Does Tall Man lettering prevent drug name confusion errors? Incomplete and conflicting evidence suggest need for definitive study

Lambert, Bruce L.; Schroeder, Scott R.; Galanter, William L.

doi:10.1136/bmjqs-2015-004929

Cited by 30 publications

(27 citation statements)

References 23 publications

(21 reference statements)

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“…For example, Galanter and colleagues examined the use of indication alerts at the time of computerized physician order entry and found that some errors were averted . Manufacturers use “tall‐man” lettering to differentiate sections of a medication name on the medication's packaging, labeling, and bottle to decrease the confusion (eg, ARIPiprazole and RABEprazole ), though the effectiveness of this methodology has not been clearly demonstrated in real‐world settings …”

Section: Discussionmentioning

confidence: 99%

“…12 Manufacturers use "tall-man" lettering to differentiate sections of a medication name on the medication's packaging, labeling, and bottle to decrease the confusion (eg, ARIPiprazole and RABEprazole), 20 though the effectiveness of this methodology has not been clearly demonstrated in real-world settings. 21,22 The strengths of our analysis include the large size of the Sentinel System and the ability to deploy readily available analytic tools to facilitate efficient identification and review of potential LASA errors. There are important limitations to consider as well.…”

Section: Discussionmentioning

confidence: 99%

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Identification of potential drug name confusion errors in the Sentinel System

Cocoros

Haynes

Her

et al. 2019

Pharmacoepidemiology and Drug

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Purpose In July 2015, the US Food and Drug Administration (FDA) published a drug safety communication regarding errors in prescribing and dispensing of the antidepressant Brintellix (vortioxetine) and the antiplatelet Brilinta (ticagrelor) that arose due to proprietary drug name confusion. Brintellix is indicated for major depressive disorder; Brilinta is indicated to reduce cardiovascular death, myocardial infarction, and stroke in patients with acute coronary syndrome or history of myocardial infarction. Brintellix was renamed to Trintellix in May 2016. Using Brilinta and Brintellix as a proof‐of‐concept feasibility use case, we assessed whether drug name confusion errors between the pair could be identified in electronic health care data via the combination of a claims‐based algorithm and limited manual claims data review. Methods Using data from the Sentinel System, we defined potential errors as Brintellix users without an on‐ or off‐label indication for Brintellix, without a dispensing for a drug with the same indications as Brintellix, and with an on‐ or off‐label indication for Brilinta between −365 and +30 days after index Brintellix dispensing; the reverse was done for Brilinta. We manually reviewed claims profiles of potential cases. Results We identified 27 (0.1%) potential errors among 21 208 Brintellix users; 16 appeared to be likely errors based on claims profile review. Fifty‐one (0.3%) of the 16 779 Brilinta users were identified as potential errors, and four appeared to be likely errors. Conclusions A claims‐based algorithm combined with manual review of claims profiles could identify potential drug name confusion errors, and narrow down likely errors that warrant further investigation.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Identification of potential drug name confusion errors in the Sentinel System

Cocoros

Haynes

Her

et al. 2019

Pharmacoepidemiology and Drug

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“…Several strategies have been proposed to reduce LASA medication errors including the use of Tall Man lettering, [22,34] computerized provider order medication entry with (or without) electronic prescription transmission, medication reconciliation processes, barcode systems, and package changes. [1,35,36] Additional proposed measures include enhancing labeling for injectable medications that have similar appearing packaging, including security symbols, putting special labels on packaging of high-risk drugs, and revising processes for selecting, maintaining and updating the list of LASA drugs.…”

Section: Discussionmentioning

confidence: 99%

Exploring the potential for using drug indications to prevent look-alike and sound-alike drug errors

Seoane‐Vazquez

Rodríguez-Monguió

Al‐Qahtani

et al. 2017

Expert Opinion on Drug Safety

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“…LASA as a cause of ME. 25 the same manufacturer, they were put into the wrong medication drawer. The ampoules contained the same concentration.…”

Section: Example 4: Sufentanil Instead Of Fentanyl 33mentioning

confidence: 99%

The problem of look‐alike, sound‐alike name errors: Drivers and solutions

Bryan

Aronson

Williams

et al. 2020

Brit J Clinical Pharma

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Look-alike or sound-alike (LASA) medication names may be mistaken for each other, e.g. mercaptamine and mercaptopurine. If an error of this sort is not intercepted, it can reach the patient and may result in harm. LASA errors occur because of shared linguistic properties between names (phonetic or orthographic), and potential for error is compounded by similar packaging, tablet appearance, tablet strength, route of administration or therapeutic indication. Estimates of prevalence range from 0.00003 to 0.0022% of all prescriptions, 7% of near misses, and between 6.2 and 14.7% of all medication error events. Solutions to LASA errors can target people or systems, and include reducing interruptions or distractions during medication administration, typographic tweaks, such as selective capitalization (Tall Man letters) or boldface, barcoding, and computerized physician order entry. K E Y W O R D Slook-alike, medication error, nomenclature, similarity, sound-alike | INTRODUCTIONIn this review we introduce the problem of look-alike, sound-alike (LASA) name errors; give an overview of the landscape of medication nomenclature; outline the scope, importance and prevalence of LASA name errors; and explore solutions. This paper is to be complemented by a systematic review in a forthcoming issue. We adopted a stepwise approach to exploring the literature. After identifying papers that are central to the problem of LASA name errors, we handsearched forward citations (paper that cited it after publication) and backward citations (key papers they cited), and identified further relevant literature. | MEDICATION ERRORS INVOLVING LASA NAMESOf all events that are reported to cause patient harm in the UK, medication errors are the most common. Between January and March 2018 they accounted for 10.7% of incidents (206 485 medication incidents out of a total of 1 936 812 incidents), and 63 deaths. 1 Medication errors can occur when medications have similar-looking or similar-sounding names, and/or shared features of product packaging.These wrong drug errors are so-called LASA errors. 2 LASA errors make up a high proportion of all medication errors; estimates range from 6.2 3 to 14.7%, 4 representing a significant threat to patient safety. 5,6 They can occur during prescribing, dispensing or administration of medicines, and can lead to administration of the wrong medication.LASA errors can result in overdosing, under-dosing, or inappropriate dosing. 7 Confusion can occur between: generic-generic names (e.g. penicillin-penicillamine); brand-brand names (e.g. Prozac-Provera); brand-generic names (e.g. Soriatane-sertraline); or genericbrand names (e.g. methadone-Metadate); these examples are taken from error reports. 8 Most LASA pairs are reciprocal, i.e. each has been mistaken for its counterpart, revealing the influence of inherent pairwise similarity, rather than external environmental factors.This review is primarily concerned with errors that are caused by look-alike names and sound-alike names, and interventions to reduce their preval...

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Does Tall Man lettering prevent drug name confusion errors? Incomplete and conflicting evidence suggest need for definitive study

Cited by 30 publications

References 23 publications

Identification of potential drug name confusion errors in the Sentinel System

Identification of potential drug name confusion errors in the Sentinel System

Exploring the potential for using drug indications to prevent look-alike and sound-alike drug errors

The problem of look‐alike, sound‐alike name errors: Drivers and solutions

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