Coumadin is a high risk medication as I mentioned in one of the previous night’s posts. I have the opportunity to frequently review medication errors at dozens of healthcare facilities. Coumadin is a tricky drug to dose and because of this, can sometimes require odd dosing schedules. I’ve seen dosing all over the place where someone may get 5 mg 2 days per week, and 2.5 mg the rest of the week or 5 mg one day a week, and 2.5 mg 6 days a week. Common sense tells us that the more complex and less routine the dosing regimen is, the more likely it is that an error will occur. It doesn’t always work this way, but it would certainly be ideal to do a consistent daily dose to minimize risk of confusing orders etc.