A tall man lettering project to enhance medication …

1 Farm Hosp. 2011;35(5) tall man lettering project to enhance medication safetyUn proyecto de uso de letras may sculas resaltadas para mejorar laseguridad de los medicamentosDavid Ua, , Michael R. CohenbaInstitute for Safe medication Practices, Institute for Safe medication Practices- Canada, Toronto, Ontario, CanadabInstitute for Safe medication Practices, Huntingdon Valley, PA, United StatesReceived 14 June 2011; accepted 27 June 2011 medication errors are still a major public safety concern forpatients and consumers. Although figures published on errorscaused by drug name confusion ranges from 9% to 25%,1,2the impact of selecting the wrong drug can be have been many attempts to develop safeguards andstrategies to reduce errors caused by similar or look-alikedrug names. One approach is to deploy a mixed-case text ortall man letters on drug names that are deemed to be ortho-graphically similar and have the potential to cause seriouspatient harm if a mix-up were to tall man letter approach has been promoted andadvocated by both FDA (Food and Drug Administration) andISMP (Institute for Safe medication Practices) in the UnitedStates for a number of years.

2 They have recommended astandard list of tall man lettering for similar drug namepairs. A survey of a broad audience of practitioners on theuse of tall man letters was conducted by ISMP in 2008. Thefindings showed an overwhelming support of the use of thistechnique. Of the 451 surveyed responses, 87% indicatedthat the use of tall man lettering helped to reduce drugselection , engaging in a project withthe Canadian Association of Provincial Cancer Agencies, alsoproduced a list of oncology drug names with the tall mantechnique. This project leveraged the success from whatwas previously developed in the United States and addedthree more project also received Corresponding U).input and endorsement from the International MedicationSafety Network to which ISMP-Spain is a member , in collaboration with a number of nationalmedication safety experts, recently undertook a study todevelop a list of similar drug name pairs requiring tall manletters to be used by Spanish healthcare study involved two sequential but related surveys thatgenerated a final list of 44 drug-name pairs using the tallman strategy.

3 Given the resources available and the scopeof the study, the subject size, the use of the Mid ruleapplying to new pairs and their statistical analysis are is important to note that although international sharingof learning is essential and cost effective, tools need to havelocal context and to contain local content to be effectivelyadopted and implemented. This case represents an illustra-tive example of a safety practice that required is clearly seen in the methodology followed, a quite siz-able proportion of the names on existing lists in the USAwere not incorporated into the Spanish list, either becausethey were names for drugs that are not commercialised inthis country or because the survey takers simply did not wishto include them, probably because they are not frequentlyused there.

4 On the other hand, other groups of names atrisk for mix-ups in Spain would not have benefited from theapplication of this technique. Besides, as cited in the Spanishstudy, many healthcare facilities in Spain are not using tallman lettering to distinguish between potentially dangerouslook-alike drug names. One of the key objectives thereforewill be to raise awareness of the use of the technique for1130-6343/$ see front matter 2011 SEFH. Published by Elsevier Espa a, All rights downloaded from , day 13/09/2011. This copy is for personal use. Any transmission of this document by any media or format is strictly U, Cohensafer patient care as well as providing a practical tool to beadopted in the technique of tall man letters evidence-based?Previous studies have failed to fully confirm or deny theeffectiveness one way or another.

5 Filik et al. have donesome initial studies and their findings did show support ofit more recent report by Gerrett et al. in the UK hassuggested improved accuracies with tall man lettering aswell as wholly capitalised drug names as compared to use ofthe natural format (lower case except the first character).7 However, Gerrett did call for more research into which is themost effective tall man letter format (Mid, CD3, and Wild).An unpublished dissertation thesis by Chermak, under-taken at the University of Illinois, Chicago in 2009, showedthat mixed case text did not significantly impact on accuracyand reaction latest study published by Filik et al.,using younger and older adults and healthcare practitioners,once again demonstrated that tall man lettering reduceddrug name confusion errors in a series of Spanish study also cites that minimising look-alikedrug name confusion errors needs a two-prong approach:a more stringent, vigorous and scientific process to screenpotential drug names for safety before they are submit-ted for product approval; and development of strategies toreduce errors with existing similar drug names.

6 FDA in theUSA has initiated their PDUFA IV (Prescription Drug User FeeAct IV) pilot project in which a defined set of proactive riskassessment processes must be undertaken by the industryas part of the drug product Canada, ISMPC anada is also working with Health Canada to develop a newframework containing scientific tests including computerdatabase searches, psycholinguistic experiments, simulationtesting, and of these projects aim to improvethe screening, selection and approval of new drug , while more research must be conducted on theapproaches used and the formatting of tall man lettering ,the Spanish study is commended for taking a big step inthe right direction. It is worth mentioning that changing theway a drug name looks, regardless of its degree of effec-tiveness, is only one strategy.

7 It is not a panacea, but sincethere is not an extensive array of specific practices to min-imise errors caused by confusion among already existingnames, it merits application in all areas where it could safer drug product packaging, both from the man-ufacturer and from healthcare facility-generated labellingcan play a critical role in preventing medication errors. Inaddition, there are other system safeguards that can bebuilt into the medication use process to enhance s project for developing tall man pairs for con-fusing drug name-pairs is admirable and commended. Thisis just another leadership move by this medication safetyorganisation, which falls in line with the safety initiativesof other organisations that truly desire to make of interestThe authors have no conflict of interest to Personal communication with ISMP Canada on search ofISMP Canada s Individual Practitioner s medication Filik R, Price J, Darker I, Gerrett D, Purdy K, Gale A.

8 The Influ-ence of tall man lettering on drug name confusion. Drug ;33 Institute for Safe medication Practices. Use of tall man let-ters is gaining wide acceptance. ISMP medication SafetyAlert! 2008;13(15):1---3. Available from URL: [ ].4. ISMP Canada. Application of TALLman lettering for drugs usedin oncology. ISMP Canada safety Bulletin 2010;10(8) from URL: [accessed ].5. Otero L pez MJ, Mart n Mu noz R, S nchez Barba M, AbadSazatornil R, Andreu Crespo A, Arteta Jim nez M, et al. Devel-opment of a list of look-alike drug names with recommendedtall man letters. Farm Hosp. 2011;35 Filik R, Purdy KJ, Gale AG, Gerret D. Drug name confu-sion: evaluating the effectiveness of capital ( Tall Man )letters using eye movement data.

9 Soc Sci Med. 2004;59 Gerrett D, Gale AG, Darker IT, Filik R, Purdy KJ. The use of tallman lettering to minimise selection errors of medicine namesin computer prescribing and dispensing systems. Report to theUK National Health Service Connecting for Health : National Health Service; 2009. Report Chermak TE. Effect of package label characteristics on phar-macists visual perception of drug names. thesis. Schoolof Pharmacy, University of Illinois, Chicago; FDA PDUFA Pilot project : Propriety Name Review ConceptPaper; 2009. Available from URL: down-loads/Drugs/GuidanceComplianceRegul atoryInformation/ [accessed ].10. Personal communication with ISMP Canada on their collabo-rating project with Health Canada in developing a conceptpaper in applying scientific methodologies to assess new downloaded from , day 13/09/2011.

10 This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.