A systematic literature review on strategies to avoid look-alike errors of labels

Karin H M Larmené-Beld,E Kim Alting,Katja Taxis

doi:10.1007/s00228-018-2471-z

Karin H M Larmené-Beld, E Kim Alting + Show 1 more

Open Access

https://doi.org/10.1007/s00228-018-2471-z

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Abstract

PurposeUnclear labeling has been recognized as an important cause of look-alike medication errors. The aim of this literature review is to systematically evaluate the current evidence on strategies to minimize medication errors due to look-alike labels.MethodsA literature search of PubMed and EMBASE for all available years was performed independently by two reviewers. Original studies assessing strategies to minimize medication errors due to look-alike labels focusing on readability of labels by health professionals or consumers were included. Data were analyzed descriptively due to the variability of study methods.ResultsSixteen studies were included. Thirteen studies were performed in a laboratory and three in a healthcare setting. Eleven studies evaluated Tall Man lettering, i.e., capitalizing parts of the drug name, two color-coding, and three studies other strategies. In six studies, lower error rates were found for the Tall Man letter strategy; one showed significantly higher error rates. Effects of Tall Man lettering on response time were more varied. A study in the hospital setting did not show an effect on the potential look-alike sound-alike error rate by introducing Tall Man lettering. Color-coding had no effect on the prevention of syringe-swaps in one study.ConclusionsStudies performed in laboratory settings showed that Tall Man lettering contributed to a better readability of medication labels. Only few studies evaluated other strategies such as color-coding. More evidence, especially from real-life setting is needed to support safe labeling strategies.

Highlights

Good labeling of medication is an important aspect of medication safety
The American Food and Drug Administration (FDA) estimated that 20% of medication errors may be attributed to confusing packaging and poor labeling; others suggested even higher rates [1, 2]
The CD3 Tall man rule as Mid Tall Man, but capitalizes a maximum of three letters # For better comparison, these percentages have been calculated based on the results presented in the paper label) was significantly longer than for the new white labels

Summary

Introduction

Good labeling of medication is an important aspect of medication safety. The American Food and Drug Administration (FDA) estimated that 20% of medication errors may be attributed to confusing packaging and poor labeling; others suggested even higher rates [1, 2]. Look-alike labels due to similar drug names, e.g. ceftazidime—ceftriaxone. Various measures have been suggested to enhance the readability of labels and reduce errors due to look-alike labels [3, 4]. A technical solution is the use of a closedloop system with barcode technology. Guidelines of the FDA and European Medicine Agency (EMA) do not give conclusive advice on how to prevent look-alike errors [5, 6]. Strategies such as Tall Man lettering and color-coding are seen as potential solutions.

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