A hospitalized woman was supposed to receive Eltroxin (levothyroxine) for treatment of her chronic hypothyroidism. Instead, an order was placed for eltrombopag, which is used to induce thrombocyte production in patients with immune blood disorders. MedAware identified the mistake and the order was changed before administration.

If treated with eltrombopag, the patient could have suffered from severe consequences, such as liver damage and spontaneous blood clots in organs.