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 multi- faceted approach to reduce the risk of look-alike and sound- alike 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 sound-alike 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 look- alike/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 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/PriorityProgram-06_NTMS last accessed 19 January 2012 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/PriorityProgram-06_NTMS last accessed 19 January 2012 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 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 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 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 US Food and Drug Administration (FDA). Name differentiation project 2001. http://www.fda.gov/Drugs/DrugSafety/MedicationErrors/ucm164587.htm last accessed 19 January 2012 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 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. 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. 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. 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. 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. David U and Cohen MR. A tall man lettering project to enhance medication safety. Farmacia hospitalaria 2011: 35(5): 223 – 224 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