Monitoring

Renal Impairment Contraindication

A hospitalized 90-year-old woman was prescribed her chronic diuretic medication, hydrochlorothiazide. During her hospitalization, she suffered from severe renal impairment, which negatively affects the drug’s safety. MedAware identified and alerted on the changes, and the treatment was replaced.

If given while suffering from severe renal impairment, the patient’s renal dysfunction could have been aggravated to the point of renal failure and the patient would have failed to realize the intended diuretic and antihypertensive effects of the medication.

Dual Prescriptions

While hospitalized, a 68-year-old man was prescribed the anticoagulant, enoxaparin, to treat deep vein thrombosis. However, the medical staff mistakenly prescribed two identical prescriptions for enoxaparin, thus doubling the daily dose the patient would have received. MedAware alerted the staff, and one of the medications was canceled before administration.

If given a double dose of enoxaparin, the patient could have suffered major internal bleeding.

Wrong Saline Concentration

While hospitalized, a 72-year-old patient was supposed to receive IV normal saline 0.9% (IV fluids). Instead, an order was placed for IV hypertonic saline 3%, which contains a high concentration of sodium and is used in cases of low blood sodium levels. However, this patient’s blood sodium levels were normal. MedAware alerted the care team of the mistake, and the order was canceled.

If treated with hypertonic saline, the patient could have suffered from dangerously high blood sodium levels, which could lead to neurological side effects such as dizziness, confusion, seizures, and even coma.

Considering Side Effect

While hospitalized for shortness of breath and low blood oxygen saturation, a 59-year-old man was prescribed his chronic cancer treatment drug, axitinib. A known side effect of this medication is shortness of breath. MedAware alerted the staff that further consideration may be warranted before administering the medication, as the shortness of breath was likely caused by his medication.

If given axitinib as prescribed, the patient’s condition could have been aggravated to a life-threatening point.

Contraindicated Chronic Drug

A 78-year-old patient was diagnosed with angioedema, a condition that causes swelling of the skin and underlying tissues or mucous membranes. However, one of his chronic medications, enalapril, is contraindicated for patients with angioedema. MedAware alerted the staff that the medication was not a safe fit for the patient’s profile, and the chronic drug was changed.

If given, the patient’s condition could have been aggravated to a life-threatening point due to airway swelling that would cause difficulty breathing.

Stimulants Overdose

A 36-year-old man overdosed on multiple drugs, including cocaine, and was admitted to the ICU. While there, the staff had ordered him his chronic ADHD medication, Ritalin (methylphenidate). MedAware identified the medication risk based on the patient’s profile and the order was corrected.

Combining Ritalin with cocaine could have resulted in devastating outcomes, such as hypertension, heart rate abnormalities, and even a heart attack and coma.

Too Much, Too Soon

A physician placed an order for the injectable antipsychotic drug zuclopenthixol decanoate to be administered daily. However, this medication should not be given more than once every two weeks. MedAware alerted to the incorrect frequency, and the prescription was corrected before being administered.

If not for this intervention, the patient would have been at significant risk for an adverse event, such as convulsions, hypotension, and even coma.

Preventing Renal Failure

While hospitalized, a patient with chronic hypertension was receiving his regular dose of the blood pressure medication, losartan. However, blood tests performed upon admission revealed signs of acute renal failure, a condition that could be worsened by losartan. Recognizing the change in the patient’s health status, MedAware alerted the care team before the medication was given.

If continued, the patient’s renal function could have deteriorated to a life-threatening condition.

Monitoring High Potassium

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.

Low Sodium Levels — Cause and Effect

A 79-year-old male developed severe hyponatremia (low blood sodium concentration). MedAware’s system associated the low sodium levels with the fact that he has been treated with the antidepressant sertraline for the past three weeks, which has a known side effect of hyponatremia. MedAware alerted the medical staff, and the order was promptly stopped.

If continued, the patient would have been at risk of severe mental deterioration, seizures, and even coma.