Comments on: Hacker Labeling

By: Allison

Allison — Fri, 17 Aug 2012 01:29:45 +0000

P.S. I’m an ICU nurse, and although I haven’t made a serious medication error (yet), I think little alarm bells would go off in my head by just glancing if I hung a DOPamine drip instead of a DOBUTamine one. I think the tall-man stuff helps nurses, even if it’s just on a subconscious level.

By: Allison

Allison — Fri, 17 Aug 2012 01:26:48 +0000

From this entry it seems that there are some studies that show tall-man lettering might help, and none that show it does any harm. It seems unlikely that this lettering could actually cause any medication errors that wouldn’t have happened anyway.

If something might help, and doesn’t harm, then what’s the problem with using it?

By: j

Wed, 15 Aug 2012 15:58:06 +0000

Sounds like a question someone prescribing meds, vs. administering 150-300 per shift would ask. Tis a nursing issue yes. But do you have a better suggestion for preventing drug errors? Our eyes are naturally drawn to larger objects by virtue of natural selection, but there is no “proven” way to prevent all med errors. It’s not always an issue of the person not knowing their med differences, but a matter of hectic schedules, interruptions, lack of sleep, work overload, skimming vs. reading, and multitasking from hell. The 5 rights alone are just not enough.

By: E

Wed, 15 Aug 2012 01:08:33 +0000

People may be drawn to the capitalization first when they are viewing a group of words.

By: Matt

Matt — Wed, 15 Aug 2012 00:17:36 +0000

It appears there is some research:

http://nottingham.academia.edu/RuthFilik/Papers/261831/Labeling_of_Medicines_and_Patient_Safety_Evaluating_Methods_of_Reducing_Drug_Name_Confusion

By: anymousie

anymousie — Wed, 15 Aug 2012 00:13:57 +0000

Joint Commission makes us do it.

Luckily, there are pharmacy interns who need projects and can check to make sure we are up to date with the latest list (it changes on occasion)

By: pete

pete — Tue, 14 Aug 2012 22:09:59 +0000

I think this is a case of something that probably doesn’t hurt and probably doesn’t cost any extra money (you’re labeling these things anyways), so why not do it if it could only make things just a little bit better?

I think the theory is that even when quickly glancing at the bottle, the capital letters will stand out enough to prevent the dreaded hydroxyzine/hydralazine mix up.

By: Ardosa

Ardosa — Tue, 14 Aug 2012 20:53:34 +0000

because, we have to.
ISMP suggests it so we have to follow the suggestions… according to your favorite people, The Joint Commission.
The problem with most of the tall man lettering is this:

it doesn’t help with verbal orders (biggest issue with cereBYX and celEXA).. those aren’t even in the same places in the pharamcy (fridge versus orals/tablets)… also, it is usually retail/out patient that uses brand names, in hospital we use generic so they try to make us do it with the various cephalosporins etc…

I dont think it helps. I dont think it always make sense… but then again, how many thing with the JOINT make sense? many don’t.

I think it is more to attempt to help nursing – when they go to an ADM (automated dispensing machine, ie pyxis) and do an over ride, and search by brand (since many don’t know generics) it is meant to help them… it doesn’t work. seriously, it doesn’t. I’ve heard of the stupidest mixups for no decent reason other than “I thought it said…” and the tall man lettering won’t change that.

I’ve heard/seen nurses grab a completely wrong drug and not even read the vial before administering. then i get a panic call of “I gave toradol instead of zofran” “how did you manage that?” “I dunno i thought i picked the right thing out of the machine, it must be in the wrong pocket”… but they didn’t read it before administering…

By: Marc B

Marc B — Tue, 14 Aug 2012 20:29:23 +0000

It is suppose to help reduce errors by people misreading the medication. It was called “tall man” lettering the hospital I worked in. It was suppose to be on all high alert meds (easy to kill someone with like digoxin, heparin, paralytics, ect) or those who were on this huge look-alike/sound-alike chart ISMP put out and we were required to have posted in the pharmacy like hydoxizine and hydrazine or probably in this case dobutamine and dopamine. If someone looks at it quickly in the med storage room and grabs the wrong thing and starts to infuse it without checking. I know that was a big thing for the pharmacy part of the JACHO inspection when they came to the hospital.

By: WhiteCoat

WhiteCoat — Tue, 14 Aug 2012 18:14:41 +0000

Point taken. Bad choice of words.

No malice intended.