Medical software blamed for fatal anticoagulant double-dosing error

Hospital doctors relying on the Cerner system accidentally prescribed an additional dose of apixaban

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,