The document discusses a study aimed at assessing the effectiveness of a Tall Man Lettering educational program on the performance of critical care nurses in safely administering look-alike sound-alike medications. It highlights the prevalence of medication errors in healthcare, particularly in intensive care units, due to confusing drug names and packaging. Through a quasi-experimental design, the study evaluates changes in nurses' knowledge and practices regarding safe medication administration before and after implementing the educational program.

1. Effect of Tall Man Lettering Educational Program on
Critical Care Nurses’ Performance Regarding Safe
Administration of Look Alike Sound Alike Medications
‫الحرجة‬ ‫الرعاية‬ ‫ممرضين‬ ‫أداء‬ ‫على‬ ‫الكبيرة‬ ‫لألحرف‬ ‫تعليمي‬ ‫برنامج‬ ‫تأثير‬
‫والصوت‬ ‫الشكل‬ ‫في‬ ‫المتشابهة‬ ‫لألدوية‬ ‫اآلمن‬ ‫اإلعطاء‬ ‫تجاه‬
By
Ahmed Gamal Fahmy
(M.Sc. Medical-Surgical Nursing- Faculty of Nursing-
Ain Shams University (2018)

2. Thesis Supervisors
Dr. Manal Salah Hassan
Professor of Medical- Surgical Nursing-Ain-Shams University
Dr. Amira Mohammed Ali Hassan
Assistant Professor of Medical-Surgical Nursing-Suez Canal University
Dr. Sheren Elsayed Shrief
Assistant Professor of Medical-Surgical Nursing-Beni-Suef University
Dr. Nagwa Mohammed Helmy
Assistant Professor of Medical-Surgical Nursing-Beni-Suef University

3. Introduction
 Medical errors are a long-standing and important problem in
patient care affecting as many as 1 in 20 patients. The cost of
medical errors, including lost income and productivity, disability,
and additional care, was estimated in 2015 to be 42 billion $
worldwide. Errors involving medications or drugs account for the
largest share (25%) of preventable errors. Wrong-drug errors,
when patients are prescribed one drug and receive another, may
cause injury, hospitalization, and death (Panagioti, Khan &
Keers, 2019).

4. Cont.
 The most serious errors reported by nurses at intensive care
units due to Look-alike Sound-alike (LASA) and refers to drugs
with visually similar physical appearances or packaging, as well
as drug names with similar spelling or phonetics. LASA
medication errors can lead to serious adverse events especially
when high-alert medications are involved. In response, a number
of design techniques have been explored for the purpose of
differentiating Look-alike sound-alike drug names.

5. Cont.
 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 (FDA, 2022).
Commonly, Look-alike Sound-alike medications labels due to
similar drug names, e.g. ceftazidime - ceftriaxone
Furthermore, tall man lettering is one such technique in which
coined by the Institute for Safe Medication Practices (ISMP).

6. Cont.

Tall man lettering is a technique that uses uppercase lettering to help
differentiate look-alike sound-alike drug names. Starting on the left side
of a drug name, TML highlights the differences between similar drug
names by capitalizing dissimilar letters (e.g., vinBLAStine versus
vinCRIStine and CISplatin versus CARBOplatin). TML can be used
along with color or bolding to draw attention to the dissimilarities
between LASA drug names, and alert healthcare providers that the drug
name can be confused with another drug name (Chan, Muller &
Mancuso, 2018).

7. Cont.
The institute of safe medication administration has maintained a
list of drug name pairs or larger groupings with recommended,
uppercase and bolded tall man (mixed case) letters to help draw
attention to the dissimilarities in look-alike sound-alike drug names.
The list includes mostly generic-generic drug name pairs, although a
few brand-brand or brand-generic name pairs are also included. The
FDA list of drug names with recommended TML was initiated in
2001 with the agency’s name differentiation (FDA & ISMP, 2023).

8. Significance of the Study
One identified reason for the occurrence of medications errors
is so-called look-alike, sound-alike (LASA) drugs with similar
drug names leading to mistakes and misidentifications (Zhong et
al., 2015). Due to the fast-paced and complex environment,
patients in hospitals and especially intensive care units (ICUs)
are prone to harm resulting from drug incidents. A number of
hospitals, clinics, and health care systems use tall man lettering
in their computerized order entry, automated dispensing
machines, medication admission records, prescription labels,
and drug product labels (World Health Organization, 2014).

9. Cont.
 Similarities as well as common problems for medications errors
at Egypt; therefore, sharing experiences on the national level is
essential to enhance learning about MEs among different
institutions. Some MEs are product-related, such as in problems
with the medication name, package, or insert. Such errors could
not be detected in internal systems and must be addressed and
managed on the national level (Hassan, 2015).

10.  In addition to some studies demonstrated high incidence
of medication errors related to look alike sound alike
medications so many safety measures should be taken to
reduce this error such as tall man lettering (Sadira et al.,
2024).
Cont.

11. Aim of the study
To assess the effect of tall man lettering educational program on
critical care nurses’ performance regarding safe administration
of look-alike sound alike medications.

12. Research Hypotheses
 To fulfill the aim of the study the following research
hypotheses are formulated:
Nurses’ knowledge regarding safe administration of look-alike
sound-alike medications using tall man lettering will be
increased after implementing educational program.
 Nurses’ Practice regarding safe administration of look-alike
sound-alike medications using tall man lettering will be
improved after implementing educational program.

13. Research Design and Methods

14. Research Design
Quasi-experimental study design of one
group pre- and post-test will be used.

15. Setting
The study will be conducted at intensive care
unit in Suez-Canal University Hospitals..

16. Sample
A convenience sample of all available nurses
working at intensive care unit.

17. Data Collection Tools
Tool I: Nurses’ interviewing questionnaire:
This tool will be adapted by the researcher based on the
literature review of (Lambert , Schroeder & Galanter , 2016),
includes four parts and will be translated into a simple Arabic
language and then will be retranslated into English and data
consists of the following parts:

18. Part I: Nurses’ demographic characteristics: -
This part will be developed by the researcher based on nurses such
as, age, gender, level of educational, job position, nursing
experience in intensive care units, and training courses regarding
look-alike sound-alike medications and tall man lettering.
Cont.

19. Cont.
Part II: Nurses’ knowledge regarding safe medications
administration: -
It will be covering the following items. The role of nurses during
drug administration, pharmacological behind drug, drips rate
calculation, routes of medications administration and medical
abbreviations on medication administration.

20. Cont.
Part III: Nurses’ knowledge regarding look-alike sound-
like medications administration: -
It will be covering the following items. Information on look-
alike sound-alike medication and pharmacological behind look-
alike sound-alike medications.

21. Cont.

Part IV: Nurses’ knowledge regarding tall man lettering: -

It will be covering the following items. Definition of tall man lettering,
correct use of tall man lettering to differentiate look-alike sound-alike
medication and most common agency which developed tall man lettering.

Scoring system

Nurse’s responses were scored “one” for correct answer, and “zero” for
incorrect answer. Nurses’ responses were summed up and then converted into
percent score. Nurses’ knowledge was considered satisfactory if percent score
was ≥ 90% and unsatisfactory if less than 90% (Hussein & Gamal, 2021).

22. Cont.
Tool II: Observational checklist of medication administration
using the tall man lettering
This tool was adopted from (ISMP, 2023). It will used to assess
nurses’ level of practice regarding administration of LASA
medications by using TML it consisted of groups of look-alike sound
alike medications and divided in to three main parts: (1) aware of
confusion, (2) correct application of tall man lettering, and (3)
effectiveness of applying tall man lettering major.

23. Cont.
The scoring system:
 One grades for every nurse done correctly tall man lettering,
zero grade for each nurse not done correctly tall man lettering.
Nurses’ practice was considered satisfactory if percent score
was ≥ 90% and unsatisfactory if less than 90% (ISMP, 2023).

24. Validity and reliability
 Content validity will be done for the developed tool by panel of
five experts in the field of medical surgical nursing in order to
review the tools for objectivity, comprehensiveness, clarity,
relevance and simplicity.
 Reliability of tools will be performed to confirm its consistency
by using alpha coefficient test.

25. Pilot study
1. A pilot study will be conducted on 10% (8 nurses) of the total
study sample (n=80) to assess feasibility of the study, clarity
&objectivity of the developed tools, as well as to examine
issues related to the design, sample, data collection, procedure
and data analysis approaches. Then the tool will be modified
according to the result of pilot study.

26. Ethical consideration
 Primary approval will be obtained from the Research and Ethics
committees at faculty of Nursing Suez Canal University, also an
official permission will be obtained from Dean of faculty of
nursing Suez Canal University to the selected hospital to conduct
the study.
 Each participant will be informed about the purpose of the study
and its significance.

27. Field of work
 Field work: Consisted of three phases as follow:
1. The preparation phase for conducting the program:
2. The Program implementation phase:
3. The Evaluation phase:

28. 1.Preparation phase
The first phase of the work will be done by observing nurse's
performance toward safe medications administration and
administration of Look-alike Sound-alike medications and using
tall man lettering at intensive care unit.

29. 2. Implementation phase
Nurses' education program regarding tall man lettering for safe
administration of look-alike sound alike medications
- - An educational program will be conducted by the researcher
for the nurses. A booklet will be prepared for nurses maintain
the main guidelines of the program and question upon which
nurses learning will be achieved.
- - An educational program will be divided into two parts, the
theoretical part and the practical part.

30. Cont.
(1)-The theoretical part: -The researcher will be
divided the nurses into four group at the theoretical part to assess
nurses’ knowledge regarding safe medications administration,
look alike sound alike medications and tall man lettering through
four sessions in the following distributions:

31. Cont.
- (1) The first group will take the first session for an hour at the
first week, (2) The second group will take the first session for an
hour at the second week, (3) The third group will take the first
session for an hour at the third week, and (4) The fourth group
will take the first session for an hour at the fourth week.
- The other three sessions will be distributed in the same way as
the first session, where the theoretical sessions that includes four
sessions will be explained within four months for all four groups.

32. Cont.
- Session one (introductory session) orientation and explanations of
reason and important of educational program and give
explanation about (safe medication administration).
- Session two: An explanation about administration of look-alike
medications
- Session three: An explanation about administration of sound-
alike medications.
- Session four: An explanation about tall man lettering in
preventing confusion from look-alike sound alike medications.

33. Cont.
- (2)-The practical part: - An educational program will be
carried out regarding practical part for the nurses immediately
after explanation of thermotical parts and the researcher will be
divided the nurses into four groups through two sessions in the
following distributions: -

34. Cont.
- (1) The first group will take the first session for an hour at the
first week, (2) The second group will take the first session for an
hour at the second week, (3) The third group will take the first
session for an hour at the third week, and (4) The fourth group
will take the first session for an hour at the fourth week.
- The other session will be distributed in the same way as the first
session, where the practical part will be implemented within two
months for all four groups.

35. Cont.
- Session one: Collecting all medications of look-alike sound
alike medications at intensive care units that may be led to
medication errors and writing medications names of look-
alike sound alike medications using tall man lettering that
are used at intensive care units.
- Session two: Applying tall man lettering during
administration of look-alike sound- alike medications.

36. 3. Evaluation phase
It will be done after implementing educational program to
determine the effect of using tall man lettering for safe
medications administration of look-alike sound alike
medications at intensive care units and will take a duration of a
month.

37. Discussion
In the light of scientifically and international
references, discussion of the obtained results will be
done based on the statistical tests and researcher point
of view.

38. Conclusion
Appropriate conclusion will be written based on the
findings of the study.

39. Recommendations
Recommendations will be derived from the results of the
study.

40. Summary
A brief description for all the work done will be
provided

41. Thank You