In an industry where we strive for the highest outcomes in health care and patient safety, it is concerning that the Quality in Australian Healthcare Study showed that nearly 17% of 14,000 hospital admissions were associated with an adverse event, half of which were preventable.

When medicine errors are identified, if they are indeed identified, it can be easy to leap to conclusions about the cause of the error. There are, in fact, many stages involved prior to the patient consuming their medicine, for example:

Prescribing

This is the process where the medical practitioner decides upon, and names, the recommended medicine to a patient.

As the range of medicine choices continues to grow, one challenge for pharmaceutical companies is to ensure that their latest product is not only considered, but that the name is remembered; ultimately ensuring the prescription is generated. Industry experience establishes that new medicine names are more likely to be remembered if they offer a sense of familiarity, achieved by the spelling or pronunciation of the name in a similar way to an existing medicine. However, this practice also creates a risk of confusion between similar lookings, or similar sounding drug names.

Documentation

Completing the prescription or drug chart requires transfer of the medicine name from thought to paper, using either pen or computer. Without diligent attention, a similar (and more familiar) name may be substituted, particularly if selecting from a computer list showing both generic and brand names that may have little variation in spelling or appearance. The interpretation and processing of the prescription by the pharmacy has similar challenges.

Pharmacy dispensing records provide relatively accessible tools for measurement, and American studies have confirmed the potential for name confusion by calculating how often different medicines were processed for the repeats of ongoing prescriptions.

Selection and Administration

With most drug charts still written by hand, it is easy for nursing staff to interpret a medication name as matching those similar items that are familiar and/or accessible within imprest stock cupboards, rather than a more obscure product which must be ordered in.

The chances for this type of error expand for a pharmacist; with the interpretation applying to both generic and brand names, the adjacent positioning of many similar products on shelves, and the consistency of branding styles on packaging from the same manufacturer.

Risk Minimisation

The introduction of the Australian National Tall Man Lettering system by the Australian Commission on Safety and Quality in Health Care, is a strategy designed to help minimise the potential for errors as described above. It draws attention to the differences between medication names by using upper case letters for the parts of the product name, differentiating it from other similar names. For example;

  • propofol and propranolol become propOFol and propRANOLol; and
  • trimeprazine, trimethoprim, and trimipramine become trimEPRAZINE, trimETHOPRIM, and trimIPRAMINE.

The United States of America introduced the first Tall Man Lettering List in 2001, with subsequent global uptake. The list, however, must be tailored for each country to suit the particular medications available and their names. The Australian Commission on Safety and Quality in Health Care have so far created a list of 204 medicine names, which will need to be applied to the Tall Man Lettering style, focusing on those medications most likely to cause confusion with the potential for severe consequences.

Tall Man Lettering contributes towards safer naming, labelling and packaging of medicines as required by the National Safety and Quality Health Service (NSQHS) Standards for accreditation. It is recommended in Australia for inclusion in computer programs operated by healthcare professionals, particularly prescribing and dispensing software. It should also be used on printed shelf labels in pharmacies and imprest cupboards in wards. It is not recommended for hand written prescriptions or for patient use at this stage, as research is yet to determine its success rate amongst non-healthcare professionals.

Implementation

HPS Pharmacies’ innovation in developing our dedicated clinical management system, Hospharm®, has provided the flexibility to once again lead the industry in the implementation of quality improvements, such as the introduction of Tall Man Lettering.

In accordance with the guidelines, the changes will appear on the selection screen of our computers, client invoices and statements, drug lists, reports, and imprest shelf labels. The changes will not appear on patient dispensing labels or medication profiles. Some manufacturers have introduced Tall Man Lettering on the package labels, to facilitate accurate recall and selection.

While the concept of differentiating similar drug names is intuitively safer, and so has gained wide support within the healthcare industry, studies have shown the benefits are more certain when users are aware of the reasoning behind Tall Man Lettering, and consciously look for it. To this end, the more healthcare personnel who understand Tall Man Lettering, and discuss it with each other, the easier it will be to help us, help our patients.

References:

  1. 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.
  2. Phatak HM, Cady PS, Heyneman CA, Culbertson VL. Retrospective detection of potential medication errors involving drugs with similar names. J Am Pharm Assoc 2005; 45: 616-624.
  3. Van de Vreede M, McRae A, Wiseman M, Dooley MJ. Successful Introduction of Tallman Letters to Reduce Medication Selection Errors in a Hospital Network. J Pharm Pract Res 2008; 38: 263-6.
  4. Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Newby L, Hamilton JD. The quality in Australian health care study. Med J Aust 1995; 163: 458-71.

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