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.