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.