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Principles for the Application of
TALLman Lettering in Canada
TALLman lettering is a method of applying uppercase lettering to sections of look-alike/sound-alike (LASA) drug names to bring attention to their points of dissimilarity.^1 By accentuating the points of difference, the application of TALLman lettering to a drug name may assist in alerting healthcare providers that the drug name in question may be confused with another drug name.^2 TALLman lettering may also assist with name recognition and comprehension by affecting the reader’s eye movements.^3 Its use does not rely on characteristics of type such as font or size. It can be used in any electronic system that accommodates uppercase and lowercase text options.
Several studies have provided evidence that highlighting sections of drug names with TALLman lettering may help to distinguish similar names,2,3,4,5^ however the evidence for its effectiveness in reducing drug name confusion errors remains mixed. Further research is needed to study the effectiveness of TALLman lettering application in practice environments. Determining the drug name pairs that would benefit from the technique and the optimal capitalization is complex. However, the implementation of TALLman lettering into practice is a simple and straightforward approach to distinguishing words that look similar. As a result, it has become an accepted differentiation strategy for LASA drug names in healthcare settings.^6 ,7,
In the United States, the Institute for Safe Medication Practices (ISMP) and the Food and Drug Administration (FDA) have done leading work on the topic of TALLman lettering.^9 Other members of the international safety community have also embraced this approach.^10 ,11,12,13^ In 2010, the Institute for Safe Medication Practices Canada (ISMP Canada) and the Canadian Association of Provincial Cancer Agencies (CAPCA) published a list of TALLman lettering recommendations to help distinguish the names of select oncology drugs.^14 Work by ISMP and ISMP Canada subsequent to a fatal incident has also resulted in the recommendation that TALLman lettering be applied to the drug name HYDROmorphone to help prevent mix-ups with morphine^15. Knowledge translation work by ISMP Canada and partners has resulted in the uptake of this recommendation across Canada.
To provide consistency locally, nationally, and potentially internationally, the approach to TALLman lettering should ideally be standardized. Global consistency could minimize confusion and facilitate implementation among stakeholders, such as pharmaceutical companies, for labelling and packaging at the manufacturing level.^12 The International Medication Safety Network (IMSN)^16 is leading collaborative work to acknowledge and build upon international efforts in this area. More specifically, the IMSN has proposed the use of TALLman lettering to improve differentiation among error-prone International Nonproprietary Names (INNs) of drugs. 12
ISMP Canada has developed the list of “TALLman Lettering for Look-Alike/Sound-Alike Drug Names in Canada” (presented below). Development of this list was guided by the following principles
Consistency in Application of TALLman lettering
TALLman lettering will have the greatest impact on the differentiation of LASA drug names if it is applied consistently. The list of “TALLman Lettering for Look-Alike/Sound-Alike Drug Names in Canada” was developed to provide consistency across the Canadian healthcare continuum (i.e., from manufacturers to end-users). Similar to international work in this area, the focus has been on confusable nonproprietary (generic) drug names, in particular prescription pharmaceuticals and
biologics.
TALLman lettering lists for confusable drug names have already been published in some other countries, e.g., the FDA and ISMP Lists of Look-alike Drug Names With Recommended Tall Man Letters (United States),^9 the National Tall Man Lettering List (Australia),^10 and the Tall Man Lettering List (New Zealand).^11 These lists were used as reference material for consideration in the local (Canadian) context.
Use of TALLman Lettering as a Differentiation Strategy
TALLman lettering is one of several risk-mitigation strategies that can be used to differentiate LASA drug name pairs.^17 ,18,
TALLman lettering is used in the context of a specific confusable pair or group of drug names.
The use of TALLman lettering should be limited to drug name pairs associated with high risk to patient safety^20.
TALLman lettering may be effective because it draws attention to drug names presented in this format^4 , and can act as a warning. Overuse of the technique may reduce its effectiveness^19 , as names may no longer appear novel.
The root causes for drug name confusion should be understood before TALLman lettering is considered as a potential solution. If the confusion arises from look-alike labelling or packaging or from knowledge deficits about drug names and their indications, alternative differentiation strategies should be applied.
Systematic risk assessment processes should be used to determine which drug name pairs would most benefit from TALLman lettering.10,11,13^ Risk criteria may include orthographic similarity (e.g., BI-SIM or EDIT distance scores^21 ); similarity of dosing, route of administration, dosage form, indication, or environment of use (e.g., intensive care unit); and frequency of use. Reported incidents involving harm or the potential for severe or catastrophic harm if the drugs are confused should also be considered.
TALLman lettering as a differentiation strategy has not been applied in the following situations, where alternative risk-mitigation strategies may be considered:
o combination products (e.g., bupivacaine vs. bupivacaine with epinephrine) o different salts of the same drug (e.g., ferrous gluconate vs. ferrous fumarate)
Approaches to TALLman lettering
In cases where drug name pairs have low orthographic similarity, the potential risk of harm and the clinical experience of practitioners should be considered before capitalization is applied. Orthographic factors that increase visual similarity include similar length of the names and number of groups of characters in the names.^22
Healthcare practitioners should be involved in the process of identifying confusable drug name pairs relevant to their respective practice settings. They should also participate in reviewing proposed TALLman options and assessing risk-reduction strategies to be implemented in their practice settings.^12 The user’s subjective perception of drug name similarity is an important consideration. The capitalized letters should make the drug names distinguishable from the user’s
o implementing bar coding or independent double checks (or both) for activities such as selection, dispensing, and administration of drugs14,
o reducing the potential for confusion between confusable name pairs by including both the brand and nonproprietary drug names on prescriptions or orders, medication administration records, automated dispensing cabinets, and computer databases and displays16, 18
o configuring the screens of computers and automatic dispensing cabinets to prevent the consecutive appearance of potentially confusable drug names 18
o including the dosage form, drug strength, complete directions, and indications for use on prescriptions or orders, to help differentiate LASA drug names^18
o storing products with LASA drug names in different locations^18
o exploring and implementing drug-specific risk-reduction strategies for confusable drug name pairs, 18 such as stocking different strengths of drugs with confusable names (e.g., morphine at 1 mg/mL and HYDROmorphone at 2 mg/mL)
Reference
(^1) Application of TALLman lettering for drugs used in oncology. ISMP Can Saf Bull. 2010 [cited 2015 Mar
24];10(8):1-4. Available from: http://www.ismp-canada.org/download/safetyBulletins/ISMPCSB2010-08- TALLmanforOncology.pdf (^2) Gerrett D, Gale AG, Darker IT, Filik R, Purdy KJ. Tall man lettering: final report of The use of tall man lettering
to minimise selection errors of medicine names in computer prescribing and dispensing systems. Loughborough (UK): National Health Service, NHS Connecting for Health; 2009 [cited 2015 Mar 15]. 52 pages. Available from: http://www.connectingforhealth.nhs.uk/systemsandservices/eprescribing/refdocs/tallman.pdf (^3) Filik R, Purdy K, Gale A, Gerrett D. Drug name confusion: evaluating the effectiveness of capital (“Tall Man”)
letters using eye movement data. Soc Sci Med. 2004;59(12):2597-2601. (^4) Filik R, Purdy K, Gale A, Gerrett D. Labeling of medicines and patient safety: evaluating methods of reducing
drug name confusion. Hum Factors. 2006;48(1):39-47. (^5) Filik R, Price J, Darker I, 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(8):677-687. (^6) Use of tall man letters is gaining wide acceptance. ISMP Med Saf Alert. 2008 Jul 31[cited 2015 Mar 20]. Available
from: 7 http://www.ismp.org/newsletters/acutecare/articles/20080731.asp 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(4):263- 266. (^8) Grissinger M. Tall man letters are gaining wide acceptance. P T. 2012 [cited 2015 Mar 19];37(3):132-133,148.
Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3351881/ (^9) FDA and ISMP lists of look-alike drug names with recommended tall man letters. Horsham (PA): Institute for Safe
Medication Practices; 2011 [cited 2015 Mar 24]. Available from: 10 https://www.ismp.org/tools/tallmanletters.pdf Australian Commission on Safety and Quality in Health Care. National tall man lettering list. Sydney (Australia): Commonwealth of Australia; 2011 [cited 2015 Mar 15]. Available from: http://www.safetyandquality.gov.au/wp- content/uploads/2012/02/National-Tall-Man-Lettering-Report-and-final-list1.pdf (^11) Health Quality & Safety Commission. Tall man lettering list report. Wellington (NZ): The Commission; 2013
Dec [cited 2015 Mar 15]. Available from: http://www.hqsc.govt.nz/assets/Medication-Safety/Tall-Man- lettering/Tall-Man-report-Dec-2013.PDF (^12) Position statement on improving the safety of international non-proprietary names of medicines (INNs). Horsham
(PA): International Medication Safety Network; 2011 Nov [cited 2015 Mar 25]. Available from: http://www.intmedsafe.net/wp-content/uploads/2014/05/IMSN_position_on_INNs_2011_10_24.pdf (^13) Otero López MJ, Martín Muñoz R, Sánchez Barba M, Abad Sazatornil R, Andreu Crespo A, Arteta Jiménez M, et
al. Development of a list of look-alike drug names with recommended tall man letters. Farm Hosp. 2011;35(5):225-
- 14 Institute for Safe Medication Practices Canada, Canadian Association of Provincial Cancer Agencies. Medication safety for drugs used in oncology: drug labelling and the application of TALLman lettering. Project report. Toronto (ON):ISMP Canada; 2010 Nov 8 [cited 2015 Mar 25]. Available from: http://www.ismp- canada.org/download/miscpub/ISMPCanada-CAPCA_Oncology_Drug_Safety_Project-2010Nov.pdf 15 An Omnipresent Risk of Morphine-Hydromorphone Mix-ups. ISMP Can Saf Bull. 2004 [cited 2015 Sept 1]; 4(6) 1-2. Available from: http://www.ismp-canada.org/download/safetyBulletins/ISMPCSB2004-06.pdf 16 International Medication Safety Network. About IMSN.Available from: http://www.intmedsafe.net/about/ (^17) Survey on LASA drug name pairs: who knows what’s on your list and the best ways to prevent mix-ups? ISMP
Med Saf Alert. 2009 May 21 [cited 2015 Mar 20]. Available from: http://www.ismp.org/newsletters/acutecare/articles/20090521.asp (^18) Or C, Wang H. A comparison of the effects of different typographical methods on the recognizability of printed
drug names. Drug Saf. 2014;37(5):351-359. (^19) Cohen MR, editor. Medication errors. 2nd ed. Washington (DC): American Pharmacists Association; 2007, p.
100-101. (^20) Emmerton L, Rizk MF. Bedford G, et al. Systematic derivation of an Australian standard for Tall Man lettering to
distinguish similar drug names. J Eval Clin Pract 2015;21(1):85-90.
