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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