Prescribing errors
Mrs C was diagnosed with pruritus by Dr. P who was at the end of a busy shift. He intended to prescribe the antihistamine hydroxyzine 25mg twice daily but in error, prescribed hydralazine 25mg twice daily.
What could be the potential consequence of this?
What type of active failure is this?
How could this have been prevented?
Case study
Mrs C’s pruritus would not be treated and she may suffer side effects such as dizziness from the hydralazine - a vasodilator.
This is a slip and probably occurred because the medicines sound similar and are used in the same dose.
This could potentially have been prevented by a second check for example by the pharmacist.
Copyright eBook 2019, University of Leeds, Leeds Institute of Medical Education.