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The experience of this patient highlights the types of medication errors that occur even when the right drug is chosen and ordered for a patient. The United States Pharmacopeia Medication Errors Reporting Program, a Food and Drug Administration Med Watch partner, catalogs medication errors, including problems with product names. Their reporting form encourages recommendations to prevent recurrence of the error. Copies of the United States Pharmacopeia Medication Errors Reporting Program report are routinely shared with the Institute for Safe Medication Practices, the manufacturer, and the Food and Drug Administration. In the past, this process has even resulted in the change of brand names. For instance, it was noted that "Losec" (omeprazole) was being confused with "Lasix" (furosemide) and so the brand name was changed to "Prilosec" (omeprazole). Physicians should work with their pharmacy and therapeutics committees to routinely report such occurrences in their hospitals, call United States Pharmacopeia Medication Errors

CLINICAL SCENARIO You recall from the first of our 2 articles 1 concerning economic analysis of clinical practice that your chief of medicine has asked you to review relevant economic evidence from the literature and report to the hospital's pharmacy and therapeutics committee, which is trying to decide on formulary guidelines for the use of streptokinase and tissuetype plasminogen activator (t-PA) in the treatment of acute myocardial infarction (AMI). Your literature search identified 2 recent key cost-effectiveness studies: an analysis of economic data collected prospectively as part of the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO) trial 2 of streptokinase vs t-PA by Mark et al, 3 and a decision-analytic model by Kalish et al. 4 In the first article of this 2-part series we showed you how to evaluate the validity of the different economic appraisal study methods. In this article, we will

CLINICAL SCENARIO You are a general internist on the staff of a large community hospital. Your chief of medicine knows of your interest in evidence-based medicine, and she asks you to help her solve a problem. The hospital's pharmacy and therapeutics committee has been trying to decide on formulary guidelines for the use of streptokinase or tissue-type plasminogen activator (t-PA) in the treatment of acute myocardial infarction (AMI). Members of the committee have been arguing for weeks about the Global Utlization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO) trial 1 and whether the added expense of t-PA is worth it. The committee has reached an impasse and has asked the chief of medicine for some outside help to reach a good decision. Knowing that the hospital faces pressure to keep costs down, the chief wants good information about this question to bring to the next committee

I read with great interest in the January 8, 1996, issue of the Archives the article by Kerin et al 1 concerning the use of intravenous amiodarone for the conversion of chronic atrial fibrillation. As a cardiologist in a rural hospital in western New York (Olean, NY), I have been tempted 2 or 3 times to use amiodarone for treatment of this condition. I suspect that because of practical considerations in this day and age, however, intravenous amiodarone will not be used for the treatment of atrial fibrillation; I remember how I had to fight, and how difficult it was, to get intravenous amiodarone in the formulary for the treatment of life-threatening ventricular arrhythmias. The cost of the drug is so high that it would be an unusual pharmacy and therapeutics committee that would allow its use for anything other than indications approved by the Food and Drug Administration.

Formularies and formulary systems are not a new concept in medical practice. In this country, they have been used in selected settings since the Revolutionary War and formal guidelines were published in 1933. They are in essence a collection of prescribing policies of physicians in a particular practice setting. Formularies are administered by a system in which medical staff members working through a pharmacy and therapeutics (P&T) committee recommend, evaluate, appraise, and select drugs to be included in the medication list. The system also develops, maintains, and enforces policies regarding how restrictive the process will be and what methods will be used to ensure compliance and verify that educational and quality standards are met. 1,2

The Pharmacy and Therapeutics committee is a frequently used mechanism for health care organizations to meet mandated standards. The control that the committee has over the formulary is often seen as a potential way of controlling the expenditures for drugs. As the Pharmacy and Therapeutics committee is the means for the clinical staff to have an effect as to what agents are available to practitioners, it is incumbent on the committee members to have a clear idea of what their role should be in cost containment. An important concept that impacts on cost is that optimal health benefit is not necessarily the result of maximum expenditure. The welfare of the patient is paramount to all in the health care field; however, it is the task of clinicians to determine what constitutes optimal health benefit and to act as agents of the patient. Clinicians must maintain patient care as their top priority. Although health care expenditures are an extremely important issue, quality of patient care cannot be subrogated to a secondary concern. ( Arch Intern Med . 1992;152:1773-1775)

To the Editor. —The Council on Ethical and Judicial Affairs of the AMA 1 has taken an important step toward clarifying the relationship between the medical service industry and physicians. Unfortunately, it is neglecting an important area of concern. Many university faculty members and prominent practicing physicians serve as paid consultants to major pharmaceutical houses and travel around the country giving seminars and educational conferences that are frequently, although not always, thinly veiled promotions for particular products. In doing so, they exercise their rights as individuals to contract for services, but they also abrogate their responsibilities as faculty members to pursue an impartial view of medical research and therapy. When they become agents of industry, they should be barred from serving on any major university or hospital committees that might cause a conflict of interest, such as pharmacy and therapeutics committees and committees that set standards of care or practice

To the Editor . —We read with interest Brook's 1 recent correspondence concerning the risks of substitution of therapeutically equivalent drugs on hospital formularies. We agree that caution is warranted and that the best interest of the patient should not be overshadowed by economic considerations. Several of Brook's statements are, however, quite disconcerting. In his discussion Brook refers to "the committees of the institution" that are responsible for decisions regarding drug substitution on hospital formularies. This type of committee is most commonly known as the Pharmacy and Therapeutics (P & T) committee. Brook's statement that the major goal of the hospital [P & T] committee is to save money is both erroneous and insulting. The hospital P & T committee is generally composed of physicians, pharmacists, nurses, and hospital administrators who dedicate their own time to ensure the efficacious, safe, and economic use of drugs within the institution. In making decisions

To the Editor. — We differ with an opinion expressed inThe Journalon April 7 regarding health care worker exposure to ribavirin, an antiviral agent with in vitro activity against respiratory syncytial virus (RSV).1Data regarding the efficacy of this agent in the treatment of RSV infections in children have been published.2,3Guidelines for the use of this drug have been published by the American Academy of Pediatrics.4Faculty from the Department of Pediatrics, University of California, San Diego, and Children's Hospital, San Diego, were faced with the same concerns regarding health care worker safety as those expressed by Guglielmo et al.1The Pharmacy and Therapeutics Committee of Children's Hospital appointed a similar task force from the University of California and Children's Hospital composed of representatives from the Divisions of Infectious Diseases, Pulmonary Medicine, General Pediatrics, and Pharmacy to discuss these issues as well as

To the Editor.— We read with interest Dr. Wilson's comments (227:481, 1974) concerning the comparable efficacy of heparin from porcine intestinal mucosa and beef lung sources. A great deal of confusion about this drug shows that additional research is needed. However, some of Dr. Wilson's comments will only add to the confusion, and he creates concern about other issues having nothing to do with heparin therapy. It is implied that patients are actually being harmed through the ignorance of hospital pharmacists who purchase heparin derived from porcine intestinal mucosa. Hospital pharmacists will certainly resent such implications. Drug purchasing decisions are based upon the best available information, including, in a great many instances, the recommendations of the pharmacy and therapeutics committee of the medical staff. If Dr. Wilson has conclusively demonstrated that the differences between the two types of heparin are so great that there has been "needless slaughter of human beings,"

The Drug Spotlight turns on anticoagulants, because the appropriate use of these agents could prevent a substantial number of the 50,000 deaths caused by venous thromboembolism annually in the United States. Experts may differ on some of the indications for anticoagulant therapy, the method of administration, and the duration of therapy. Nonetheless, it is important to determine how the use of anticoagulants in your hospital measures up to the ideas presented by Dr. Stanford Wessler, on page 757 and the opinions expressed in the other scientific reports presented in the other journals participating in the program. Listed below are suggestions for studies of anticoagulant therapy. Your pharmacy and therapeutics committee should gather data on one or more of these subjects or on some other aspect of anticoagulation. The analysis of your data might lead to more effective use of anticoagulants and to a reduction in morbidity and mortality from venous

To the Editor.— I would like to reply to the editorial by Dr Ballin entitled "Therapeutic Substitution—Usurpation of the Physician's Prerogative." 1 The author states rather broadly that therapeutic substitution is a practice in which the pharmacist can substitute any drug believed by the pharmacist to have a similar therapeutic effect as the drug prescribed by the physician. He gives the impression that the pharmacist acts totally independently of the physician in deciding which drug to substitute. I feel that this is misleading for several reasons. First, pharmacists are not authorized, in any state, to make therapeutic substitutions without physician approval. Second, in all the examples cited by Dr Ballin, the pharmacist is making substitutions only with the authorization of the physician or the institution. The example of how pharmacy and therapeutics committees determine therapeutic substitutions best represents the cooperative effort between physicians and pharmacists. Rational decisions are made by

The profession is being overwhelmed by proprietary remedies. The manufacturers who project them copyright the name by which they are to be known, patent the process by which they are made, and patent the resulting product, so that these remedies must remain a monopoly for all time. Coblentz, in his recent edition of "Newer Remedies," gives a succinct account of about two thousand, all introduced during the last few years, and Lehn and Fink, in "Progress in Pharmacy and Therapeutics," enumerate about five hundred more. I have recently had three of the leading dispensing druggists of Chicago, Messrs. Gale & Blocki, Dale & Sempill, and D. R. Dyche & Co., examine the last 1000 prescriptions on their files for the purpose of ascertaining how many of them contained these proprietary remedies, with the result that one firm finds about 20 per cent., another 21 per cent., and the third 26

As I appear before you to-day, I am deeply moved by the honor which you conferred upon me one year ago, when you selected me to be your chairman. Then and until now, I have sought to be ever mindful of the obligation which the position brings, and, as in previous years, have held the welfare and continuous advancement of the Section constantly before me. It has been my pleasure to be intimately associated with this Section for several years, during which time I have attended the sessions of none other; for two consecutive terms I served as secretary, and to-day, having a feeling of close affiliation with the work before us, I can appreciate all the more the honor of being your chief executive officer. And just here, let me say, greater good would come, I believe, to the individual sections of the Association, did the men who read

Among the available textbooks of pharmacology and therapeutics, this seventh edition of Grollman and Grollman's Pharmacy and Therapeutics occupies an intermediate position in its treatment of the subject. The book is neither a succinct, "essentials" textbook, nor is it a "Goodman and Gilman." It probably will have most appeal to the average student attempting to learn enough pharmacology to earn him his MD degree. The book is well written, and since the book has two authors only, there is a consistency of style that the reader can expect from chapter to chapter. But, probably for the same reason, there is an inconsistency of the quality of each chapter. The reader who is not interested in scholarly referencing of statements or findings will find this book to his liking. However, since much of the science of pharmacology is not "hard facts," and controversial views exist in many areas, the lack of