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The patient was diagnosed with Deep Vein Thrombosis at the Emergency Department and started on rivaroxaban, although the patient was already taking edoxaban. This therapeutic duplication was noticed only one week later, even though she was already experiencing significant bleeding managed through a prescribing cascade. Despite the technical error (action-based), it is possible to identify several weaknesses in the organisation\u2019s structure, which provided a trajectory of accident opportunity.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>CONCLUSION:<\/jats:title>\n            <jats:p>Anticoagulants are ranked first for the highest priority to receive a medication reconciliation. To achieve an optimal level of medication reconciliation, we ought to recognise and correct latent failures.<\/jats:p>\n          <\/jats:sec>","DOI":"10.3233\/jrs-230002","type":"journal-article","created":{"date-parts":[[2023,9,15]],"date-time":"2023-09-15T15:22:26Z","timestamp":1694791346000},"page":"19-24","update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":1,"title":["A medication reconciliation failure: A case report and incident analysis"],"prefix":"10.1177","volume":"35","author":[{"given":"R.","family":"Ascen\u00e7\u00e3o","sequence":"first","affiliation":[{"name":"Laborat\u00f3rio de Farmacologia Cl\u00ednica e Terap\u00eautica, Faculdade de Medicina da Universidade de Lisboa,  Lisbon, Portugal"}]},{"given":"P.","family":"Lopes Vaz","sequence":"additional","affiliation":[{"name":"USF Viriato - ACeS D\u00e3o Laf\u00f5es, Administra\u00e7\u00e3o Regional de Sa\u00fade Centro,  Viseu, Portugal"}]},{"given":"C.","family":"Pereira Gomes","sequence":"additional","affiliation":[{"name":"USF Terras de Azurara - ACeS D\u00e3o Laf\u00f5es, Administra\u00e7\u00e3o Regional de Sa\u00fade Centro,  Mangualde, Portugal"}]},{"given":"J.","family":"Costa","sequence":"additional","affiliation":[{"name":"Laborat\u00f3rio de Farmacologia Cl\u00ednica e Terap\u00eautica, Faculdade de Medicina da Universidade de Lisboa,  Lisbon, Portugal"}]},{"given":"P.","family":"Broeiro-Gon\u00e7alves","sequence":"additional","affiliation":[{"name":"Escola de Sa\u00fade e Desenvolvimento Humano, Universidade de \u00c9vora,  \u00c9vora, Portugal"},{"name":"UCSP dos Olivais - ACeS Lisboa Central, Administra\u00e7\u00e3o Regional de Sa\u00fade de Lisboa e Vale do Tejo,  Lisbon, Portugal"},{"name":"NOVA Medical School, Universidade Nova de Lisboa,  Lisbon, Portugal"}]}],"member":"179","published-online":{"date-parts":[[2024,2]]},"reference":[{"key":"e_1_3_6_2_2","doi-asserted-by":"publisher","DOI":"10.1007\/s40264-020-00918-3"},{"issue":"4","key":"e_1_3_6_3_2","first-page":"230","article-title":"Using medication reconciliation to prevent errors","volume":"32","year":"2006","unstructured":"Using medication reconciliation to prevent errors. 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