Systematic derivation of an Australian standard for Tall Man lettering to distinguish similar drug names
Rationale, aims and objectives - Confusion between similar drug names can cause harmful medication errors. Similar drug names can be visually differentiated using a typographical technique known as Tall Man lettering. While international conventions exist to derive Tall Man representation for drug n...
| Main Authors: | , , , |
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| Format: | Journal Article |
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Wiley-Blackwell Publishing
2015
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| Online Access: | http://hdl.handle.net/20.500.11937/32153 |
| _version_ | 1848753582224965632 |
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| author | Emmerton, Lynne Rizk, M. Bedford, G. Lalor, D. |
| author_facet | Emmerton, Lynne Rizk, M. Bedford, G. Lalor, D. |
| author_sort | Emmerton, Lynne |
| building | Curtin Institutional Repository |
| collection | Online Access |
| description | Rationale, aims and objectives - Confusion between similar drug names can cause harmful medication errors. Similar drug names can be visually differentiated using a typographical technique known as Tall Man lettering. While international conventions exist to derive Tall Man representation for drug names, there has been no national standard developed in Australia. This paper describes the derivation of a risk-based, standardized approach for use of Tall Man lettering in Australia, and known as National Tall Man Lettering. Method - A three-stage approach was applied. An Australian list of similar drug names was systematically compiled from the literature and clinical error reports. Secondly, drug name pairs were prioritized using a risk matrix based on the likelihood of name confusion (a four-component score) vs. consensus ratings of the potential severity of the confusion by 31 expert reviewers. The mid-type Tall Man convention was then applied to derive the typography for the highest priority drug pair names. Results - Of 250 pairs of confusable Australian drug names, comprising 341 discrete names, 35 pairs were identified by the matrix as an ‘extreme’ risk if confused. The mid-type Tall Man convention was successfully applied to the majority of the prioritized drugs; some adaption of the convention was required. Conclusion - This systematic process for identification of confusable drug names and associated risk, followed by application of a convention for Tall Man lettering, has produced a standard now endorsed for use in clinical settings in Australia. Periodic updating is recommended to accommodate new drug names and error reports. |
| first_indexed | 2025-11-14T08:26:48Z |
| format | Journal Article |
| id | curtin-20.500.11937-32153 |
| institution | Curtin University Malaysia |
| institution_category | Local University |
| last_indexed | 2025-11-14T08:26:48Z |
| publishDate | 2015 |
| publisher | Wiley-Blackwell Publishing |
| recordtype | eprints |
| repository_type | Digital Repository |
| spelling | curtin-20.500.11937-321532019-02-19T05:35:35Z Systematic derivation of an Australian standard for Tall Man lettering to distinguish similar drug names Emmerton, Lynne Rizk, M. Bedford, G. Lalor, D. errors standard look-alike Tall Man sound-alike drug confusion Rationale, aims and objectives - Confusion between similar drug names can cause harmful medication errors. Similar drug names can be visually differentiated using a typographical technique known as Tall Man lettering. While international conventions exist to derive Tall Man representation for drug names, there has been no national standard developed in Australia. This paper describes the derivation of a risk-based, standardized approach for use of Tall Man lettering in Australia, and known as National Tall Man Lettering. Method - A three-stage approach was applied. An Australian list of similar drug names was systematically compiled from the literature and clinical error reports. Secondly, drug name pairs were prioritized using a risk matrix based on the likelihood of name confusion (a four-component score) vs. consensus ratings of the potential severity of the confusion by 31 expert reviewers. The mid-type Tall Man convention was then applied to derive the typography for the highest priority drug pair names. Results - Of 250 pairs of confusable Australian drug names, comprising 341 discrete names, 35 pairs were identified by the matrix as an ‘extreme’ risk if confused. The mid-type Tall Man convention was successfully applied to the majority of the prioritized drugs; some adaption of the convention was required. Conclusion - This systematic process for identification of confusable drug names and associated risk, followed by application of a convention for Tall Man lettering, has produced a standard now endorsed for use in clinical settings in Australia. Periodic updating is recommended to accommodate new drug names and error reports. 2015 Journal Article http://hdl.handle.net/20.500.11937/32153 10.1111/jep.12247 Wiley-Blackwell Publishing fulltext |
| spellingShingle | errors standard look-alike Tall Man sound-alike drug confusion Emmerton, Lynne Rizk, M. Bedford, G. Lalor, D. Systematic derivation of an Australian standard for Tall Man lettering to distinguish similar drug names |
| title | Systematic derivation of an Australian standard for Tall Man lettering to distinguish similar drug names |
| title_full | Systematic derivation of an Australian standard for Tall Man lettering to distinguish similar drug names |
| title_fullStr | Systematic derivation of an Australian standard for Tall Man lettering to distinguish similar drug names |
| title_full_unstemmed | Systematic derivation of an Australian standard for Tall Man lettering to distinguish similar drug names |
| title_short | Systematic derivation of an Australian standard for Tall Man lettering to distinguish similar drug names |
| title_sort | systematic derivation of an australian standard for tall man lettering to distinguish similar drug names |
| topic | errors standard look-alike Tall Man sound-alike drug confusion |
| url | http://hdl.handle.net/20.500.11937/32153 |