Drug name confusion: evaluating the effectiveness of capital (“Tall Man”) letters using eye movement data

Filik, Ruth; Purdy, Kevin; Gale, Alastair G.; Gerrett, David

doi:10.1016/j.socscimed.2004.04.008

Cited by 73 publications

(85 citation statements)

References 6 publications

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“…The extent of variations in HEPs revealed by our results requires a move from traditional observational studies towards experimental research based on randomised controlled trials. In this regard, much remains to be done, although some task details [24][25][26][27] as well as a few performance-shaping factors are already under investigation [28][29][30]. For instance, the reliability of various tasks in relation to label design (e.g.…”

Section: Discussionmentioning

confidence: 99%

Measuring human-error probabilities in drug preparation: a pilot simulation study

Garnerin

Pellet-Meier

Chopard

et al. 2007

Eur J Clin Pharmacol

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Objectives Designing a safe medication process requires the ability to model its reliability using methods such as probabilistic risk assessment (PRA). However, lack of data, especially on human-error probabilities (HEPs), limits its use. To assess whether small-scale simulations could help generate HEP data, a pilot study was conducted among nurses and anaesthetists. It focused on two core activities, namely, the manual preparation of medications and the arithmetic necessary to prepare drugs. Its specific objectives were to evaluate whether HEPs could be high enough to be measurable and to determine whether these HEPs could be sensitive to individuals and task details. These would give some insight into the level of detail required by PRA analysis. Methods Thirty nurse and 28 anaesthetist volunteers were involved in the experiment. Nurses and anaesthetists had to prepare medications for 20 patients and 22 syringes of various drugs, respectively. Both groups had to perform 22 calculations relating to the preparation of drugs. HEPs, distribution of HEPs and dependency of HEPs on individuals and task details were assessed. ResultsIn the preparation tasks, overall HEP was 3.0% for nurses and 6.5% for anaesthetists. In the arithmetic tasks, overall HEP was 23.8% for nurses and 8.9% for anaesthetists. A statistically significant difference was noted between the two groups. In both preparation and arithmetic tasks, HEPs were dependent on individual nurses but not on individual anaesthetists. In every instance, HEPs were dependent on task details. Conclusion Our study illustrates that small-scale simulations represent an interesting way of generating HEPs. HEPs are, indeed, in the range of 10 −2 and 10 −1 . But in most cases, HEPs depend heavily on operators and task details. This dependency means that the influence of these parameters must be determined before advanced PRA analysis. There is therefore an urgent need to develop experimental research into assessing this influence by means of randomised controlled trials.

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Section: Discussionmentioning

confidence: 99%

Measuring human-error probabilities in drug preparation: a pilot simulation study

Garnerin

Pellet-Meier

Chopard

et al. 2007

Eur J Clin Pharmacol

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“…[39] Other research suggests that tall-man letters can reduce the number of errors made in selecting a target medicine when faced with an array of medication packs. [40] Tall-man lettering has been reported to reduce medication name confusion in a number of different groups of people, of different ages and professions, in laboratorybased tasks. [45] However, an evaluation conducted for the UK National Health Service cautions a pragmatic approach to the widespread implementation of tall-man lettering and suggests that the prevalence of other more likely errors indicate the need for broad research rather than just this limited potential solution to one aspect of the problem.…”

Section: Medication Name Remediesmentioning

confidence: 99%

Quality Use of Medicines – medication safety issues in naming; look-alike, sound-alike medicine names

Ostini

Roughead

Kirkpatrick

et al. 2012

International Journal of Pharmacy Practice

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Objective To review current literature with the objective of developing strategies and recommendations to enhance patient safety and minimise clinical issues with look-alike, sound-alike medication names. Methods A comprehensive search of the PubMed database and an Australian online repository of Quality Use of Medicines projects was conducted to identify publications addressing look-alike, sound-alike medication problems. Author networks, grey literature and the reference lists of published articles were also used to identify additional material. Key findings Thirty-two publications describing the extent of the specific problem and recommending solutions were identified. The majority of these publications provided a qualitative assessment of the issues, with few quantitative estimates of the severity of the problem and very little intervention research. As a result, most recommendations for addressing the problem are the result of expert deliberations and not experimental research. This will affect the capacity of the recommendations to ameliorate and resolve problems caused by look-alike, sound-alike medication names. Themes identified from articles included the nature and causes of look-alike, soundalike problems, potential solutions and recommendations. Conclusions There are many existing medications which can potentially cause clinical issues due to mix-ups because of similar sounding or looking medication names. This confusion can be lethal for some medication errors. A multifaceted, integrated approach involving all aspects of the medication use process, from initial naming of INN through to consumer education, is suggested to minimise this issue for medication safety.

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“…22 Presenting similar drug names in a novel format may act as a warning about the risk of confusion associated with these products and help prevent product selection errors by health professionals. 22,23 Tall man lettering was recommended by the Food and Drug Administration in the USA for 16 products with confusable names.…”

Section: Product Confusionmentioning

confidence: 99%

Medicines labelling

Lalor¹

2011

Aust Prescr

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SummaryThe design and content of labels on medicines can have a significant impact on the quality and safety of medicines use. Labels must clearly identify a particular product and provide sufficient information to allow people to make safe and informed decisions about its use. Some advances have been made in the regulation of medicines labelling in Australia, however problems related to poorly designed labels and packaging still exist. improving labelling by applying knowledge from other fields can support the quality use of medicines.

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Drug name confusion: evaluating the effectiveness of capital (“Tall Man”) letters using eye movement data

Cited by 73 publications

References 6 publications

Measuring human-error probabilities in drug preparation: a pilot simulation study

Measuring human-error probabilities in drug preparation: a pilot simulation study

Quality Use of Medicines – medication safety issues in naming; look-alike, sound-alike medicine names

Medicines labelling

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