5 Medicine name Suggestion that the names NSW Sept Not to be added to the Tall Man Lettering Considered by expert advisory panel. clozapine: are very similar and orders 2017 List 2017 BISIM and risk assessment result could be misread, especially misreading showed a low risk of confusion. for staff less familiar with potential with other clozapine. medicine names such as clomipramine and clonidine 6 Medicine name Potential for harm identified NSW Sept Not to be added to the Tall Man Lettering Considered by expert advisory panel. pair: risedronate (no actual incident reported) 2017 List 2017 BISIM and risk assessment result and alendronate relating to look-alike showed a low risk of confusion. packaging: Sandoz brand. 7 BRAND NAMES Following the listing of the International Sept Not to be added to the Tall Man Lettering Brand name pair considered by expert dabigatran reversal Medication 2017 List 2017 advisory panel. Medicine name overseas initially during Safety pair: Pradaxa BISIM and risk assessment result 2015, and now in Australia Network (dabigatran) and showed a low risk of confusion. on the ARTG (May 2016), (IMSN) Praxbind the need to consider (idarucizumab) - whether there is a risk in the Australian environment. 8 Medicine name Several incidents involving Western Sept Added to Tall Man Lettering List 2017 Considered by expert advisory panel. pair: tramadol and administration of tapentadol Australia 2017 BISIM and risk assessment result tapentadol instead of tramadol. These demonstrated a medium to high risk medicines have a common of confusion. indication and considered at increased risk of selection error. 9 Medicine name Potential for harm identified International Sept Added to Tall Man Lettering List 2017 Considered by expert advisory panel. pair: rifampicin and internationally by the listing 2017 BISIM and risk assessment result rifaximin Institute for Safe Medication demonstrated a medium to high risk Practices (ISMP) and of confusion. medicines available in Australia (no known incidents reported).
5 Medicine name clozapine: misreading potential with other medicine names such as clomipramine and clonidine Suggestion that the names are very similar and orders could be misread, especially for staff less familiar with clozapine. 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. 6 Medicine name pair: risedronate and alendronate Potential for harm identified (no actual incident reported) relating to look-alike packaging: Sandoz brand. 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. 7 BRAND NAMES Medicine name pair: Pradaxa (dabigatran) and Praxbind (idarucizumab) - Following the listing of the dabigatran reversal overseas initially during 2015, and now in Australia on the ARTG (May 2016), the need to consider whether there is a risk in the Australian environment. International Medication Safety Network (IMSN) Sept 2017 Not to be added to the Tall Man Lettering List 2017 Brand name pair considered by expert advisory panel. BISIM and risk assessment result showed a low risk of confusion. 8 Medicine name pair: tramadol and tapentadol Several incidents involving administration of tapentadol instead of tramadol. These medicines have a common indication and considered at increased risk of selection error. Western Australia Sept 2017 Added to Tall Man Lettering List 2017 Considered by expert advisory panel. BISIM and risk assessment result demonstrated a medium to high risk of confusion. 9 Medicine name pair: rifampicin and rifaximin Potential for harm identified internationally by the Institute for Safe Medication Practices (ISMP) and medicines available in Australia (no known incidents reported). International listing Sept 2017 Added to Tall Man Lettering List 2017 Considered by expert advisory panel. BISIM and risk assessment result demonstrated a medium to high risk of confusion.
National-Tall-Man-Lettering-List-Issues-register-report-November-2017.docx