SAFETY LEARNING STORY # 1 (Duplication of Medication)


  • What Happened?


A patient was prescribed Warfarin but just before being discharged from the Hospital, his doctors changed the type of medication from Warfarin to RIVAROXABN (XARELTO®).

A few months later, the patient presented to the department of emergency with the son requesting for Warfarin refill. After one week, the patient had a surgery clinic appointment where the son requested for RIVAROXABN (XARELTO®) refill.

The patient presented to the department of emergency after one month with gastrointestinal bleeding and high (International Normalization Ratio (INR) was 11) and the patient was admitted to the Intensive Care Unit. The patient was taking RIVAROXABN (XARELTO®) while she was already on Warfarin. This combination led to severe Drug-Drug interaction.


What can patient and family do to prevent this from happening again?

  • Keep your medications record up-to-date

  • Remember to include:

    • Drug allergies
    • Vitamins and minerals
    • Herbal/natural products
    • All medications including non-prescription products
  • Ask your doctor, nurse or pharmacist to review all your medications to see if any can be stopped or reduced.

  • 5 Questions to Ask about Your Medications when you see your doctor, nurse, or pharmacist:

  1. Changes

    • Have any medications been added,stopped or changed, and why?
  2. Continue?

    • What medications do i need to keep taking, and why?
  3. Proper use?

    • How do i take my medication, and for how long?
  4. Monitor?

    • How will i know if medication is working, and what side effects do i watch for?
  5. Follow-up?

    • Do i need any tests and when do i book my next visit?