Avoiding medication mixups. Identifiable imprint codes

This study was done to determine if current imprinting of solid medication forms permits health care professionals to identify the manufacturers involved so as to be able to activate the hierarchic identification system mandated by the Food and Drug Administration. We tested 15 representatives of 6 groups of health professionals for their ability to identify the manufacturer after having examined 30 solid-dosage forms drawn from a pseudo-random sample of stock hospital formulary products. The correct identification of the manufacturer was the sole criterion. Of the 2,700 opportunities, the manufacturer was able to be identified for only 43%. Nurses and medical students had a 35% success rate, pharmacists and poison center specialists a 55% success rate, and residents and attending physicians a 40% rate. None approached 95% accuracy. Currently employed imprints fail in their objective to permit health care professionals--or the general public--to rapidly identify prescription drugs. The manufacturers' logotypes need to be modified if this identification system is to be implemented. We propose a simple voluntary collaborative effort by the pharmaceutical industry to solve the problem.