| Course | HCA 105 Pharmacology |
|---|---|
| Module | Module 6 |
| Paper type | Medication error analysis |
| Length | About 1,016 words, 6 pages |
| Format | APA 7 student paper |
| School | Aspen University |
| Program | Health Care Administration |
| Updated | September 2026 |
Free sample paper for HCA 105 Module 6
Hydroxyzine or Hydralazine? A Near Miss in an Outpatient Clinic and the System Fixes That Would Have Prevented It
Student Name
Health Care Administration Program, Aspen University
HCA 105: Pharmacology
Instructor Name
Month Day, Year
Hydroxyzine or Hydralazine? A Near Miss in an Outpatient Clinic and the System Fixes That Would Have Prevented It
Medication errors in outpatient clinics are less studied than hospital errors, but they happen for the same reasons: similar drug names, interruptions, unclear orders and systems that make the wrong choice easy. The composite near miss examined here, a medical assistant preparing the wrong drug, identifies the causes, proposes system fixes and draws on a quality improvement project that cut errors in an ambulatory setting. The scenario is a composite written for teaching.
The Scenario
On a busy Monday morning at the composite clinic, a provider asked a medical assistant, between patients, to give Mrs. W. her hydralazine dose before she left, because her blood pressure was high. The assistant went to the medication cabinet, where hydroxyzine, an antihistamine used for itching and anxiety, sat on the shelf beside hydralazine, a blood pressure drug. While reaching for the bottle, the assistant was interrupted twice by questions from colleagues. The assistant took hydroxyzine, prepared a tablet and walked toward the room. At the door, while checking the label against the order a final time, the assistant noticed the difference and stopped. No harm occurred. The patient was waiting in the exam room, having already been told she would receive a blood pressure pill before leaving.
Why the Names Matter
The two names share their opening letters, similar length and much of their sound, so a hurried reader can take one for the other. Look-alike, sound-alike drug names are a recognized cause of medication errors, and responding to them requires system changes such as label design and storage, not only reminders to be careful (Trbovich & Hyland, 2017). In this case, a sedating antihistamine given instead of a blood pressure drug could have left a patient with dangerously high blood pressure and drowsiness on the drive home. Hydralazine is also sometimes confused with other drugs, so the problem is not unique to this pair.
Contributing Causes
Several causes combined. The two drugs were stored side by side in alphabetical order. The order was verbal and given between patients, with no written order to check. The assistant was interrupted twice while selecting the drug. The clinic had no rule separating look-alike drugs or marking their labels. The assistant's final label check at the door, a habit taught in training, was the only barrier that worked. Removing any one of these conditions would have made the slip less likely.
The Human Factors View
The assistant made a slip, choosing the wrong bottle while intending to choose the right one. Human factors research treats slips as predictable results of how tasks and environments are designed: people under time pressure and interruption recognize familiar shapes and letters rather than reading every character. Blaming the individual would not prevent the next slip. Redesigning storage, labels and workflow so that the wrong choice is harder to make is more effective, which is the logic behind the system fixes below.
System Fixes
Each cause suggests a system fix.
| Cause | System fix |
|---|---|
| Look-alike drugs stored side by side | Separate them on different shelves; add tall-man lettering such as hydrOXYzine and hydrALAZINE; add a warning label |
| Verbal order between patients | Enter orders in the record before preparation except in emergencies; read back verbal orders |
| Interruptions while selecting drugs | Create a quiet medication preparation zone; signal that the preparer should not be interrupted |
| Reliance on one final check | Check the label against the order when selecting, preparing and before giving |
Evidence From an Ambulatory Center
Reducing interruptions works. In a quality improvement project at an ambulatory medical center, nurses, nursing assistants and unit secretaries developed a Safe Zone protocol with clear medication preparation areas, administration checklists and staff and patient education. Distractions fell by 20% over 90 days, and medication errors fell from 0.97 to 0.20 events per 1,000 doses administered (Bentil et al., 2025). A similar zone at the composite clinic would address one of the main causes of this near miss.
Involving Patients
Patients can also help prevent errors. At the composite clinic, staff now tell patients the name and purpose of any medicine before giving it, for example: This is hydralazine, for your blood pressure. A patient who expected a blood pressure pill but hears the name of an allergy medicine, or who says they have never taken this before, can stop an error. Encouraging patients to ask questions about their medicines turns them into an additional check.
Reporting and Learning
The assistant reported the near miss to the office manager the same day. Near misses reveal weaknesses before anyone is harmed, but only if they are reported without fear of blame. The manager thanked the assistant, reviewed the storage and order process with the team and moved the two drugs apart that afternoon. Reporting is also part of professional integrity; codes for medical assistants emphasize honesty and high standards (American Association of Medical Assistants, n.d.). The next staff meeting reviewed the event without naming the assistant, so that everyone could learn from it.
The Role of Individual Habits
System fixes do not replace personal habits. Checking the label three times, when selecting, preparing and giving, confirming the patient with two identifiers and questioning anything unusual remain essential. In this scenario, one habit prevented harm. The goal of system fixes is to make sure that the next time, safety does not depend on a single final check. Training new staff to value these habits, and modeling them, keeps them alive even when the clinic is busy.
Conclusion
A near miss between hydroxyzine and hydralazine arose from look-alike names, side-by-side storage, a verbal order and interruptions. A final label check stopped it. Separating look-alike drugs, using tall-man lettering, requiring written or read-back orders and creating a quiet preparation zone would make the error far less likely, and evidence from an ambulatory center shows that reducing distractions cuts errors. The clinic's quick response after the report, moving the bottles the same afternoon, shows how a near miss can improve a system when it is shared rather than hidden.
References
American Association of Medical Assistants. (n.d.). AAMA medical assistant code of ethics. https://www.aama-ntl.org
Bentil, S., Sengul, T., & Kirkland-Kyhn, H. (2025). Reducing medication errors in an ambulatory medical center. Journal of Nursing Care Quality, 40(4), 332-337. https://doi.org/10.1097/NCQ.0000000000000856
Trbovich, P. L., & Hyland, S. (2017). Responding to the challenge of look-alike, sound-alike drug names. BMJ Quality & Safety, 26(5), 357-359. https://doi.org/10.1136/bmjqs-2016-005629
HCA 105 Module 6 instructions, in plain terms
HCA 105 in Aspen's catalog pairs drug administration with legal and ethical principles, and this sample follows that pairing because the module's instructions reach only students in the course. An error analysis assignment usually presents a medication error or near miss and asks you to identify causes, explain why they occurred and recommend ways to prevent recurrence. Some instructors want a root cause framework; others accept a structured narrative. Check whether you must use a published error or may write a composite, whether a table of causes and fixes is welcome, and whether reporting and ethics should be addressed. Keep the analysis focused on systems rather than on blaming the person involved. Some courses also ask you to describe how the error would be reported in your workplace.
How this HCA 105 Module 6 example is built
Eleven headings and a table of fixes hold close to 1,000 words. It opens by noting that outpatient errors follow the same patterns as hospital errors. The scenario is described, then a section explains why the two names cause confusion. Contributing causes are listed, followed by a human factors view of the slip. The table matches causes to fixes, and evidence from an ambulatory quality project supports reducing distractions. Involving patients, reporting and learning, individual habits and a conclusion complete the paper. The scenario is labeled as a composite written for teaching.
HCA 105 Module 6 rubric: what earns full marks
Error analyses tend to be graded on identification of causes, a systems perspective, realistic prevention and use of evidence. Causes are identified at several levels, from names to interruptions. The systems perspective is explained through human factors, which a margin note connects to the choice of fixes. A second note credits the table for matching each cause to a specific change. Evidence from a published quality project adds weight, and a third note explains why a near miss deserves full attention. Reporting without blame and patient involvement show breadth. The look-alike naming commentary, the Safe Zone study and the professional code are each cited where the paper leans on them. The paper keeps a respectful tone toward the assistant throughout, which models a just culture.
HCA 105 Module 6 help from the desk
The most common weakness is blaming the individual and recommending that staff be more careful. Look for system causes. Students also list causes without matching each to a fix; a table helps. Another frequent gap is ignoring near misses as unimportant because no harm occurred, when they are the cheapest lessons available. Treat them seriously. Some papers recommend only training, a weak fix on its own. Add storage, labeling and workflow changes. Finally, remember patients, who can catch errors if staff tell them the name and purpose of each medicine before giving it. Describe the person's action neutrally, as a slip in a system rather than a failing. Keep it practical.
Write yours, or have the desk draft it
This paper is an original model document written by our desk, not a submitted student paper and not an official Aspen University document. Read it for the moves, then write your own to the instructions in your classroom. If you want one built to your exact prompt and rubric, the first custom sample is free and arrives in 24 to 48 hours.
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HCA 105 Module 6 questions, answered
What does HCA 105 Module 6 usually ask for?
Aspen's HCA 105 description covers legal and ethical principles and drug administration, so analyzing a medication error scenario and its prevention is a typical assignment. Check your classroom for the prompt.
What is tall-man lettering?
Using capital letters for the parts of look-alike drug names that differ, such as hydrOXYzine and hydrALAZINE, so the difference stands out.
Should near misses be reported?
Yes. They reveal weaknesses before anyone is harmed and should be reported promptly in a culture that does not punish honest reporting.
Where can I find a free HCA 105 Module 6 sample paper?
The complete near-miss analysis, fixes table and annotations included, is published above and costs nothing. It is the sixth HCA 105 sample.
What system fixes prevent look-alike drug errors in HCA 105 Module 6?
Separating look-alike drugs in storage, using tall-man lettering, requiring written or read-back orders and protecting medication preparation from interruptions.