| Course | NR 293 Pharmacology for Nursing Practice |
|---|---|
| Week | 4 |
| Paper type | Medication safety analysis |
| Length | About 1,160 words, 3 pages |
| Format | APA 7 student paper |
| School | Chamberlain University |
| Program | BSN (pre-licensure) |
| Updated | October 2026 |
Free sample paper for NR 293 Week 4
Medication Safety Analysis: Hydroxyzine Given for Hydralazine at 2210 After a Scanner Failed, With Every Check on the Timeline Marked
Student Name
College of Nursing, Chamberlain University
NR 293: Pharmacology for Nursing Practice
Instructor Name
Month Day, Year
Medication Safety Analysis: Hydroxyzine Given for Hydralazine at 2210 After a Scanner Failed, With Every Check on the Timeline Marked
The Event, Told Flatly
On a medical unit, a 67-year-old man with a blood pressure of 188/102 was ordered hydralazine 25 mg by mouth once at 2200. At 2210 he received hydroxyzine 25 mg by mouth instead. His blood pressure at 2310 was 184/100. At 0005 he was difficult to wake, and his nurse asked the pharmacist to review his medicines. The pharmacist identified the substitution at 0020. The provider was notified, hydralazine was given at 0035, and his blood pressure fell to 158/90 by 0200. He became more alert over the next several hours and had no lasting harm. He and his wife were told what had happened the next morning. Details are composite.
The analysis below does not assign blame. It looks at the process that allowed the error and the properties of the two drugs that made it likely.
A Timeline With the Checks Marked
Table 1 sets out the steps in the process, with each verification point marked as performed, partial or skipped.
Table 1
Timeline of the Event With Verification Points
| Time | Step | Check |
|---|---|---|
| 2155 | Order entered by the provider: hydralazine 25 mg PO once | Performed: pharmacist verified the order in the electronic record |
| 2200 | Nurse selects the patient in the automated dispensing cabinet and the drug from the profile | Partial: the profile listed hydralazine; the drawer that opened held two adjacent pockets |
| 2202 | Nurse removes a tablet from the pocket labeled hydroxyzine | Skipped: label on the package not compared with the order at the cabinet |
| 2208 | At the bedside, nurse scans the patient's wristband | Performed |
| 2208 | Nurse attempts to scan the tablet's barcode; the handheld scanner fails to read | Skipped: nurse overrides the scan, selecting "barcode unreadable" |
| 2209 | Nurse compares the medication with the electronic record visually | Partial: names read quickly; both begin with "hydr" and end in "-zine" |
| 2210 | Medication given | No further check at this step |
| 2310 | Blood pressure rechecked: 184/100 | Performed; no response recognized as unexpected |
| 0005 to 0020 | Patient drowsy; pharmacist reviews and identifies the substitution | Performed |
Note. "Partial" means a check was started but did not compare the drug in hand with the order.
Properties, Not Personalities
Several properties of the drugs and the system made this error likely. The first is the names. Hydralazine and hydroxyzine look and sound alike: both begin with "hydr," both have three syllables after it, and both are commonly ordered as 25 mg oral tablets. The U.S. Food and Drug Administration includes the pair in its Name Differentiation Project, which since 2001 has evaluated reports of name confusion and recommended tall man lettering, displayed as hydrALAZINE and hydrOXYzine, to highlight the parts of the names that differ (U.S. Food and Drug Administration [FDA], 2023). On this unit, the cabinet labels used ordinary lowercase names.
The second property is storage. The two drugs were in adjacent pockets of the same drawer, because the cabinet was stocked alphabetically. Alphabetical storage places look-alike names side by side.
The third property is the barcode system, and its override. Bar-code medication administration is designed to catch exactly this kind of error at the bedside. Poon et al. (2010) found that units using a bar-code electronic medication administration record had a 41.4% relative reduction in nontiming administration errors and a 50.8% relative reduction in potential adverse drug events, compared with units without it. The protection, however, depends on the scan happening. When the scanner failed, the system offered an override with no second check, and the one step designed to catch a look-alike substitution was bypassed.
Why the Person at the Cabinet Is Not the Finding
It would be easy to end the analysis at 2202, when a nurse took a tablet from the wrong pocket, and to conclude that the nurse was careless. That conclusion would be inaccurate and would not prevent the next error. The nurse on this shift had six patients and had given more than forty doses that evening; the two drugs sat side by side, in lookalike packaging, with nearly identical names, in a drawer that opened when the correct drug was selected; and the one check designed to catch the error, the barcode scan, had been failing on that unit for two weeks, a problem staff had reported. Any nurse working under those conditions could have made the same substitution, and the system's override log showed that failed scans had been overridden by several nurses on the unit that week.
Looking at properties rather than personalities does not mean no one is accountable. The nurse is accountable for reporting the error honestly, which happened, and for comparing the label with the order at the cabinet, which did not. The unit is accountable for the storage, the labels and the scanners. An analysis that fixes only the person leaves the drawer, the names and the scanner exactly as they were for the next nurse on the next busy night.
A Fix Somebody Could Install
Four changes follow from the properties above, each specific enough to install:
1. Tall man lettering on all cabinet labels, the electronic medication record and pharmacy labels for hydrALAZINE and hydrOXYzine, and for the other pairs on the FDA list.
2. Separate storage: move hydroxyzine and hydralazine to different drawers in every cabinet on the unit, breaking the alphabetical adjacency.
3. Scanner reliability: replace the unit's failing handheld scanners, which staff reported had been intermittently failing for two weeks, and keep a spare on the unit.
4. Override with a second check: change the system so that a "barcode unreadable" override for a medication requires a second nurse to confirm the drug against the order at the bedside, and send a report of overrides to the unit manager weekly.
What Happened to the Patient
The patient received a sedating antihistamine instead of a blood pressure medicine. The harm was twofold: his blood pressure stayed high for more than two hours longer than planned, and he became drowsy, which in a 67-year-old increases the risk of falls and of breathing problems if other sedating drugs had been given. Neither led to lasting harm. The unexpected drowsiness was the clue that led to discovery; the unchanged blood pressure at 2310 could also have been a clue, but a single high reading after one dose did not prompt the question of whether the right drug had been given. Recognizing that an expected effect has not happened is itself a check, and adding "did the drug do what it should?" to the recheck after one-time doses is a small change the unit can make in its practice alongside the four system fixes.
References
Poon, E. G., Keohane, C. A., Yoon, C. S., Ditmore, M., Bane, A., Levtzion-Korach, O., Moniz, T., Rothschild, J. M., Kachalia, A. B., Hayes, J., Churchill, W. W., Lipsitz, S., Whittemore, A. D., Bates, D. W., & Gandhi, T. K. (2010). Effect of bar-code technology on the safety of medication administration. New England Journal of Medicine, 362(18), 1698-1707. https://doi.org/10.1056/NEJMsa0907115
U.S. Food and Drug Administration. (2023). FDA name differentiation project. https://www.fda.gov/drugs/medication-errors-related-cder-regulated-drug-products/fda-name-differentiation-project
What the NR 293 Week 4 assignment asks for
Week 4 hands you a medication error or near miss to take apart, either supplied as a case or drawn from a composite. The prompt usually wants the event, the checks that failed, the contributing factors, the harm and the changes, written in APA and supported by ISMP, FDA or safety technology research. A systems approach is expected, so the analysis should look at processes, storage, technology and drug properties rather than blaming an individual. Recommendations must be specific enough to install and audit. Include the patient's outcome and the nurse's reporting duties. Keep people unnamed, and use the drug's pharmacology only where it explains the error or harm.
How this NR 293 Week 4 example is built
The analysis opens with the facts: a 67-year-old with a pressure of 188/102, hydralazine ordered at 2200, hydroxyzine given at 2210, his pressure still 184/100 an hour later and drowsiness at 0005. Table 1 lays out the timeline from order entry to administration, marking each check. A properties section covers names that look and sound alike, adjacent drawer pockets and a scanner override, citing Poon et al. (2010) on barcode systems. A section explains why stopping at the nurse would prevent nothing. Four fixes follow, including tall man lettering from the FDA project and a second-nurse check for overrides. The last section describes the patient's harm and monitoring.
Reading the NR 293 Week 4 grading rubric
Medication safety rubrics usually grade a clear description of the event, identification of failed checks, systems analysis of contributing factors, quality of recommendations, attention to the patient and reporting, and APA. Systems analysis and recommendations carry the most weight, so each property is tied to the check it defeated and each fix to the property it addresses. The timeline table makes failed checks easy to see and grade. Recommendations score when they can be installed, such as separating drawers, not when they ask for care. Including the patient's blood pressure and drowsiness shows the outcome criterion. Evidence on barcode technology and the FDA name differentiation project supports the fixes.
NR 293 Week 4 help from the desk
The most expensive move is writing an accusation, which stops the analysis from finding causes. A full timeline with no analysis in the middle loses points. Recommendations to be more careful cannot be installed or audited. Leaving out what happened to the patient turns care into a puzzle. Naming a factor without saying which check it defeated and skipping documentation and reporting also cost marks. Near misses usually count for this assignment. Keep names out. Use pharmacology only where it explains why the error mattered. Bring us the event as described to you, and a systems analysis with installable fixes can be written from it. A flat, factual tone throughout keeps the focus on the process.
Get a NR 293 Week 4 example written to your instructions
Send the prompt and whatever incident template your classroom uses, and a worked example comes back inside 24-48h, first one free. Do not send an event from a unit you work on: incident reports, charts, an administration record with a name on it, anything a preceptor or instructor signs, those stay yours and are never drafted here. We work from your section's scenario.
More NR 293 papers and pre-licensure samples
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- NR 293 Week 3: Dosage Calculation Practice Set
- NR 293 Week 5: Drug Class Write-up
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- NR 293 Week 8: Medication Care Plan
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NR 293 Week 4 questions, answered
Does a near miss count, or does it have to reach the patient?
A near miss is usually the better subject and most sections accept it explicitly. Nothing reached anybody, so the analysis can be honest without becoming a defense, and the interception itself gives you a recovery point to write about. Confirm the published wording first, since a few prompts specify an event that reached a patient in order to make the aftermath section assessable.
Should the analysis name the people involved?
No, and roles carry the argument better anyway. Write the nurse preparing the dose, the prescriber taking the call, the technician stocking the cabinet, because a role tells a reader what access and what pressure the person had. Names add nothing analytically and pull the document toward blame, which is the single failure that costs most of the available points.
How much pharmacology belongs in this one?
Only what makes the harm plausible. Enough about the agent to show why the wrong dose or the wrong route mattered, then straight back to the process. Sections vary on whether they want the class described at all, and a paragraph of mechanism in a safety document usually reads as padding written to reach a word count rather than as evidence.
Where can I find a free NR 293 Week 4 sample paper?
The complete Week 4 analysis of the hydroxyzine and hydralazine error, with the marked timeline and four installable fixes, is posted further down this page.
What fixes does the NR 293 Week 4 analysis recommend?
Tall man lettering for both names, separate drawers instead of alphabetical neighbors, replacement of failing scanners and a second-nurse check whenever a barcode override is used.