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A recent report by the Institute for Safe Medication Practices (ISMP) notes that some health professionals and patients may not realize that Jantoven is a brand name for the drug warfarin. That could result in inadvertently prescribing and dispensing two warfarin-containing medications for the same patient. ISMP cites the case of a patient who had been taking warfarin at home and continued the drug while in the hospital. On discharge, the physician instructed that the patient continue warfarin at home, and he wrote a new warfarin prescription. The community pharmacy dispensed Jantoven without discussing the nature of the drug with the patient or asking whether the patient was already taking warfarin. The patient, not realizing that the newly prescribed drug was warfarin by another name, took both medications, and that resulted in a severely elevated INR. ISMP suggests several ways to avoid these kinds of errors, including: • If a brand name warfarin is prescribed, show both the brand name and the generic name on the prescription label. • When dispensing the prescription, discuss the nature of the drug with the patient to be sure that he or she is not already taking another warfarin-containing drug. • When patients are discharged from the hospital, counsel them about the prescriptions they are receiving and what each of them is for.