Page 1 of 5
California – Neurology – Lack Of Documentation When Diagnosing Neuropathic Pain, RLS, and Carpal Tunnel Syndrome With Normal Neurological Examination
A 43-year-old male was referred by his primary care physician to a neurologist for multiple medical issues, including obesity, chronic post-operative pain following lumbar spine surgery, major depressive disorder, familial tremor, shoulder pain, excessive daytime sleepiness, congestive heart failure, and peripheral neuropathy. The patient had been on Norco and was switched to Tramadol. The dose of Tramadol was 100 mg 4 times a day. Other medications were trazodone 100 mg h.s., zolpidem 10 mg h.s., HCTZ 25 mg, Lasix 40 mg, Flomax 0.5 mg, and topiramate 100 mg twice daily.
On 3/27/2014, the neurologist saw the patient for an office visit. The patient complained of symptoms of foot pain, burning, and restless leg syndrome (RLS) symptoms. The neurologist diagnosed neuropathic pain, RLS, obesity, carpal tunnel syndrome, low back pain, and tremor. She planned to do B12 and ferritin levels, and she recommended an EMG/NCV of both upper and lower extremities. The neurologist noted a normal neurological examination. Despite the normal neurological examination, the neurologist failed to keep adequate documentation to establish her multiple diagnoses. She coded the visit as a level 5 new patient evaluation. The neurologist failed to document her 14-point review of systems and other required examinations to substantiate level 5 billing.
During a subsequent interview with the Medical Board, the neurologist initially stated that she had no recollection of the patient. Her medical report timed the office visit at 9:15, and the encounter ended at 11:11 a.m., approximately 2 hours. She stated that she spent 40 minutes with him. She could not account for the other time. She stated that “the rest was not me” and that she did not know what the time was “in between.” The patient claimed that she asked him only to stand and to try to stand on his heels and to squeeze her fingers. When asked why she ordered the EMG, she answered, “For neuropathy versus radiculopathy versus carpal tunnel syndrome could have CDIP.” She did not know what a Controlled Substance Utilization Review and Evaluation System (CURES) report was.
The Medical Board of California judged that the neurologist’s conduct departed from the standard of care because she failed to keep accurate, timely, complete medical records to support her diagnoses, coded and billed for level 5 services not substantiated in her records, and was not aware of CURES reports and did not utilize it in her practice.
For this case and others, the Medical Board of California placed the neurologist on probation and ordered the neurologist to complete a medical record keeping course, a professionalism program (ethics course), an education course (at least 40 hours per year for each year of probation), and a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine. The neurologist was assigned a practice monitor and was prohibited from supervising physician assistants and advanced practice nurses.
State: California
Date: January 2018
Specialty: Neurology
Symptom: Extremity Pain, Back Pain, Joint Pain, Psychiatric Symptoms
Diagnosis: Neurological Disease
Medical Error: Lack of proper documentation, Procedural error
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
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
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
Florida – Family Medicine – Improper Prescribing Of Controlled Substances To A Patient With Drug Seeking Behavior, Dependence, and Withdrawals
On 7/13/2006 through 8/6/2013, a family practitioner treated a 37-year-old female for chronic neck and back pain. The patient presented to the family practitioner with a history of hypertension, depression, anxiety, and back pain from a 2004 motor vehicle accident.
The patient’s medical records from her previous treating physicians indicated that the patient was addicted to Xanax, had attempted suicide via overdose of alcohol and Tylenol in 2004, and was a high-risk patient with regards to controlled substances.
Throughout the course of the treatment, the family practitioner prescribed controlled substances to the patient including Nucynta, Percocet, Xanax, Klonopin, Vicodin, and Soma.
On 10/7/2008, the family practitioner noted that the patient exhibited drug seeking behavior, had undergone physical withdrawals, and was having psychological dependence. The family practitioner documented “no further controlled substances after this.”
On 10/7/2008, the family practitioner referred the patient to a pain management specialist.
From 10/17/2008 to 5/6/2010, the patient presented to a pain management specialist for her chronic pain.
Beginning on 5/17/2010, the patient discontinued treatment with the pain management specialist and resumed her treatment with the family practitioner for her chronic pain.
From 9/2/2011 through 8/6/2013, the patient presented to the family practitioner approximately every three months. Despite the patient only presenting every three months, the family practitioner prescribed monthly refills of controlled substances for the patient. The family practitioner prescribed Nucynta, Percocet, Xanax, Klonopin, Vicodin, and Soma to the patient in various combinations and amounts.
The prevailing standard of care requires that a physician treating a patient for chronic pain prescribe controlled substances appropriately. The quantity and/or combination of controlled substances the family practitioner prescribed to the patient on one or more occasions from 9/2/2011 through 8/6/2013 were inappropriate.
The prevailing standard of care requires that a physician treating a high-risk patient for chronic pain create and implement an appropriate treatment plan.
The family practitioner did not create or implement, or did not document creating or implementing, an appropriate treatment plan for the patient. The prevailing standard of care requires that a physician treating a high-risk patient for chronic pain evaluate the patient prior to refilling prescriptions for controlled substances. On one or more occasions, the family practitioner prescribed multiple refills of controlled substances for the patient at a single office visit.
The prevailing standard of care required that a family physician treating a high-risk patient for chronic pain refer the patient to a chronic pain specialist. The family practitioner did not refer, or did not document referring, the patient to a chronic pain specialist on or after 9/2/2011.
It was requested that the Board order one or more of the following penalties for the family practitioner: 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: August 2017
Specialty: Family Medicine
Symptom: Head/Neck Pain, Back Pain, Psychiatric Symptoms
Diagnosis: Drug Overdose, Side Effects, or Withdrawal
Medical Error: Improper medication management, Referral failure to hospital or specialist, 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
Kansas – Physician Assistant – High Dosing Regimen Of Amitriptyline For A Pediatric Patient With Headache, Vomiting, And Incontinence
On 11/19/2015, a patient presented to a physician assistant at a family care clinic with chief complaints of headache, vomiting, and incontinence since 11/17/2015. The patient’s father reported, in addition to the severe headache, the patient was experiencing involuntary arm jerking. Furthermore, the night prior, the patient experienced hearing voices.
The patient had a history of respiratory problems, was noted to have “poor” functional status, and was noted to be in preschool.
The physician assistant did not complete a neurological examination; however, he diagnosed the patient with pediatric migraine and ordered thirty 10 mg tablets of amitriptyline with instructions for the patient to take one tablet three times daily and the patient was to have one refill. The physician assistant did not perform a thorough workup to include additional studies or tests prior to prescribing amitriptyline.
On 2/3/2016, the Board received a response from the physician assistant wherein he indicated, “I recall little about the episode, except possibly after reviewing his chart and the nurses [sic] report, in investigating his headache and cyclic vomiting and physical exam in UpToDate that the treatment I initiated would have been per the UpToDate recommendations.”
UpToDate is an online website claiming to be an evidence-based, physician-authored clinical decision support resource.
The physician assistant inappropriately prescribed amitriptyline due to the excessive dose and age of the patient.
The Board judged the physician assistant’s conduct to be below the minimum standard of competence given his inappropriate prescribing of amitriptyline.
For this allegation and others, the Board ordered the physician assistant to contact The Center for Personalized Education for Physicians, (“CPEP”) for a competence assessment, follow all recommendations of the CPEP assessment, and complete a medical record keeping seminar.
State: Kansas
Date: April 2017
Specialty: Physician Assistant, Family Medicine, Pediatrics
Symptom: Headache, Nausea Or Vomiting, Psychiatric Symptoms, Urinary Problems
Diagnosis: Neurological Disease
Medical Error: Improper medication management, Accidental Medication Error, Failure to examine or evaluate patient properly
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
California – Internal Medicine – Narcotic Medication Mismanagement And Lack Of Treatment For Hypertension And Weight Gain
A 31-year-old man was a history of anxiety and chronic left shoulder pain from a left labral tear documented by a shoulder Magnetic Resonance Imaging (MRI) in July 2009. The patient was 77 inches tall and weighed 325 pounds.
On 6/11/2007, the patient first saw an internist. He was diagnosed with a “sprain of the scapula.” The only positive finding noted was tenderness of his left scapula wing, and he was prescribed hydrocodone/acetaminophen 10 mg/325 mg and alprazolam.
On 6/18/2007, the patient returned complaining of insomnia. The internist prescribed zolpidem and carisoprodol.
On 7/6/2007, the patient came back complaining of abdominal pain that was attributed to ibuprofen. He was given esomeprazole and hydrocodone/acetaminophen was discontinued. He was given a dietary supplement called “Sleep Tight” for his sleep disorder, which he preferred to zolpidem.
On 8/21/2007, the patient returned. His gastritis had resolved, and he was given alprazolam for anxiety and tramadol for pain.
On 11/9/2007, the patient was given alprazolam 2 mg every 6 hours.
On 12/7/2007, the patient was seen for anxiety. The internist prescribed buspirone daily and continued alprazolam 2 mg every 6 hours. The patient was then not seen by the internist for a year and a half.
On 5/6/2009, the patient presented with complaints of anxiety and insomnia. Blood pressure was noted to be 185/98. The internist advised the patient to start on a 2 gm per day sodium-restricted diet. The internist continued the patient on alprazolam. The Board noted that the internist neither took an adequate history nor performed an adequate physical examination. The internist neither recommended a weight loss program and nor medications to address the patient’s elevated blood pressure.
On 6/19/2009, the patient came in for a dislocation of his shoulder. The patient’s blood pressure was better. The internist prescribed oxycodone/acetaminophen. The internist tapered his alprazolam and again noted the patient’s problems with anxiety and insomnia. The internist prescribed the patient tramadol and hydromorphone.
On 7/1/2009, the patient returned for a clinic visit and stated that he had obtained an MRI. He was found to have had a torn labrum and had been seen by an orthopedic surgeon with plans to perform a left shoulder arthroscopy. The patient had been prescribed hydromorphone.
On 7/22/2009, the internist prescribed a fentanyl patch for baseline pain control and hydromorphone for breakthrough pain. There was no documentation that the internist had communicated with the orthopedic surgeon.
On 8/10/2009, the patient visited the internist and said that he had undergone arthroscopic surgery, which went well.
On 08/31/2009, the patient returned and stated that his shoulder pain had resolved. He complained of low back pain. The internist then prescribed a fentanyl patch at a dose of 125 mcg (100 mcg plus 25 mcg). Hydromorphone was discontinued. The patient’s blood pressure was 180/100 and was not addressed.
On 9/25/2009, the patient had lost a substantial amount of weight. Blood pressure decreased down to 150/92. The internist continued to prescribe fentanyl.
On 11/20/2009, the internist refilled the fentanyl patch prescription for both the 100 mcg and 25 mcg patches.
On 1/15/2010, the patient’s weight had gone up to 244 pounds. He was using hydrocodone/acetaminophen. The internist prescribed citalopram 60 mg (which the Board noted was a high starting dose that may increase the risk of cardiotoxicity).
On 4/26/2010, the patient presented for a clinic visit. The internist had switched from a sparsely documented written record to an electronic typed record. It was noted that the patient was on hydrocodone/acetaminophen 7.5 mg/325 mg and alprazolam 2 mg three times a day. His blood pressure was 156/88, and his weight had increased to 283 pounds. The hydrocodone/acetaminophen was stopped and hydrocodone/acetaminophen 10 mg/325 mg was prescribed. Per the Board, this note had much better documentation, but still no analysis of the patient’s clinical problem. The Board noted that the patient had Kaiser Insurance and noted that the internist did not document why the patient was getting pain medications outside of Kaiser’s clinics. The internist did not address the patient’s weight gain or hypertension.
On 9/30/2010, the internist’s assessment was a sprain of the shoulder, and he again prescribed hydrocodone/acetaminophen 10 mg/325 mg. He suggested heat, ice, and physical therapy.
The patient’s last visit with the internist occurred on 10/26/2010. The patient explained that he had hurt his back. He had been taking hydrocodone/acetaminophen, which reduced the pain from a 10 to a 7. His blood pressure was 178/106. His weight had increased to 308 pounds. The internist did not address the patient’s weight gain or hypertension. The only diagnosis was sprain/strain at the unspecified site of the upper arm. Hydrocodone/acetaminophen 10 mg/325 mg was prescribed with 8 mg hydromorphone for breakthrough pain. The patient was later seen by a different doctor who prescribed methadone.
On 11/11/2010, the patient was found unconsciousness and brought to an emergency department where he was pronounced dead.
The Board judged the internist’s conduct to have fallen below the standard of care given failure to coordinate with other physicians regarding pain control, failure of documentation, failure to address the patient’s hypertension, failure to monitor the efficacy of the narcotic medications, failure to appropriately prescribe narcotic medications, and failure to administer citalopram at a reasonable starting dose.
The internist was placed on probation for 35 months with the stipulations that he complete 20 hours of continuing medical education per year for each year of probation, complete a prescribing practices course, complete a medical record keeping course, and undergo monitoring by a designated clinical monitor.
State: California
Date: March 2017
Specialty: Internal Medicine
Symptom: Pain, Back Pain, Extremity Pain, Joint Pain, Psychiatric Symptoms
Diagnosis: Drug Overdose, Side Effects, or Withdrawal
Medical Error: Improper medication management, Failure to examine or evaluate patient properly, Failure of communication with other providers, Failure to properly monitor patient, Improper treatment, Lack of proper documentation
Significant Outcome: Death
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 – 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