To the Editor: We note a similar experience to that described in Carradice and Maxwell’s report of coagulopathy caused by inadvertent substitution of Coumadin for Coversyl.1 A patient aged over 80 years was found to have an international normalised ratio of greater than 9 after ingesting warfarin instead of perindopril in 2011: a consequence of a pharmacy labelling error identical to that described by Carradice and Maxwell.
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- 1. Carradice DP, Maxwell EL. Inadvertent dispensing of Coumadin instead of Coversyl. Med J Aust 2013; 199: 750. <MJA full text>
- 2. Anto B, Barlow D, Oborne CA, Whittlesea C. Incorrect drug selection at the point of dispensing: a study of potential predisposing factors. Int J Pharm Pract 2011; 19: 51-60.
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