Systematic derivation of an <scp>A</scp>ustralian standard for <scp>T</scp>all <scp>M</scp>an lettering to distinguish similar drug names

Emmerton, Lynne; Rizk, Mariam; Bedford, Graham; Lalor, Daniel

doi:10.1111/jep.12247

Cited by 6 publications

(11 citation statements)

References 21 publications

(25 reference statements)

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“…Tapentadol is available in multiple dosage forms, as an immediate release and slow release product, and shares LASA characteristics with tramadol, all of which contribute to an increased risk of medication-related incidents. Strategies such as 'Tall Man lettering' 21 and including the brand name when prescribing the product may assist in differentiating look-alike, sound-alike products. Medication-related clinical incidents involve a complex interplay of clinical communication failures, hospital processes, human error and patient factors, 14 and therefore often require multiple strategies to address a single incident type.…”

Section: Discussionmentioning

confidence: 99%

Opioid related medication incidents in Western Australia public hospitals: types, causes and level of harm

Fitzsimons

Ferguson

Jovanovska

et al. 2020

Pharmacy Practice and Res

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Background: Medication incidents in hospitals are common and occur at all phases of the medication management cycle. Clinical incidents for high-risk medications such as opioids have the potential to cause significant harm, yet opioid incidents are an under researched area of health service safety and quality. Aim: The aim of this study was to identify opioid medication safety incident types, occurrence in the medication management cycle, causative factors and level of patient harm to inform clinical care. Method: A multi-methods analysis of all reported opioid-related medication incidents, in all 93 Western Australian (WA) public hospitals, between 1 July 2017 and 30 June 2018 was conducted. Results: Opioid medications as a class were implicated in 11.0% (857) of all medication-related clinical incidents reported in 2017-18, with tapentadol, a relatively new opioid, the most reported (131; 15.3%). No reported incidents resulted in death, however, 0.5% (4) caused severe harm and 3.5% (30) caused moderate harm. The majority of incidents occurred during the administration phase of the medication management cycle (630; 73.5%). 'Incorrect dose' (146; 17%) followed by 'omission of dose' (116; 13.5%) were the most frequent incident types reported. 'Not checking properly' (554; 64.6%) followed by 'not following procedures' (167; 19.5%) were the most frequent causative factors. Conclusion: Vigilance in identifying, reporting and reviewing opioid medication safety incidents and causative factors are imperative to mitigating errors and preventing patient harm. Study findings should be used to develop targeted strategies to reduce opioid incidents in public hospitals.

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Section: Discussionmentioning

confidence: 99%

Opioid related medication incidents in Western Australia public hospitals: types, causes and level of harm

Fitzsimons

Ferguson

Jovanovska

et al. 2020

Pharmacy Practice and Res

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“…Initially adopted by FDA, the Tall Man lettering scheme has since been endorsed by multiple safety regulatory and accreditation bodies in the USA and other parts of the world,11 12 including the Joint Commission and the Institute for Safe Medication Practices (ISMP). In one of the 2007 National Patient Safety Goals (NPSGs), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO, now renamed as ‘the Joint Commission’) stated that health organisations should compile a list of LA-SA drugs and recommended to use boldface, colour or capital letters (‘Tall Man’ letters), to call attention to the difference between similar drug names 13…”

Section: Introductionmentioning

confidence: 99%

Tall Man lettering and potential prescription errors: a time series analysis of 42 children's hospitals in the USA over 9 years

et al. 2015

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BackgroundDespite the widespread implementation of Tall Man lettering, little evidence exists regarding whether this technique has reduced drug errors due to look-alike sound-alike (LA-SA) drug names. This study evaluated rates of potential LA-SA drug errors in the drug management process through to the point of dispensing before and after implementation of Tall Man lettering in 2007.MethodsWe used detailed pharmacy data for paediatric inpatients (<21 years old) from 42 children's hospitals in 2004–2012. After prespecifying a set of 8 potential LA-SA drug error patterns we searched within each hospitalisation for the occurrence of one of these patterns for a total of 12 LA-SA drug pairs deemed highly relevant to paediatric inpatients. To assess for potential change of error rates before and after Tall Man lettering implementation, we performed segmented regression analyses for each of 11 LA-SA drug pairs (because 1 pair had no detected potential errors) and for the overall total errors of all 11 LA-SA drug pairs.ResultsAmong 1 676 700 hospitalisations, no statistically significant change was detected for either the intercept or the slope of LA-SA error rate for each of the 11 drug pairs or for the combined error rate. In a sensitivity analysis of the moving average of the potential error rate over the entire study period, no downward trend in potential LA-SA drug error rates was evident over any time period 2004 onwards.ConclusionsImplementation of Tall Man lettering in 2007 was not associated with a reduction in the potential LA-SA error rate. Whether Tall Man lettering is effective in clinical practice warrants further study.

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“…17,23,34,38 Since over 1 billion prescriptions are issued in the UK each year (1.1 billion in England in 2017 39 ), we can extrapolate this error incidence to 2.2 million such errors each year. It is often stated that they account for up to 25% of medication errors, 13,15,22,40 although this seems to be a rather shaky upper ceiling, as the sources cited in these papers are not original studies (e.g. 41 If LASA pairs were identified at the pre-marketing stage, the errors would not have occurred, because the names would not exist, and several similarity measures between proposed names and existing names have been created.…”

Section: Prevalencementioning

confidence: 99%

“…Tall Man lettering is a popular way of changing the typography of medicinal product names; it has been endorsed by the US Food and Drug Administration since 2001,55 and is used in many hospital pharmacies in the UK (personal communication, ABMU pharmacist). Tall Man lettering uses selective capitalization of LASA name pairs to highlight characters that distinguish them from each other, for example, DOBUTamine and DOPamine, or hydrALAzine and hydrOXYzine 17,22. Tall Man lettering has the potential to reduce LASA errors in written/typed, but not spoken, communications, and it differentiates look-alike packaging.…”

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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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Systematic derivation of an Australian standard for Tall Man lettering to distinguish similar drug names

Cited by 6 publications

References 21 publications

Opioid related medication incidents in Western Australia public hospitals: types, causes and level of harm

Opioid related medication incidents in Western Australia public hospitals: types, causes and level of harm

Tall Man lettering and potential prescription errors: a time series analysis of 42 children's hospitals in the USA over 9 years

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

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