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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 randomised 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 capitalisation 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 there 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.

Original publication




Journal article


Br J Clin Pharmacol

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