A 4-month-old was admitted to the hospital for a crucial heart procedure. Prior to surgery, an order should have been placed for Hexakapron (tranexamic acid), a blood-clotting agent, to prevent excessive blood loss. Instead, he was mistakenly ordered the chemotherapy drug, Hexalen (altretamine). MedAware identified that the drug was inconsistent with the patient’s clinical profile and promptly canceled the order before being given.

If given, it could have resulted in severe blood loss during the operation, while also exposing the infant to the adverse effects of chemotherapy.