Mepergan fortis. Memorable Pharmacy Errors: Lessons from Retail Pharmacist Experiences
What are some notable medication dispensing errors made by retail pharmacists. How can pharmacists prevent dangerous medication mix-ups and improve patient safety. What consequences can result from pharmacy dispensing mistakes.
The Mepergan Fortis and Cephalexin Mix-Up
One of the most alarming pharmacy errors involves the accidental dispensing of Mepergan Fortis instead of cephalexin. Both medications come in dark red capsules, making them visually similar. However, their effects are drastically different:
- Mepergan Fortis: A powerful narcotic pain reliever containing meperidine and promethazine
- Cephalexin: An antibiotic used to treat bacterial infections
This mix-up could have severe consequences for the patient. The pharmacist who made this error immediately sent her husband to retrieve the incorrectly dispensed medication from the customer’s home, emphasizing the urgency of the situation with frantic cries of “GO GET IT! GO GET IT!”
Why is this error so dangerous?
Dispensing a potent narcotic instead of an antibiotic poses significant risks:
- Untreated infection: The patient’s bacterial infection would go untreated without the intended antibiotic.
- Opioid exposure: An opioid-naive patient could experience severe side effects or overdose from the unexpected narcotic.
- Drug interactions: Mepergan Fortis could dangerously interact with other medications the patient may be taking.
- Addiction risk: Even short-term exposure to opioids can potentially lead to dependence in some individuals.
The Carbamazepine and Theophylline Confusion
Another concerning incident involved dispensing carbamazepine instead of theophylline. This error resulted in a patient’s asthma being out of control for a week, prompting an angry doctor’s call to the pharmacy.
Key differences between these medications:
- Carbamazepine: An anticonvulsant used to treat seizures and certain types of pain
- Theophylline: A bronchodilator used to treat asthma and other respiratory conditions
While the patient wasn’t in immediate danger, the error significantly impacted their quality of life and asthma management. This case ultimately resulted in a lawsuit against the responsible pharmacist.
Legal and Professional Consequences of Pharmacy Errors
Medication errors can have serious repercussions for pharmacists, including:
- Lawsuits and potential financial liability
- Disciplinary action from state boards of pharmacy
- Damage to professional reputation
- Emotional distress and decreased job satisfaction
- Potential for criminal charges in severe cases
The carbamazepine/theophylline case demonstrates how even non-life-threatening errors can lead to legal action. Pharmacists must be prepared to face the consequences of their mistakes and take steps to prevent future occurrences.
Strategies for Preventing Medication Dispensing Errors
To reduce the risk of dangerous medication mix-ups, pharmacists and pharmacy staff can implement several safety measures:
- Double-check system: Have a second pharmacist or technician verify prescriptions before dispensing.
- Barcode scanning: Utilize barcode technology to ensure the correct medication is selected.
- Separate look-alike medications: Store visually similar drugs in different areas to prevent confusion.
- Clear labeling: Use large, easy-to-read labels on medication containers and shelves.
- Patient counseling: Educate patients about their medications to catch potential errors.
- Regular staff training: Conduct ongoing education on medication safety and error prevention.
- Implement computerized physician order entry (CPOE) systems to reduce transcription errors.
How can technology improve medication safety?
Advancements in pharmacy technology can significantly reduce the risk of errors:
- Electronic prescribing systems that eliminate handwriting interpretation issues
- Clinical decision support software that alerts pharmacists to potential drug interactions or contraindications
- Automated dispensing cabinets that improve inventory management and reduce selection errors
- Robotic dispensing systems for high-volume medications
The Importance of Effective Communication in Pharmacy Practice
Both case studies highlight the critical role of communication in managing medication errors and their aftermath. Key aspects include:
- Prompt notification of patients and prescribers when errors are discovered
- Clear, empathetic communication with affected patients
- Professional interactions with healthcare providers, even in tense situations
- Open dialogue within the pharmacy team to address and learn from mistakes
- Thorough documentation of errors and corrective actions taken
How can pharmacists improve their communication skills?
Enhancing communication abilities can help pharmacists navigate challenging situations:
- Practice active listening to fully understand patient and provider concerns
- Develop a calm, professional demeanor when dealing with upset individuals
- Use clear, jargon-free language when explaining medication information to patients
- Participate in role-playing exercises to prepare for difficult conversations
- Seek feedback from colleagues and patients to identify areas for improvement
The Psychological Impact of Medication Errors on Pharmacists
Making a serious medication error can have profound emotional effects on pharmacists:
- Guilt and shame over potentially harming a patient
- Anxiety about future errors and heightened stress levels
- Loss of confidence in professional abilities
- Depression or burnout in severe cases
- Post-traumatic stress symptoms, especially if a patient was seriously harmed
The pharmacist’s emotional reaction in the Mepergan Fortis case, crying while recounting the incident, illustrates the lasting impact these events can have on healthcare professionals.
How can pharmacists cope with the emotional toll of medication errors?
Strategies for managing the psychological impact of errors include:
- Seeking support from colleagues, mentors, or professional counseling services
- Participating in peer support groups for healthcare professionals
- Engaging in stress-reduction techniques like mindfulness or meditation
- Focusing on learning from the mistake to improve future practice
- Maintaining work-life balance to promote overall well-being
Building a Culture of Safety in Pharmacy Practice
Preventing medication errors requires a systemic approach that goes beyond individual vigilance. Key elements of a safety culture in pharmacy include:
- Non-punitive error reporting systems that encourage transparency
- Regular analysis of near-misses and errors to identify trends and improvement opportunities
- Continuous quality improvement initiatives focused on medication safety
- Empowering all staff members to speak up about potential safety issues
- Collaboration with other healthcare providers to improve medication use processes
How can pharmacy leaders foster a safety-focused environment?
To create a culture that prioritizes patient safety, pharmacy managers and owners can:
- Lead by example, openly discussing and learning from their own mistakes
- Implement anonymous reporting systems for errors and near-misses
- Regularly review and update safety protocols based on incident data
- Recognize and reward staff members who identify and prevent potential errors
- Allocate resources for ongoing safety training and technology improvements
The Role of Pharmacy Education in Error Prevention
Preparing future pharmacists to minimize medication errors begins in pharmacy school. Key areas of focus should include:
- In-depth study of look-alike and sound-alike drugs
- Hands-on training with medication dispensing systems and technologies
- Simulated error scenarios to practice problem-solving and communication skills
- Coursework on human factors and error prevention strategies
- Emphasis on the importance of continuing education throughout one’s career
How can pharmacy curricula evolve to better address medication safety?
To enhance medication safety education, pharmacy schools can:
- Integrate safety concepts throughout the curriculum, rather than treating it as a separate topic
- Provide more opportunities for interprofessional education with other healthcare students
- Incorporate real-world case studies of medication errors and their consequences
- Offer advanced electives focused on medication safety and quality improvement
- Partner with healthcare organizations to provide students with practical experience in safety initiatives
By implementing these educational strategies, pharmacy schools can produce graduates who are better equipped to prevent and manage medication errors in their future practice.
The cases of the Mepergan Fortis/cephalexin mix-up and the carbamazepine/theophylline confusion serve as stark reminders of the potential for error in pharmacy practice. These incidents highlight the critical importance of vigilance, effective systems, and ongoing education in preventing dangerous medication mistakes. By learning from these experiences and implementing robust safety measures, pharmacists can work to minimize errors and provide the highest quality care to their patients.
As the pharmacy profession continues to evolve, maintaining a focus on medication safety will be crucial. Embracing new technologies, fostering open communication, and cultivating a culture of continuous improvement will help ensure that pharmacists remain at the forefront of safe and effective medication use. By working together and learning from past mistakes, the pharmacy community can strive to eliminate preventable errors and enhance patient outcomes.
Memorable misfills of a retail pharmacist
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000″>Apr 16, 2007
Every pharmacist has his own horror stories that are seared into his brain. Here are some that stand out in my mind.
1. Mepergan Fortis/cephalexin: A pharmacist told me this story. She discovered that she had dispensed Mepergan Fortis (meperidine/promethazine, Wyeth) (a powerful narcotic pain reliever) instead of cephalexin 500 mg (an antibiotic). It’s easy to see how this error occurred. Both are dark red capsules. She called her husband and told him to go to the customer’s house to retrieve the Mepergan Fortis. She cried into the phone to her husband: “GO GET IT! GO GET IT!” Her voice broke as she told me the story.
5. Carbamazepine/theophylline: A local doctor told me that one of his patients was in his office “and he’s dying.” The doctor proceeded to tell me that we had dispensed carbamazepine (which treats seizures) rather than theophylline (which treats asthma). We had dispensed the drugs in the manufacturer’s original container, so the doctor knew the contents from the exposed label. After I listened to the doctor’s tirade, I asked, “Are you serious that he’s dying?” The doctor said, “No, but he’s pretty damned mad. His asthma has been out of control for a week.” I finally asked the doctor the question that was uppermost on my mind: “Which pharmacist’s name is on the bottle?” It turned out to be my partner’s name. I told the doctor that I was not responsible for the error, so he backed off. I found out later that my partner was indeed sued.
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Opiate Odyssey: Experiences of a Painkiller Addict
Without question, opioid drugs represent one of the most important, celebrated conquests of medicine due to their tremendous effectiveness at relieving pain. First, we found and isolated natural opioids like morphine and codeine; and since the 1950s, several synthetic opioids have been introduced, including popular pain-killing drugs like hydrocodone (the active component of Vicodin®), oxycodone (Percocet®, OxyContin®), pethidine (Demerol®), fentanyl (Durogesic®), and others. On the flip side, the veritable cornucopia of opiates has led to an exponential rise in the abuse of prescription painkillers along with a corresponding torrent of overdose deaths. In fact, the current trend of opiate abuse, dependence, and addiction is nothing short of an epidemic in the United States and elsewhere. Equally lamentable is the fact that, once dependent or addicted, getting off of opiates is notoriously difficult. As a result, many opiate addicts end up on extended opioid maintenance rather than getting clean, essentially trading one drug addiction for another. This was my experience for almost six years; more on that later. As is surely the case with countless others, my own opiate odyssey began as a teen after my wisdom teeth were removed. At least, that’s the first time I can presently recall taking more pain medication than prescribed and thoroughly enjoying the experience. (Actually, that characterization barely begins to describe my early affection for opiates, which the addict in me felt sure represented the elixir for all my ills, from fear & inhibition to depression & sloth.
) I can still remember the dark red Mepergan Fortis capsules I was prescribed by the dentist. Little did I know, my poppy pilgrimage would carry on for decades and end in misery with an extended, miserable buprenorphine weaning. I soon began a very specific, all-too-common type of theiving: I became a surreptitious, stealthy, often bold raider of any medicine cabinet I could gain access to as guest in the homes of family and friends. I began to look forward to visiting certain homes whose medicine cabinets I had successfully raided in the past, including those of aunts & uncles, both sets of grandparents, and my one-time fiancee. When my dear grandfather passed away, I recall having to be particularly cautious and sly to pocket the stash of painkillers he no longer needed. To my dismay (though I did not worry about it too much at the time), that opiate theft was blamed by some on an aunt of mine who was a nurse. This regrettable action eventually evolved into a gnawing guilt in spite my decreasingly vocal conscience.
What began as recreational use of opiates quickly became an integral part of my life. I felt self-medicating was justified in order to (1) assuage the symptoms of major depressive disorder, (2) drive away my social inhibitions, (3) reduce my medical expenses by skipping the doctor visits, and (4) most importantly, bring about that euphoric, seemingly insuppressible good mood. This was particularly true during my online pharmacy phase, during which I discovered many pharmacies across the globe which were more than happy to have another paying customer for prescription drugs of virtually any variety.
Some years before, I had become a fan of grey-market, controversial books from publishers like Paladin Press and Loompanics: books on subjects like growing mushrooms, creating new identities, moving abroad, concealing drugs, and what was now one of my favorite subjects and activities: using the global network of dropshipping online pharmacies. I eventually accumulated quite a collection of such books and catalogs. I knew my name and address must have been making it onto various law enforcement watchlists; however, I was certain they’d spend their time on more serious activity. All I am really doing, my flawed reasoning told me at the time, is saving money through DIY diagnosing, prescribing, and medicating. It’s all good!
I was quickly reminded that mixing opiate-based prescription drugs with some of my other favorite mood-adjusters was far more enjoyable than limiting myself to the played-out combination of opiates and alcohol. With a mixture of opioids, amphetamines (usually methylphenidate), benzos (alprazolam, diazepam, clonazepam), and muscle relaxers (chiefly Soma®) I could achieve a state of bliss in which I felt virtually unstoppable. What had been introversion changed to a more enjoyable extroversion; where I had been fearful of calling web development prospects to close sales, I became confident and skillful; what had been depressive lethargy and sloth were transformed into vibrant enthusiasm for all sorts of work and research on web development, search engine optimization, and other subjects that interested me.
But opiates are a short-lived fix. The ongoing use of opiates to achieve the desired attitude adjustment is ultimately an unsustainable solution; I proved this to myself repeatedly and with great pain. Over time, chasing the ephemeral effects of opiates caused more problems than I had before I started taking them. As mentioned elsewhere, I had already been exposed to Alcoholics Anonymous, attended countless AA meetings, and performed much Twelve-Step work. However, I still harbored many reservations to the effect, “Although I have much in common with realaddicts and alcoholics, I am not one of them… not completely, at least. The Twelve-Step thing simply does not work for me; I can stop drinking before getting drunk, and I can taper off prescription drugs when I truly want to.”
For example, I rarely drank enough to cause such unpleasantness as the dreaded, miserable hangover. I despised hangovers. I could and would usually stop drinking when I reached a certain level; I wasn’t one of those who kept drinking until oblivion. Similarly, I came to believe I could manage my prescription drug use by popping pills in my favorite combinations and then weaning myself off for a couple of weeks now and then.
My benzo addiction & opiate addiction management procedures became a regular part of life as the online pharmacy era progressed. I would:
- Order a continual stream of prescription drugs, staggered in time and variety, from my list of trusted online pharmacies
- Engage in mood management first thing in the morning & as needed throughout the day; create what I then thought were ideal conditions for 36-hour shifts of web work
- Collect money from clients or by obtaining a fresh credit card in order to keep the flow of pills arriving in my Marietta, GA mailbox
- Wean myself off the benzos and painkillers for a couple of weeks when my drug supply got low for whatever reason (e.g., purposely scaling back, running low on funds, gain too much drug tolerance,, etc.
), as I convalesced in my bedroom sipping vodka and watching Sanford & Son, science documentaries, & movies
- Begin the process all over again, fending off concerns of my girlfriend, family, friends, AA members, web clients, and other concerned parties in the meantime
Toward the end of this phase, I weighed around 125 pounds and was told I did not look as fit, trim, and healthy as I did in my mind’s eye. Friends (some of them in recovery) insisted I stop self-medicating; so, with others present, I flushed large quantities of pills down the toilet (again), keeping only enough for me to wean myself off of the opiates and benzos for what I thought was one last time (again).
The depression soon returned in full force, what with my largely untreated addiction and alcoholism, depressive tendencies, low self-esteem, and guilt-ridden conscience. I worked less and less, eventually ignoring most of my commitments; I acceded to my depression, allowing it take over my psyche yet again. I spent increasing amounts of time in bed isolating, not answering the phone, staring at the idiot box, and bearing the relentless insomnia. I was soon unable to continue living in the Atlanta-area apartment I shared with another addict; I admitted defeat and moved into my parents’ home in Nashville, where I went through the motions of yet another attempt at recovery.After a few months of bouncing in and out of the rooms of Alcoholics Anonymous and drinking/ using here and there, a longtime friend recommended I start taking Suboxone. I had procured a few Suboxone tablets and really enjoyed the minimalist buzz, the general feeling of well-being I got from the buprenorphine, as long as I allowed a few days between doses. I saw a highly recommended addictionologist at Vanderbilt University Medical Center and entered their ridiculously expensive Suboxone program which required regular visits, drug testing, and weekly group sessions. These were the last days of my Blue Cross/Blue Shield medical insurance; out of necessity, I soon began seeing another, more reasonably priced psychiatrist for my Suboxone.
Soon, Adderall was added to the regimen… this time, via a legitimate prescription. This went on for almost six years. I viewed Suboxone as my savior — a real miracle drug — for the better part of those years. (My long, drawn-out experience with buprenorphine will be detailed in an upcoming post.) During the last phase of my active alcoholism and drug addiction (from 2009 to early 2013), I began to yearn for more substantial opioid escapes from reality — and frequently, from life itself. Had I not been penniless and socially isolated, I would probably would’ve given heroin a shot. I wanted to try snorting or smoking heroin at first, and if it did for me what I believed it would, I have no doubt I’d have gone the intravenous route. But I did not know anyone from whom I could procure what I suspected would prove to be my panacea: the final cure-all for the unbearable “issues” by which I felt hopelessly trapped. As it happened, I had become such a hermit — a slothful misanthrope who fancied himself an ascetic — that I never did undertake any such criminal activity as breaking into cars and homes for money or drugs.
Even if I had, I may not have gone looking for heroin; perhaps I’d have contented myself with whatever benzos and painkillers I could steal along with more & better vodka from Bud’s Liquors in Green Hills. But none of that mattered; I was powerless over drugs and alcohol and ended up in drug rehab yet again.
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Fortis – equipment for rehabilitation
Medical rehabilitation is carried out on the basis of past illnesses or for the treatment of chronic pathologies. The complex of measures is designed to restore the physiological functions of the human body, return the patient to a full life, social and labor. In the totality of procedures of a different nature, much attention is paid to physiotherapy and physiotherapy exercises, which are carried out with the help of special technical devices – rehabilitation equipment.
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Offer to purchase:
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- Trainers
In the development of all devices, the achievements of scientific and technological progress are introduced. Devices are used outside the acute phase of pathology for regular effects on the body or individual systems. The high efficiency of the use of equipment for the purpose of habilitation, that is, to control the quality of physical activity, to teach the correct operation of the “mental tension / relaxation” systems (alpha, beta training), and to increase the adaptive capabilities of the body, has been proven. Equipment for rehabilitation and physiotherapy is used to prevent diseases, treat chronic disorders, accelerate recovery after surgery, injuries.
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In order not to make a mistake in choosing rehabilitation equipment for the home and buy the right option, you need to consult a rehabilitation doctor or our specialists. December 03, 2018
From December 3 to December 7, 2018 in Moscow, at the Expocentre Central Exhibition Complex, the international scientific and practical Forum “Russian Health Care Week” will be held – the largest exhibition and congress event in Russia in the field of healthcare, the country’s largest review of achievements in scientific and practical medicine. The central event of the forum is the 28th international exhibition “Healthcare-2018”.
October 04, 2018
VIII International Scientific and Practical Conference “Kaishibaev Readings”, dedicated to the 10th anniversary of the NGO “League of Neurologists – Scientific and Practical Center “Institute of Neurology named after Smagul Kaishibaev”
Dear colleagues! We invite you to visit V III International Scientific practical conference “Kaishibaev Readings”, which will be held on October 4, 5, 2018 in the Reception House at the address: Almaty, Kurmangazy st., 44.
FORTIS | Participant of the Skolkovo project
LIMITED LIABILITY COMPANY “FORTIS”
Primary activity (OKVED)
62.01 –
Development of computer software
About the company
The company “Fortis” (part of the MONOPOLY Group) develops scalable logistics services for the market of moving goods by road. The main product of the company is the high-tech web platform Monopoly. online, which hosts services for solving transport logistics problems. The company strives to solve the problem of digital disruption of the logistics industry, build a real holistic ecosystem for transport companies, retailers and manufacturers of goods, implement a full-fledged sharing economy and aggregation of resources participating in the industry. To solve these problems, the company has united in one place the best IT specialists of the country with relevant competencies and extensive experience in building an effective transport business for the MONOPOLY company. The company employs 167 employees. General Director: Mikhailova Ekaterina Vladimirovna. Founders: Monopoly JSC (
The company operates in the regions
St. Petersburg
Company maturity assessment
6
CRL (company readiness level)
8
IRL (investment readiness level)
Main activity (OKVED)
62.01 –
Computer software development
Projects
Business model
Business to Business to Consumer (B2B2C) Business to Business (B2B)
Project maturity assessment
9
TRL (Technology readiness level)
9
MRL (Market readiness level)
9 0002 Description of the project
ensuring the process of cargo transportation.
The solution is a digital platform that combines all the services necessary for organizing cargo transportation, from cargo search to cardless fuel processing and services from a network of proven road complexes throughout Russia.
The main functionality has been implemented: searching for cargo, paying for fuel and services of road complexes, receiving payments for transportation.
The immediate goals are to close the entire customer path of the cargo carrier into an ecosystem of products.
Products
Product Description
Multiservice
MONOPOLY.MULTISERVICE
MONOPOLY.Multiservice
Monocard
Register of Russian programs for electronic computers and databases
https://reestr.digital.gov.ru/reestr/1445121/
URL of the copyright holder’s website with information
https://multiservice99.monopoly.su /
Product type
Software
Product description
The digital logistics platform monopoly. online combines the services necessary for the organization of cargo transportation: search for cargo and carriers, payment for fuel and roadside services. The platform is designed for the efficient organization of cargo transportation, at the moment the platform provides the possibility of agreeing on an application for the transportation of goods, creating a convenient route for cargo transportation, searching for cargo taking into account the needs of the cargo carrier, and more.
Product maturity assessment
8
TRL (Technology readiness level)
9
MRL (Market readiness level)
Project team
262 people
Revenue
368 112 000 ₽
Volume of attracted investments
425 800 000 ₽
Rates growth
2022 | 2021 | 2020 | ||
---|---|---|---|---|
Revenue | 368 112,000 ₽+12% 9Net profit 9018 7 | -179 549 000 ₽-25% | -143 862 000 ₽+15% | -170 015 000 ₽ |
Number | 262 +25% | 210 +26% | 167 | |
Intellectual property | 0 0% | 0 0% | 0 |
Contact now
Analytics
0002 Financial indicators
Balance sheet
Taxes
Headcount
Intellectual property
2023 | |
Certificate of state registration of the computer program 2023610744 MONOPOLY. |
2018 | |
Certificate of state registration of the computer program 2018617451 90 002 “CARGO. VERSION 1.2″ | |
Certificate of state registration of the computer program 2018617448 “REGULATORY BUS. VERSION 1.1” | |
Certificate of state registration of the computer program 2018617406 “ROUTING UNIT. VERSION 1.0” | |
Certificate of state registration of the computer program 2018617447 “SERVICE BUS. VERSION 1.1″ | |
Certificate of state registration of the computer program 2018617450 “TARIFF CALCULATOR. VERSION 1.0” | |
Certificate of state registration of the computer program 2018617377 “INTEGRATION BLOCK. VERSION 1.1” | |
Certificate of state registration of the computer program 2018618163 “WEB PORTAL MANAGEMENT PROGRAM FOR RESOURCE OWNERS. | |
Certificate of state registration of the computer program 2018617376 “TASK CONSTRUCTOR. VERSION 1.0” | |
Certificate of state registration of the computer program 2018617449 “TICKET-SYSTEM. VERSION 1.0” | |
Certificate of state registration of the computer program 2018618033 “PROGRAM FOR MANAGEMENT OF THE WEB PORTAL OF THE TRANSPORT COMPANY. VERSION 1.4″ |
2017 | |
Certificate of state registration of the computer program 201761478 5 MONOCARD VERSION 1.0 |
Company Information
Founders
JOINT STOCK COMPANY “MONOPOLIA”
100%
MONOPOLY
0%
Share capital
10,000 ₽
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RailCommerce
IT LOGARITM
TMS Logarithm – a logistics platform for the selection, planning and dispatching of freight transport
POINT-TO-POINT
Digital platform for the distribution of palletized cargo among carriers on the principles of sharing and free competition using AI technologies and the IoT concept
9 0411 IIT
4TRUCK – fuel card processing system
Promtech
SMARTTRAY
AgroGo
Energotech
O24
OPERATOR24
WEB LOGISTICS
Deliver 2.0 – innovative electronic forwarder, commercially successful freight forwarder “uber”
Energotech
TEUSTAT
Development of the TEUSTAT online portal – an aggregator of information on the infrastructure and logistics of container transportation and a platform for direct communication between market participants
Promtech
LOGISTAT
Logistat
Promtech
KINTSUGI PRO
IT platform for automating the processes of interaction between insurers and policyholders using telecommunication network technologies, blockchain, AI and Big Data .