Inadvertent dispensing of Coumadin instead of Coversyl

Alexander M Owen and Sara L Hungerford
Med J Aust 2014; 200 (4): . || doi: 10.5694/mja13.00246
Published online: 3 March 2014

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.

  • Alexander M Owen1
  • Sara L Hungerford2

  • 1 Department of Obstetrics and Gynaecology, Liverpool Hospital, Sydney, NSW.
  • 2 Department of Cardiology, St Vincent’s Hospital, Sydney, NSW.


Competing interests:

No relevant disclosures.


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