Tallman lettering
From Rx-wiki
Tallman lettering (or Tall Man lettering) is the practice of writing part of a drug's name in upper case letters to help distinguish sound-alike, look-alike drugs from one another in order to avoid medication errors. Several studies have shown that highlighting sections of drug names using tallman letters can help distinguish similar drug names, making them less prone to mix-ups. ISMP, FDA, The Joint Commission, and other safety-conscious organizations have promoted the use of tallman letters as one means of reducing confusion between similar drug names.
Below are two lists with recommendations for the use of tallman lettering. The first list is of FDA-approved established drug names with recommended tallman letters, which were first identified during the FDA Name Differentiation Project. The second list is of additional drug names with recommendations from ISMP regarding the use and placement of tallman letters.
FDA's list
The following is a Food and Drug Administration approved list of generic drug names with tallman letters. The medications have been grouped to emphasize which medications are commonly mistaken by having sound sound-alike, look-alike names.
Established Name | Recommended Name |
acetohexamide acetazolamide |
acetaHEXAMIDE acetaZOLAMIDE |
bupropion buspirone |
buPROPion busPIRone |
chlorpromazine chlorpropamide |
chlorproMAZINE chlorproPAMIDE |
clomiphene clomipramine |
clomiPHENE clomiPRAMINE |
cyclosporine cycloserine |
cycloSPORINE cycloSERINE |
daunorubicin doxorubicin |
DAUNOrubicin DOXOrubicin |
dimenhydrinate diphenhydramine |
dimenhyDRINATE diphenhydrAMINE |
dobutamine dopamine |
DOBUTamine DOPamine |
glipizide glyburide |
glipiZIDE glyBURIDE |
hydralazine hydromorphone hydroxyzine |
hydrALAZINE HYDROmorphone hydrOXYzine |
medroxyprogesterone methylprednisolone methyltestosterone mitoxantrone |
medroxyPROGESTERone methylPREDNISolone methylTESTOSTERone mitoXANTRONE |
nicardipine nifedipine |
niCARdipine NIFEdipine |
prednisone prednisolone |
predniSONE prednisoLONE |
risperidone ropinirole |
risperiDONE rOPINIRole |
sulfadiazine sulfisoxazole |
sulfADIAZINE sulfiSOXAZOLE |
tolazamide tolbutamide |
TOLAZamide TOLBUTamide |
vinblastine vincristine |
vinBLAStine vinCRIStine |
ISMP's list
The following is an Institute for Safe Medication Practices recommended list of drug names with tallman letters. The medications have been grouped to emphasize which medications are commonly mistaken by having sound sound-alike, look-alike names.
Established Name | Recommended Name |
alprazolam lorazepam |
ALPRAZolam LORazepam |
amiloride amlodipine |
aMILoride amLODIPine |
aripirazole rabeprazole |
ARIPiprazole RABEprazole |
Avinza Invanz |
AVINza INVanz |
azacitidine azathioprine |
azaCITIDine azaTHIOprine |
carbamazepine oxcarbazepine |
carBAMazepine OXcarbazepine |
carboplatin cisplatin |
CARBOplatin CISplatin |
cefazolin cefotetan cefoxitin ceftazidime ceftriaxone |
ceFAZolin cefoTEtan cefOXitin cefTAZidime cefTRIAXone |
Celebrex Celexa |
CeleBREX CeleXA |
chlordiazepoxide chlopromazine |
chlodiazePOXIDE chlorproMAZINE |
clonazepam clonidine clozapine Klonopin lorazepam |
clonazePAM cloNIDine cloZAPine KlonoPIN LORazepam |
dactinomycin daptomycin |
DACTINomycin DAPTOmycin |
docetaxel paclitaxel |
DOCEtaxel PACLitaxel |
doxorubicin idarubicin |
DOXOrubicin IDArubicin |
duloxetine fluoxetine paroxetine |
DULoxetine FLUoxetine PARoxetine |
ephedrine epinephrine |
ePHEDrine EPINEPHrine |
fentanyl sufentanil |
fentaNYL SUFentanil |
flavoxate fluphenazine fluvoxamine |
flavoxATE fluPHENAZine fluvoxaMINE |
guaifenesin guanfacine |
guaiFENesin guanFACINE |
Humalog Humulin |
HomaLOG HumuLIN |
hydrocodone oxycodone Oxycontin |
HYDROcodone oxyCODONE OxyCONTIN |
hydromorphone morphine |
HYDROmorphone morphine |
infliximab rituximab |
inFLIXimab riTUXimab |
isotretinoin tretinoin |
ISOtretinoin tretinoin |
Lamictal Lamisil |
LaMICtal LamISIL |
lamivudine lamotrigine |
lamiVUDine lamoTRIgine |
levetiracetam levocarnitine |
levETIRAcetam levOCARNitine |
metformin metronidazole |
metFORMIN metroNIDAZOLE |
mitomycin mitoxantrone |
mitoMYcin mitoXANtrone |
Nexavar Nexium |
NexAVAR NexIUM |
nicardipine nifedipine nimodipine |
niCARdipine NIFEdipine niMODipine |
Novolin Novolog |
NovoLIN NovoLOG |
olanzapine quetiapine |
OLANZipine QUEtiapine |
pemetrexed pralatrexate |
PEMEtrexed PRALAtrexate |
pentobarbital phenobarbital |
PENTobarbital PHENobarbital |
Prilosec Prozac |
PriLOSEC PROzac |
quinidine quinine |
quiNIDine quiNINE |
Risperidal risperidone ropinirole |
RisperDAL risperiDONE rOPINIRole |
romidepsin romiplostim |
romiDEPsin romiPLOStim |
Sandimmune Sandostatin |
SandIMMUNE SandoSTATIN |
Seroquel Sinequan |
SEROquel SINEquan |
sitagliptin sumatriptan zolmitriptan |
sitaGLIPtin SUMAtriptan ZOLMitriptan |
Solu-Cortef Solu-Medrol |
Solu-CORTEF Solu-MEDROL |
sorafenib sunitinib |
SORAfenib SUNItinib |
sulfadiazine sulfasalazine |
sulfADIAZINE sulfaSALAzine |
Tegretol Trental |
TEGretol TRENtal |
tiagabine tizanidine |
tiaGABine tiZANidine |
tramadol trazodone |
traMADol traZODone |
valacyclovir valganciclovir |
valACYclovir valGANciclovir |
Zyprexa Zyrtec |
ZyPREXA ZyrTEC |
Difficulties with tallman lettering
One of the difficulties with the use of tallman lettering includes inconsistent application in health settings and lack of standardization regarding which letters to present in uppercase.
See also
Five rights
MedWatch
Drug recalls
Vaccine Adverse Event Reporting System
Antidote
Medication errors
High-alert medications
Barcoding technologies
Medication safety
References
- ISMP, FDA and ISMP Lists of Look-Alike Drug Names with Recommended Tall Man Letters, http://ismp.org/Tools/tallmanletters.pdf
- FDA, Name Differentiation Project, http://www.fda.gov/Drugs/DrugSafety/MedicationErrors/ucm164587.htm
- Wikipedia, Tall man lettering, http://en.wikipedia.org/wiki/Tall_Man_lettering