Is there some scientific basis why we laBEL mEDIcatION BoTtLeS liKE We’RE COMPuter HACKers?
The practice appears to me to be more commonplace, so I tried to find some scientific studies demonstrating its effectiveness.
While several articles show “tall man” lettering may improve drug name recognition, I was only able to find a reference to one “technical report” from Grasha et al. from 2000 that purportedly demonstrated an actual decrease in medication errors by capitalizing dissimilar parts of similar medication names. I wasn’t able to find any clinical studies demonstrating that the hacker labeling actually decreased medication errors.
If people who administer medications don’t know that 1000 phenytoin equivalents of “CereBYX” solution are given for seizures, that 20 mg CelEXA tablets are used for treating depression, and that 100 mg “CeleBREX” pills help alleviate arthritis pain, then they shouldn’t be administering medications. Similar concept to the MS04 and MgSo4 argument from years ago.
Is there other research showing improved safety of “tall man lettering” in clinical practice? If so, it should be widely disseminated.
If not, why are we basing the national standard for medication labels on a single “technical report”?
How do we know that writing names in this manner doesn’t cause more medication errors without performing double blind studies?
At some point, I think that “alarm fatigue” is going to set in and that “tall man” lettering is going to be used so much that medical providers will be conditioned to ignore the lettering completely.