Real examples of medication errors missed by traditional systems, identified by MedAware.
Antipsychotics for Hypertension
While hospitalized, an 85-year-old man was meant to receive Tritace (ramipril) to help manage his high blood pressure. Instead, he was prescribed a similarly named drug, Taroctyl (chlorpromazine), which is an antipsychotic. Recognizing the inconsistency with the patient’s clinical profile, MedAware identified and alerted the care team of the error and the order was canceled.
If given, the patient would have been exposed to adverse effects of antipsychotic drugs, such as seizures and sedation, while still suffering from hypertension and its consequences.
Opioid for Dematitis
While hospitalized a 3-year-old boy was meant to receive the medication, methotrexate, for his chronic atopic dermatitis. Instead, the physician mistakenly prescribed the opioid, methadone. MedAware identified the mistake and the physician promptly canceled the order.
If given, the child may have suffered from dangerous adverse effects of opioids, including respiratory depression and coma.
Fentanyl: IV or Patch?
A 68-year-old man with metastatic lung cancer was treated in the emergency room for shortness of breath and back pain. The physician meant to prescribe a fentanyl dermal patch to relieve his pain. Mistakenly, the patient was prescribed intravenous fentanyl, which is used for sedation. MedAware identified the mistake and the order was promptly canceled.
If given to non-ventilated patients, intravenous fentanyl may cause severe respiratory depression and even death.
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.
Preventing Blood Loss
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.