TY - JOUR T1 - Beyond mixed case lettering: reducing the risk of wrong drug errors requires a multimodal response JF - BMJ Quality & Safety JO - BMJ Qual Saf DO - 10.1136/bmjqs-2022-014841 SP - bmjqs-2022-014841 AU - Bruce L Lambert AU - Scott Ryan Schroeder AU - Michael R Cohen AU - Susan Paparella Y1 - 2022/08/04 UR - http://qualitysafety.bmj.com/content/early/2022/08/04/bmjqs-2022-014841.abstract N2 - Confusion between drug names that look and sound alike continues to occur and causes harm in all care settings, despite persistent prevention and mitigation efforts by industry, regulators, health systems, clinicians, patients and families. In this issue of BMJ Quality and Safety, Lohmeyer et al examined the effect of mixed case (often referred to as ‘tall man’) text enhancement on critical care nurses’ ability to correctly identify a specific syringe from an array of similarly labelled syringes.1 Here, we reflect on their study, summarising its key findings and commenting on its strengths as well as suggesting further developments in this field of research. We then make the case that significant, reliable reduction in drug name confusion errors will require multimodal interventions.Lohmeyer et al tested the effect of mixed case lettering on a syringe selection task with 30 critical care nurses as particpants. They showed that mixed case lettering caused a reduction in selection errors from 5.3% to 0.7%. The study has several strengths. The first has to do with the use of syringe labels realistically formatted using an international standard. The more realistic the labels are, the greater the external generalisability of the findings. A second strength is that it uses practising healthcare professionals as participants. Many previous studies of text enhancement to prevent look-alike/sound-alike (LASA) errors have used laypeople as participants. Use of laypeople as participants is not inherently wrong, since they too can make LASA errors when selecting non-prescription drugs. But the exclusive use of lay participants limits generalisability because drug names are a specialised vocabulary. To understand the effects of text enhancements in clinical settings, it is therefore important to use clinicians as study participants. This is especially true because one of the most powerful effects on word memory and perception is familiarity,2 … ER -