Hydralazine, meet hydroxyzine

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

#lasa

Specialist input

No specialist has been asked about this case yet.

Discussion

No replies yet. Say what you'd have done.

Similar cases

Nothing similar yet — check back as more cases are posted.