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Patient Cases
MedAware’s medication safety monitoring platform identifies medication-related risks that are otherwise missed by existing tools and systems. With MedAware, wrong medications, wrong doses, and evolving adverse drug events are caught before harm can come to the patient.
How can MedAware catch these errors while others can’t? When taken in aggregate, prescribing errors are tragically common. However each individual example is both rare and unexpected, and no rules-based system could practically have all the necessary if/then scenarios. MedAware’s AI technology analyzes millions of patient records to understand what normal prescribing patterns look like. As a result, it can identify outlier prescriptions and inconsistencies, flagging potential errors without needing a comprehensive list of examples.
The following cases are real examples of medication errors that were caught by MedAware. They are also part of the social media campaign, #MedSafetyMonday. Follow MedAware to see a new case each Monday.
Featured Cases
Case #42:
Similar First Letters
A 1.5-year-old child was supposed to receive propranolol for treatment of hemangioma (a vascular benign tumor). Instead, he was mistakenly prescribed the chemotherapy medication, procarbazine, which is used to treat lymphoma or brain cancers. MedAware alerted the care team of the mistake, and the order was canceled.
If treated with the wrong drug, the child could have suffered from the chemotherapy’s side effects, such as low platelet count, nerve damage, and even seizures and coma.
Case #41:
An Antibiotic for Seizures
To treat her seizures, a 76-year-old woman was supposed to receive the drug Keppra (levetiracetam). Instead, she was mistakenly prescribed the similarly named antibiotic, Keflex (cefalexin). MedAware alerted the care team of the mistake and the order was canceled.
If treated with the wrong drug, the patient could have suffered from untreated seizures and consequential brain damage.
Case #40:
The Wrong “Cyclo”
A 36-year-old man who underwent a bone marrow transplant was supposed to receive the immunosuppressive drug, cyclosporine. Instead, he was mistakenly prescribed the chemotherapy medication, cyclophosphamide. MedAware alerted the care team of the error, and the order was canceled.
If treated with the wrong drug, the patient would have been at high risk of transplant organ rejection and may have suffered from the chemotherapy’s side effects.
Case #39:
Not a Chemo Patient
While hospitalized, an 82-year-old woman was supposed to receive her chronic drug, Eltroxin, (levothyroxine) for treatment of hypothyroidism. Instead, she was mistakenly prescribed the chemotherapy drug, Eloxatin (oxaliplatin). MedAware alerted the care team of the mistake, and the order was canceled.
If treated with Eloxatin, the patient could have suffered from untreated hypothyroidism, as well as the chemotherapy’s side effects.
Case #38:
Just a Child’s Flu
A 1.5-year-old boy was supposed to receive Tamiflu for seasonal flu treatment. Instead, he was prescribed the chemotherapy drug, tamoxifen. MedAware alerted the care team of the mistake, and the order was canceled.
If treated with tamoxifen, the child could have suffered from side effects of chemotherapy, such as hypertension, nausea, hepatic impairment, and thrombotic events. Additionally, untreated flu can lead to complications in young children.
Case #37:
Chemotherapy as Infection Prophylaxis
A 2-year-old child who underwent bone marrow transplantation was supposed to receive the antifungal drug fluconazole, as a preventative treatment. Instead, he was mistakenly prescribed with the chemotherapy drug, fludarabine. MedAware alerted the care team of the mistake, and the order was canceled.
If treated with the wrong drug, the patient would have been at risk of contracting a fungal infection, which can be life-threatening to his condition. Additionally, he would have unnecessarily suffered side effects of chemotherapy.
Case #36:
Antihypertensive for Pain Relief
An 85-year-old hospice patient was supposed to receive levomepromazine for light sedation to ease her pain. Instead, she was mistakenly prescribed with the antihypertensive combination drug Naprizide (enalapril+hydrochlorothiazide). MedAware alerted the care team of the mistake and the order was canceled.
If treated with the wrong drug, the patient would have suffered from untreated pain, while being at risk of hypotension.
Case #35:
Renal Impairment Contraindication
A hospitalized 90-year-old woman was prescribed her chronic diuretic medication, hydrochlorothiazide. During her hospitalization, she suffered from severe renal impairment, which negatively affects the drug’s safety. MedAware identified and alerted on the changes, and the treatment was replaced.
If given while suffering from severe renal impairment, the patient’s renal dysfunction could have been aggravated to the point of renal failure and the patient would have failed to realize the intended diuretic and antihypertensive effects of the medication.
Case #34:
Chemotherapy as an Anticoagulant
A 51-year-old man suffering from back pain was prescribed an injection of Venclexta (venetoclax), a chemotherapy medication, instead of an injection of the anticoagulant, Clexane (enoxaparin). MedAware alerted the care team of the mistake, and the order was canceled.
If treated with the wrong medication, the patient would have been at severe risk of thrombotic events, including myocardial infarction. He also would have suffered from the unpleasant side effects of chemotherapy.
Case #33:
Sound-Alike Drug for Edema
While hospitalized, a 56-year-old woman was supposed to receive Zaroxolyn (metolazone), a diuretic for treatment of her pulmonary edema. Instead, she was mistakenly prescribed the antiseizure medication, Zarontin (ethosuximide). MedAware alerted to the error, and the order was canceled.
If given the wrong medication, the patient could have suffered from the drug’s side effects, such as behavioral changes and low white blood cells.
Case #32:
Antiretroviral for Hypertension
An 18-month-old toddler was supposed to receive the drug Norvasc (amlodipine) for hypertension while hospitalized. Instead, she was mistakenly prescribed Norvir (ritonavir), an antiretroviral drug for HIV/AIDS treatment. MedAware notified the care team of the mistake, and the order was canceled.
If treated with Norvir, the child could have suffered from the drug’s side effects, including fatigue, joint pain, and hepatitis, while still suffering from untreated hypertension.
Case #31:
Dual Prescriptions
While hospitalized, a 68-year-old man was prescribed the anticoagulant, enoxaparin, to treat deep vein thrombosis. However, the medical staff mistakenly prescribed two identical prescriptions for enoxaparin, thus doubling the daily dose the patient would have received. MedAware alerted the staff, and one of the medications was canceled before administration.
If given a double dose of enoxaparin, the patient could have suffered major internal bleeding.
Case #30:
No Heart Failure Present
A healthy 62-year-old woman was admitted to the hospital for surgery on a fractured hand after suffering a car accident. During her admission, she was mistakenly prescribed digoxin, a drug used to treat heart failure. Because the patient was otherwise healthy, MedAware identified the mismatch with the patient profile and alerted the care team, who promptly canceled the order.
If given digoxin, the patient could have suffered from life-threatening heart rate abnormalities.
Case #29:
Wrong Saline Concentration
While hospitalized, a 72-year-old patient was supposed to receive IV normal saline 0.9% (IV fluids). Instead, an order was placed for IV hypertonic saline 3%, which contains a high concentration of sodium and is used in cases of low blood sodium levels. However, this patient’s blood sodium levels were normal. MedAware alerted the care team of the mistake, and the order was canceled.
If treated with hypertonic saline, the patient could have suffered from dangerously high blood sodium levels, which could lead to neurological side effects such as dizziness, confusion, seizures, and even coma.
Case #28:
Contraindicated Drug for a Child
A 1-year-old boy was admitted to the hospital due to a severe asthma attack. The staff intended to prescribe him Betnesole (betamethasone), a steroidal drug for asthma treatment. Instead, he was mistakenly prescribed Betistine (betahistine), which treats vertigo symptoms. MedAware alerted the care team to the mistake, noting that the prescribed medication did not match the patient profile.
Additionally, Betahistine is contraindicated for pediatric use and not recommended for use in asthmatic patients.
Case #27:
Dilantin or Dilatam?
While hospitalized, a 13-year-old girl with a history of epilepsy was mistakenly prescribed the anti-hypertensive drug, Dilatam (diltiazem), instead of her chronic anti-seizure drug, Dilantin (phenytoin). MedAware’s technology identified that this medication was inconsistent with the patient profile and alerted the care team to the error so it could be canceled before being given.
If given, the patient could have suffered from low blood pressure, as well as seizures due to her untreated epilepsy.
Case #26:
Trauma or Diabetes Patient?
A 20-year-old male was injured in a motorcycle accident and taken to the emergency department. While hospitalized, he was mistakenly prescribed the diabetes drug metformin, even though he was not diabetic.
In this case, the drug was likely intended for a different patient. MedAware alerted the care team of the mistake, and the prescription was canceled.
Case #25:
Not the Time for Aspirin
A 97-year-old was admitted to the hospital due to blood in her vomit and stools—signs of acute gastrointestinal tract bleeding. During her stay, the physician accidentally prescribed a painkilling tablet that combined Aspirin and Codeine. Thankfully, MedAware caught the mistake and alerted the care team prior to administering.
Aspirin is contraindicated during an active bleed, as it prevents blood clotting. If given, the patient’s condition could have become life threatening.
Case #24:
Considering Side Effect
While hospitalized for shortness of breath and low blood oxygen saturation, a 59-year-old man was prescribed his chronic cancer treatment drug, axitinib. A known side effect of this medication is shortness of breath. MedAware alerted the staff that further consideration may be warranted before administering the medication, as the shortness of breath was likely caused by his medication.
If given axitinib as prescribed, the patient’s condition could have been aggravated to a life-threatening point.
Case #23:
Chemotherapy vs Antipsychotic
An 88-year-old patient was supposed to receive her chronic antipsychotic drug, Modal (sulpiride). Instead, she was prescribed the similarly named chemotherapy drug, Temodal (temozolomide). MedAware alerted the staff that the medication was suspicious for the patient’s condition and after review, the order was canceled.
If given the wrong drug, the patient could have suffered from chemotherapy’s side effects, such as hair loss and bone marrow suppression.
Case #22:
Contraindicated Chronic Drug
A 78-year-old patient was diagnosed with angioedema, a condition that causes swelling of the skin and underlying tissues or mucous membranes. However, one of his chronic medications, enalapril, is contraindicated for patients with angioedema. MedAware alerted the staff that the medication was not a safe fit for the patient’s profile, and the chronic drug was changed.
If given, the patient’s condition could have been aggravated to a life-threatening point due to airway swelling that would cause difficulty breathing.
Case #21:
Not the Right Patient
While hospitalized, an 81-year-old man was ordered the medication, primaquine, which is used to treat Malaria. However, he had no suspected signs of the disease. The drug was likely meant for another patient. MedAware alerted the staff that the medication did not match the patient profile and the order was canceled.
If given, the patient could have unnecessarily suffered from adverse reactions to primaquine, such as skin irritation, vomiting, and abnormal heart rate.
Case #20:
Tuberculosis Drug for Minor Infection
An 82-year-old woman had a minor bacterial infection that should have been treated with Zinnat (cefuroxime). Instead, the woman was accidentally prescribed a similarly named medication, Zinamide (pyrazinamide), a very potent drug used to treat Tuberculosis. MedAware identified the error and the order was corrected before administration.
If given as ordered, the patient could have suffered from liver damage, as well as from her ongoing untreated infection.
Case #19:
Sound alike, not alike
A hospitalized woman was supposed to receive Eltroxin (levothyroxine) for treatment of her chronic hypothyroidism. Instead, an order was placed for eltrombopag, which is used to induce thrombocyte production in patients with immune blood disorders. MedAware identified the mistake and the order was changed before administration.
If treated with eltrombopag, the patient could have suffered from severe consequences, such as liver damage and spontaneous blood clots in organs.
Case #18:
Stimulants Overdose
A 36-year-old man overdosed on multiple drugs, including cocaine, and was admitted to the ICU. While there, the staff had ordered him his chronic ADHD medication, Ritalin (methylphenidate). MedAware identified the medication risk based on the patient’s profile and the order was corrected.
Combining Ritalin with cocaine could have resulted in devastating outcomes, such as hypertension, heart rate abnormalities, and even a heart attack and coma.
Case #17:
Preventing Opioid Overdose
A doctor mistakenly prescribed a patient 600 mg per day of the opioid, tramadol, at discharge. However, the maximum daily dose of tramadol is 400 mg. MedAware immediately alerted the physician to the dosing error in this opioid-naive patient and the prescription was changed accordingly.
If given as initially prescribed, the patient would have been at increased risk of opioid overdose.
Case #16:
No Migraines Present
A physician intended to place an order for imatinib to treat a 4-year-old’s leukemia. However, the physician accidentally selected the similarly named drug, Imitrex (sumatriptan), which is used to treat migraines. MedAware identified the mistake, and the prescription was corrected.
This error could have had a catastrophic impact on the treatment of this child’s cancer.
Case #15:
Choosing the Right Shot
An 89-year-old was supposed to receive a tetanus shot, after suffering a cut on his head. The ER physician accidentally ordered a polio vaccine instead. MedAware identified the mistake, and the patient received the correct vaccine.
If given the wrong shot, the patient may have contracted a tetanus infection, which could have resulted in uncontrolled muscle spasms, leading to an inability to swallow and breathe.
Case #14:
Saving a Kidney
To prevent organ rejection, a kidney transplant patient was supposed to receive Thymoglobuline (antithymocyte globulin). Instead, she was prescribed a similarly named drug, Thyrogen (thyrotropin alfa), which is used to diagnose thyroid diseases. MedAware identified the error, and the medication was changed prior to administering.
If given, the patient would have been at risk of suffering a severe immune reaction to the transplant, including losing her donated kidney.
Case #13:
Too Much, Too Soon
A physician placed an order for the injectable antipsychotic drug zuclopenthixol decanoate to be administered daily. However, this medication should not be given more than once every two weeks. MedAware alerted to the incorrect frequency, and the prescription was corrected before being administered.
If not for this intervention, the patient would have been at significant risk for an adverse event, such as convulsions, hypotension, and even coma.
Case #12:
Not a Transplant Patient
Upon hospital admission, a cancer surgery patient was mistakenly prescribed Prograf (tacrolimus), an immune suppressant given to transplant patients. It was likely intended for a lung transplant patient admitted at the same time. MedAware identified the inconsistency with the patient’s clinical profile and the order was canceled.
Should the patient have received the medication, his immune system would have been suppressed, which is especially dangerous when recovering from surgery.
Case #11:
Preventing Renal Failure
While hospitalized, a patient with chronic hypertension was receiving his regular dose of the blood pressure medication, losartan. However, blood tests performed upon admission revealed signs of acute renal failure, a condition that could be worsened by losartan. Recognizing the change in the patient’s health status, MedAware alerted the care team before the medication was given.
If continued, the patient’s renal function could have deteriorated to a life-threatening condition.
Case #10:
Opioid for Dematitis
While hospitalized a 3-year-old boy was meant to receive the medication, methotrexate, for his chronic atopic dermatitis. Instead, the physician mistakenly prescribed the opioid, methadone. MedAware identified the mistake and the physician promptly canceled the order.
If given, the child may have suffered from dangerous adverse effects of opioids, including respiratory depression and coma.
Case #9:
Antipsychotics for Hypertension
While hospitalized, an 85-year-old man was meant to receive Tritace (ramipril) to help manage his high blood pressure. Instead, he was prescribed a similarly named drug, Taroctyl (chlorpromazine), which is an antipsychotic. Recognizing the inconsistency with the patient’s clinical profile, MedAware identified and alerted the care team of the error and the order was canceled.
If given, the patient would have been exposed to adverse effects of antipsychotic drugs, such as seizures and sedation, while still suffering from hypertension and its consequences.
Case #8:
Fentanyl: IV or Patch?
A 68-year-old man with metastatic lung cancer was treated in the emergency room for shortness of breath and back pain. The physician meant to prescribe a fentanyl dermal patch to relieve his pain. Mistakenly, the patient was prescribed intravenous fentanyl, which is used for sedation. MedAware identified the mistake and the order was promptly canceled.
If given to non-ventilated patients, intravenous fentanyl may cause severe respiratory depression and even death.
Case #7:
Monitoring High Potassium
While prepping for prostate surgery, a 74-year-old man was prescribed a routine fluid regimen, which contained potassium. However, the patient’s chart noted that he already had dangerously high blood potassium levels. MedAware identified what could have been a hazardous mistake, and the medical order was promptly canceled by the physician.
If given, the patient would have suffered from extremely high potassium levels, which can cause serious heart rate irregularities and death.
Case #6:
Preventing Blood Loss
A 4-month-old was admitted to the hospital for a crucial heart procedure. Prior to surgery, an order should have been placed for Hexakapron (tranexamic acid), a blood-clotting agent, to prevent excessive blood loss. Instead, he was mistakenly ordered the chemotherapy drug, Hexalen (altretamine). MedAware identified that the drug was inconsistent with the patient’s clinical profile and promptly canceled the order before being given.
If given, it could have resulted in severe blood loss during the operation, while also exposing the infant to the adverse effects of chemotherapy.
Case #5:
Low Sodium Levels — Cause and Effect
A 79-year-old male developed severe hyponatremia (low blood sodium concentration). MedAware’s system associated the low sodium levels with the fact that he has been treated with the antidepressant sertraline for the past three weeks, which has a known side effect of hyponatremia. MedAware alerted the medical staff, and the order was promptly stopped.
If continued, the patient would have been at risk of severe mental deterioration, seizures, and even coma.
Case #4:
Unnecessary Sedation
A 75-year-old woman was admitted to the hospital with chest pain and shortness of breath. She was conscious, alert, and stable. Upon admission, she was mistakenly prescribed with the anaesthetic drug, propofol. MedAware identified the erroneous order, and the physician promptly cancelled it.
If given, the patient would have been unnecessarily sedated and put at serious risk.
Case #3:
Overactive Parathyroid
An 80-year-old patient with a history of hyperparathyroidism (overactive parathyroid gland) was mistakenly prescribed mercaptizole, a medication used to treat hyperthyroidism (overactive thyroid gland). MedAware’s AI algorithm identified the error, and the order was promptly canceled by the physician.
If given, the patient may have experienced dangerously low white blood counts, heart rate abnormalities and mental deterioration.
Case #2:
Chemotherapy for an Eye Infection
A 68-year-old man was hospitalized due to a serious corneal infection that required urgent antibiotic treatment. The medical staff intended to prescribe the antibiotic, Doxy 100 (doxycycline). However, a highly-toxic chemotherapy drug, Doxil (doxorubicin), was prescribed by mistake. MedAware’s AI identified the error and the order was canceled.
If given, the patient may have risked suffering from toxic side effects of chemotherapy, while losing his eyesight due to untreated infection.
Case #1:
Elevated Heart Rate
A hospitalized 89-year-old woman was meant to receive Deralin (propranolol) as treatment for a rapid heart rate. However, the clinician accidentally ordered the ADHD medication, Adderall. MedAware’s AI identified the mistake, and the order was promptly canceled.
If given, the patient’s heart rate could have increased even more and put her at serious risk.
Case #35:
Renal Impairment Contraindication
A hospitalized 90-year-old woman was prescribed her chronic diuretic medication, hydrochlorothiazide. During her hospitalization, she suffered from severe renal impairment, which negatively affects the drug’s safety. MedAware identified and alerted on the changes, and the treatment was replaced.
If given while suffering from severe renal impairment, the patient’s renal dysfunction could have been aggravated to the point of renal failure and the patient would have failed to realize the intended diuretic and antihypertensive effects of the medication.
Case #31:
Dual Prescriptions
While hospitalized, a 68-year-old man was prescribed the anticoagulant, enoxaparin, to treat deep vein thrombosis. However, the medical staff mistakenly prescribed two identical prescriptions for enoxaparin, thus doubling the daily dose the patient would have received. MedAware alerted the staff, and one of the medications was canceled before administration.
If given a double dose of enoxaparin, the patient could have suffered major internal bleeding.
Case #29:
Wrong Saline Concentration
While hospitalized, a 72-year-old patient was supposed to receive IV normal saline 0.9% (IV fluids). Instead, an order was placed for IV hypertonic saline 3%, which contains a high concentration of sodium and is used in cases of low blood sodium levels. However, this patient’s blood sodium levels were normal. MedAware alerted the care team of the mistake, and the order was canceled.
If treated with hypertonic saline, the patient could have suffered from dangerously high blood sodium levels, which could lead to neurological side effects such as dizziness, confusion, seizures, and even coma.
Case #24:
Considering Side Effect
While hospitalized for shortness of breath and low blood oxygen saturation, a 59-year-old man was prescribed his chronic cancer treatment drug, axitinib. A known side effect of this medication is shortness of breath. MedAware alerted the staff that further consideration may be warranted before administering the medication, as the shortness of breath was likely caused by his medication.
If given axitinib as prescribed, the patient’s condition could have been aggravated to a life-threatening point.
Case #22:
Contraindicated Chronic Drug
A 78-year-old patient was diagnosed with angioedema, a condition that causes swelling of the skin and underlying tissues or mucous membranes. However, one of his chronic medications, enalapril, is contraindicated for patients with angioedema. MedAware alerted the staff that the medication was not a safe fit for the patient’s profile, and the chronic drug was changed.
If given, the patient’s condition could have been aggravated to a life-threatening point due to airway swelling that would cause difficulty breathing.
Case #18:
Stimulants Overdose
A 36-year-old man overdosed on multiple drugs, including cocaine, and was admitted to the ICU. While there, the staff had ordered him his chronic ADHD medication, Ritalin (methylphenidate). MedAware identified the medication risk based on the patient’s profile and the order was corrected.
Combining Ritalin with cocaine could have resulted in devastating outcomes, such as hypertension, heart rate abnormalities, and even a heart attack and coma.
Case #13:
Too Much, Too Soon
A physician placed an order for the injectable antipsychotic drug zuclopenthixol decanoate to be administered daily. However, this medication should not be given more than once every two weeks. MedAware alerted to the incorrect frequency, and the prescription was corrected before being administered.
If not for this intervention, the patient would have been at significant risk for an adverse event, such as convulsions, hypotension, and even coma.
Case #11:
Preventing Renal Failure
While hospitalized, a patient with chronic hypertension was receiving his regular dose of the blood pressure medication, losartan. However, blood tests performed upon admission revealed signs of acute renal failure, a condition that could be worsened by losartan. Recognizing the change in the patient’s health status, MedAware alerted the care team before the medication was given.
If continued, the patient’s renal function could have deteriorated to a life-threatening condition.
Case #7:
Monitoring High Potassium
While prepping for prostate surgery, a 74-year-old man was prescribed a routine fluid regimen, which contained potassium. However, the patient’s chart noted that he already had dangerously high blood potassium levels. MedAware identified what could have been a hazardous mistake, and the medical order was promptly canceled by the physician.
If given, the patient would have suffered from extremely high potassium levels, which can cause serious heart rate irregularities and death.
Case #5:
Low Sodium Levels — Cause and Effect
A 79-year-old male developed severe hyponatremia (low blood sodium concentration). MedAware’s system associated the low sodium levels with the fact that he has been treated with the antidepressant sertraline for the past three weeks, which has a known side effect of hyponatremia. MedAware alerted the medical staff, and the order was promptly stopped.
If continued, the patient would have been at risk of severe mental deterioration, seizures, and even coma.
Case #42:
Similar First Letters
A 1.5-year-old child was supposed to receive propranolol for treatment of hemangioma (a vascular benign tumor). Instead, he was mistakenly prescribed the chemotherapy medication, procarbazine, which is used to treat lymphoma or brain cancers. MedAware alerted the care team of the mistake, and the order was canceled.
If treated with the wrong drug, the child could have suffered from the chemotherapy’s side effects, such as low platelet count, nerve damage, and even seizures and coma.
Case #41:
An Antibiotic for Seizures
To treat her seizures, a 76-year-old woman was supposed to receive the drug Keppra (levetiracetam). Instead, she was mistakenly prescribed the similarly named antibiotic, Keflex (cefalexin). MedAware alerted the care team of the mistake and the order was canceled.
If treated with the wrong drug, the patient could have suffered from untreated seizures and consequential brain damage.
Case #40:
The Wrong “Cyclo”
A 36-year-old man who underwent a bone marrow transplant was supposed to receive the immunosuppressive drug, cyclosporine. Instead, he was mistakenly prescribed the chemotherapy medication, cyclophosphamide. MedAware alerted the care team of the error, and the order was canceled.
If treated with the wrong drug, the patient would have been at high risk of transplant organ rejection and may have suffered from the chemotherapy’s side effects.
Case #39:
Not a Chemo Patient
While hospitalized, an 82-year-old woman was supposed to receive her chronic drug, Eltroxin, (levothyroxine) for treatment of hypothyroidism. Instead, she was mistakenly prescribed the chemotherapy drug, Eloxatin (oxaliplatin). MedAware alerted the care team of the mistake, and the order was canceled.
If treated with Eloxatin, the patient could have suffered from untreated hypothyroidism, as well as the chemotherapy’s side effects.
Case #38:
Just a Child’s Flu
A 1.5-year-old boy was supposed to receive Tamiflu for seasonal flu treatment. Instead, he was prescribed the chemotherapy drug, tamoxifen. MedAware alerted the care team of the mistake, and the order was canceled.
If treated with tamoxifen, the child could have suffered from side effects of chemotherapy, such as hypertension, nausea, hepatic impairment, and thrombotic events. Additionally, untreated flu can lead to complications in young children.
Case #37:
Chemotherapy as Infection Prophylaxis
A 2-year-old child who underwent bone marrow transplantation was supposed to receive the antifungal drug fluconazole, as a preventative treatment. Instead, he was mistakenly prescribed with the chemotherapy drug, fludarabine. MedAware alerted the care team of the mistake, and the order was canceled.
If treated with the wrong drug, the patient would have been at risk of contracting a fungal infection, which can be life-threatening to his condition. Additionally, he would have unnecessarily suffered side effects of chemotherapy.
Case #36:
Antihypertensive for Pain Relief
An 85-year-old hospice patient was supposed to receive levomepromazine for light sedation to ease her pain. Instead, she was mistakenly prescribed with the antihypertensive combination drug Naprizide (enalapril+hydrochlorothiazide). MedAware alerted the care team of the mistake and the order was canceled.
If treated with the wrong drug, the patient would have suffered from untreated pain, while being at risk of hypotension.
Case #34:
Chemotherapy as an Anticoagulant
A 51-year-old man suffering from back pain was prescribed an injection of Venclexta (venetoclax), a chemotherapy medication, instead of an injection of the anticoagulant, Clexane (enoxaparin). MedAware alerted the care team of the mistake, and the order was canceled.
If treated with the wrong medication, the patient would have been at severe risk of thrombotic events, including myocardial infarction. He also would have suffered from the unpleasant side effects of chemotherapy.
Case #33:
Sound-Alike Drug for Edema
While hospitalized, a 56-year-old woman was supposed to receive Zaroxolyn (metolazone), a diuretic for treatment of her pulmonary edema. Instead, she was mistakenly prescribed the antiseizure medication, Zarontin (ethosuximide). MedAware alerted to the error, and the order was canceled.
If given the wrong medication, the patient could have suffered from the drug’s side effects, such as behavioral changes and low white blood cells.
Case #32:
Antiretroviral for Hypertension
An 18-month-old toddler was supposed to receive the drug Norvasc (amlodipine) for hypertension while hospitalized. Instead, she was mistakenly prescribed Norvir (ritonavir), an antiretroviral drug for HIV/AIDS treatment. MedAware notified the care team of the mistake, and the order was canceled.
If treated with Norvir, the child could have suffered from the drug’s side effects, including fatigue, joint pain, and hepatitis, while still suffering from untreated hypertension.
Case #30:
No Heart Failure Present
A healthy 62-year-old woman was admitted to the hospital for surgery on a fractured hand after suffering a car accident. During her admission, she was mistakenly prescribed digoxin, a drug used to treat heart failure. Because the patient was otherwise healthy, MedAware identified the mismatch with the patient profile and alerted the care team, who promptly canceled the order.
If given digoxin, the patient could have suffered from life-threatening heart rate abnormalities.
Case #28:
Contraindicated Drug for a Child
A 1-year-old boy was admitted to the hospital due to a severe asthma attack. The staff intended to prescribe him Betnesole (betamethasone), a steroidal drug for asthma treatment. Instead, he was mistakenly prescribed Betistine (betahistine), which treats vertigo symptoms. MedAware alerted the care team to the mistake, noting that the prescribed medication did not match the patient profile.
Additionally, Betahistine is contraindicated for pediatric use and not recommended for use in asthmatic patients.
Case #27:
Dilantin or Dilatam?
While hospitalized, a 13-year-old girl with a history of epilepsy was mistakenly prescribed the anti-hypertensive drug, Dilatam (diltiazem), instead of her chronic anti-seizure drug, Dilantin (phenytoin). MedAware’s technology identified that this medication was inconsistent with the patient profile and alerted the care team to the error so it could be canceled before being given.
If given, the patient could have suffered from low blood pressure, as well as seizures due to her untreated epilepsy.
Case #26:
Trauma or Diabetes Patient?
A 20-year-old male was injured in a motorcycle accident and taken to the emergency department. While hospitalized, he was mistakenly prescribed the diabetes drug metformin, even though he was not diabetic.
In this case, the drug was likely intended for a different patient. MedAware alerted the care team of the mistake, and the prescription was canceled.
Case #25:
Not the Time for Aspirin
A 97-year-old was admitted to the hospital due to blood in her vomit and stools—signs of acute gastrointestinal tract bleeding. During her stay, the physician accidentally prescribed a painkilling tablet that combined Aspirin and Codeine. Thankfully, MedAware caught the mistake and alerted the care team prior to administering.
Aspirin is contraindicated during an active bleed, as it prevents blood clotting. If given, the patient’s condition could have become life threatening.
Case #23:
Chemotherapy vs Antipsychotic
An 88-year-old patient was supposed to receive her chronic antipsychotic drug, Modal (sulpiride). Instead, she was prescribed the similarly named chemotherapy drug, Temodal (temozolomide). MedAware alerted the staff that the medication was suspicious for the patient’s condition and after review, the order was canceled.
If given the wrong drug, the patient could have suffered from chemotherapy’s side effects, such as hair loss and bone marrow suppression.
Case #21:
Not the Right Patient
While hospitalized, an 81-year-old man was ordered the medication, primaquine, which is used to treat Malaria. However, he had no suspected signs of the disease. The drug was likely meant for another patient. MedAware alerted the staff that the medication did not match the patient profile and the order was canceled.
If given, the patient could have unnecessarily suffered from adverse reactions to primaquine, such as skin irritation, vomiting, and abnormal heart rate.
Case #20:
Tuberculosis Drug for Minor Infection
An 82-year-old woman had a minor bacterial infection that should have been treated with Zinnat (cefuroxime). Instead, the woman was accidentally prescribed a similarly named medication, Zinamide (pyrazinamide), a very potent drug used to treat Tuberculosis. MedAware identified the error and the order was corrected before administration.
If given as ordered, the patient could have suffered from liver damage, as well as from her ongoing untreated infection.
Case #19:
Sound alike, not alike
A hospitalized woman was supposed to receive Eltroxin (levothyroxine) for treatment of her chronic hypothyroidism. Instead, an order was placed for eltrombopag, which is used to induce thrombocyte production in patients with immune blood disorders. MedAware identified the mistake and the order was changed before administration.
If treated with eltrombopag, the patient could have suffered from severe consequences, such as liver damage and spontaneous blood clots in organs.
Case #17:
Preventing Opioid Overdose
A doctor mistakenly prescribed a patient 600 mg per day of the opioid, tramadol, at discharge. However, the maximum daily dose of tramadol is 400 mg. MedAware immediately alerted the physician to the dosing error in this opioid-naive patient and the prescription was changed accordingly.
If given as initially prescribed, the patient would have been at increased risk of opioid overdose.
Case #16:
No Migraines Present
A physician intended to place an order for imatinib to treat a 4-year-old’s leukemia. However, the physician accidentally selected the similarly named drug, Imitrex (sumatriptan), which is used to treat migraines. MedAware identified the mistake, and the prescription was corrected.
This error could have had a catastrophic impact on the treatment of this child’s cancer.
Case #15:
Choosing the Right Shot
An 89-year-old was supposed to receive a tetanus shot, after suffering a cut on his head. The ER physician accidentally ordered a polio vaccine instead. MedAware identified the mistake, and the patient received the correct vaccine.
If given the wrong shot, the patient may have contracted a tetanus infection, which could have resulted in uncontrolled muscle spasms, leading to an inability to swallow and breathe.
Case #14:
Saving a Kidney
To prevent organ rejection, a kidney transplant patient was supposed to receive Thymoglobuline (antithymocyte globulin). Instead, she was prescribed a similarly named drug, Thyrogen (thyrotropin alfa), which is used to diagnose thyroid diseases. MedAware identified the error, and the medication was changed prior to administering.
If given, the patient would have been at risk of suffering a severe immune reaction to the transplant, including losing her donated kidney.
Case #12:
Not a Transplant Patient
Upon hospital admission, a cancer surgery patient was mistakenly prescribed Prograf (tacrolimus), an immune suppressant given to transplant patients. It was likely intended for a lung transplant patient admitted at the same time. MedAware identified the inconsistency with the patient’s clinical profile and the order was canceled.
Should the patient have received the medication, his immune system would have been suppressed, which is especially dangerous when recovering from surgery.
Case #10:
Opioid for Dematitis
While hospitalized a 3-year-old boy was meant to receive the medication, methotrexate, for his chronic atopic dermatitis. Instead, the physician mistakenly prescribed the opioid, methadone. MedAware identified the mistake and the physician promptly canceled the order.
If given, the child may have suffered from dangerous adverse effects of opioids, including respiratory depression and coma.
Case #9:
Antipsychotics for Hypertension
While hospitalized, an 85-year-old man was meant to receive Tritace (ramipril) to help manage his high blood pressure. Instead, he was prescribed a similarly named drug, Taroctyl (chlorpromazine), which is an antipsychotic. Recognizing the inconsistency with the patient’s clinical profile, MedAware identified and alerted the care team of the error and the order was canceled.
If given, the patient would have been exposed to adverse effects of antipsychotic drugs, such as seizures and sedation, while still suffering from hypertension and its consequences.
Case #8:
Fentanyl: IV or Patch?
A 68-year-old man with metastatic lung cancer was treated in the emergency room for shortness of breath and back pain. The physician meant to prescribe a fentanyl dermal patch to relieve his pain. Mistakenly, the patient was prescribed intravenous fentanyl, which is used for sedation. MedAware identified the mistake and the order was promptly canceled.
If given to non-ventilated patients, intravenous fentanyl may cause severe respiratory depression and even death.
Case #6:
Preventing Blood Loss
A 4-month-old was admitted to the hospital for a crucial heart procedure. Prior to surgery, an order should have been placed for Hexakapron (tranexamic acid), a blood-clotting agent, to prevent excessive blood loss. Instead, he was mistakenly ordered the chemotherapy drug, Hexalen (altretamine). MedAware identified that the drug was inconsistent with the patient’s clinical profile and promptly canceled the order before being given.
If given, it could have resulted in severe blood loss during the operation, while also exposing the infant to the adverse effects of chemotherapy.
Case #4:
Unnecessary Sedation
A 75-year-old woman was admitted to the hospital with chest pain and shortness of breath. She was conscious, alert, and stable. Upon admission, she was mistakenly prescribed with the anaesthetic drug, propofol. MedAware identified the erroneous order, and the physician promptly cancelled it.
If given, the patient would have been unnecessarily sedated and put at serious risk.
Case #3:
Overactive Parathyroid
An 80-year-old patient with a history of hyperparathyroidism (overactive parathyroid gland) was mistakenly prescribed mercaptizole, a medication used to treat hyperthyroidism (overactive thyroid gland). MedAware’s AI algorithm identified the error, and the order was promptly canceled by the physician.
If given, the patient may have experienced dangerously low white blood counts, heart rate abnormalities and mental deterioration.
Case #2:
Chemotherapy for an Eye Infection
A 68-year-old man was hospitalized due to a serious corneal infection that required urgent antibiotic treatment. The medical staff intended to prescribe the antibiotic, Doxy 100 (doxycycline). However, a highly-toxic chemotherapy drug, Doxil (doxorubicin), was prescribed by mistake. MedAware’s AI identified the error and the order was canceled.
If given, the patient may have risked suffering from toxic side effects of chemotherapy, while losing his eyesight due to untreated infection.
Case #1:
Elevated Heart Rate
A hospitalized 89-year-old woman was meant to receive Deralin (propranolol) as treatment for a rapid heart rate. However, the clinician accidentally ordered the ADHD medication, Adderall. MedAware’s AI identified the mistake, and the order was promptly canceled.
If given, the patient’s heart rate could have increased even more and put her at serious risk.