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Cover may 2012.indd
Are you short or TALL?
Reducing risk of drug errors
Medical Devices Trainer, Scarborough and
North East Yorkshire Healthcare NHS Trust
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
administration of drugs has been a risk for
patients. Over the years there have been many ideas about how to solve the problem.
Initially it was ‘leaving the ampoule on the
end of the syringe’; this then led to labelling
TALL? Reducing risk of drug errors. Technic
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
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
. 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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