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Hacker Labeling

I’ve got a question for all you pharmacists and other experts out there.

Is there some scientific basis why we laBEL mEDIcatION BoTtLeS liKE We’RE COMPuter HACKers?

The practice appears to me to be more commonplace, so I tried to find some scientific studies demonstrating its effectiveness.

While several articles show “tall man” lettering may improve drug name recognition, I was only able to find a reference to one “technical report” from Grasha et al. from 2000 that purportedly demonstrated an actual decrease in medication errors by capitalizing dissimilar parts of similar medication names. I wasn’t able to find any clinical studies demonstrating that the hacker labeling actually decreased medication errors.

If people who administer medications don’t know that 1000 phenytoin equivalents of “CereBYX” solution are given for seizures, that 20 mg CelEXA tablets are used for treating depression, and that 100 mg “CeleBREX” pills help alleviate arthritis pain, then they shouldn’t be administering medications. Similar concept to the MS04 and MgSo4 argument from years ago.

Is there other research showing improved safety of “tall man lettering” in clinical practice? If so, it should be widely disseminated.

If not, why are we basing the national standard for medication labels on a single “technical report”?

How do we know that writing names in this manner doesn’t cause more medication errors without performing double blind studies?

At some point, I think that “alarm fatigue” is going to set in and that “tall man” lettering is going to be used so much that medical providers will be conditioned to ignore the lettering completely.


  1. Most hackers would be offended that you called this “hacker lettering”. More like 12-year-old-Facebook-user-lettering

  2. It is suppose to help reduce errors by people misreading the medication. It was called “tall man” lettering the hospital I worked in. It was suppose to be on all high alert meds (easy to kill someone with like digoxin, heparin, paralytics, ect) or those who were on this huge look-alike/sound-alike chart ISMP put out and we were required to have posted in the pharmacy like hydoxizine and hydrazine or probably in this case dobutamine and dopamine. If someone looks at it quickly in the med storage room and grabs the wrong thing and starts to infuse it without checking. I know that was a big thing for the pharmacy part of the JACHO inspection when they came to the hospital.

  3. because, we have to.
    ISMP suggests it so we have to follow the suggestions… according to your favorite people, The Joint Commission.
    The problem with most of the tall man lettering is this:

    it doesn’t help with verbal orders (biggest issue with cereBYX and celEXA).. those aren’t even in the same places in the pharamcy (fridge versus orals/tablets)… also, it is usually retail/out patient that uses brand names, in hospital we use generic so they try to make us do it with the various cephalosporins etc…

    I dont think it helps. I dont think it always make sense… but then again, how many thing with the JOINT make sense? many don’t.

    I think it is more to attempt to help nursing – when they go to an ADM (automated dispensing machine, ie pyxis) and do an over ride, and search by brand (since many don’t know generics) it is meant to help them… it doesn’t work. seriously, it doesn’t. I’ve heard of the stupidest mixups for no decent reason other than “I thought it said…” and the tall man lettering won’t change that.

    I’ve heard/seen nurses grab a completely wrong drug and not even read the vial before administering. then i get a panic call of “I gave toradol instead of zofran” “how did you manage that?” “I dunno i thought i picked the right thing out of the machine, it must be in the wrong pocket”… but they didn’t read it before administering…

  4. I think this is a case of something that probably doesn’t hurt and probably doesn’t cost any extra money (you’re labeling these things anyways), so why not do it if it could only make things just a little bit better?

    I think the theory is that even when quickly glancing at the bottle, the capital letters will stand out enough to prevent the dreaded hydroxyzine/hydralazine mix up.

  5. Joint Commission makes us do it.

    Luckily, there are pharmacy interns who need projects and can check to make sure we are up to date with the latest list (it changes on occasion)

  6. People may be drawn to the capitalization first when they are viewing a group of words.

  7. Sounds like a question someone prescribing meds, vs. administering 150-300 per shift would ask. Tis a nursing issue yes. But do you have a better suggestion for preventing drug errors? Our eyes are naturally drawn to larger objects by virtue of natural selection, but there is no “proven” way to prevent all med errors. It’s not always an issue of the person not knowing their med differences, but a matter of hectic schedules, interruptions, lack of sleep, work overload, skimming vs. reading, and multitasking from hell. The 5 rights alone are just not enough.

  8. From this entry it seems that there are some studies that show tall-man lettering might help, and none that show it does any harm. It seems unlikely that this lettering could actually cause any medication errors that wouldn’t have happened anyway.

    If something might help, and doesn’t harm, then what’s the problem with using it?

  9. P.S. I’m an ICU nurse, and although I haven’t made a serious medication error (yet), I think little alarm bells would go off in my head by just glancing if I hung a DOPamine drip instead of a DOBUTamine one. I think the tall-man stuff helps nurses, even if it’s just on a subconscious level.

  10. I’ve been trying to find evidence for it as well; not a whole lot out there. Though, as Allison pointed out, there’s no evidence that it would hamper care.

    That said, and especially given some results that suggest that putting everything in ALL-CAPS INSTEAD OF JUST TALL MAN LETTERING, this may be a case where disfluency results in better comprehension.

    Here’s a great example of it:
    Diemand-Yauman, Oppenheimer, and Vaughan (2010):
    Fortune Favors the Bold (and the Italicized): Effects of Disfluency on Educational Outcomes

    In other words, precisely because we’re annoyed by the lettering (since it’s more difficult to read), we (likely) process the information more deeply, spending more time and attention on reading and comprehending it (indeed, the studies that have been done have shown that it does take more time to read Tall Man Lettering). That, in turn, helps make sure that we’re intentionally prescribing or dispensing, say, DOCEtaxel instead of PACLItaxel, or predniSONE instead of prednisoLONE.

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