Have you ever proofread information and overlooked a typo, like reading “form” when it was supposed to say “from?” Because of the similarity, it’s easy to miss the error. The same challenge occurs in healthcare with medications.

Naming a drug is a complex process involving chemical, nonproprietary, and brand names. With more than 20,000 prescription drug products approved for marketing in the U.S., avoiding similar-sounding or similar-looking names is a major challenge. The result? Some medications end up with names that are dangerously easy to confuse.

These “look-alike, sound-alike” (LASA) drugs are a well documented cause of medication errors. The World Health Organization cites LASA errors as a leading safety concern, contributing to at least one death per day and injuring 1.3 million people each year in the U.S. alone.

What is Tall Man Lettering?

One proven strategy to reduce LASA errors is Tall Man lettering. It’s a typographic strategy that enhances drug name visibility by capitalizing the parts of the name that differ from another, similar-looking or similar-sounding drug. For instance, hydrOXYzine and hydrALAzine may appear similar at a glance, but when Tall Man labels are applied, the distinguishing portions stand out, reducing the likelihood of confusion.

The Institute for Safe Medication Practices (ISMP), which pioneered the use of Tall Man lettering in the U.S., has published a list of recommended drug name pairs with Tall Man enhancements. Examples include:

  • DOBUTamine vs. DOPamine
  • cloNIDine vs. cloZAPine
  • vinCRIStine vs. vinBLAStine

In practice, Tall Man lettering appears on a range of critical communication tools including medication labels, electronic health record systems (EHRs), pharmacy dispensing software, IV bags, and packaging. When used consistently, it significantly enhances visibility and reduces confusion, especially in environments with high-alert medications.

Why It Matters: Reducing LASA Medication Errors

LASA errors are often the result of rushed workflows, miscommunication, and visual misidentification. According to a review published in the Journal of Patient Safety¹, LASA errors account for approximately one in every four medication errors. The consequences can be severe, particularly when the medications involved are high-alert drugs that require precise dosing and administration.

Tall Man lettering helps mitigate these risks. Studies show that capitalizing distinct sections of LASA drug names improves visual perception and helps healthcare workers correctly identify medications, even under pressure. For example, in a study by the Institute of Safe Medication Practices (ISMP), 95% of respondents said Tall Man lettering reduced selection errors, and 87% recalled specific instances where it prevented them from prescribing or dispensing the wrong medication!

In fast-paced environments such as hospital pharmacies, emergency departments, and ICUs, Tall Man lettering provides a critical layer of safety. It helps staff to quickly and accurately distinguish between medications that could otherwise be mistaken for one another.

Improving Workflow and Reducing Cognitive Load for Nurses

Nurses, particularly those working long shifts or floating between units, juggle a multitude of responsibilities. Any tool that reduces cognitive load and streamlines decision-making supports better, safer care.

Tall Man lettering labels act as clear, visual prompts. When used on syringe labels, IV lines, or storage bins, they enable nurses to quickly verify medication names, especially in high-stress moments or when multitasking. By minimizing reliance on memory or the need to cross-check with other sources, these labels help reduce the likelihood of error.

This is especially beneficial during handoffs, shift changes or emergencies.

Industry Standards and Support for Tall Man Lettering

Tall Man lettering isn’t just a helpful suggestion, it’s a practice supported by healthcare safety authorities including:

Each recommends the use of Tall Man lettering as part of comprehensive medication safety strategies.

How Tall Man Lettering Labels Are Used in Clinical Settings

United Ad Label provides stock and custom medication Tall Man labels that support a wide range of clinical scenarios, including:

  • Syringe labels - clearly identify LASA medications during preparation and administration.
  • IV bags and tubing labels -clarify contents during patient handoffs or multi-drug infusion setups.
  • Dispensing containers - help pharmacists and nurses distinguish look-alike drugs at the point of care.
  • Smart pump displays - reinforce accurate drug identification throughout administration.

In situations where multiple medications with similar names are prescribed concurrently,  such as critical care or anesthesia and surgery, Tall Man labels are especially critical. They offer a physical, visual layer of safety that complements electronic verification systems.

Implementation Tips for Healthcare Facilities

To leverage the benefits of Tall Man lettering, healthcare facilities should take a structured approach. Here are some best practices for implementation:

  • Standardize Label Formats - Use consistent Tall Man formatting across the operation, for both printed labels and those used in electronic systems.
    Utilize Standardized Lists - Update labels based on the most recent ISMP recommendations and LASA alerts.
  • Involve Supply Chain and IT - Ensure that purchased products, printers, and EHR systems support Tall Man label standards.
    Educate Staff - Train the clinical staff on the purpose and interpretation of Tall Man lettering. Reinforce its use in medication safety protocols.
    Review and Audit Appropriate Use - Regularly review the use of Tall Man lettering to ensure compliance with established lists and configurations.

Implementing Tall Man lettering is a small adjustment that can make a big impact. When integrated into a healthcare organization's labeling workflow, it improves accuracy, supports clinical workflows, and elevates patient safety.

United Ad Label Tall Man Labeling

United Ad Label offers dependable labeling solutions that enhance medication safety. Our Tall Man lettering labels are designed in accordance with ISMP guidelines and built to support real-world clinical workflows. Contact us to learn more or request samples to evaluate in your facility.

Footnotes

¹Ciociano N, Bagnasco L. Look alike/sound alike drugs: a literature review on causes and solutions. Int J Clin Pharm. 2014;36:233–242.