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
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
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
ingly refuse counseling when signing for prescrip- Suggested
tions. Too often, patients want to “get in…getout” of the pharmacy, a practice that must 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
hydrALAZINE – hydrOXYzine
medication. Some e-prescribing systems print out buPROPion - busPIRone
the prescription for the patient to take to the chlorproMAZINE – chlorproPAMIDE
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
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
questions for their pharmacists before picking up amLODIPine – aMILoride
morphine – HYDROmorphone
prescriptions, or contact their physicians if they azaCITIDine – azaTHIOprine
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
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*
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
information to effect change. This dynamic guanFACINE – guaiFENesin
SEROquel* – SINEquan*
two-part teleconference series wil be offered HumaLOG* – HumuLIN*
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
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 as brand 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.
(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.
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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