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.