Introduction The Australian Commission on Safety and Quality in Health Care (the Commission) is responsible for the development and stewardship of the National Tall Man Lettering List. Implementing relevant action items in the National Safety and Quality Health Service (NSQHS) Standards will assist clinicians to safely store, prescribe, dispense and administer medicines. Health services seeking accreditation under the Australian Health Service Safety and Quality Accreditation scheme are required to: Provide evidence of implementation of safety strategies Undertake regular assessments of the medication management pathway Identify risks and take action to reduce these risks. The National Tall Man Lettering List is referred to within NSQHS Standard 4: Medication Safety. Health service organisations are encouraged to consider the application of Tall Man lettering to minimise harm associated with look-alike sound-alike (LASA) medicine name pairs, along with other measures such as use of bar code scanners, electronic alerts and separate storage locations. National Tall Man Lettering Issues Register As part of the National Tall Man Lettering List stewardship, the Commission encourages frontline clinicians to report any adverse incidents or near-misses related to LASA medicine pairs. Issues notified to the Commission are logged in the National Tall Man Lettering Issues Register and are reviewed by the National Tall Man Lettering Expert Advisory Panel (the panel). The panel is responsible for making recommendations on the medicine name pairs that need to be included in the National Tall Man Lettering List. The panel follows a systematic process to decide on the medicine name pairs that would most benefit from the application of Tall Man lettering. The National Tall Man Lettering List has evolved since its introduction in 2011. The majority of issues lodged on the Commission’s Issues Register have been addressed in the , so it is important that these issues and their outcomes are reported and publicly available. Figure 1 lists the issues and outcome summaries. This report also contains information about the rationale for the general revision of the National Tall Man Lettering List. It should be noted that monoclonal antibodies (MABs) and tyrosine kinase inhibitors are not included in the National Tall Man Lettering List 2017, and will be considered in future revisions. Further explanation is provided within this report under the rationale for general revision of the National Tall Man Lettering List. For further information refer to available on the Commission’s website. The Commission invites requests for changes to the National Tall Man Lettering List, which can be made to your state or territory representative on the Health Service Medication Expert Advisory Group. Requests should be accompanied by evidence of confusion, including other
5 Medicine name clozapine: misreading potential with other medicine names such as clomipramine and clonidine Suggestion that the names are very similar and orders could be misread, especially for staff less familiar with clozapine. NSW Sept 2017 Not to be added to the Tall Man Lettering List 2017 Considered by expert advisory panel. BISIM and risk assessment result showed a low risk of confusion. 6 Medicine name pair: risedronate and alendronate Potential for harm identified (no actual incident reported) relating to look-alike packaging: Sandoz brand. NSW Sept 2017 Not to be added to the Tall Man Lettering List 2017 Considered by expert advisory panel. BISIM and risk assessment result showed a low risk of confusion. 7 BRAND NAMES Medicine name pair: Pradaxa (dabigatran) and Praxbind (idarucizumab) - Following the listing of the dabigatran reversal overseas initially during 2015, and now in Australia on the ARTG (May 2016), the need to consider whether there is a risk in the Australian environment. International Medication Safety Network (IMSN) Sept 2017 Not to be added to the Tall Man Lettering List 2017 Brand name pair considered by expert advisory panel. BISIM and risk assessment result showed a low risk of confusion. 8 Medicine name pair: tramadol and tapentadol Several incidents involving administration of tapentadol instead of tramadol. These medicines have a common indication and considered at increased risk of selection error. Western Australia Sept 2017 Added to Tall Man Lettering List 2017 Considered by expert advisory panel. BISIM and risk assessment result demonstrated a medium to high risk of confusion. 9 Medicine name pair: rifampicin and rifaximin Potential for harm identified internationally by the Institute for Safe Medication Practices (ISMP) and medicines available in Australia (no known incidents reported). International listing Sept 2017 Added to Tall Man Lettering List 2017 Considered by expert advisory panel. BISIM and risk assessment result demonstrated a medium to high risk of confusion.