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hydrOXYzene and hydrALAzine Mix-Ups
PA PSRS Patient Saf Advis 2006 Jun;3(2):21. 
 

The December 2004 Advisory article “Medication Errors Linked to Drug Name Confusion” noted that mix-ups due to look-alike and sound-alike drug names had been reported in Pennsylvania facilities, and these types of errors continue to happen.

One look-alike and sound-alike pair that continues to be problematic is hydroxyzine and hydralazine (see Figures 1 and 2). Because the first four letters of their names are identical, they are frequently stored next to one another on pharmacy shelves and listed adjacently on computer screens. Their similar dosage strengths (10, 25, 50 and 100 mg) and tablet dosage forms also contribute to confusion.

Figure 1. Package Labels WITHOUT Tall Man Lettering.

  Figure 1. Package Labels WITHOUT Tall Man Lettering

 

 

 

Figure 2. Package Labels WITH Tall Man Lettering.

  Figure 2. Package Labels WITH Tall Man Lettering

 

 

 

If your institution stocks these drugs, relying on people to read labels does not prevent errors. People may believe that they have read the label, but other factors beyond their control may mislead them. Instead, change the appearance of look-alike product names on computer screens, pharmacy and nursing unit shelf labels and bins (including automated dispensing cabinets), pharmacy product labels, and medication administration records. You can differentiate these drug names by using boldface, color, and/or “tall man” letters, to help emphasize the parts of the names that are different (e.g., hydrOXYzine, hydrALAzine). The accompanying pictures illustrate this technique.
 
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hydrOXYzene and hydrALAzine Mix-Ups



THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS  
PSA LOGO The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s Web site at www.patientsafetyauthority.org .      
ECRI LOGO ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for more than 40 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology.      

ISMP Logo The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions.      
 
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