Successful Introduction of Tallman Letters to Reduce Medication Selection Errors in a Hospital Network

Abstract

ABSTRACTAimTo implement Tallman letters into the medication selection process at a hospital network, including dispensing and drug administration, to reduce errors associated with look‐alike sound‐alike (LASA) drugs.MethodThe 3 phases of the study were overseen by a working party consisting of pharmacists at the Alfred Hospital (May 2006 to May 2008). The 3 phases consisted of piloting Tallman letters in the pharmacy department, developing a LASA drug list appropriate to the hospital network, and implementing Tallman letters into the hospital network's medication selection process.ResultsA short LASA drug list was piloted in the inpatient dispensary for 6 months. When this was considered successful, a comprehensive LASA drug list was developed that consisted of 51 items to distinguish between generic names (n = 41), brand names (n = 6) and generic and brand name combinations (n = 4). Tallman letters were included into the pharmacy dispensing software. Finally, Tallman letters were implemented across the 3 hospitals in the network, i.e. 7 dispensaries and 40 ward medication storage areas.ConclusionTallman letters were successfully introduced and implemented into a hospital network. This was achieved with the expenditure of minimal resources and has improved safety by minimising the risk of selecting the wrong medication.