ISMP updates its list of drug name pairs with Tall man letters.

Newspaper/Magazine Article

ISMP updates its list of drug name pairs with Tall man letters.

December 1, 2010

ISMP Medication Safety Alert! Acute Care Edition. November 18, 2010;15:1-3.

This article reports results of a national survey on how "tall man" lettering has clarified high-consequence drug name confusion and includes a list of medication name pairs in such lettering.

Free full text

Related Resources From the Same Author(s)

Electronic prescribing vulnerabilities: height and weight mix-up leads to dosing error.

September 8, 2010

Latest heparin fatality speaks loudly—what have you done to stop the bleeding?

April 21, 2010

Unverified patient-reported error: a false alarm can have real consequences.

December 3, 2014

Side tracks on the safety express. Interruptions lead to errors and unfinished…wait, what was I doing?

December 19, 2012

Reduce readmissions with pharmacy programs that focus on transitions from the hospital to the community.

November 28, 2012

Order scanning systems may pull multiple pages through the scanner at the same time, leading to drug omissions.

November 18, 2009

Promethazine conundrum: IV can hurt more than IM injection!

November 15, 2006

Drug shortages threaten patient safety.

August 11, 2010

Preventing catheter/tubing misconnections: much needed help is on the way.

August 4, 2010

DTaP–Tdap mix-ups now affecting hundreds of patients.

July 14, 2010

CMS 30-minute rule for drug administration needs revision.

September 22, 2010

Building patient safety skills: common pitfalls when conducting a root cause analysis.

May 5, 2010

Survey shows recession has weakened patient safety net.

January 27, 2010

Actively caring for safety: overcoming bystander apathy.

December 10, 2008

A lot happens when you report a hazard or error to ISMP—there’s no “black hole” here!

December 4, 2019

Errors with injectable medications: unlabeled syringes are surprisingly common!

November 28, 2007

Pharmaceutical industry and medical device companies: part of the solution?

November 29, 2006

Are national efforts to reduce drug name confusion paying off?

December 12, 2018

Is an indication-based prescribing system in our future?

November 30, 2016

ISMP survey shows provider text messaging often runs afoul of patient safety.

November 29, 2017

Strengthen your resolve: no unlabeled containers anywhere, ever!

November 19, 2014

Ingestion or aspiration of foreign objects or toxic substances is not just a safety concern with children.

November 16, 2011

Key vulnerabilities in the surgical environment: container mix-ups and syringe swaps.

November 18, 2015

First annual review of data submitted to the ISMP National Vaccine Errors Reporting Program (VERP).

December 11, 2013

Understanding and managing IV container overfill.

December 4, 2013

Preventing errors when preparing and administering medications via enteral feeding tubes.

December 7, 2022

Using external errors to signal a clear and present danger.

November 26, 2008

Learning from influenza vaccine errors to prepare for COVID-19 vaccination campaigns.

December 2, 2020

ISMP Survey provides insights into preparation and admixture practices OUTSIDE the pharmacy.

November 18, 2020

Managing hospitalized patients with ambulatory pumps: findings from an ISMP survey—Part 1.

September 23, 2015

Prevent errors during emergency use of hypertonic sodium chloride solutions.

November 17, 2021

IV push medications survey results—part 1 and part 2.

November 28, 2018

A mislabeling event with batched drugs: the unintended consequences of practice changes.

February 19, 2014

November 14, 2007

Error-prone conditions that lead to student nurse-related errors.

October 31, 2007

Accidental IV infusion of heparinized irrigation in the OR.

December 21, 2016

"Use as directed" can cause confusion for both patients and practitioners.

September 14, 2016

What price must we pay for safety? Excessive cost of EPINEPHrine auto-injectors leads to error-prone use of ampuls or vials and unprepared consumers.

August 24, 2016

Unreadable barcodes and multiple barcodes on packages can lead to errors.

November 8, 2017

Drawn curtains, muted alarms, and diverted attention lead to tragedy in the postanesthesia care unit.

April 3, 2013

A clinical reminder about the safe use of insulin vials.

March 6, 2013

Fatal PCA adverse events continue to happen...better patient monitoring is essential to prevent harm.

June 19, 2013

Administering a saline flush "site unseen" can lead to a wrong route error.

May 29, 2013

Good intention, uncertain outcome...our take on physician dispensing in offices and clinics.

March 21, 2012

Misadministration of IV insulin associated with dose measurement and hyperkalemia treatment.

August 31, 2011

Oral solid medication appearance should play a greater role in medication error prevention.

August 10, 2011

Too many abandon the "second victims" of medical errors.

July 27, 2011

Parents can detect, contribute to, or be affected by critical events during a child’s hospitalization.

June 29, 2011

Raising the index of suspicion: red flags that represent credible threats to patient safety.

August 8, 2012

Mismatched prescribing and pharmacy templates for parenteral nutrition (PN) lead to data entry errors.

July 18, 2012

A shortage of everything except errors: harm associated with drug shortages.

May 2, 2012

Durasal–Durezol mix-up illustrates how dangerous product problems persist long after recognition.

October 5, 2011

Telling true stories is an ISMP hallmark: here's why you should tell stories, too.

September 21, 2011

Survey on LASA drug name pairs: who knows what’s on your list and the best ways to prevent mix-ups?

June 3, 2009

Shared MDIs: can cross-contamination be avoided?

April 22, 2009

Beware of basal opioid infusions with PCA therapy.

March 25, 2009

Inattentional blindness: what captures your attention?

March 11, 2009

Safe practice environment chapter proposed by USP.

December 17, 2008

Preventing medication errors during codes.

February 23, 2011

Eric Cropp weighs in on the error that sent him to prison.

December 16, 2009

Oral syringes: a crucial and economical risk-reduction strategy that has not been fully utilized.

November 4, 2009

Some red rules shouldn't rule in hospitals.

May 14, 2008

ISMP's second QuarterWatch report shows sharp increase in reports of serious adverse drug events.

November 5, 2008

Collaboration focused on priority issues promotes safety.

October 22, 2008

Don't underestimate the impact of change on risk potential.

September 24, 2008

Misprogramming PCA concentration leads to dosing errors.

September 10, 2008

Multiple latent failures align to allow a serious drug interaction to harm a patient.

May 18, 2011

Another tragic parenteral nutrition compounding error.

May 11, 2011

Proper positioning of pharmacy label on Hospira PCA vials will avoid interference with scanning.

August 27, 2008

Use of tall man letters is gaining wide acceptance.

August 13, 2008

Epidural-IV route mix-ups: reducing the risk of deadly errors.

July 16, 2008

FDA Advise-ERR: prevent dangerous drug-device interaction causing falsely elevated glucose levels.

July 2, 2008

Benefits and risks of including patients on RCA teams.

June 18, 2008

Considering insulin pens for routine hospital use? Consider this...

May 28, 2008

Anticoagulant safety takes center stage in 2007.

January 24, 2007

Progress with preventing name confusion errors.

August 22, 2007

Ongoing, preventable fatal events with fentanyl transdermal patches are alarming!

July 18, 2007

High-reliability organizations (HROs): what they know that we don't (Part II).

August 24, 2005

Paralyzed by mistakes: preventing errors with neuromuscular blocking agents.

October 5, 2005

Remote CPOE error—a situation that's more than remotely possible.

June 13, 2007

Safety still compromised by computer weaknesses.

September 7, 2005

FDA Advise-ERR: reported medication errors with Veklury (remdesivir) emergency use authorization.

September 23, 2020

The differences between human error, at-risk behavior, and reckless behavior are key to a just culture.

July 1, 2020

Despite technology, verbal orders persist, read back is not widespread, and errors continue.

May 31, 2017

Sterile compounding tragedy is a symptom of a broken system on many levels.

October 31, 2012

Tragic error with neuromuscular blocker should prompt risk assessment by all hospitals.

January 14, 2015

Accidental overdoses involving fluorouracil infusions.

July 1, 2015

Tablet splitting: Do it only if you "half" to, and then do it safely.

May 31, 2006

Prevent administration of ear drops into the eyes.

December 14, 2022

Challenges with requiring five characters during ADC drug searches via override.

November 3, 2021

Disrespectful behavior in healthcare: has it improved? Please take our survey!

October 21, 2021

Just Culture and its critical link to patient safety—part 1 and part 2.

July 25, 2012

Start the year off right by preventing these top 10 medication errors and hazards from 2020.

February 10, 2021

Over-the-top risky: overuse of ADC overrides, removal of drugs without an order, and use of non-profiled cabinets.

November 13, 2019

Speaking up about patient safety requires an observant questioner and a high index of suspicion.

October 30, 2019

Incorrect use of smart infusion pump in the operating room (OR) leads to milrinone overdose.

May 20, 2020

What's in a name? Newborn naming conventions and wrong-patient errors.

May 8, 2019

Another round of the blame game: a paralyzing criminal indictment that recklessly "overrides" just culture.

February 27, 2019

Partnering with families and patient advocates: another line of defense in adverse event surveillance.

August 14, 2019

Disrespectful behavior in healthcare...have we made any progress in the last decade?

July 17, 2013

Related Resources

Taking a closer look at medication errors that involve oxytocin.

June 14, 2023

Perspectives on Safety

Annual Perspective

Technology as a Tool for Improving Patient Safety

March 29, 2023

Medication errors: the year in review: January through December 2021.

January 11, 2023

At US hospitals, a drug mix-up is just a few keystrokes away.

May 11, 2022

Geriatric medication reconciliation in the home setting.

July 21, 2021

COVID-19 Content. ISMP Medication Safety Alert!

January 14, 2021

Annual Perspective

Pharmacist Role in Patient Safety

February 21, 2020

Annual Perspective

Updates in the Role of Health IT in Patient Safety

February 21, 2020

Over-the-top risky: overuse of ADC overrides, removal of drugs without an order, and use of non-profiled cabinets.

November 13, 2019

Medication errors: the year in review.

October 23, 2019

Identifying potential medication discrepancies during medication reconciliation in the post-acute long-term care setting.

July 17, 2019

Another round of the blame game: a paralyzing criminal indictment that recklessly "overrides" just culture.

February 27, 2019

Systematic review of computerized prescriber order entry and clinical decision support.

February 6, 2019

Safety enhancements every hospital must consider in wake of another tragic neuromuscular blocker event.

January 23, 2019

Are national efforts to reduce drug name confusion paying off?

December 12, 2018

Direct oral anticoagulants: a review of common medication errors.

November 21, 2018

How to prevent the top 4 medication errors.

October 17, 2018

Strategies for optimizing OR drug safety.

April 4, 2018

Medication safety in the neonatal intensive care unit: big measures for our smallest patients.

March 8, 2017

Prescribing errors that cause harm.

October 5, 2016

Hardwiring safety into the computer system: one hospital's actions to provide technology support for U-500 insulin.

May 18, 2016

FDA Advise-ERR: avoid using the error-prone abbreviation, TPA.

October 14, 2015

Maximizing smart pump technology to enhance patient safety.

July 29, 2015

Approaches for improving continuity of care in medication management: a systematic review.

October 9, 2013

Engaging patients in medication reconciliation via a patient portal following hospital discharge.

October 2, 2013

Examining medication reconciliation from a perspective of safety.

September 25, 2013

Medication reconciliation: comparing a customized medication history form to a standard medication form in a specialty clinic (CAMPII 2).

September 18, 2013

Estimating the information gap between emergency department records of community medication compared to on-line access to the community-based pharmacy records.

September 11, 2013

Survey results: community liaison programs to decrease hospital readmissions.

March 20, 2013

ASHP statement on the pharmacist's role in medication reconciliation.

February 27, 2013

See More About The Topic

Health Care Providers

Quality and Safety Professionals

Pharmacy

Medication Errors/Preventable Adverse Drug Events

Active Errors

ISMP updates its list of drug name pairs with Tall man letters.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

ISMP updates its list of drug name pairs with Tall man letters.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site