A hospital software system has been blamed for a fatal anticoagulant double-dosing error after it displayed a prescribing icon so small that it could not be seen on a standard computer screen. 

In 2019, Ian Fraser was admitted to the Sunshine Hospital in Melbourne with an exacerbation of his congestive cardiac failure as well as community-acquired pneumonia.

He had a complex medical history ranging from rheumatoid arthritis and COPD to hypertension, AF and osteoporotic spinal crush fractures, with the result that he was on 14 different regular medications, including anticoagulants.

The 68-year-old eventually underwent a pleural tap. His condition improved slightly and he was restarted on enoxaparin.