Tallman lettering

  

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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 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
alprazolam
lorazepam
ALPRAZolam
LORazepam
amiloride
amlodipine
aMILoride
amLODIPine

See also

MedWatch
High-alert medications
Five rights

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