Successful Introduction of Tallman Letters to Reduce

RESEARCH
Successful Introduction of Tallman Letters to Reduce
Medication Selection Errors in a Hospital Network
Melita Van de Vreede, Amy McRae, Meredith Wiseman, Michael J Dooley
ABSTRACT
Aim: To implement Tallman letters into the medication selection
process at a hospital network, including dispensing and drug
administration, to reduce errors associated with look-alike
sound-alike (LASA) drugs.
Method: The 3 phases of the study were overseen by a working
party consisting of pharmacists at the Alfred Hospital (May
2006 to May 2008). The 3 phases consisted of piloting Tallman
letters in the pharmacy department, developing a LASA drug
list appropriate to the hospital network, and implementing
Tallman letters into the hospital network’s medication selection
process.
Results: A short LASA drug list was piloted in the inpatient
dispensary for 6 months. When this was considered successful,
a comprehensive LASA drug list was developed that consisted
of 51 items to distinguish between generic names (n = 41),
brand names (n = 6) and generic and brand name combinations
(n = 4). Tallman letters were included into the pharmacy
dispensing software. Finally, Tallman letters were implemented
across the 3 hospitals in the network, i.e. 7 dispensaries and 40
ward medication storage areas.
Conclusion: Tallman letters were successfully introduced and
implemented into a hospital network. This was achieved with
the expenditure of minimal resources and has improved safety
by minimising the risk of selecting the wrong medication.
J Pharm Pract Res 2008; 38: 263-6.
INTRODUCTION
Numerous studies have identified that medication errors
and adverse drug events result in considerable patient
harm and are a cost to the community. 1-3 Therefore,
strategies need to be implemented that decrease the risk
of medication errors by identifying the root cause and
contributory factors, and introducing system-based
improvements.4,5
One well recognised root cause of medication errors
are look-alike sound-alike (LASA) drugs.5,6 The LASA
component may be a generic or active ingredient name, a
trade name or the product packaging (outer or inner
container, e.g. foil pack, ampoule, label). The LASA drug
name may cause confusion and result in the incorrect
medication being prescribed, transcribed or selected
during dispensing or administration, if the products are
stored adjacent to each other.
Melita Van de Vreede, BPharm, GradDipHospPharm, MHSM, QUM Manager,
Alfred Health, currently Deputy Director of Pharmacy (QUM), Box Hill
Hospital, and QUM Pharmacist, Eastern Health, and Honorary Research Fellow,
Department of Pharmacy Practice, Monash University, Amy McRae, BPharm,
Medication Safety Pharmacist, Meredith Wiseman, BPharm, Senior Pharmacist,
Alfred Health, Michael J Dooley, BPharm, GradDipHospPharm, FSHP, Director
of Pharmacy, Alfred Health, and Professor of Clinical Pharmacy, Department of
Pharmacy Practice, Monash University, Parkville, Victoria
Address for correspondence: Melita Van de Vreede, Pharmacy Department,
Box Hill Hospital, Box Hill Vic. 3128, Australia.
E-mail: melita.vandevreede@easternhealth.org.au
Journal of Pharmacy Practice and Research Volume 38, No. 4, 2008.
One strategy that can reduce the risks associated
with LASA drugs is the application of Tallman letters.7
For Tallman lettering, the dissimilar letters in two LASA
drug names are highlighted (upper case, bolded), so as
to distinguish between them (e.g. azATHIOprine and
azITHRomycin) and avoid confusion. Tallman letters can
be used on medication labels and be incorporated into
the electronic prescribing or dispensing systems, so that
they are visible when LASA drug names are viewed on
the computer screen.
At the start of 2006, a review of several medication
errors at Alfred Health, a 700-bed tertiary teaching
hospital network in Melbourne, identified that a
significant contributory factor was that the drugs had
look-alike or sound-alike names. The network’s
Medication Safety Committee completed the Medication
Safety Self Assessment, which recommended the
implementation of Tallman letters as a safety strategy.7
This study aimed to implement Tallman letters into
medication selection processes, including dispensing
and drug administration, to reduce errors associated with
LASA drugs.
METHOD
The study consisted of three distinct phases, which were
overseen by a working party of clinical and Quality Use
of Medicine pharmacists at the Alfred Hospital.
Phase 1: Pilot Tallman Letters in the Pharmacy
Department
In phase 1, a short LASA drug list with Tallman letters
was piloted in the inpatient dispensary. Tallman letter
labels of the drug names were generated by free text and
included the drug strength and form in small font. These
were printed on yellow adhesive labels and cut to size
for clear plastic shelf labels and added to shelving by
the working party (Figure 1). The Tallman letter labels
were placed directly below the existing label (drug name
and barcode) to avoid confusion with the adjacent
medications and also to make the LASA drugs visible
from a distance.
Phase 2: Develop a Look-Alike, Sound-Alike Drug List
The working party agreed that a LASA drug list tailored
to the hospital network was required. This LASA drug
list was developed by the working party via the following
process:
• review the existing published Tallman letter lists;8-10
• review the hospital network’s medication errors and
near-miss reports, including the voluntary error
(Riskman) reports and internal documentation of
pharmacy dispensing near-misses where LASA
drugs may have been a contributory factor;
• compile an initial drug list;
• identify the drugs for Tallman lettering;
263
Figure 1. Example of Tallman letter labelling in the pharmacy department’s inpatient dispensary
•
•
•
input from pharmacy staff on the selected LASA drug
list and the letters for Tallman lettering;
develop with the hospital pharmacists principles for
selecting the letters of the LASA drug names to be
Tallman lettered (if there was disagreement, the
working party continued discussions until
consensus was reached); and
develop an expanded LASA drug list for ward storage
areas after feedback from nursing staff.
Phase 3: Implement Tallman letters in the Medication
Selection Process
The three key areas in the medication selection process
identified for implementation of Tallman letters were:
• shelf-labelling in the dispensaries;
• shelf-labelling in the ward imprest cupboards; and
• pharmacy dispensing software (iPharmacy).
Tallman letter labels were generated for all areas on
yellow labels. Tallman letters were incorporated into the
pharmacy dispensing software (iPharmacy) by typing into
the specific drug and/or brand name of the master drug
file (relevant generic names and brand names if the brand
name included a generic name component). The inclusion
of Tallman letters into iPharmacy resulted in Tallman
letters also printing on the aseptic batch working sheets
(to guide product manufacture by staff), another area
where the selection of the wrong product can also be
reduced. The pharmacy and nursing staff were provided
education on the safety rationale and the principles for
the use of Tallman letters.
RESULTS
Phase 1: Pilot Tallman Letters in the Pharmacy
Department
The pilot of shelf-labelling in the inpatient dispensary
commenced in May 2006 with the labelling of 20 LASA
drugs. Pharmacy staff were enthusiastic about the
Tallman letters and requested extra products for Tallman
lettering after nearly selecting the wrong drug. The pilot
264
was considered successful and the working party agreed
to continue with the implementation of Tallman letters
across the hospital network.
Phase 2: Develop Look-Alike Sound-Alike Drug List
A review of the hospital network’s medication error and
near-miss reports identified LASA drugs, such as Hydrea
and Hydrene; Xalatan and Xalacom; azathioprine and
azithromycin; valaciclovir and valganciclovir; amiodarone
and amlodipine; nimodopine and nifedipine. The initial
short LASA drug list of 20 names was expanded after
feedback from pharmacists and nursing staff. The final list
consisted of 51 items to distinguish between generic
names (n = 41), brand names (n = 6) and generic and brand
name combinations (n = 4) (Table 1).
The guiding principles developed for selecting the
letters for Tallman lettering were:
• highlight three to five letters that were different;
• choose, if possible, letters that formed a syllable; and
• highlight letters closest to the beginning of the word
that were different, to facilitate correct selection when
electronic drop-down menus are used.
Phase 3: Implement Tallman Letters in the Medication
Selection Process
Over three weeks, Tallman letter labels were prepared for
all three hospitals in the network by a working party
member. At the Alfred Hospital, labels were added to
dispensary shelves by one pharmacist over one afternoon
for all five dispensaries, and the shelf-labelling in the
ward imprest cupboards was completed by three
pharmacists in quiet times for periods of one to two hours
over two weeks.
Tallman letter labels were placed in all ward
medication storage areas in the first ward at the Alfred
Hospital in August 2007 and then rolled out to 20 wards
in November 2007. In May 2008, the dispensaries and all
imprest sites at the two other hospitals were labelled over
two days by two pharmacists.
Journal of Pharmacy Practice and Research Volume 38, No. 4, 2008.
Table 1. Tallman lettering implemented at the Alfred Health network (n = 51)
Drug name
Tallman lettering
Drug name
Tallman lettering
Azathioprine
AzATHIOprine
Glimepiride
GliMEPiride
Azithromycin
AzITHRomycin
Ifosfamide
IFOSfamide
Amiodarone
AmIODARone
Cyclophosphamide
CYCLOphosphamide
Amlodipine
AmLODIPine
Hydroxyurea
HyDREA
Bimatoprost (Lumigan)
BimatoPROST (LUMIgan)
Hydrochlorothiazide/ triamterene
HyDRENE
Brimonidine (Alphagan)
BrimoniDINE (ALPHAgan)
Mencevax
MenCEVax
Cefaclor
CefaCLOr
Meningitec
MenINGitec
Cephalexin
CephaLEXin
Nizatidine
NiZATidine
Cefoxitin
CefoXITin
Nifedipine
NiFEDipine
Ceftazidime
CefTAZidime
Nimodipine
NiMODipine
Cefepime
CefEPIMe
Novomix
NovoMIX
Cefotaxime
CefOTAXime
Novorapid
NovoRAPID
Cephalothin
CephaLOTHin
Promethazine
ProMETHazine
Cephazolin
CephaZOLin
Prochlorperazine
ProCHLORperazine
Ceftriaxone
CefTRIaxone
Prazosin
PraZOSin
Colchicine
CoLCHICine
Pravastatin
PraVAStatin
Cortisone
CoRTISone
Rifampicin
RifaMPICIN
Dobutamine
DOBUTamine
Rifabutin
RifaBUTIN
Dopamine
DOPamine
Salbutamol
SalBUTamol
Daunorubicin
DAUNOrubicin
Salmeterol
SalMETerol
Doxorubicin
DOXOrubicin
Vinblastine
VinBLAStine
Fluoxetine
FluOXETine
Vincristine
VinCRIStine
Fluvoxamine
FluVOXamine
Valaciclovir
ValACIclovir
Glibenclamide
GliBENclamide
Valganciclovir
ValGANciclovir
Gliclazide
GliCLAzide
Xalatan
XalaTAN
Glipizide
GliPIzide
Xalacom
XalaCOM
The inclusion of Tallman letters into iPharmacy was
completed by one pharmacist with access to the master
file and crystal reports over three hours. Due to the nature
of iPharmacy, only capitalisation of the selected letters
was possible as all drug and brand names are
automatically printed in bold. Once completed, this
functionality was available to all dispensing sites in the
hospital network. Tallman lettering was not included on
dispensing labels as it was believed this may cause
confusion.
DISCUSSION
There are a range of strategies to reduce errors and the
most effective intervention is to remove the risk.11 As
this is not an option for many drugs, the next most
effective intervention is to introduce a prompt or
checklist, such as Tallman letters, that guides and reminds
staff of the correct procedure.
The implementation of Tallman letters into an
Australian hospital network was a simple quality
improvement initiative. Pharmacy staff indicated that
medication selection errors were prevented by the
implementation of Tallman letters. Tallman lettering is
inexpensive, easy to sustain and likely to reduce the risk
of medication selection errors, even though the actual
impact on the reduction of errors was not measured.
Journal of Pharmacy Practice and Research Volume 38, No. 4, 2008.
The use of Tallman letters is well established in the
US, but is not widely known or used in Australia. The
problem with LASA drugs was publicised by the US
Joint Commission on Accreditation for Healthcare who
issued a Sentinel Event Alert in 2001.11 Risk reduction
strategies recommend minimising the purchase of LASA
products and storing them out of alphabetical order.
Although this strategy may reduce the risk of incorrect
medication selection, it may prevent staff from locating
the correct product, and consequently patients may not
receive their medication on time. This issue was given
prominence in 2007 when the Joint Commission included
a patient safety goal (Goal 3) for hospitals – ‘Identify
and, at a minimum, annually review a list of look-alike/
sound-alike drugs used by the organisation, and take
action to prevent errors involving the interchange of
these drugs’.12
The LASA drug list recommended in the US is
partially useful in Australia. Australian hospitals use the
generic names in preference to brand names, which can
vary from those used in the US. In addition, a smaller
range of drugs is marketed in Australia.
The list of LASA drugs for Tallman lettering chosen
at Alfred Health was developed from the drugs stocked
at this institution. At Alfred Health, the LASA drug list
will be reviewed periodically as the formulary list is
changed and medication errors or near-misses with LASA
drugs are reported.
265
The decision as to which letters to highlight required
considerable discussion and the actual letters were
chosen by consensus. However, once these decisions
were made the rollout of the Tallman letters across all
areas was simple, resources required were minimal, the
labels were generated in quiet periods and gradually
implemented on the wards by staff.
It is envisaged that although these improvements
are sustainable, they will require ongoing enthusiasm
and the vigilance of an individual responsible for updating
changes as they arise. This responsibility has been
allocated to the hospital network’s Medication Safety
Pharmacist.
The concerns with LASA drugs is international and
although several patient safety organisations have issued
alerts and introduced strategies they do not address the
root cause, i.e. registration of similar drug names, labels
and packaging. The ultimate solution would be to prevent
any medication with a LASA drug name being registered
for marketing and ensure that labels and packaging are
designed to minimise the risk of confusion.
The UK National Patient Safety Agency has
produced a guide for the design of dispensed medicines,
which outlines product labels and packaging to reduce
the risk of LASA errors.14 In Australia, the Therapeutics
Goods Administration in conjunction with stakeholders
has produced a guideline for best practice prescription
labelling to guide pharmaceutical sponsors about
acceptable labels and packaging.15 However, changing
labels and packaging will take time and may impose a
considerable cost if sponsors have to purchase new
machinery to fulfil the requirements. Furthermore,
cooperation between manufacturers is needed to ensure
similar product packaging and brand names are not
proposed for registration.
The solution needs to be global as products are
marketed by pharmaceutical companies in numerous
countries. The International Network of Safe Medication
Practice Centres has been formed to improve global
medication safety and prevent medication errors. One of
their recommendations is an update of the manufacturing
regulations for mandatory pre-testing of nomenclature,
labels and packaging for safety prior to marketing.
Tallman lettering can be implemented at all facilities
where medications are stored and could have a national
impact on reducing medication errors. A national list of
LASA drugs for Tallman lettering should be considered
as well as Tallman lettering of national labelling and
packaging requirements, dispensing software, electronic
prescribing and decision support and progressed
internationally to ensure a sustainable improvement to
patient safety.
In conclusion, Tallman letters were successfully
introduced an implemented into a hospital network. This
was achieved with the expenditure of minimal resources
and has improved safety by minimising the risk of
selecting the wrong medication and has been
enthusiastically embraced by staff.
2. Australian Council for Safety and Quality in Health Care. Second national
report on patient safety: improving medication safety. Canberra: Australian
Council for Safety and Quality in Health Care; 2002.
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incidence and nature of in-hospital adverse events: a systematic review. Qual
Saf Health Care 2008; 17: 216-23.
4. Helmreich RL. On error management: lessons from aviation. BMJ 2000; 320:
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Drug Saf 2003; 26: 445-52.
6. McCoy LK. Look-alike, sound alike drugs review. J Qual Pat Saf 2005; 31:
47-53.
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assessment for hospitals. Horsham: Institute for Safe Medication Practices; 2004.
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Rockville: Center for Drug Evaluation and Research; 2006. Available from
<www.fda.gov/cder/drug/MedErrors/nameDiff.htm>. Accessed 24 June 2006.
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editorial rules. Version 2.0. Appendix I 10.1.2: Tallman lettering convention–
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— looking beyond what meets the eye. Pat Saf Advisory 2007; 4: 69, 73-7.
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advisory_v4_n3.pdf>. Accessed 11 January 2008.
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Root cause analysis and risk reduction action plan summaries. Melbourne:
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clinrisk/sentinel/rca.htm>. Accessed 11 January 2008.
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Alert 2001; 19 (May). Available from <www.jointcommission.org/Sentinel
Events/SentinelEventAlert/sea_19.htm>. Accessed 13 July 2008.
13. The Joint Commission. National patient safety goals. Goal 3. Oakbrook
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/PatientSafety/NationalPatientSafetyGoals/08_amb_npsgs.htm>. Accessed 13
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design of dispensed medicines. London: National Patient Safety Agency; 2008.
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design/dispensed-medicines/>. Accessed 13 July 2008.
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from <www.tga.health.gov.au/pmeds/pmbestpractice.htm>. Accessed 13 July 2008.
Received: 13 August 2008
Revisions requested after external review: 23 September 2008
Revised version received: 17 October 2008
Accepted: 13 November 2008
Acknowledgment
The authors would like to acknowledge all of the Alfred Health pharmacy staff
who gave their input into the medications and letters for Tallman lettering.
Competing interests: None declared
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