A healthy 62-year-old woman was admitted to the hospital for surgery on a fractured hand after suffering a car accident. During her admission, she was mistakenly prescribed digoxin, a drug used to treat heart failure. Because the patient was otherwise healthy, MedAware identified the mismatch with the patient profile and alerted the care team, who promptly canceled the order.

If given digoxin, the patient could have suffered from life-threatening heart rate abnormalities.