Transcript What is Tall Man lettering? - Health Quality & Safety Commission

Tall Man lettering
Learning outcomes
After this session, you will be able to:
• explain what Tall Man lettering is
• identify situations where Tall Man
lettering can be used to reduce risk of
wrong medicine error
• describe the evidence level for Tall Man
lettering as an error-reduction technique.
Background
Medicine name errors, particularly with regard to medicines with
‘look-alike, sound-alike’ names, are common and harm can occur.
Patient received tamoxifen 20mg rather than the
prescribed tenoxicam 20mg. Patient took the
tamoxifen for three weeks and suffered from hair
loss, constipation and sweating.
Patient was dispensed Atropt (atropine) instead of
Azopt (brinzolamide) and developed blurred
vision, dilated pupils and raised intra-ocular
pressure in each eye for three weeks measured at
26mmHg. Luckily no permanent harm occurred.
What is Tall Man lettering?
• It is an error-prevention strategy used as part of a multifaceted approach to reduce the risk of look-alike and soundalike medicine name confusion and errors.
• It is a typographic technique that uses selective capitalisation
to help make similar-looking medicine names easier to
differentiate.
• Its purpose is to help select or supply the right medicine.
How does it work?
Tall Man lettering combines lower- and
upper-case letters to highlight the
differences between look-alike and soundalike medicine names, like fluOXETine and
fluVOXAMine, making them easier for the
eye to distinguish.
Evidence
• Evaluation shows considerable variation in the
effectiveness of Tall Man lettering1-15.
• Small amount of literature available shows that, at a
minimum, Tall Man lettering should alert clinicians’ to
medicines that are at risk of name confusion and possible
medication error without increasing the risk of errors.1, 9-14
• Inconclusive data on whether technique is effective in
preventing medicine selection errors.15
• Mid Tall Man lettering format advocated as being the most
effective and easily applied variant.2,11
Why are we doing this?
• The Commission has received numerous
enquires about Tall Man lettering
standards, endorsement and application
techniques from clinicians and software
vendors.
• A New Zealand list would prevent
proliferations of local Tall Man lists and
inconsistent technique application.
What could Tall Man
lettering be used on?
• electronic drop-down medicine lists
• automated dispensing cabinet screens
• SMART pumps
• computer-generated pharmacy labels
• medicine shelf labels
• pre-printed order sheets
Final messages
• Train staff on what Tall Man lettering is
and how it works before it is introduced.
• Familiarise staff to existing lookalike/sound-alike name pairs to improve
risk awareness.
• Don’t overuse Tall Man lettering as this is
likely to reduce the error-reduction effect.
• Don’t use different styles of Tall Man
lettering as this will cause confusion.
References
1. Australian Commission on Safety and Quality in Healthcare. Evaluating the effect of the Australian List of Tall Man Names. Australian Commission on
Safety and Quality in Health Care, Sydney, June 2011. http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/PriorityProgram06_NTMS last accessed 19 January 2012
2. Australian Commission on Safety and Quality in Healthcare. National Standard for the application of Tall Man Lettering. Australian Commission on
Safety and Quality in Health Care, Sydney, January 2011. http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/PriorityProgram06_NTMS last accessed 19 January 2012
3. NHS National Patient Safety Agency and the Helen Hamlym Research Centre. Design for patient safety. A guide to the design of electronic infusion
devices. London, 2010 http://www.nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd?AssetID=68536 last accessed 19 January 2012
4. MHRA. Best practice on labelling and packaging of medicines - name differentiation designs for generic cephalosporin products. November 2009
http://www.mhra.gov.uk/Howweregulate/Medicines/Labelspatientinformationleafletsandpackaging/index.htm last accessed 19 January 2012
5. Institute of Safe Medication Practices. FDA and ISMP Lists of Look-Alike Drug Names with Recommended Tall Man Letters. 2011
http://www.ismp.org/tools/tallmanletters.pdf last accessed 19 January 2012
6. Institute of Safe Medication Practices Canada. Application of TALLman lettering for drugs used in oncology. ISMP Canada Safety Bulletin
2010;10(8):1-4 http://www.ismp-canada.org/download/safetyBulletins/ISMPCSB2010-08-TALLmanforOncology.pdf last accessed 19 January 2012
7. US Food and Drug Administration (FDA). Name differentiation project 2001. http://www.fda.gov/Drugs/DrugSafety/MedicationErrors/ucm164587.htm
last accessed 19 January 2012
8. Medsafe. Guideline on the Regulation of Therapeutic Products in New Zealand, Part 5: Labelling of medicines and other related products. August
2011. http://www.medsafe.govt.nz/regulatory/guidelines.asp last accessed 19 January 2012
9. Darker IT, Gerrett D, FIlik R, Purdy K, Gale A. The influence of 'Tall Man' lettering on errors of visual perception in the recognition of written drug
names. Ergonomics 2011; 54(1):21-33.
10. FIlik R, Purdy K, Gale A, Gerrett D. Drug name confusion: evaluating the effectiveness of capital ("Tall Man") letters using eye movement data. Social
Science and Medicine 2004; 59: 2597-601.
11. Gerrett D, Gale A, Darker IT, FIlik R, Purdy KJ. Final Report of the Use of Tall Man Lettering to Minimise Selection Errors of Medicine Names in
Computer Prescribing and Dispensing Systems: NHS Connecting for Health 2009.
12. FIlik R, Purdy K, Gale A, Gerrett D. Labelling of Medicines and Patient Safety: Evaluating Methods of Reducing Drug Name Confusion. Human
Factors 2006; 48(1):39-47.
13. FIlik R, Price J, Darker IT, Gerrett D, Purdy K, Gale A. The Influence of Tall Man Lettering on Drug Name Confusion - A Laboratory-Based
Investigation in the UK Using Younger and Older Adults and Healthcare Practitioners. Drug Saf 2010; 33:677-87.
14. David U and Cohen MR. A tall man lettering project to enhance medication safety. Farmacia hospitalaria 2011: 35(5): 223 – 224
15. Gabriele S, Hyland S, Gosbee LL, Singh MD, Ninan A, Evans R, Evans, Fernandes O. Visual Differentiation in Look-alike Medication Names. Report
to the Canadian Patient Safety Institute. February 10, 2012