A medication error is any incorrect or wrongful administration of a medication, such as a mistake in dosage or route of administration, failure to prescribe or administer the correct drug or formulation for a particular disease or condition, use of outdated drugs, failure to observe the correct time for administration of the drug, or lack of awareness of adverse effects of certain drug combinations. Causes of medication error may include difficulty in reading handwritten orders, confusion about different drugs with similar names, and lack of information about a patient's drug allergies or sensitivities.

A number of medications have names with similar spellings (hydroxyzine and hydralazine), similar appearance (captopril and carvedilol are both available as small round white tablets), and some medication names can be misheard for each other (Doribax and Zovirax are nearly homophones). A modern term for this last category is a mondegreen. Barcoding technologies and tall man lettering are two of the more common strategies used to overcome these challenges and are discussed further later in this chapter.

High-alert medications are drugs that bear a heightened risk of causing significant patient harm when they are used in error. Although mistakes may or may not be more common with these drugs, the consequences of an error are clearly more devastating to patients. The Institute for Safe Medication Practice (ISMP) has assembled a list to identify which medications require special safeguards to reduce the risk of errors. This may include strategies such as standardizing the ordering, storage, preparation, and administration of these products; improving access to information about these drugs; limiting access to high-alert medications; using auxiliary labels and automated alerts; and employing redundancies such as automated or independent double-checks when necessary.

The medical profession has a responsibility to provide safe and effective health care and that includes reducing medication misadventures. There are a broad array of error prevention tools out there including using the five rights (sometimes also expanded to the seven rights), using extra precautions with respect to high-alert medications, adopting system wide use of Tallman lettering, avoiding error prone abbreviations, using barcoding technology, and even just separating inventory. Providing information to patients through medications guides, patient counselling, and drug utilization reviews (DURs) improves compliance and decreases errors as well.

Below are two lists with recommendations for the use of tall man lettering. The first list is of FDA-approved established drug names with recommended tall man 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 tall man letters.

Regards
Rutherford
Managing editor
Journal of Pharmacy Practice and Education