Tall Man lettering

The Aotearoa New Zealand Tall Man lettering list was updated  in October 2023, to remove the medicine PHENOXYMETHylpenicillin from the Tall Man letter list, due to a near miss and re-evaluation of the medicine on the list. There are now 224 medicine names with Tall Man lettering format in the Aotearoa New Zealand list. The number of medicines on the list is kept to a minimum to prevent over-use.

The updated list (PDF and Excel versions) is available below.

Background

Tall Man lettering is an error prevention strategy used to reduce the risk of look-alike and sound-alike medicine names errors. Tall Man lettering uses a combination of lower and upper case letters to highlight the differences between look-alike and sound-alike medicine names, like fluOXETine and fluVOXAMine, helping to make them more easily distinguishable.

The purpose of Tall Man lettering is to help health professionals select or supply the right medicine. Tall Man lettering serves as a warning about the risk of confusing a particular medicine name based on the orthography of the medicine name. The small amount of published literature available shows that, at the minimum, Tall Man lettering will or should alert clinicians’ to medicines that are at risk of name confusion and possible medication error without increasing the risk of errors[1-8].

The Commission supports the use of Tall Man lettering as one of several ways to reduce the risk of getting medicine names confused. Other interventions like barcode verification and premarket assessment processes also contribute to risk reduction.

The Aotearoa New Zealand Tall Man lettering list is recommended for use by:

• software vendors in medicine pick or drop-down lists in pharmacy and prescriber systems, to support prescribing and dispensing activities
• software vendors in medicine pick or drop-down lists requiring a person to select individual medicines as part of the creation of a clinical record or some other clinical tasks 
• users who download New Zealand Universal List of Medicines (NZULM) data to generate their own medicine lists for a variety of in-house uses, including drop-down lists in ‘smart’ pumps, electronic medicine administration records and automated dispensing cabinet screens such as PYXIS medicine storage layout.

Related resources

• Resource: Aotearoa New Zealand Tall Man lettering list (October 2023)