FDA and ISMP: Making them work with your Drug File Look-Alike Drug Names and Recommended Tall Man Letters

Why Tall Man Lettering Several studies have shown that highlighting sections of drug names using tall man letters can help distinguish similar drug names, making them less prone to mix-ups. ISMP, FDA, The Joint Commission, and other safety-conscious organizations have promoted the use of tall man letters as one means of reducing confusion between similar drug names.

Where do Tallman names need to be used? Anywhere that non-pharmacists see it –Quick Order Display Text Is seen on the EHR Medication Order menu –Orderable Item name Is seen by provider when the order dialog box is displayed –Drug Name Is seen by pharmacist during prescription processing Is seen by patient (on RX label) Is seen by all users on various medication lists –IV Additive/Solution Print Name Shows up on IV labels Shows up on MARs (inpatient)

Quick Order Menu

Medication Order Dialog

Drug File, etc. ELLERBY,SUSAN TAKE ONE (1) TABLET BY MOUTH EVERY DAY FOR BLOOD PRESSURE amLODIPine BESYLATE 5MG TAB #30 TAB RFx11 Rx SU USER,S. MD

Limitations of RPMS RPMS alphabetizes upper case letters differently than lower case letters Causes problems with searches because drugs do not appear in the list where expected No clear solution at present but creating a synonym in ALL CAPS appears to work

Orderable Item Now editing Orderable Item: amLODIPine TAB Orderable Item Name: amLODIPine// This Orderable Item is Non-Formulary. This Orderable Item is marked as a Non-VA Med. Select OI-DRUG TEXT ENTRY: INACTIVE DATE: DAY (nD) or DOSE (nL) LIMIT: MED ROUTE: SCHEDULE TYPE: SCHEDULE: QDAY// PATIENT INSTRUCTIONS: FBP// Select SYNONYM: ? Answer with SYNONYM Choose from: AMLODIPINE

Predictable Mis-alphabetization All-Caps Synonym Drug name with small letter at front

IV Additive/Solution Print Names (for sites using the IV package) This is the way the drug name appears on the IV label PRINT NAME: CefTRIAXone 1GM// GENERIC DRUG: CefTRIAXone 1GM INJ// USED IN IV FLUID ORDER ENTRY: NO// DRUG UNIT: GM// NUMBER OF DAYS FOR IV ORDER: 7// USUAL IV SCHEDULE: Q24H// ADMINISTRATION TIMES: Select QUICK CODE: AVERAGE DRUG COST PER UNIT: 2.18// Select ELECTROLYTE: Select SYNONYM: CEFTRIAXON// (Limited to 10 characters) DRUG INFORMATION: No existing text Edit? NO// INACTIVATION DATE: CONCENTRATION: MESSAGE: Edit Additives or Solutions:

Questions?