MONDAY, May 1, 2006 (HealthDay News) -- Just by looking at them, doctors and pharmacists could not correctly identify three common pills more than one-third of the time, a new study found.
"That's really terrible," said lead researcher Dr. Gordon Schiff, a professor of medicine at Rush Medical College and senior attending physician at Cook County Hospital in Chicago.
"In an acute situation, it could be lifesaving to know what a person took," he noted. "And day-to-day, patients come into the hospital and have all their medication in a pill organizer or handkerchief, and they don't know what they are."
However, Schiff also stressed that doctors do their best, given the myriad of drugs out there. "It's not the doctors' fault. We were really testing the system for identifying the medication," he said.
The study appears in the May 1 issue of the American Journal of Health-System Pharmacy.
Schiff said he envisions a standardized, international coding system whereby each pill would be identified by its generic, chemical makeup. The solution should not lie in more training for already overburdened health-care professionals, he said.
Another expert agreed.
"This would not be the best use of doctors' educational efforts," said Dr. A. Mark Fendrick, a professor of internal medicine at the University of Michigan School of Medicine and professor of health management and policy at the University of Michigan School of Public Health.
According to the study, confusion and error resulting from not being able to identify medications is common. More than half a million calls are made annually to poison centers for medication identification.
Currently, there is no standardization of identification: Each manufacturer uses its own codes and symbols. And the study pointed out that the pharmaceutical industry sees no compelling reason to change this practice.
"It's as if people could choose their own license plate numbers and social security numbers," Schiff said.
Misidentification may also lead to the vast number of medication errors that occur each year.
In 1998, the U.S. Institute of Medicine (IOM) published a landmark report which found that "at least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented."
For this study, investigators asked 100 pharmacists and physicians at two urban teaching hospitals to identify three commonly used tablets: Zocor (a brand-name statin), lorazepam (a generic sedative) and naproxen (a nonprescription generic pain reliever). Participants were allowed to consult the resources "usually available to them," including the Internet and the Physicians' Desk Reference, to help identify unknown medications.
Overall, medications were correctly identified 63 percent of the time. The brand name table was correctly identified 78 percent of the time, the generic prescription tablet 64 percent of the time, and the generic nonprescription tablet only 48 percent of the time.
Only 18 physicians (36 percent) and 24 pharmacists (48 percent) correctly identified all three, while 10 physicians (20 percent) and 5 pharmacists (10 percent) couldn't identify any.
The mean time required to identify a tablet was 3.65 minutes.
The majority (77 percent) of participants said they were dissatisfied with the current system, while 91 percent said they were in favor of a universal imprint coding system.
More than half of the doctors and pharmacists reported that these situations arose once a month, with many saying once a week.
A standardized database might also help law enforcement personnel, Schiff added.
"When a person [student] has a bunch of drugs in their pocket and the police are trying to sort these out, are they narcotics or are they legitimate, schoolteachers wise," Schiff said. "It would allow us to identify what these pills are."
More information
The Institute of Medicine report can be viewed online.
