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.