Confusion of drug names arise especially because of look-alike or sound-alike name attributes are a major factor to medication related adverse effects. TALLman lettering is one of many risk mitigation strategies to minimize errors involving LASA drug names.
By applying TALLman lettering to drug names can alert the healthcare professional that the drug name can be confused with another drug name.
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[1]
The International Medication
Safety Network is working collaboratively to acknowledge and build the efforts to increase global consistency and thus minimize confusion, and facilitate implementation of consistent TALLman lettering among the pharmaceutical companies.
A systematic assessment[2] of the risk was done to find which of the drug name pairs would benefit most from the application of TALLman lettering as a new differentiation strategy. This assessment examined orthographic and phonetic (LASA : look-alike, sound alike)
similarities, clinical risk of confusability such as similar dosing, availability in similar dosage forms, similar routes of administration, use for similar indications or in similar clinical settings and potential or actual risk of harm should the two drugs be confused.
The confusable sections of the drug name pairs were identified and TALLman lettering was proposed, with consideration of psycho-linguistic factors, published international TALLman lists.
Unidoses' SmartPack software will print the TALLman drug name by default while packaging.
References
[1] Never Events for Hospital Care in Canada. Canadian Patient Safety Institute and Health Quality Ontario; 2015 Sept : http://www.hqontario.ca/Portals/0/documents/about/report-never-events-hospital-care-en.pdf
[2] Application of TALLman lettering for drugs used in oncology. ISMP 2010 : http://www.ismp-canada.org/download/safetyBulletins/ISMPCSB2010-08-
TALLmanforOncology.pdf
