Zhong Wenjun, Feinstein James A, Patel Neil S, Dai Dingwei, Feudtner Chirs
Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
Division of General Pediatrics, Children's Hospital Colorado, Aurora, Colorado, USA.
BMJ Qual Saf. 2016 Apr;25(4):233-40. doi: 10.1136/bmjqs-2015-004562. Epub 2015 Nov 3.
Despite the widespread implementation of Tall Man lettering, little evidence exists regarding whether this technique has reduced drug errors due to look-alike sound-alike (LA-SA) drug names. This study evaluated rates of potential LA-SA drug errors in the drug management process through to the point of dispensing before and after implementation of Tall Man lettering in 2007.
We used detailed pharmacy data for paediatric inpatients (<21 years old) from 42 children's hospitals in 2004-2012. After prespecifying a set of 8 potential LA-SA drug error patterns we searched within each hospitalisation for the occurrence of one of these patterns for a total of 12 LA-SA drug pairs deemed highly relevant to paediatric inpatients. To assess for potential change of error rates before and after Tall Man lettering implementation, we performed segmented regression analyses for each of 11 LA-SA drug pairs (because 1 pair had no detected potential errors) and for the overall total errors of all 11 LA-SA drug pairs.
Among 1 676 700 hospitalisations, no statistically significant change was detected for either the intercept or the slope of LA-SA error rate for each of the 11 drug pairs or for the combined error rate. In a sensitivity analysis of the moving average of the potential error rate over the entire study period, no downward trend in potential LA-SA drug error rates was evident over any time period 2004 onwards.
Implementation of Tall Man lettering in 2007 was not associated with a reduction in the potential LA-SA error rate. Whether Tall Man lettering is effective in clinical practice warrants further study.
尽管“醒目大字”（Tall Man lettering）已广泛应用，但关于该技术是否减少了因药品名称相似发音相同（LA - SA）而导致的用药错误，几乎没有证据。本研究评估了2007年实施“醒目大字”前后，直至配药环节的药品管理过程中潜在的LA - SA用药错误发生率。
我们使用了2004 - 2012年42家儿童医院儿科住院患者（<21岁）的详细药房数据。在预先设定一组8种潜在的LA - SA用药错误模式后，我们在每次住院记录中搜索这些模式之一的出现情况，共涉及12对被认为与儿科住院患者高度相关的LA - SA药品组合。为评估实施“醒目大字”前后错误率的潜在变化，我们对11对LA - SA药品组合中的每一对（因为有一对未检测到潜在错误）以及所有11对LA - SA药品组合的总体错误进行了分段回归分析。
在1676700次住院记录中，11对药品组合中每一对的LA - SA错误率的截距或斜率以及综合错误率均未检测到统计学上的显著变化。在对整个研究期间潜在错误率移动平均值的敏感性分析中，2004年以后的任何时间段内，潜在的LA - SA用药错误率均无明显下降趋势。
2007年实施“醒目大字”与潜在的LA - SA错误率降低无关。“醒目大字”在临床实践中是否有效值得进一步研究。
