visit, the patient took with him the results of a blood test, which were reported on 1/27/2011.  The blood test included testing for Lyme disease antibodies. The result of the Lyme disease test showed IgG/IgM values at <0.91 (Reference Range: Negative<0.91; Equivocal 0.91 – 1.09; Positive>1.90).  The laboratory report contains the following: “Note: The CDC currently advises that Western Blot testing be performed following all equivocal or positive EIA results. Final diagnosis should include appropriate clinical findings and positive EIA which is positive by Western Blot.”  The patient was attended to by the family practitioner’s nurse practitioner. The nurse practitioner attended to the patient on all five of his visits between February 2011 and September 2011. The family practitioner reviewed and approved of all the care and treatment the nurse practitioner provided with the patient.

The nurse practitioner obtained a medical history and performed a physical examination of the patient.  She noted that the patient had a history of “tick exposure” and a rash, which she noted to be erythema migraines.  However, the nurse practitioner failed to note where (geographical location) the tick exposure occurred, the character of the rash, and whether the rash was related to the tick bite.  Despite the mental health symptoms the patient noted in the Questionnaire, the nurse practitioner failed to perform and/or note she performed a psychological assessment of the patient on this visit.  The nurse practitioner ordered laboratory tests to be performed by IgeneX Inc. Her assessment included Lyme disease and “GI yeast.” There was no medical justification for the Lyme disease assessment.  The nurse practitioner prescribed amoxicillin and Flagyl for the Lyme disease and nystatin for the “GI yeast.”

The patient made a follow-up visit on 4/13/2011.  He was again seen by the nurse practitioner, who noted that the IgeneX lab tests results reported on 3/24/2011 were “positive” for Lyme disease.  This notation was incorrect because the IgeneX results were actually negative for Lyme disease according to CDC criteria. Also, the nurse practitioner failed to note that the lab results the patient brought with him to the 1/21/2011 visit were also negative for Lyme disease.  The nurse practitioner’s plan included ordering lab tests for Babesia and Bartonella. The nurse practitioner added rifampin and artemisinin to the amoxicillin and Flagyl medications. The nurse practitioner failed to note the medical justification and/or rationale for the addition of rifampin and artemisinin medications.

On 5/27/2011, the patient had a telephone consultation with the nurse practitioner.  The nurse practitioner noted the patient reported he felt better, but she failed to inquire or note she inquired about the patient’s psychological issues or whether he was in the care of a psychiatrist.  On this date, the nurse practitioner noted a diagnosis that included Babesia. There was no medical justification for this diagnosis. Indeed, the Babesia serology results from IgeneX reported on 5/10/2011 were “negative” for Babesia.  Also, the nurse practitioner arrived at the diagnosis without performing any standard testing, such as obtaining and examining blood smears, for Babesia. The nurse practitioner’s plan included prescribing Malarone to treat Babesia.

The patient made a visit to the family practitioner’s office on 6/14/2011.  He was again attended by the nurse practitioner, who noted the patient reported feeling better, but she failed to inquire into or note she inquired into the patient’s psychological issues or whether the patient was in the care of a psychiatrist.  The nurse practitioner’s assessment included Babesia and Candida. The nurse practitioner prescribed Malarone for the Babesia and added Mycelex for the yeast infection. There was no medical justification for the Babesia assessment and no medical justification for the Malarone prescription.  On 6/20/2011, the nurse practitioner issued a telephone prescription for fluconazole, another antifungal agent, for the patient. There was no notation of the medical justification for prescribing a third antifungal agent for this patient. Also, the nurse practitioner failed to discontinue the nystatin and Mycelex medications before prescribing the fluconazole.

On 6/27/2011, the patient telephoned the family practitioner’s clinic to inquire whether he should be taking rifampin and Malarone medications simultaneously.  The patient indicated that the label on the Malarone medication container indicated the two medications should not be taken together. On 6/29/2011, the nurse practitioner informed the patient it was “ok” to take Rifampin and Malarone simultaneously so long as they are taken two hours apart.

On 8/7/2011, the patient made a follow-up visit and was attended to by the nurse practitioner.  Among other things, she noted that the patient reported he was having “waves of nausea daily.” The nurse practitioner again failed to inquire into or note she inquired into the patient’s psychological symptoms or whether the patient was in the care of a psychiatrist.  She performed a physical examination of the patient, but she failed to perform a psychological evaluation of the patient during this examination. The nurse practitioner’s plan included increasing the rifampin and Malarone medications to treat the Lyme disease and adding doxycycline and Lariam medications to treat the Babesia.

On 10/27/2011, the police received a report stating the patient had become mentally ill, had been referring to himself as the “Angel of Death,” and had threatened to assault his girlfriend.  The girlfriend reported that the patient’s behavior “changed” after use of the Lariam medication. The patient was arrested and hospitalized.

The Medical Board of California judged that the family practitioner’s conduct departed from the standard of care because he failed to obtain appropriate history for the patient’s psychological issues, arrive at an appropriate diagnosis for the psychological issues, adequately follow up on the patient’s psychological issues, and properly refer patient to a psychiatrist for evaluation for his psychological issues.  The family practitioner also inappropriate treated the patient for Lyme disease and Babesia with artemisinin, Malarone, and Lariam as well as diagnosing the patient with Lyme disease without obtaining an appropriate history and inappropriately diagnosed the patient with Lyme disease despite the fact that the IgeneX lab results were “negative” for Lyme disease according to the CDC criteria.  The family practitioner also inappropriately prescribed rifampin and Flagyl over a long period of time for the treatment of Lyme disease and failed to consider and/or document she considered the effect of the “drug interaction” from the multiple drugs she prescribed to the patient for treatment of Lyme disease, Babesia, and yeast infection.

The Medical Board of California ordered the family practitioner to complete a prescribing practices course, a clinical training program, and a chronic disease training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California


Date: March 2015


Specialty: Family Medicine, Internal Medicine, Psychiatry


Symptom: Nausea Or Vomiting, Rash, Psychiatric Symptoms


Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Infectious Disease


Medical Error: Failure to examine or evaluate patient properly, Accidental error, Failure to order appropriate diagnostic test, Referral failure to hospital or specialist, Failure to follow up, Improper supervision, Improper medication management


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



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



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

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

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

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

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

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

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

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

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

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

State: California


Date: February 2015


Specialty: Psychiatry


Symptom: Psychiatric Symptoms


Diagnosis: Psychiatric Disorder


Medical Error: Lack of proper documentation


Significant Outcome: Death


Case Rating: 1


Link to Original Case File: Download PDF



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