A 36-year-old man who underwent a bone marrow transplant was supposed to receive the immunosuppressive drug, cyclosporine. Instead, he was mistakenly prescribed the chemotherapy medication, cyclophosphamide. MedAware alerted the care team of the error, and the order was canceled.

If treated with the wrong drug, the patient would have been at high risk of transplant organ rejection and may have suffered from the chemotherapy’s side effects.