Survey on tall man lettering to reduce drug name confusion

ISMP is considering development of a list of look-alike drug name pairs with suggested tall man (mixed case) letters, to be used to guide practitioners and healthcare organizations in differentiating these products on pharmacy-generated labels, documents, and computer databases. We’d like your opinion regarding the usefulness of tall man letters, including those used in the name pairs below, which are among those most frequently reported mix-ups submitted to the Pennsylvania Patient Safety Reporting Program. Please submit your responses by June 27, 2008.

Please tell us whether you agree that the tall man letters used in the following drug name pairs (a-j) help differentiate the product names.

Question and Drug Name Pairs	Strongly Disagree	Disagree	Neutral or Don’t Know	Agree	Strongly Agree	Alternate Suggestions for Tall Man Lettering
a. HYDROcodone – oxyCODONE
b. oxyCODONE - oxyCONTIN
c. ALprazoLAM - LORazePAM
d. NovoLOG – NovoLIN
e. HumaLOG - HumuLIN
f. morphine - HYDROmorphone
g. morphine - HYDROmorPHONE
h. ceFAZolin – cefTRIAXONE
i. FLUoxetine - DULOXetine
j. clonazePAM - LORazePAM

Other name pairs that should appear on the list: (please specify)

In your facility, please tell us if tall man letters are used in conjunction with the stated items, and if YES, whether you feel this strategy is effective in reducing the risk of drug selection errors.

		Using tall man lettering
Question and Items	Not using tall man lettering	Not Effective	Partly Effective	Neutral or Don’t Know	Effective	Very Effective
a. Computer-generated pharmacy labels
b. Shelf labels
c. Computer drug selection screens (pharmacy)
d. Computer drug selection screens (prescriber)
e. Automated dispensing cabinet screens
f. Computer-generated medication administration records (MARs)
g. Preprinted order sheets/sets
h. Smart pump libraries

Do you believe the use of tall man letters by the medical product industry helps to reduce drug selection errors?
Yes No Not Sure

Please rank these methods of expressing unique letter characters in look-alike name pairs by using a numerical scoring system with 1 for the most effective method, 2 for the next most effective method, and so on until you have ranked the least effective method.

Upper case
Font differentiation
Color background
Italics
Underline
Reverse print
Other:

Answer question 5 only if you use tall man letters in your facility.

In your facility, please tell us if tall man letters are used in conjunction with the stated items, and if yes, please tell us whether you feel this strategy is effective in reducing the risk of drug selection errors.

If tall man letters are used at your facility:
a. Which drug name pairs are they used for?

Other (please specify):

b. For how many drug name pairs are you using tall man lettering differentiation? (each look-alike drug name pair counts as one)
1-16 17-25 26-36 > 37

c. Do you believe tall man lettering has prevented you from dispensing or administering the wrong medication?
Yes No Not sure

If you have an internal list of drug names with incorporated tall man letters, please email it to: ismpinfo@ismp.org