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.