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Questions/Professional Practice/Q56 of 63
hardpatient safetymedication errorssystems-based practicelook-alike sound-alikequality improvement
A PMHNP in a community mental health center discovers that a medication error occurred when a patient received hydroxyzine 50 mg instead of the prescribed hydralazine 50 mg from an external pharmacy. The patient was not harmed but reported drowsiness at work the following day. The PMHNP reviews the incident and notes that both medications were prescribed by different providers in the same electronic health record and the names appear similar in the pharmacy dispensing system. Which of the following actions best reflects a systems-based approach to patient safety and medication error prevention?
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