TALLman letters
Serious medication errors are common in the ICU setting and are estimated to be around 15%. Per anecdotal reports, most of the errors are in late afternoons when most of the orders are carried or during the time nurses change shifts. There has been several ways to reduce these errors including
- trained intensivists running close units,
- dedicated ICU pharmacist,
- switching to electronic orders and barcode system,
- avoid (dangerous) abbreviations,
- use of smart pumps for infusions among others, and
- using TALLman letters,
What are TALLman letters:FDA's Office of Generic Drugs requested manufacturers of sixteen look-alike name pairs to voluntarily revise the appearance of their established names in order to minimize medication errors "by TALLing the confused letters". Examples are
DOBUTamine and DOPamine
GlipiZIDE and GlyBURIDE
Related link: Institute for safe medication practices
