List of most confused meds - TallManLetters.pdf - Institute for Safe Medication Practices FDA and ISMP Lists of Look-Alike Drug Names with Recommended

List of most confused meds - TallManLetters.pdf - Institute...

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©ISMP 2011.Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other reproduction is prohibitedwithout written permission from ISMP. Report actual and potential medication errors to the Medication Errors Reporting Program (MERP) via the Web ator by calling 1-800-FAIL-SAF(E).he look-alike drug names in the Tables that follow have beenmodified using tall man (mixed case) letters to help draw attentionto the dissimilarities in their names. Several studies have shown thathighlighting sections of drug names using tall man letters can helpdistinguish similar drug names,1making them less prone to mix-ups.2-3ISMP, FDA, The Joint Commission, and other safety-conscious organiza-tions have promoted the use of tall man letters as one means ofreducing confusion between similar drug names.Table 1provides an alphabetized list of FDA-approved established drugnames with recommended tall man letters, which were first identifiedduring the FDA Name Differentiation Project (DrugSafety/MedicationErrors/ucm164587.htm).Table 2provides an alphabetized list of additional drug names withrecommendations from ISMP regarding the use and placement of tallman letters. This is not an official list approved by FDA. It is intendedfor voluntary use by healthcare practitioners and drug informationvendors. Any product label changes by manufacturers require FDAapproval.One of the difficulties with the use of tall man letters includes incon-sistent application in health settings and lack of standardizationregarding which letters to present in uppercase. A new study byGerrett4describes several ways to determine which of the dissimilarletters in each drug name should be highlighted. To promote standardi-zation, ISMP followed one of these tested methodologies wheneverpossible. Called the CD3 rule, the methodology suggests working fromthe left of the word first by capitalizing all the characters to the rightonce two or more dissimilar letters are encountered, and then, workingfrom the right of the word back, returning two or more letters commonto both words to lowercase letters. When the rule cannot be appliedbecause there are no common letters on the right side of the word, themethodology suggests capitalizing the central part of the word only.ISMP suggests that the tall man lettering scheme provided in Tables 1and 2 be followed when presenting these drug names to healthcareproviders to promote consistency. At this time, scientific studies do notsupport the use of tall man letters when presenting drug names topatients.
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