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ISMP Adds Mixed Case Letters to Its List of Drug Names

The goal is to help differentiate look-alike drug names in an effort to thwart medication selection errors.

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We all know drug names are famously confusing. They somehow defy the laws of spelling physics with seemingly endless strings of consonants, making them not only difficult to pronounce, but also at risk of being confused with other similarly spelled drugs. According to a recent Institute for Safe Medication Practices (ISMP) article, the Institute has updated its list of drug names to include “tall man” letters to help decipher between drugs with similar names. 

Between October and December 2022, ISMP conducted a survey with the help of 298 healthcare practitioner respondents, including pharmacists, nurses, and pharmacy technicians. 94% of respondents said that their facility uses tall man letters, however only 18% use tall man letters for one or more drug names that do NOT comply with the configurations on the FDA and ISMP lists of look-alike drug names. 95% of respondents believe that the use of tall man letters help to reduce drug selection errors, and a surprising 87% could actually remember an instance in which tall man lettering had prevented them from prescribing, transcribing, dispensing, or administering the wrong drug.

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