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

  1. ISMP, FDA and ISMP Lists of Look-Alike Drug Names with Recommended Tall Man Letters, http://ismp.org/Tools/tallmanletters.pdf
  2. FDA, Name Differentiation Project, http://www.fda.gov/Drugs/DrugSafety/MedicationErrors/ucm164587.htm
  3. Wikipedia, Tall man lettering, http://en.wikipedia.org/wiki/Tall_Man_lettering