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                                                                                        Institute for Safe Medication Practices


                                     FDA and ISMP Lists of
                  Look-Alike Drug Name Sets With Recommended Tall Man Letters
                  he sets of look-alike drug names in the Tables below have been                                         One of the difficulties with the use of tall man letters is the lack of
              T   modified using "tall man" letters to help draw attention to the
                  dissimilarities in their names. Several studies have shown that
                                                                                                                         scientific evidence regarding which name pairs would most benefit from
                                                                                                                         this error-reduction strategy as well as which letters to present in
              highlighting sections of drug names using tall man (mixed case) letters                                    uppercase. Until further evidence is available, ISMP suggests that the
              can help distinguish similar drug names,1 making them less prone to                                        tall man lettering scheme provided in these Tables be followed to
              mix-ups.2-3 ISMP, FDA, The Joint Commission, and other safety-                                             promote consistency.
              conscious organizations have promoted the use of tall man letters as
              one means of reducing confusion between similar drug names.                                                 Table 2. ISMP List of Additional Drug Names with Tall Man Letters

              Table 1 provides a list of FDA-approved established drug name sets                                          ALPRAZolam - LORazepam                     metroNIDAZOLE ­ metFORMIN
              with recommended tall man letters, which were first identified during
                                                                                                                          amLODIPine ­ aMILoride                     morphine ­ HYDROmorphone
              the FDA Name Differentiation Project (www.fda.gov/CDER/Drug/
              MedErrors/nameDiff.htm).                                                                                    azaCITIDine ­ azaTHIOprine                 NexIUM*­ NexAVAR*

              Table 2 provides a list of additional drug name sets with recommenda-                                       ceFAZolin ­ cefTRIAXone                    niMODipine ­ NIFEdipine
              tions from ISMP regarding the use and placement of tall man letters.                                        CeleBREX* ­ CeleXA*                        NovoLOG* ­ NovoLIN*
              This is not an official list approved by FDA. It is intended for voluntary
              use by healthcare practitioners and drug information vendors. Any                                           chlorproMAZINE ­ chlordiazePOXIDE          OXcarbazepine ­ carBAMazepine
              product label changes by manufacturers require FDA approval.                                                CISplatin ­ CARBOplatin                    oxyCODONE ­ OxyCONTIN*

                                                                                                                          clonazePAM ­ cloNIDine                     PARoxetine ­ FLUoxetine
               Table 1. FDA-Approved List of Established Drug Names with Tall Man Letters
                                                                                                                          clonazePAM - LORazepam                     PENTobarbital ­ PHENobarbital
               acetoHEXAMIDE - acetaZOLAMIDE                      hydrALAZINE ­ hydrOXYzine
                                                                                                                          cloNIDine ­ KlonoPIN*                      PriLOSEC* ­ PROzac*
               buPROPion - busPIRone
                                                                                                                          DACTINomycin ­ DAPTOmycin                  QUEtiapine ­ OLANZapine
                                                                  medroxyPROGESTERone
               chlorproMAZINE ­ chlorproPAMIDE                    methylPREDNISolone                                      ePHEDrine ­ EPINEPHrine                    quiNINE ­ quiNIDine
                                                                  methylTESTOSTERone
               clomiPHENE ­ clomiPRAMINE                                                                                  fentaNYL ­ SUFentanil                      riTUXimab inFLIXimab

               cycloSPORINE ­ cycloSERINE                         niCARdipine ­ NIFEdipine                                FLUoxetine ­ DULoxetine                    SandIMMUNE* ­ SandoSTATIN*

                                                                                                                          guanFACINE ­ guaiFENesin                   SEROquel* ­ SINEquan*
               DAUNOrubicin ­ DOXOrubicin                         predniSONE ­ prednisoLONE
                                                                                                                          HumaLOG* ­ HumuLIN*                        Solu-MEDROL* ­ Solu-CORTEF*
               dimenhyDRINATE ­ diphenhydrAMINE                   sulfADIAZINE ­ sulfiSOXAZOLE
                                                                                                                          HYDROcodone ­ oxyCODONE                    SUMAtriptan ­ sitaGLIPtin
               DOBUTamine ­ DOPamine                              TOLAZamide ­ TOLBUTamide
                                                                                                                          IDArubicin ­ DOXOrubicin                   tiZANidine - tiaGABine
               glipiZIDE ­ glyBURIDE                              vinBLAStine ­ vinCRIStine                               INVanz* ­ AVINza*                          traZODone - traMADol

              References: 1) Filik R, Purdy K, Gale A, Gerrett D. Drug name confusion: eval-                              LaMICtal* ­ LamISIL*                       TRENtal ­ TEGretol*
              uating the effectiveness of capital ("Tall Man") letters using eye movement data.
                                                                                                                          lamiVUDine ­ lamoTRIgine                   ZyPREXA* ­ ZyrTEC*
© ISMP 2008




              Social Science & Medicine 2004;59(12):2597-2601. 2) Filik R, Purdy K, Gale A,
              Gerrett D. Labeling of medicines and patient safety: evaluating methods of
              reducing drug name confusion. Human Factors 2006;48(1):39-47. 3) Grasha A.
              Cognitive systems perspective on human performance in the pharmacy: impli-                                * Brand names always start with an uppercase letter. Some brand names incor-
              cations for accuracy, effectiveness, and job satisfaction. Alexandria (VA):                               porate tall man letters in initial characters and may not be readily recognized as
                                                                                                                        brand names. An asterisk follows all brand names in Table 2.
              NACDS; 2000 Report No. 062100.




              © ISMP 2008. Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other reproduction
              is prohibited without written permission from ISMP. Report actual and potential medication errors to the Medication Errors Reporting Program                Institute for Safe
              (MERP) via the Web at www.ismp.org or by calling 1-800-FAIL-SAF(E).                                                                                         Medication Practices
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