Aims: The aim of this systematic review was to explore and evaluate the efficacy of interventions to reduce the prevalence of look-alike, sound-alike (LASA) medication name errors.
Methods: We conducted a systematic review of the literature, searching PubMed, EMBASE, Scopus and Web of Science up to December 2016, and re-ran the search in February 2020 for later results. We included studies of interventions to reduce LASA errors and included randomized controlled trials, controlled before-and-after studies, and interrupted time series. Details were registered in Prospero (ID: CRD42016048198).
Results: We identified six studies that fulfilled our inclusion criteria. All were conducted in laboratories. Given the diversity in the included studies, we did not conduct a meta-analysis and instead report the findings narratively. The only intervention explored in RCTs was capitalization of selected letters ("Tall Man"), for which we found limited efficacy and no consensus.
Conclusions: Tall Man lettering is a marginally effective intervention to reduce LASA errors, with a number of caveats. We suggest that Tall Man gives rise to a "quasi-placebo effect", whereby a user derives more benefit from Tall Man lettering if they are aware of its purpose.
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| http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9328434 | PMC |
| http://dx.doi.org/10.1111/bcp.14644 | DOI Listing |
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