Published Online: Thursday, June 1, 2006

Pharmacists and physicians may need to brush up on their memory skills when it comes to identifying pills on sight. A standardized drug-coding system, however, could solve this dangerous situation.

In a study reported in the May 1, 2006, issue of the American Journal of Health- System Pharmacy, 1000 pharmacists and physicians at 2 urban teaching hospitals were asked to identify 3 commonly used tablet medications: Zocor (a brand name statin), lorazepam (a generic sedative), and naproxen (a nonprescription generic pain reliever). The participants were allowed to consult the resources "usually available to them."

Overall, medications were correctly identified 63% of the time. Zocor was correctly identified 78% of the time, lorazepam 64% of the time, and naproxen 48% of the time. Only 24 pharmacists (48%) and 18 physicians (36%) correctly identified all 3 drugs, whereas 5 pharmacists (10%) and 10 physicians (20%) batted zero.

The study also found that confusion and error resulting in not being able to correctly identify medications is common.

Currently, there is no standardization of identification, because manufacturers use their own codes and symbols. The researchers also noted that the pharmaceutical industry sees reason to change this practice.

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