Standardized pill imprint codes: a pharma fantasy.

To safely use medications, professionals and consumers need usable and reliable methods to identify tablets patients are prescribed and taking. Currently, each manufacturer assigns its own identifying codes and symbols. Standardization of the system for identifying solid dosage forms is a goal that has been widely advocated, yet stubbornly resistant to progress. Physicians, pharmacists, and consumers attempting to identify pills must use various methods which have shortcomings in ease of use, availability, and accuracy. Arguments have been advanced, particularly by pharmaceutical manufacturers, that evidence of unworkability of the current system is not compelling, and costs of retooling current manufacturing processes could be prohibitive. These issues are currently being explored by a task force led by the U.S. Pharmacopeia Safe Medication Use, and Pharmaceutical Forms Dosage Expert Committees. This paper presents a fictitious case study of an elderly patient succumbing to digoxin overdose illustrating the dilemmas posed in the tablet-imprint debate.