Best Strategy to Prevent Look-Alike/Sound-Alike Medication Errors
The best strategy to prevent prescribing errors between hydralazine and hydroxyzine is to use Tall Man lettering (Option B), which capitalizes the dissimilar portions of confusable drug names (e.g., hydrALAzine vs hydrOXYzine). 1
Why Tall Man Lettering is the Evidence-Based Choice
Tall Man lettering has been proven to reduce medication errors by highlighting the differences between orthographically similar drug names through passive visual enhancement. 2, 3, 4
Supporting Evidence for Tall Man Lettering:
Healthcare providers detect changes in confusable drug name pairs more often (P < 0.0001) and more quickly (P < 0.05) when Tall Man lettering is used 2
Meta-analysis demonstrates significant reduction in omission errors (wrong medication selection) with Tall Man lettering compared to lowercase text (SMD = -0.628,95% CI: -1.018 to -0.238, P = .002) 5
Both younger and older adults, as well as healthcare practitioners, make fewer name confusion errors when drug names contain Tall Man letters in laboratory-based tasks 6
International guidelines specifically recommend avoiding similarities in shape, color, and name among medications, with Tall Man lettering serving as a passive organizational measure to minimize selection errors 1
Why Other Options Are Inadequate
Option A (Verbal Orders):
Verbal orders actually increase error risk and should not be allowed. 1 Guidelines explicitly state that verbal prescriptions should be prohibited to improve communication between medical staff and nurses. 1
Option C (Drug Name with Dose Only):
Writing only the drug name and dose provides no mechanism to differentiate look-alike names. This approach fails to address the core problem of visual similarity between hydralazine and hydroxyzine.
Option D (Brand Names):
Using brand names instead of generic names is not recommended in current guidelines, which emphasize using the International Nonproprietary Name (INN) for drug identification. 1 Brand names can introduce their own confusion and are not standardized across healthcare systems.
Implementation Context
Tall Man lettering works as part of a comprehensive passive safety system that includes: 1
- International color coding of labels for syringes and administration routes 1
- Careful reading of labels before administration 1
- Limiting medications with similar names in the same storage area 1
- Bar-code readers and error-reduction devices as complementary active checking measures 1
Key Mechanism of Action
Character size appears to be a key determinant of perceptual accuracy—Tall Man lettering draws attention to the capitalized letters while readers still process the entire name, creating a dual-processing advantage. 3, 4 The intervention works by making similar names easier to distinguish when healthcare providers are aware this is the purpose of the formatting. 4
Common Pitfall to Avoid
Familiarity with both drug names in a confusable pair can mitigate the benefit of Tall Man lettering 2, so this strategy is most effective when combined with other safety measures like careful label reading and the five-rights rule (right medication, right dose, right time, right route, right patient). 1