Cover may 2012.indd

Clinical
Are you short or TALL?
Reducing risk of drug errors
Keith Underwood
Medical Devices Trainer, Scarborough and North East Yorkshire Healthcare NHS Trust Abstract
Drug errors pose great risks to patients, that uses capital letters to distinguish similar. However, the system itself is not standardised, and this is a necessary next step to further minimise drug errors and Ever since I began working in the operating Key words
administration of drugs has been a risk for patients. Over the years there have been many ideas about how to solve the problem. Reference
Initially it was ‘leaving the ampoule on the end of the syringe’; this then led to labelling TALL? Reducing risk of drug errors. Technic 3(3): 6-7.
provided detachable labels that could be taken off the ampoule and placed directly onto the syringe. Others provided a strip of Figure 1. Tal man lettering systems vary between labels within the box (Figure 1). Eventually manufacturers label manufacturers started to provide a standardised labelling system for drugs; this in the emergency environment, where a included a colour coding system for the team approach is used for the maximum category of drug, such as muscle relaxants, care of a patient, and individual tasks are opioids, and local anaesthetics – this will be given to individual staff members. In these discussed later. As time went on discussions led to up might not be the one giving it, so to recommendations, and now policies, on this end, a procedure must be in place who should draw up and administer drugs. to facilitate first- and second-person drug In today’s clinical practice, the individual checks prior to administration. giving the drug should be the one drawing Even with the practices described above, it up. This practice may need to be adapted there is a risk of incorrect drugs being administered, particularly in emergency and highly stressed environments. Box 1. Sample of drug names
stored in the Alaris GH+
lettering Scarborough and North East Yorkshire Healthcare NHS Trust decided to use Tallman lettering (Figure 1) in pre-programming 30 Technic: The Journal of Operating Department Practice May 2012 Volume 3 Issue 3 Clinical
driver (Figure 2) when the device was being states: ‘The findings that error in practice is more likely to occur with dose, formulations or a According to Wikipedia, ‘Tall Man lettering combination of these with look-alike medicines (or Tallman lettering) is the practice of writing names highlights the need for broader research.’ part of a drug’s name in upper case to help distinguish sound-alike, look-alike drugs from one another in order to avoid medication The majority of people working in anaesthetics errors. For example, in Tall Man lettering, should be aware of the label ing system being ‘prednisone’ and ‘prednisolone’ should be written ‘predniSONE’ and ‘prednisoLONE’, developed after a joint initiative on syringe respectively. The Office of Generic Drugs label ing in critical care areas undertaken by a number of professional associations encourages manufacturers to use Tall Man Tallman for the electronic pharmacy list for (Royal College of Anasthetists et al, 2003). lettering labels to visually differentiate their wards and departments. However, the way It categorises drug types and colour codes drugs’ names, and a number of hospitals, the computer program works means it is them accordingly; for example, al muscle clinics, and healthcare systems use Tall becoming an impractical method of searching relaxants are label ed red, while narcotics Man lettering in their computerised order for drugs. This is because the standard method are blue. Walters Medical, one of the biggest entry, automated dispensing machines, of searching for drugs is by an alphabetical list, drug label ing companies in the UK, has medication admission records, prescription which searches for capital letters first and then stated that it had no plans to produce labels labels, and drug product labels’.
for lower case. This means that in the sample with Tal man lettering, mainly because it had To ensure trust staff were aware of the list shown in Box 1, for example, DOPamine not been asked to do so. However, after introduction of Tallman lettering across the would be in the first half of the complete list being approached to discuss the issue the trust, the system was discussed as part of and doPEXamine would be in the second company is seeking further information on the device training for the rollout of the half, even though both begin with the same Tallman lettering and the potential for it to be new syringe driver. However, it was felt letter – the search would recognise the D of incorporated within its labelling system.
that it would be helpful to disseminate DOPamine but the P of doPEXamine. This can the information in an additional format so lead to some confusion when searching on an Conclusion the fol owing information was placed in electronic pharmaceutical list. the staff newsletter. ‘Tallman Lettering was To make searching drug names using labelling drugs to help to minimise drug introduced into the pharmaceutical industry Tal man lettering practicable, the search errors within clinical practice. Label ing can be some time ago, and is advocated by the protocol within al computer programs would electronic within medical devices, but should National Patient Safety Agency (NPSA). You will need to understand that lower and uppercase also incorporate appropriate label ing of the find it becoming more frequently used within letters could be mixed alphabetical y to form syringe itself, and should also incorporate the pharmaceutical industry, and it is being one long list. Having said that, in the clinical a first- and second-person drug check, incorporated not only in infusion devices, but area and on drug libraries associated with irrespective of who is administering the drug. also on the electronic pharmacy lists for wards devices in our trust, this does not tend to I am convinced that using Tal man lettering and department and also on the label ing be a problem. The devices that have been wil help to reduce drug errors in the clinical of the drug boxes themselves… the Alaris checked have an A-to-Z library and sort drug area. However, if we are to achieve this, GH+ syringe drivers within our trust have 30 names irrespective of capitalisation.
we need a standardised system of Tallman pre-programmed drug names, they include; The Medicines and Healthcare products lettering. As Figure 1 illustrates, there are at AMINOphyl ine, AMIODArone, DOBUTamine, Regulatory Agency (MHRA) website has a least three different styles, and this in itself DOPamine, doPEXamine, FUROSemide, section entitled ‘Labels, patient information could lead to drug errors. Standardisation in NORadrenaline. So, if you see drug names with leaflets and packaging for medicines’, which Tal man lettering would not only need to be unusual typeface setting, it is not a misprint, it looks specifically at Tallman lettering and shows adopted by the pharmaceutical industry, but is there to help you correctly identify the drug of some examples. The website also includes also the computer programming companies choice so making the administration safer.’ a link to Best Practice Guidance on Labelling – irrespective of if they are specialist medical and Packaging of Medicines, which goes into programmers or bigger corporations like greater detail on al aspects related to label ing Microsoft.
of drugs and there packaging (MHRA, 2003).
As Figure 1 illustrates, there is no consensus Garrett et al (2009) conducted a study for References among drug manufacturers on how Tallman NHS Connecting for Health investigating Gerrett D, Gale AG, Darker IT et al. (2009) Tall Man Lettering. Loughborough: Loughborough University Enterprises. lettering is used. Different systems include: drug errors before and after the introduction of Tal man lettering. Part of their conclusion Medicines and Healthcare products Regulatory Agency (2003) Best Practice Guidance on Labelling and Packaging of states: ‘Given the results of the experiments the Medicines. London: MHRA. tinyurl.com/MHRA-labelling authors would advocate a pragmatic approach Royal Colege of Anaesthetists, Association of Anaesthetists of l Combining colour and capitalisation or with the implementation of a specific rule-based Great Britain and Ireland, Faculty of Accident and Emergency Tall Man variant for a limited and specified Medicine, Intensive Care Society (2003) Syringe Labelling in The trust’s pharmacy department has used set of look-alike, sound-alike medicines.’ It also Intensive Care Areas. London: RCA. tinyrul.com/AA-labelling Technic: The Journal of Operating Department Practice May 2012 Volume 3 Issue 3

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