Found 35 Results Sorted by Case Date
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California – Psychiatry – Patient With History Of Bipolar Disorder Placed On Topiramate, Quetiapine, Aripiprazole, Temazepam, And Cyproheptadine



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

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

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

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

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

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

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

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

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

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

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

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

The psychiatrist was placed on probation for 3 years with stipulations to complete 40 hours annually of continuing medical education in areas of deficient practice, a prescribing practices course, a medical record keeping course, an ethics course, a professional boundaries program, and a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California, San Diego School of Medicine.  She was ordered to undergo clinical monitoring and was prohibited from engaging in the solo practice of medicine.

State: California


Date: January 2015


Specialty: Psychiatry


Symptom: Psychiatric Symptoms


Diagnosis: Psychiatric Disorder


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


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



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



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

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

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

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

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

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

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

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

State: Wisconsin


Date: June 2014


Specialty: Psychiatry


Symptom: Psychiatric Symptoms


Diagnosis: Psychiatric Disorder


Medical Error: Failure to examine or evaluate patient properly


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Wisconsin – Psychiatry – Family Practitioner Prescribes Numerous Psychiatric Medications



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

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

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

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

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

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

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

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

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

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

State: Wisconsin


Date: April 2014


Specialty: Psychiatry, Family Medicine


Symptom: Psychiatric Symptoms


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


Medical Error: Improper medication management, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



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



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

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

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

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

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

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

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

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

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

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

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

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

State: Washington


Date: August 2013


Specialty: Psychiatry


Symptom: Psychiatric Symptoms


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


Medical Error: Improper medication management


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



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



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

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

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

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

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

State: California


Date: July 2011


Specialty: Psychiatry


Symptom: N/A


Diagnosis: Psychiatric Disorder


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


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



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



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

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

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

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

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

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

State: California


Date: July 2011


Specialty: Psychiatry


Symptom: N/A


Diagnosis: Psychiatric Disorder


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


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



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



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

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

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

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

State: California


Date: July 2011


Specialty: Psychiatry


Symptom: N/A


Diagnosis: Psychiatric Disorder


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


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



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



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

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

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

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

State: California


Date: July 2011


Specialty: Psychiatry


Symptom: N/A


Diagnosis: Psychiatric Disorder


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


Significant Outcome: Death


Case Rating: 1


Link to Original Case File: Download PDF



California – Psychiatry – Improper Diagnostic Documentation And Continued Medication Regimen Despite Lack Of Improvement



A psychiatrist evaluated a patient five times between 9/19/2006 and 12/12/2007.  The patient was diagnosed with major depression with psychotic features.

The psychiatrist’s documentation of the appointments appear to be repetitive and do not contain updated, relevant, and interval information.

There is no documentation that the psychiatrist considered a differential diagnosis, especially when his medical treatment appeared to be unsuccessful.

The psychiatrist continued to treat the patient with ziprasidone, mirtazapine, sertraline, and diphenhydramine, failed to consider other medications, and failed to treat his patient with other psychotropic options, despite evidence that the patient’s symptoms were not improving/changing.

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

State: California


Date: July 2011


Specialty: Psychiatry


Symptom: N/A


Diagnosis: Psychiatric Disorder


Medical Error: Improper medication management, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Psychiatry – Improper Diagnostic Documentation And Lack Of Medication Regimen Justification



A psychiatrist evaluated a patient who was diagnosed with schizoaffective disorder between 5/21/2007 and 3/11/2008.  This was an acutely suicidal patient who was placed on suicidal observation/precautions.  On 3/11/2008, the patient was admitted to a special psychiatric unit for the risk of suicide.

The psychiatrist’s progress notes failed to comprehensively assess the patient’s suicidal symptoms, psychotic, and mood symptoms, including the risk for imminent suicidal behavior, a recent change in mood symptoms, and an assessment of the patient’s danger to self and others.

The psychiatrist’s documentation did not reflect a critical assessment of the symptoms that would lead one to arrive at a diagnosis of schizoaffective disorder, as there was rarely a discussion of psychotic symptoms in his progress notes.  Moreover, the psychiatrist’s notes did not show that he considered or ruled out a differential diagnosis.

The psychiatrist’s management of this patient’s fluctuating symptoms consisted of an apparent regimen of bupropion (an antidepressant), ziprasidone (an antipsychotic), and Depakote.  There was a brief trial of ziprasidone and bupropion.  The psychiatrist’s notes did not reflect that he logically, methodically, and appropriately used a reasonable algorithm to treat his patient’s psychiatric symptoms, as the use of medications by the psychiatrist to treat this patient appeared capricious, incomplete, and at times random.

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

State: California


Date: July 2011


Specialty: Psychiatry


Symptom: Psychiatric Symptoms


Diagnosis: Psychiatric Disorder


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


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



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