Figure 1: Issues and outcome summaries No Issue Issue summary Proponent Date Outcome Reason 1 Medicine name Three (3) mixup incidents South Sept Added to Tall Man Lettering List 2017 Considered by expert advisory panel. pair: within a four-month period. Australia 2017 and risk assessment result Both medicines are 600mg lincomycin and demonstrated a medium to high risk strength, although linezolid of confusion packaging distinctly different: 2 mL vial and 300 mL infusion bag respectively 2 Medicine name Concern raised re potential Queensland Sept Not to be added to the Tall Man Lettering Considered by expert advisory rather than actual incidence 2017 List 2017 BISIM and risk assessment result of adverse events and - adrenaline and showed a low risk of confusion, also and that this may be noradrenaline noting application of International an under-representation. Harmonisation of Medicine Names to: adrenaline (epinephrine) noradrenaline (norepinephrine) 3 Medicine name A near miss incident NSW Sept Not to be added to the Tall Man Lettering Considered by expert advisory panel pair: occurred where the 2017 List 2017 BISIM and risk assessment result difference between the showed a low risk of confusion dexmedetomidine names was not recognised. and Dexamethasone dose/rate dexamethasone selected in the smart pump when the dexmedetomidine dose was charted, prepared for administration. 4 Medicine name TGA has released a safety NSW Sept Added to Tall Man Lettering List 2017 Considered by expert advisory pair: mercaptamine advisory re the change of 2017 BISIM and risk assessment result (cysteamine) and ingredient name of demonstrated a medium to high risk mercaptopurine cysteamine to mercaptamine of confusion. at
Figure 1: Issues and outcome summaries No Issue Issue summary Proponent Date Outcome Reason 1 Medicine name pair: lincomycin and linezolid Three (3) mixup incidents within a four-month period. Both medicines are 600mg strength, although packaging distinctly different: 2 mL vial and 300 mL infusion bag respectively South Australia Sept 2017 Added to Tall Man Lettering List 2017 Considered by expert advisory panel. and risk assessment result demonstrated a medium to high risk of confusion 2 Medicine name - adrenaline and noradrenaline Concern raised re potential rather than actual incidence of adverse events and and that this may be an under-representation. Queensland Sept 2017 Not to be added to the Tall Man Lettering List 2017 Considered by expert advisory BISIM and risk assessment result showed a low risk of confusion, also noting application of International Harmonisation of Medicine Names to: adrenaline (epinephrine) noradrenaline (norepinephrine) 3 Medicine name pair: dexmedetomidine and dexamethasone A near miss incident occurred where the difference between the names was not recognised. Dexamethasone dose/rate selected in the smart pump when the dexmedetomidine dose was charted, prepared for administration. NSW Sept 2017 Not to be added to the Tall Man Lettering List 2017 Considered by expert advisory panel BISIM and risk assessment result showed a low risk of confusion 4 Medicine name pair: mercaptamine (cysteamine) and mercaptopurine TGA has released a safety advisory re the change of ingredient name of cysteamine to mercaptamine at NSW Sept 2017 Added to Tall Man Lettering List 2017 Considered by expert advisory BISIM and risk assessment result demonstrated a medium to high risk of confusion.