Does Tall Man lettering prevent drug name confusion errors? Incomplete and conflicting evidence suggest need for definitive study

Wrong-drug errors, thought to be caused primarily by drug names that look and/or sound alike, occur at a rate of about one error per thousand dispensed prescriptions in the outpatient setting and one per thousand orders in the inpatient setting.1 2 Most are relatively benign, but some cause severe or even fatal harm.3–5 One of the best known attempts to reduce drug name confusion has been the use of mixed case or ‘Tall Man’ lettering.6 The idea is to use capital letters to maximise the visual perceptual difference between two similar drug names. Thus, vinblastine and vincristine become vinBLAStine and vinCRIStine. If some look-alike/sound-alike (LASA) mix-ups are caused by errors in visual perception, the reasoning goes, then making the names more visually distinct should reduce the probability of confusion and error. After being endorsed by the US...

Source: Quality and Safety in Health Care - March 17, 2016 Category: Health Management Authors: Lambert, B. L., Schroeder, S. R., Galanter, W. L. Tags: Editor's choice, BMJQS Noteworthy articles Editorials Source Type: research