CASE-0013 · Pharmacy · Saudi Arabia
EvolvingHydralazine, meet hydroxyzine
Faisal AljemaiahverifiedSign in to follow this case.
A look-alike/sound-alike order almost sent an antihypertensive to a patient who needed itch relief. A quick verification call caught it.
Presentation
An adult outpatient was picked up at the window with a new oral order. The written order read "hydralazine 25 mg PO," but the accompanying diagnosis on the prescription referenced pruritus and an allergic skin reaction. No cardiovascular indication was documented anywhere on the order.
What was tricky
Hydralazine (a vasodilator antihypertensive) and hydroxyzine (an antihistamine used for pruritus and anxiety) are a classic look-alike/sound-alike pair. The strength "25 mg" is a valid tablet size for both, so the number offered no red flag. Dispensing hydralazine to a patient who needed antihistamine could have caused hypotension, reflex tachycardia, and left the actual symptom untreated.
What we did
- Confirmed the order against the indication
- Called the prescriber to verify intent
- Corrected the order to hydroxyzine 25 mg PO
- Documented the intervention as a look-alike/sound-alike near-miss
- Counseled the patient on sedation and to avoid alcohol
The lesson
When the drug name and the documented indication don't match, treat the mismatch as the alarm — not the dose. LASA errors are caught by cross-checking indication, not by trusting a plausible strength.
How this case unfolded
Initial presentation
Order corrected
Prescriber confirmed the intended drug was hydroxyzine for pruritus, not hydralazine. The order was amended to hydroxyzine 25 mg PO, the patient was counseled on sedation and alcohol avoidance, and the event was logged as a look-alike/sound-alike near-miss. The catch came from the name–indication mismatch, not the dose — the 25 mg strength was plausible for either drug and would not have flagged on its own.
Aug 22
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