Wrong Medication

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A 1.5-year-old child was supposed to receive propranolol for treatment of hemangioma (a vascular benign tumor). Instead, he was mistakenly prescribed the chemotherapy medication, procarbazine, which is used to treat lymphoma or brain cancers. MedAware alerted the care team of the mistake, and the order was canceled.

If treated with the wrong drug, the child could have suffered from the chemotherapy’s side effects, such as low platelet count, nerve damage, and even seizures and coma.

An Antibiotic for Seizures

To treat her seizures, a 76-year-old woman was supposed to receive the drug Keppra (levetiracetam). Instead, she was mistakenly prescribed the similarly named antibiotic, Keflex (cefalexin). MedAware alerted the care team of the mistake and the order was canceled.

If treated with the wrong drug, the patient could have suffered from untreated seizures and consequential brain damage.

The Wrong “Cyclo”

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.

Not a Chemo Patient

While hospitalized, an 82-year-old woman was supposed to receive her chronic drug, Eltroxin, (levothyroxine) for treatment of hypothyroidism. Instead, she was mistakenly prescribed the chemotherapy drug, Eloxatin (oxaliplatin). MedAware alerted the care team of the mistake, and the order was canceled.

If treated with Eloxatin, the patient could have suffered from untreated hypothyroidism, as well as the chemotherapy’s side effects.

Just a Child’s Flu

A 1.5-year-old boy was supposed to receive Tamiflu for seasonal flu treatment. Instead, he was prescribed the chemotherapy drug, tamoxifen. MedAware alerted the care team of the mistake, and the order was canceled.

If treated with tamoxifen, the child could have suffered from side effects of chemotherapy, such as hypertension, nausea, hepatic impairment, and thrombotic events. Additionally, untreated flu can lead to complications in young children.

Chemotherapy as Infection Prophylaxis

A 2-year-old child who underwent bone marrow transplantation was supposed to receive the antifungal drug fluconazole, as a preventative treatment. Instead, he was mistakenly prescribed with the chemotherapy drug, fludarabine. MedAware alerted the care team of the mistake, and the order was canceled.

If treated with the wrong drug, the patient would have been at risk of contracting a fungal infection, which can be life-threatening to his condition. Additionally, he would have unnecessarily suffered side effects of chemotherapy.

Antihypertensive for Pain Relief

An 85-year-old hospice patient was supposed to receive levomepromazine for light sedation to ease her pain. Instead, she was mistakenly prescribed with the antihypertensive combination drug Naprizide (enalapril+hydrochlorothiazide). MedAware alerted the care team of the mistake and the order was canceled.

If treated with the wrong drug, the patient would have suffered from untreated pain, while being at risk of hypotension.

Chemotherapy as an Anticoagulant

A 51-year-old man suffering from back pain was prescribed an injection of Venclexta (venetoclax), a chemotherapy medication, instead of an injection of the anticoagulant, Clexane (enoxaparin). MedAware alerted the care team of the mistake, and the order was canceled.

If treated with the wrong medication, the patient would have been at severe risk of thrombotic events, including myocardial infarction. He also would have suffered from the unpleasant side effects of chemotherapy.

Sound-Alike Drug for Edema

While hospitalized, a 56-year-old woman was supposed to receive Zaroxolyn (metolazone), a diuretic for treatment of her pulmonary edema. Instead, she was mistakenly prescribed the antiseizure medication, Zarontin (ethosuximide). MedAware alerted to the error, and the order was canceled.

If given the wrong medication, the patient could have suffered from the drug’s side effects, such as behavioral changes and low white blood cells.

Antiretroviral for Hypertension

An 18-month-old toddler was supposed to receive the drug Norvasc (amlodipine) for hypertension while hospitalized. Instead, she was mistakenly prescribed Norvir (ritonavir), an antiretroviral drug for HIV/AIDS treatment. MedAware notified the care team of the mistake, and the order was canceled.

If treated with Norvir, the child could have suffered from the drug’s side effects, including fatigue, joint pain, and hepatitis, while still suffering from untreated hypertension.

No Heart Failure Present

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.

Contraindicated Drug for a Child

A 1-year-old boy was admitted to the hospital due to a severe asthma attack. The staff intended to prescribe him Betnesole (betamethasone), a steroidal drug for asthma treatment. Instead, he was mistakenly prescribed Betistine (betahistine), which treats vertigo symptoms. MedAware alerted the care team to the mistake, noting that the prescribed medication did not match the patient profile.

Additionally, Betahistine is contraindicated for pediatric use and not recommended for use in asthmatic patients.

Dilantin or Dilatam?

While hospitalized, a 13-year-old girl with a history of epilepsy was mistakenly prescribed the anti-hypertensive drug, Dilatam (diltiazem), instead of her chronic anti-seizure drug, Dilantin (phenytoin). MedAware’s technology identified that this medication was inconsistent with the patient profile and alerted the care team to the error so it could be canceled before being given.

If given, the patient could have suffered from low blood pressure, as well as seizures due to her untreated epilepsy.

Trauma or Diabetes Patient?

A 20-year-old male was injured in a motorcycle accident and taken to the emergency department. While hospitalized, he was mistakenly prescribed the diabetes drug metformin, even though he was not diabetic.

In this case, the drug was likely intended for a different patient. MedAware alerted the care team of the mistake, and the prescription was canceled.

Not the Time for Aspirin

A 97-year-old was admitted to the hospital due to blood in her vomit and stools—signs of acute gastrointestinal tract bleeding. During her stay, the physician accidentally prescribed a painkilling tablet that combined Aspirin and Codeine. Thankfully, MedAware caught the mistake and alerted the care team prior to administering.

Aspirin is contraindicated during an active bleed, as it prevents blood clotting. If given, the patient’s condition could have become life threatening.

Chemotherapy vs Antipsychotic

An 88-year-old patient was supposed to receive her chronic antipsychotic drug, Modal (sulpiride). Instead, she was prescribed the similarly named chemotherapy drug, Temodal (temozolomide). MedAware alerted the staff that the medication was suspicious for the patient’s condition and after review, the order was canceled.

If given the wrong drug, the patient could have suffered from chemotherapy’s side effects, such as hair loss and bone marrow suppression.

Not the Right Patient

While hospitalized, an 81-year-old man was ordered the medication, primaquine, which is used to treat Malaria. However, he had no suspected signs of the disease. The drug was likely meant for another patient. MedAware alerted the staff that the medication did not match the patient profile and the order was canceled.

If given, the patient could have unnecessarily suffered from adverse reactions to primaquine, such as skin irritation, vomiting, and abnormal heart rate.

Tuberculosis Drug for Minor Infection

An 82-year-old woman had a minor bacterial infection that should have been treated with Zinnat (cefuroxime). Instead, the woman was accidentally prescribed a similarly named medication, Zinamide (pyrazinamide), a very potent drug used to treat Tuberculosis. MedAware identified the error and the order was corrected before administration.

If given as ordered, the patient could have suffered from liver damage, as well as from her ongoing untreated infection.

Sound alike, not alike

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.

Preventing Opioid Overdose

A doctor mistakenly prescribed a patient 600 mg per day of the opioid, tramadol, at discharge. However, the maximum daily dose of tramadol is 400 mg. MedAware immediately alerted the physician to the dosing error in this opioid-naive patient and the prescription was changed accordingly.

If given as initially prescribed, the patient would have been at increased risk of opioid overdose.