Denver—In a situation recently reported to the Institute for Safe Medication Practices, a patient hospitalized for atrial flutter was started on 20 mg daily of rivaroxaban, with the intention to switch to apixaban after the first 30 days. However, both prescriptions were written at the same time, and the patient mistakenly took both for several days before presenting with a gastrointestinal bleed.
This is just one of more than 2,000 events submitted to ISMP’s national