A tall man lettering project to enhance medication safety.

Medication errors are still a major public safety concern for patients and consumers. Although figures published on errors caused by drug name confusion ranges from 9% to 25%, the impact of selecting the wrong drug can be catastrophic. There have been many attempts to develop safeguards and strategies to reduce errors caused by similar or look-alike drug names. One approach is to deploy a mixed-case text or tall man letters on drug names that are deemed to be orthographically similar and have the potential to cause serious patient harm if a mix-up were to occur. The tall man letter approach has been promoted and advocated by both FDA (Food and Drug Administration) and ISMP (Institute for Safe Medication Practices) in the United States for a number of years. They have recommended a standard list of tall man lettering for similar drug name pairs. A survey of a broad audience of practitioners on the use of tall man letters was conducted by ISMP in 2008. The findings showed an overwhelming support of the use of this technique. Of the 451 surveyed responses, 87% indicated that the use of tall man lettering helped to reduce drug selection errors. ISMP-Canada, engaging in a project with the Canadian Association of Provincial Cancer Agencies, also produced a list of oncology drug names with the tall man technique. This project leveraged the success from what was previously developed in the United States and added three more recommendations. The project also received