Medication Safety>Error Prevention Practice Test

In the emergency department, a new nurse retrieves medication from the automated dispensing cabinet (ADC) after a physician orders IV hydralazine for acute hypertension. Hydralazine 20 mg/mL vials and hydroxyzine 25 mg tablets are stocked on adjacent shelves with similar green labels. During a busy shift with frequent interruptions, the nurse nearly selects hydroxyzine from the ADC screen because both drug names look alike. The pharmacy manager reviews near-miss reports and notes multiple confusion incidents between hydralazine and hydroxyzine on the unit, including in the EHR pick lists and ADC bins. The department uses barcode scanning inconsistently and has limited space for storage. The leadership team asks the pharmacist to recommend a practical, system-level change to reduce the risk of this specific look-alike/sound-alike mix-up.

During a busy evening in the ED, a physician enters a STAT order for hydralazine IV for a hypertensive emergency. In the automated dispensing cabinet, hydralazine vials are stocked on the same shelf as hydroxyzine vials; both products are similar in size and teal labeling. Nurses report several recent near-misses where hydroxyzine was pulled for hydralazine, especially when the barcode label was wrinkled or unreadable, prompting overrides. In the EHR, both names appear adjacent in the drop-down list, and the labels print in all lowercase. The pharmacy manager is reviewing options to reduce risk without delaying access during emergencies. Leadership asks the pharmacist to recommend a practical, system-level change that addresses this look-alike, sound-alike vulnerability.