MedicationSafetyAlert! Use of tall man letters is gaining wide acceptance In the News… Fatal medication errors in the home
tive, while use on preprinted order forms
A review of US deaths between January 1983 and
completed our recent survey1 on the use of
tall man letters to differentiate products
360.5% increase in fatal medication error (FME)
with look-alike names. Tall man letters are
rates (Phil ips DP, et al. A steep increase in
domestic fatal medication errors with use of
drug name to highlight its primary dissimi-
tiveness of tall man letters, but very few
reported that tall man letters were wholly
ineffective in reducing the risk of errors.
indicates where the deaths occurred.
For respondents who use tall man letters,
40% are using this error-reduction strategy
for 1-16 drug name pairs; 28% are using it
pairs; and 14% for more than 36 drug name
pairs. Table 2 (next page) provides informa-
SafetyBriefs Ambulatory e-Rx requires
have promoted the use of tall man Table 1. Use and Perceived Effectiveness of Tal Man Letters patient’s check. A col eague told us Effectiveness (%)
about a recent experience he had at the doctor’s
Use of Tall Effective
office with e-prescribing. He and his wife took
Man Letters Not Effective
their daughter to a doctor for a skin rash. The
(Don’t Know)
doctor prescribed a topical corticosteroid, using a
Hospital
handheld device to place the order electronical y.
He had asked the couple which pharmacy they’d
like to use, which, al in al , seemed very efficient
except for one thing: The doctor never told the
family exactly WHAT drug he was prescribing. He
just instructed the parents to pick up the
medication at their community pharmacy. This
raises an important question when prescriptions
are sent electronical y to a pharmacy: How wil
the patient know what they’re supposed to receiveif they are not told the prescribed medication,
Scope and effectiveness of tall man letters
tion on the use of tall man letters for the
strength, and directions for use, and given a
written copy of the information to compare with
reported using tall man letters in conjunc-
the dispensed medication? Thus, e-prescribing
may lead to an unintended weakness in the
system if the patient doesn’t know what to expect
letters for look-alike drug name pairs have
Hospital
when he picks up his prescriptions at the pharm-
acy. Ideal y, with e-prescribing, patients should
pairs; however, 20% were not sure if their
receive verbal instructions from the prescriber, be
list of drug name pairs included any or all
given an opportunity to ask questions, and also
pairs felt that this strategy was effective
be provided with some sort of corresponding
in reducing the risk of errors, depending
“voucher” that lists the prescribed medication,
dose, and directions for use. Then the patient can
Provided as a service to its members by HealthTrust In the News… cont’d from page 1 Tall man letters cont’d from page 1
poisoning, and adverse drug events in which the
tall man letters helped to prevent mix-ups
correct drug was properly given in therapeutic or
prophylactic doses (non-preventable adverse drug
reactions) were not coded as FMEs. FMEs in the
letter characters in look-alike name pairs,
home where alcohol and/or street drugs were
the use of uppercase letters (i.e., tall man
only one drug name pair in the survey that
involved increased by 3,196%, while those not
letters) was, by far, the most prevalent first
less than half of the respondents felt was
associated with alcohol increased by 564%. FMEs
effective: clonazePAM and LORazePAM.
outside the home where alcohol/street drugs were
Table 2. Types of Drug Name Pairs for which
involved increased by 555%, while those not
often left the “PAM” part of both drug
associated with alcohol increased by only 5% (the
smal increase surprised us). The authors note
drawing attention to “PAM” in both drug
Types of Drug Name Pairs Respondents
that a shift in location of medication consumption
from clinical to home settings between 1983 and
2004 is most likely linked to the steep increase in
FMEs. Growth in the number and variety of
ISMP list of name pairs with tall man letters
available prescription drugs, increases in per
capita consumption, direct-to-consumer adver-
tising of pharmaceuticals, Web availability of
findings to prepare an unofficial list of
prescription drugs, sample drugs, mail service
look-alike drug name pairs with suggested
pharmacy, and growth in over-the-counter (OTC)
tall man letters to guide practitioners and
drug marketing are al factors that may have
impacted this situation. Clearly, more attention
needs to be paid to medication safety in home
following order: font differentiation, color
settings. Consumers need to be aware of the
background, italics, underline, and reverse
potential for harm with prescription and OTC
drugs, especial y when combined with alcohol
lettering). Some respondents also suggested
and/or street drugs. The importance of medication
using bold letters and enlarging the font
from using tall man letters that were not
reconciliation upon hospital discharge and
education of patients about medications cannot be
overemphasized. Mandatory scripted patient
education by health professionals for certain
Tall man lettering with specific name pairs
prescription drugs and drug categories is
medication, and the need to keep the list
warranted in the inpatient, outpatient, and
agreed that the tall man letters suggested in
short enough to avoid diluting the effec-
community pharmacy settings. In most states,
(“counseling”) rates are low (less than 35%)
names with tall man letters as well as a list
even though Medicare and various state regula-
thirds (60-66%) of respondents agreed that
tions require it. Changes also need to be made
Table 3. Perceived Effectiveness of Tall Man Letters in Name Pairs Presented in the Survey
with the methods used to offer “counseling” incommunity pharmacies so patients understand
Alternative Suggestions
the offer, recognize its value, and do not unknow-
Effective Name Pairs Effective Alternative
ingly refuse counseling when signing for prescrip-
Suggested Examples
tions. Too often, patients want to “get in…getout” of the pharmacy, a practice that must
HumaLOG - HumuLIN
HumALOG - HumULIN
change in order to provide patient education. New
NovoLOG - NovoLIN
NovoLOG - Novolin
black box warnings about potential y serious
oxyCODONE -OxyCONTIN OXYcodone - OxyconTIN
problems should appear on drug information
FLUoxetine – DULOXetine FLUoxetine - DULoxetine
sheets given to patients when they fil a prescrip-
ceFAZolin – cefTRIAXONE
ceFAZOlin - cefTRIAXone
tion. We also need to do a better job of gettingpatients to read these information sheets. Balance
ALprazoLAM - LORazePAM ALPRAZolam - LORazepam
between community pharmacy dispensing fees
morphine - HYDROmorPHONE
morphINE - HYDROmorphone
and patient education fees is needed, and more
morphine - HYDROmorphone
must be done in the area of health literacy and
HYDROcodone - oxyCODONE HYDROcodone - OXYcodone
translating information into languages and lay
clonazePAM - LORazePAM CLONazepam - LORazepam
ISMP MedicationSafetyAlert! SafetyBriefs cont’d from page 1 Tall man letters cont’d from page 2
use the voucher to check the prescription by
of the drug name pairs for Table 4. Drug Name Pairs with Recommended Tall Man Letters
matching it to what he or she actual y receives in
FDA-Approved List of Generic Drug Names with Tall Man Letters
acetoHEXAMIDE - acetaZOLAMIDE
hydrALAZINE – hydrOXYzine
medication. Some e-prescribing systems print out
buPROPion - busPIRone
medroxyPROGESTERone
the prescription for the patient to take to the
chlorproMAZINE – chlorproPAMIDE
methylPREDNISolone
pharmacy. Other e-prescriptions are faxed from
methylTESTOSTERone
clomiPHENE – clomiPRAMINE
the office computer to the pharmacy, or sent
cycloSPORINE – cycloSERINE
niCARdipine – NIFEdipine
directly to the pharmacy computer system queue
DAUNOrubicin – DOXOrubicin
predniSONE – prednisoLONE
(the ideal for e-prescribing). For the latter two
dimenhyDRINATE – diphenhydrAMINE
sulfADIAZINE – sulfiSOXAZOLE
situations, physicians and other prescribers need to
DOBUTamine – DOPamine TOLAZamide – TOLBUTamide
simultaneously provide a printed version of the
glipiZIDE – glyBURIDE
vinBLAStine – vinCRIStine
prescription to the patient that is properly identified
as a duplicate. This way, patients can know what
ISMP List of Additional Drug Name Pairs with Tall Man Letters**
to expect, read about the drugs and formulate any
ALPRAZolam - LORazepam
metroNIDAZOLE – metFORMIN
questions for their pharmacists before picking up
amLODIPine – aMILoride
morphine – HYDROmorphone
prescriptions, or contact their physicians if they
azaCITIDine – azaTHIOprine
NexIUM*– NexAVAR*
have concerns about taking the medications.
ceFAZolin – cefTRIAXone
niMODipine – NIFEdipine S p e c i a l A n n o u n c e m e n t s . . .
CeleBREX* – CeleXA*
NovoLOG* – NovoLIN*
chlorproMAZINE – chlordiazePOXIDE OXcarbazepine – carBAMazepine Maximize the effectiveness of CISplatin – CARBOplatin
oxyCODONE – OxyCONTIN* your medication safety team!
clonazePAM – cloNIDine PARoxetine – FLUoxetine
ISMP wil hold a two-part teleconference
clonazePAM - LORazepam PENTobarbital – PHENobarbital series to help healthcare organizations meet
cloNIDine – KlonoPIN*
PriLOSEC* – PROzac*
the chal enges involved with creating and
DACTINomycin – DAPTOmycin QUEtiapine – OLANZapine
maintaining a successful medication safety
ePHEDrine – EPINEPHrine
quiNINE – quiNIDine
team, including establishing a joint accounta-
fentaNYL – SUFentanil
riTUXimab inFLIXimab
physician leader, and using data and external
FLUoxetine – DULoxetine
SandIMMUNE* – SandoSTATIN*
information to effect change. This dynamic
guanFACINE – guaiFENesin SEROquel* – SINEquan*
two-part teleconference series wil be offered
HumaLOG* – HumuLIN*
Solu-MEDROL* – Solu-CORTEF*
on September 17, 2008 and October 23, HYDROcodone – oxyCODONE SUMAtriptan – sitaGLIPtin 2008 at 1:30 pm (ET). For details, visit: IDArubicin – DOXOrubicin
tiZANidine - tiaGABine INVanz* – AVINza*
traZODone - traMADol
LaMICtal* – LamISIL* TRENtal – TEGretol* Take our survey. ISMP is conducting a
lamiVUDine – lamoTRIgine
ZyPREXA* – ZyrTEC*
survey on smart infusion pumps. If you use
4 for which tall man letters * Brand names always start with an uppercase letter. Some brand names incor-smart pumps, please direct the survey found
are recommended. Please porate tall man letters in initial characters and may not be readily recognized asbrand names. An asterisk follows all brand names on the ISMP list.
edgeable about current use of the pumps.
s you ** The ISMP list is not an official list approved by FDA. It is intended for vol-untary use by healthcare practitioners and drug information vendors. Any man-
have consistently shown, ufacturers’ product label changes requires FDA approval. No scientific studies
you can make a difference! have demonstrated the error-reduction potential of the specific tall man letters
(ISSN 1550-6312) 2008 Institute for Safe
recommended in the name pairs on this list.
Medication Practices (ISMP). Permission isgranted to subscribers to reproduce material for
References: 1) ISMP. Survey on tall man lettering to reduce drug name confusion. ISMP Med Saf Alert!
internal communications. Other reproduction is
2008;13(10):4. 2) Filik R, Purdy K, Gale A, Gerrett D. Drug name confusion: evaluating the effectiveness of cap-
prohibited without permission. Report medica-
ital (“Tall Man”) letters using eye movement data. Social Science & Medicine 2004;59(12):2597-2601. 3) Filik R,
tion errors to the USP-ISMP Medication Errors
Purdy K, Gale A, Gerrett D. Labeling of medicines and patient safety: evaluating methods of reducing drug name
confusion. Human Factors 2006;48(1):39-47. 4) Grasha A. Cognitive systems perspective on human performance
SAF(E). Unless noted, published errors were
in the pharmacy: implications for accuracy, effectiveness, and job satisfaction. Alexandria (VA): NACDS; 2000
received through the MERP. ISMP guarantees
Report No. 062100. 5) ISMP. What’s in a name? Ways to prevent dispensing errors linked to name confusion.
confidentiality of information received and
ISMP Med Saf Alert! 2002;7(12):1-3. 6) ISMP. Draft guidelines for safe electronic communication of medication
respects reporters' wishes as to the level of detail
orders. ISMP Med Saf Alert! 2003;8(4):3-4. 7) ISMP. Let us know if “tall man” letters have been effective. ISMP
included in publications. Editors: Judy Smetzer,
Med Saf Alert! 2003;8(19):3. 8) FDA. Name differentiation project. Center for Drug Evaluation and Research.
2002. 9) The Joint Commission. NPSG: Identify and, at a
minimum, annually review a list of look-alike/sound-alike drugs used in the organization, and take action to pre-
Lakeside Drive, Suite 200, Horsham, PA 19044.
vent errors involving the interchange of these drug
0) National Association of Boards of Pharmacy. “TALL MAN” let-
ter utilization for look-alike drug names. 2008;
ISMP MedicationSafetyAlert! ISMP Survey on Smart Infusion Pumps
ISMP is conducting a survey on smart infusion pumps (programmable pumps with dose error-reduction software) to gather information about current practices when using these devices. If you use smart pumps in your facility, please direct this survey to the individual most knowledgeable about implementation and current use of the smart pumps. Dear smart pump facility representative: Please take a few minutes to tel us how smart pumps are being used in your facility. Please submit your responses to ISMP by September 5, 2008,by fax (215-914-1492) if you do not have Internet access.
1 How long have you been using smart infusion pumps?
2 For which of the fol owing activities do you use a wireless system? (select all that apply)
3 How many times per year do you typical y modify the drug library?
4 Your drug library/profile selections are based on which criteria? (select all that apply)
5 For each patient care unit listed in the first column of the table, select the types of infusions for which you employ smart infusion pumps. Select Y (Yes) if you
use smart pumps for the specified infusion; select N (No) if you do not use smart infusion pumps for the specified infusions; select NA (Not Applicable) if you do not administer the type of infusion on the specified unit, or if you do not have the specified unit in your facility. Intermittent Titrating Infusions Infusions Infusions (e.g., antibiotics) Patient Care Units
6 For each type of drug infusion listed across the top of the table, please tel us how many concentrations exist in the drug library, and whether you employ a soft
stop (can bypass dose warning), hard stop (cannot bypass dose warning), or no stop (no warning) if a maximum dose is exceeded when programming the pump. Key: No = No Standard Concentration or No Hard or Soft Stops. Propofol DOBUTamine DOPamine EPINEPHrine Morphine morphone Concentrations
Number of concentrations inthe drug library
Soft Hard No Soft Hard No Soft Hard No Soft Hard No Soft Hard No Soft Hard No Soft Hard No Soft Hard No Soft Hard No
Use of soft stops, hard stops,or no stops if maximum doseexceeded
7 How often do you review data from the smart infusion pumps?
8 During the past 12 months, has your organization experienced pump programming errors associated with the fol owing factors that have reached patients,
a) Selection of a zero instead of a decimal point (e.g., 1.2 entered as 102)
b) Omission of a decimal point (e.g., 1.2 entered as 12, 1.0 entered as 10)
9 Please tel us how many licensed beds are in your facility. Thank you for participating in our survey! Please submit your responses by September 5, 2008, at:
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