Tallman lettering as a strategy for differentiation in look-alike, sound-alike drug names: The role of familiarity in differentiating drug doppelgangers

DeHenau, Carly; Becker, Mark W.; Bello, Nora M.; Liu, Sichang; Bix, Laura

doi:10.1016/j.apergo.2015.06.009

Cited by 19 publications

(46 citation statements)

References 24 publications

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“…Eleven studies evaluated the use of Tall Man lettering (Tables 1 and 2 and Table 3 (Appendix)) [18–20, 22, 24, 25, 27–29, 31, 32]. A wide range of different drug names were tested.…”

Section: Resultsmentioning

confidence: 99%

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A systematic literature review on strategies to avoid look-alike errors of labels

Larmené-Beld

Alting

Taxis

2018

Eur J Clin Pharmacol

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PurposeUnclear labeling has been recognized as an important cause of look-alike medication errors. The aim of this literature review is to systematically evaluate the current evidence on strategies to minimize medication errors due to look-alike labels.MethodsA literature search of PubMed and EMBASE for all available years was performed independently by two reviewers. Original studies assessing strategies to minimize medication errors due to look-alike labels focusing on readability of labels by health professionals or consumers were included. Data were analyzed descriptively due to the variability of study methods.ResultsSixteen studies were included. Thirteen studies were performed in a laboratory and three in a healthcare setting. Eleven studies evaluated Tall Man lettering, i.e., capitalizing parts of the drug name, two color-coding, and three studies other strategies. In six studies, lower error rates were found for the Tall Man letter strategy; one showed significantly higher error rates. Effects of Tall Man lettering on response time were more varied. A study in the hospital setting did not show an effect on the potential look-alike sound-alike error rate by introducing Tall Man lettering. Color-coding had no effect on the prevention of syringe-swaps in one study.ConclusionsStudies performed in laboratory settings showed that Tall Man lettering contributed to a better readability of medication labels. Only few studies evaluated other strategies such as color-coding. More evidence, especially from real-life setting is needed to support safe labeling strategies.Electronic supplementary materialThe online version of this article (10.1007/s00228-018-2471-z) contains supplementary material, which is available to authorized users.

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“…Eleven studies evaluated the use of Tall Man lettering (Tables 1 and 2 and Table 3 (Appendix)) [18–20, 22, 24, 25, 27–29, 31, 32]. A wide range of different drug names were tested.…”

Section: Resultsmentioning

confidence: 99%

“…Studies investigating the effects of Tall Man lettering on response time are less conclusive. Only three out of nine experiments showed significant results in favor of Tall Man lettering [19, 24, 32]. Interestingly, Filik et al showed that response time depended whether or not participants knew about the purpose of Tall Man lettering [19].…”

Section: Discussionmentioning

confidence: 99%

A systematic literature review on strategies to avoid look-alike errors of labels

Larmené-Beld

Alting

Taxis

2018

Eur J Clin Pharmacol

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“…Look-alike drug names can be emphasised by different coloured tall-man lettering to reduce dispensing errors 8 13 17. A recent literature review also showed that nurses, other health providers and lay people can detect changes in LASA drug pairs more often and more quickly by tall man letters 18. The authors suggest that attentional allocation to tall man letters is involved with both bottom-up and top-down cognitive systems.…”

Section: Discussionmentioning

confidence: 99%

“…The bottom-up attentional system works in a fast and automatic manner regardless of a person's knowledge about the purpose of tall man lettering. The top-down attentional system should require knowledge of the tall man lettering scheme 18. However, new look-alike drug pairs and other factors also contributed to dispensing errors, and strategies are needed to prevent all of them.…”

Section: Discussionmentioning

confidence: 99%

Dispensing errors from look-alike drug trade names

et al. 2016

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ObjectivesTo improve patient safety, we investigated near-miss dispensing errors in our hospital and evaluated the effectiveness of specific preventive strategies.MethodsThe incidence and type of near-miss dispensing errors in a single hospital in Taiwan were identified in 2013. The causes of dispensing errors were analysed by consensus of an expert panel comprising a senior pharmacist on duty, a group leader in the pharmacy and an author. Because alphabetical trade names were routinely used in our pharmacy, they were used for similarity analysis. Trigram-2b and normalised edit distance (NED) were used to calculate orthographic similarity and distance measure, respectively. The correlation between drug-name confusion and dispensing errors was then studied. Preventive strategies, including the introduction of tall man letters, were completed at the end of 2013, and error data were then recollected in 2014. Differences between before and after the interventions were examined by t-test.ResultsBefore the intervention, look-alike alphabetical names were the main cause of dispensing wrong medicine (134/202, 66.3%). The frequency of near-miss dispensing errors correlated significantly with drug-name similarity (p<0.01). After implementation of preventive strategies, dispensing errors due to drug-name confusion were reduced significantly (77/140, 55.0%, p=0.004).ConclusionsThe frequency of near-miss drug dispensing errors correlated with greater similarity or lower NED scores, and dispensing errors related to drug-name confusion were significantly reduced by our interventions. However, other dispensing errors might need to be investigated in order to prevent them.

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“…Tall Man lettering highlights the differences between look-alike drug names due to use of a combination of lower and upper case letters. The use of Tall man lettering is recommended in several countries [ 14 – 16 ], although evidence of a beneficial effect for Tall Man lettering is limited [ 10 , 17 – 19 ]. Alerts in the pharmacy information system (PIS) warn the pharmacist or pharmacy technicians for possible drug name or strength confusion at the time of entering the prescription in the PIS.…”

Section: Introductionmentioning

confidence: 99%

Preventing dispensing errors by alerting for drug confusions in the pharmacy information system—A survey of users

Campmans

Rhijn²,

Dull³

et al. 2018

PLoS ONE

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IntroductionDrug confusion is thought to be the most common type of dispensing error. Several strategies can be implemented to reduce the risk of medication errors. One of these are alerts in the pharmacy information system.ObjectiveTo evaluate the experiences of pharmacists and pharmacy technicians with alerts for drug name and strength confusion.MethodsIn May 2017, a cross-sectional survey of pharmacists and pharmacy technicians was performed in community pharmacies in the Netherlands using an online questionnaire.ResultsOf the 269 respondents, 86% (n = 230) had noticed the alert for drug name confusion, and 26% (n = 67) for drug strength confusion. Of those 230, 9% (n = 20) had experienced that the alert had prevented dispensing the wrong drug. For drug strength confusion, this proportion was 12% (n = 8). Respondents preferred to have an alert for drug name and strength confusion in the pharmacy information system. ‘Alert fatigue’ was an important issue, so alerts should only be introduced for frequent confusions or confusions with serious consequences.ConclusionPharmacists and pharmacy technicians were positive about having alerts for drug confusions in their pharmacy information system and experienced that alerts contributed to the prevention of dispensing errors. To prevent alert fatigue, it was considered important not to include all possible confusions as a new alert: the potential contribution to the prevention of drug confusion should be weighed against the risk of alert fatigue.

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Tallman lettering as a strategy for differentiation in look-alike, sound-alike drug names: The role of familiarity in differentiating drug doppelgangers

Cited by 19 publications

References 24 publications

A systematic literature review on strategies to avoid look-alike errors of labels

A systematic literature review on strategies to avoid look-alike errors of labels

Dispensing errors from look-alike drug trade names

Preventing dispensing errors by alerting for drug confusions in the pharmacy information system—A survey of users

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