Open Collections

D E V E L O P M E N T O F A PROVINCIAL DRUG FORMULARY  by E L I Z A B E T H ANN P A G E Bv. Sc., (Pharm.), University of British Columbia, 1971  A THESIS SUBMITTED IN P A R T I A L F U L F I L M E N T O F T H E REQUIREMENTS FOR T H E D E G R E E OF M A S T E R O F SCIENCE  in the Division of Clinical Pharmacy of the Faculty of Pharmaceutical Sciences  We accept this thesis as conforming to the required standard  T H E UNIVERSITY OF BRITISH COLUMBIA September, 1973  In  presenting  an  advanced degree a t the U n i v e r s i t y  the  Library  I further for  this thesis  agree that  permission  s c h o l a r l y p u r p o s e s may  this thesis  written  of B r i t i s h  Columbia, I agree  f o r reference  f o r extensive  copying  f o r f i n a n c i a l gain  shall  that  study.  of this  b e g r a n t e d by t h e Head o f my  I t i s understood  and  that  thesis  Department o r  copying or  publication  n o t be a l l o w e d w i t h o u t  my  permission.  Department o f  Clinical Pharmacy,  The U n i v e r s i t y o f B r i t i s h Vancouver 8 , Canada  Date  f u l f i l m e n t of the requirements f o r  s h a l l make i t f r e e l y a v a i l a b l e  by h i s r e p r e s e n t a t i v e s . of  in partial  September  10,  1973  Columbia  F a c u l t y of P h a r m a c e u t i c a l S c i e n c e s  D E V E L O P M E N T OF  A  PROVINCIAL  DRUG  FORMULARY  ABSTRACT  The  a d o p t i o n o f the L i o n s G a t e H o s p i t a l D r u g F o r m u l a r y b y  B r i t i s h C o l u m b i a H o s p i t a l A s s o c i a t i o n f o r d i s t r i b u t i o n and use  the  in a l l  p r o v i n c i a l h o s p i t a l s e n d o r s e s the g r o w i n g t r e n d t o w a r d r e g i o n a l i z a t i o n of drug information.  S e v e r a l a s p e c t s of this F o r m u l a r y w e r e i n v e s t i g a t e d i n  the p r e s e n t s t u d y w i t h the o b j e c t i v e o f d e s i g n i n g to the v a r i e d n e e d s o f the p r o v i n c e .  The  a text e v e n m o r e a p p l i c a b l e  f o r m a t o f the F o r m u l a r y a n d  m e c h a n i s m f o r r e g u l a r l y e v a l u a t i n g a n d u p d a t i n g the i n f o r m a t i o n  a  therein  w e r e the m a j o r a r e a s r e c e i v i n g c o n s i d e r a t i o n .  One  m a j o r c h a n g e i n f o r m a t p r o p o s e d i s the i n c r e a s e i n the n u m b e r  o f d r u g m o n o g r a p h s to a p p r o x i m a t e l y 600 increase  f r o m the p r e s e n t 300  entries.  i s b a s e d on the r e q u e s t s f o r a d d i t i o n a l d r u g s f r o m the  t i v e h o s p i t a l s s a m p l e d i n the p r o v i n c e .  This  representa-  C h a n g e s i n the f o r m a t of i n d i v i d u a l  m o n o g r a p h s i n c l u d e an e x p a n s i o n of i n f o r m a t i o n u n d e r the h e a d i n g " M o d e of A c t i o n " , that an a d d i t i o n a l s e c t i o n on " I n s t r u c t i o n s to the P a t i e n t " be  added  to f a c i l i t a t e e f f e c t i v e i n s t r u c t i o n s f o r s e l f - a d m i n i s t r a t i o n i n a m b u l a t o r y s e r v i c e s , that e a c h m o n o g r a p h r e c e i v e a C a n a d i a n D r u g I d e n t i f i c a t i o n C o d e reference  a n d that the i n f o r m a t i o n i n e a c h m o n o g r a p h be r e f e r e n c e d  p o s s i b l e to the p r i m a r y l i t e r a t u r e  source.  where  ii  C h a n g e s i n the f o r m a t o f the o v e r a l l F o r m u l a r y i n c l u d e a c r o s s i n d e x o f m o n o g r a p h s to m a n u f a c t u r e r s ' b r a n d n a m e s , a b i b l i o g r a p h y o f the r e f e r e n c e d i n f o r m a t i o n and a " M i n i " F o r m u l a r y f o r m a t for use on individual hospital wards.  T h e l a t t e r r e c o m m e n d a t i o n i s m a d e i n r e c o g n i t i o n o f the  p o t e n t i a l b u l k o f the o v e r a l l M a s t e r F o r m u l a r y w h i c h w o u l d m a k e i t a w k w a r d for efficient and frequent u s e .  In t h i s r e s p e c t , i t i s a n t i c i p a t e d that o n e  M a s t e r F o r m u l a r y c o n t a i n i n g a l l 600 e v e n t u a l m o n o g r a p h s , the b i b l i o g r a p h y f o r e a c h a n d the v a r i o u s i n d i c e s b e m a d e a v a i l a b l e i n e a c h h o s p i t a l f o r resource reference.  On each ward a complete F o r m u l a r y of all drug mono-  g r a p h s b u t n o t the a c c o m p a n y i n g  b i b l i o g r a p h i e s w o u l d be a v a i l a b l e .  Studies  s h o w e d that s o m e t h i n g l e s s t h a n 100 o f t h e s e d r u g s ( l e s s t h a n 20 p e r c e n t ) were u s e d with any frequency on any specialty w a r d studied.  Therefore, a  " M i n i " F o r m u l a r y c o n t a i n i n g o n l y the m o n o g r a p h s o f d r u g s f r e q u e n t l y u s e d i n a s p e c i a l t y a r e a w o u l d m a k e the i n f o r m a t i o n m o r e r e a d i l y a v a i l a b l e i n that service.  C h a n g e s i n p r i n t i n g f o r m a t a l s o a r e r e c o m m e n d e d w i t h the o b j e c -  t i v e o f r e d u c i n g the b u l k o f the p r o p o s e d F o r m u l a r y .  A r e g u l a r u p d a t i n g m e c h a n i s m m u s t b e a c t i v a t e d to k e e p the i n f o r m a t i o n i n the F o r m u l a r y c u r r e n t .  S u c h a m e c h a n i s m r e l a t e d to a n a n n u a l  l i t e r a t u r e e v a l u a t i o n a s s i g n m e n t b y the s e n i o r s t u d e n t s o f the F a c u l t y o f P h a r m a c e u t i c a l Sciences, University of B r i t i s h Columbia, is proposed. B a s e d on this a c a d e m i c  e x e r c i s e , two t y p e s o f u p d a t i n g a r e i d e n t i f i e d .  F i r s t , a c o m p l e t e e v a l u a t i o n a n d r e f e r e n c i n g o f the e x i s t i n g m o n o g r a p h information is required.  Second, annual updating o f this i n f o r m a t i o n  from  iii  c u r r e n t l i t e r a t u r e s h o u l d be m a i n t a i n e d .  T o evaluate, r e v i s e and condense  the s t u d e n t s ' e v a l u a t i o n s to m o n o g r a p h f o r m a t , faculty instructor time and of stenographer  a " s e r v i c e " component of  t i m e h a v e b e e n p r o j e c t e d . It i s  a n t i c i p a t e d that the p r o v i s i o n o f a p p r o x i m a t e l y o n e - h a l f t i m e i n s t r u c t o r p e r y e a r and one-tenth time stenographer  w i l l be r e q u i r e d bn a " s e r v i c e " b a s i s  to e n a b l e the r e g u l a r u p d a t i n g o f the c u r r e n t F o r m u l a r y a s d e f i n e d a b o v e . The  a r r a n g e m e n t f o r a M e d i c a l R e v i e w B o a r d to r e v i e w the e v a l u a t e d m o n o -  graphs f r o m a c l i n i c a l v a l i d i t y standpoint also should be m a d e .  T h e above  p r o j e c t i o n s a r e b a s e d o n s t u d i e s r e l a t e d to the e v a l u a t i o n a n d u p d a t i n g o f 100 d r u g m o n o g r a p h s d u r i n g 1972-73.  A f i n a l r e c o m m e n d a t i o n i s that the b a s i s  f o r g e n e r a t i n g , u p d a t i n g a n d a d d i t i o n a l r e f e r e n c i n g o f the D r u g should be a p r o v i n c i a l D r u g Information  Formulary  Centre.  Signature of Supervisor  ACKNOWLEDGEMENTS  The  a u t h o r w i s h e s to e x p r e s s h e r g r a t i t u d e to D r . J . N . H l y n k a  a n d D r . D . L . S m i t h f o r t h e i r i n s t r u c t i o n a n d a s s i s t a n c e t h r o u g h o u t the p r e p a r a t i o n o f this t h e s i s a n d h e r G r a d u a t e Student T e a c h i n g A s s i g n m e n t . In a d d i t i o n , the c o - o p e r a t i o n o f the p h a r m a c i s t s o f the L i o n s G a t e the B r i t i s h C o l u m b i a H o s p i t a l A s s o c i a t i o n a n d the B r i t i s h  Hospital,  Columbia  p h a r m a c i s t s who p a r t i c i p a t e d i n the s e v e r a l s u r v e y s c o n d u c t e d d u r i n g this study i s g r e a t l y a p p r e c i a t e d .  T h e f i n a n c i a l a s s i s t a n c e o f the W a r n e r - L a m b e r t R e s e a r c h F e l l o w s h i p i n P h a r m a c y a n d the U n i v e r s i t y o f B r i t i s h C o l u m b i a G r a d u a t e  Fellow-  s h i p a n d S u m m e r R e s e a r c h S c h o l a r s h i p e n a b l e d the a u t h o r to c o n t i n u e h e r studies and i s hereby  acknowledged.  V  T A B L E O F CONTENTS  Page  ABSTRACT  ..  ACKNOWLEDGEMENTS  i .  T A B L E OF CONTENTS LIST OF T A B L E S LIST O F FIGURES  iv v vii ix  LIST O F APPENDICES  x  L I T E R A T U R E SURVEY  1  I. Need for Drug Information  1  II. Hospital Drug Formularies  5  III. Regional Drug Formularies  11  IV.  18  Provincial Hospital Drug Formulary  V. Academic Role  20  S T A T E M E N T OF O B J E C T I V E S  22  METHODOLOGY  23  I. Identifying the Provincial Needs  23  (a) Popularity of Use  24  (b) Number of Drug Monographs  24  (c) Format of Drug Monographs  28  (d) Monograph Utilization Survey  31  vi  T A B L E O F CONTENTS (Continued)  Page  II. Evaluation and Updating the Formulary  .....  34  (a) Mechanism of Updating  37  (b) Nature and Frequency of Change  41  (c) Time Evaluation  R E S U L T S AND DISCUSSION I. Identifying the Provincial Needs  . .  41  42 42  (a) Popularity of Use  43  (b) Number of Drug Monographs  46  (c) Format of Drug Monographs  48  (d) Format of the Formulary  57  II. Evaluation and Updating the Formulary  70  (a) Nature and Frequency of Change  71  (b) Time Evaluation  74  RECOMMENDATIONS  82  BIBLIOGRAPHY  84  APPENDICES  89  vii  LIST O F T A B L E S  Table  I  II  Page  DRUG F O R M U L A R Y UTILIZATION  REASONS FOR NOT USING T H E DRUG FORMULARY  III  44  45  F R E Q U E N C Y O F T H E USE O F PROVINCIAL F O R M U L A R Y DRUGS (483) IN PEDIATRIC WARDS O F VARIOUS HOSPITALS  IV  61  F R E Q U E N C Y O F T H E USE O F PROVINCIAL F O R M U L A R Y DRUGS (483) IN E M E R G E N C Y WARDS O F VARIOUS HOSPITALS  V  62  F R E Q U E N C Y O F T H E USE O F PROVINCIAL F O R M U L A R Y DRUGS (483) IN E X T E N D E D C A R E WARDS O F VARIOUS HOSPITALS  VI  64  F R E Q U E N C Y O F T H E USE O F PROVINCIAL F O R M U L A R Y DRUGS (483) IN PSYCHIATRIC  VII  WARDS O F VARIOUS HOSPITALS  65  MONOGRAPH CHANGES  73  viii  LIST O F T A B L E S (Continued)  Table  VIII  IX  Page  REVISION TIMES  F U T U R E REVISION S C H E D U L E  '  75  78  ix  LIST O F FIGURES  Figure  1  Page  E X A M P L E O F T H E FORMAT  AND  CONTENT O F T H E DRUG MONOGRAPHS O F T H E LIONS G A T E HOSPITAL DRUG FORMULARY  .  2  CHIEF PHARMACISTS QUESTIONNAIRE .....  3  S A M P L E O F DRUG LISTS USED FOR MONOGRAPH UTILIZATION SURVEY  4  8  26  33  INSTRUCTIONS FOR MONOGRAPH UTILIZATION SURVEY  35  5  CHANGE S H E E T E X A M P L E  39  6  S A M P L E MONOGRAPH O F E R Y T H R O M Y C I N F R O M T H E EXISTING DRUG F O R M U L A R Y B E F O R E REVISION  7  49  S A M P L E MONOGRAPH O F ERYTHROMYCIN INCLUDING BIBLIOGRAPHY A F T E R REVISION  51  X  LIST O F APPENDICES  Appendix  I  Page  COST O F T H R E E MAJOR DRUG INFORMATION SERVICES  II  8$  LISTS O F DRUGS RECEIVING TWO OR M O R E REQUESTS FOR INCLUSION IN T H E DRUG F O R M U L A R Y  III  90  STUDENT MONOGRAPH UPDATING ASSIGNMENT 1972-73  98  LITERATURE  I.  SURVEY  Need F o r Drug Information  " A c c u r a t e a n d u n b i a s e d i n f o r m a t i o n about d r u g s i s e s s e n t i a l i f g o o d m e d i c i n e i s to b e p r a c t i c e d . In t h e s e d a y s w h e n m a n y n e w a n d p o t e n t d r u g s a r e being i n t r o d u c e d s u c h i n f o r m a t i o n m u s t be r e a d i l y available and should include a l l facts r e l e v a n t to the u s e o f the d r u g , i n c l u d i n g b o t h e f f i c a c y and a d v e r s e r e a c t i o n s . " (1).  (a) V o l u m e o f D r u g  The  Literature  v o l u m e a n d d i v e r s i t y o f d r u g l i t e r a t u r e a n d the p r o b l e m s o f  c o m p i l i n g and d i s t r i b u t i n g d r u g i n f o r m a t i o n have been w i d e l y e x p r e s s e d (2-15). 1963  A W o r l d L i s t of P h a r m a c y P e r i o d i c a l s which was c o m p i l e d i n  c o n t a i n s o v e r 900 e n t r i e s .  In a d d i t i o n to p h a r m a c e u t i c a l p u b l i c a t i o n s ,  drug i n f o r m a t i o n i s also found i n other j o u r n a l s such as m e d i c i n e , d e n t i s t r y , b i o l o g y , a g r i c u l t u r e a n d e n g i n e e r i n g (3).  Dr. A.F.  Langlykke  i n 1958 e s t i m a t e d that 200, 000 o r i g i n a l p a p e r s w e r e p u b l i s h e d y e a r l y i n r e g a r d to p h a r m a c y a n d d r u g s ( 4 ) . D r . D . B u r k h o l d e r p r o j e c t e d i n 1967 that 33 p e r c e n t o f p u b l i s h e d b i o m e d i c a l l i t e r a t u r e d e a l t w i t h d r u g s (6). S i n c e B u r k h o l d e r w a s r e f e r r i n g to d o c u m e n t e d s o u r c e s o f d r u g i n f o r m a t i o n such as textbooks, r e v i e w a r t i c l e s , j o u r n a l s and product l i t e r a t u r e , h i s e s t i m a t e w a s p r o b a b l y c o n s i d e r a b l y l a r g e r than L a n g l y k k e ' s w h i c h only with o r i g i n a l p a p e r s .  dealt  2  In a d d i t i o n to the l i t e r a t u r e r e g a r d i n g new d r u g s , n e w a p p l i c a t i o n s of d r u g s , dosages and therapeutic indications p r e v i o u s l y m e n t i o n e d , a great deal of i n f o r m a t i o n has been a c c u m u l a t e d r e g a r d i n g a d v e r s e drug r e a c t i o n s b y s e v e r a l o r g a n i z a t i o n s i n c l u d i n g the W o r l d H e a l t h  Organization  (9, 1 0 ) . In the f i r s t t h r e e y e a r s o f o p e r a t i o n , the C a n a d i a n D r u g A d v e r s e R e a c t i o n P r o g r a m r e c e i v e d 11, 000 r e p o r t s o f s u s p e c t e d (9).  adverse reactions  Unfortunately, m u c h of this valuable i n f o r m a t i o n i s unpublished  and  the p u b l i s h e d p o r t i o n i s o f t e n n o t r e p r e s e n t a t i v e o f the o v e r a l l p i c t u r e ( 1 3 ) . F o r e x a m p l e , a l t h o u g h the n u m b e r o f r e p o r t s o f a n a d v e r s e r e a c t i o n i s p u b l i s h e d , i t i s a l m o s t i m p o s s i b l e to d e t e r m i n e the n u m b e r o f p e o p l e e x p o s e d to the p a r t i c u l a r p r o b l e m .  F o r t h i s r e a s o n i t i s d i f f i c u l t to o b t a i n a c l e a r  p i c t u r e o f the i m p o r t a n c e o f a d v e r s e d r u g r e a c t i o n s .  The 900  existence of a list of p h a r m a c y periodicals containing over  e n t r i e s , the e s t i m a t e s o f L a n g l y k k e and B u r k h o l d e r ,  a n d the a m o u n t  o f i n f o r m a t i o n c o l l e c t e d i n r e g a r d to a d v e r s e d r u g r e a c t i o n s a r e s o m e i n d i c a t i o n s o f the v o l u m e o f d r u g l i t e r a t u r e w h i c h m u s t b e e f f e c t i v e l y d e a l t w i t h i n p r o v i d i n g " . . . a c c u r a t e a n d u n b i a s e d i n f o r m a t i o n about d r u g s " (1).  D r . C.S. Keefer  (11), i n r e c o g n i t i o n o f the v a s t a n d d i v e r s e  s o u r c e s o f d r u g i n f o r m a t i o n , e x p r e s s e d i t w e l l w h e n he s a i d " . . . t h e r e i s no d e a r t h o f i n f o r m a t i o n about d r u g s . "  3  (b)  Compiling Drug Literature  It b e c a m e a p p a r e n t that any l i m i t a t i o n s i n d r u g i n f o r m a t i o n t o d a y a r e not due  to a s h o r t a g e of d r u g l i t e r a t u r e but r a t h e r to an i n a d e q u a t e  o r g a n i z a t i o n a n d e v a l u a t i o n o f the e x i s t i n g i n f o r m a t i o n (16).  The  need for  b e t t e r d i s s e m i n a t i o n of the e x i s t i n g l i t e r a t u r e has b e e n r e c o g n i z e d b y  the  d e v e l o p m e n t of v a r i o u s d r u g i n f o r m a t i o n and a b s t r a c t i n g s u b s c r i p t i o n services.  T h r e e o f the m a j o r d r u g i n f o r m a t i o n s e r v i c e s i n c l u d e :  deHaen series "Drugs in Use",  " D r u g s i n C o m b i n a t i o n " and  R e s e a r c h " ; the Iowa D r u g I n f o r m a t i o n  involved with p h a r m a c e u t i c a l s are: A b s t r a c t s , Index M e d i c u s and  Other services less  Chemical Abstracts,  and  specifically  Biological  s p e c i a l i z e d i n d e x s e r v i c e s s u c h as  C h e m o t h e r a p y A b s t r a c t s and M e n t a l R e t a r d a t i o n  The  "Drugs in  Service microfliche system  International P h a r m a c e u t i c a l A b s t r a c t s .  the  Cancer  Abstracts.  m a j o r s u b s c r i p t i o n s e r v i c e s h a v e the c o m m o n f e a t u r e o f b e i n g  a b s t r a c t i n g s y s t e m s w h i c h a r e s i m i l a r i n the s e r v i c e s o f f e r e d .  The  d e H a e n s y s t e m a b s t r a c t s , i n f o r m a t i o n f r o m 400 j o u r n a l s i n the h e a l t h c a r e f i e l d as w e l l as v a r i o u s m e d i c a l a s s o c i a t i o n m e e t i n g s (17).  The  c a r d s o f the d e H a e n s e r v i c e c o n t a i n s i g n i f i c a n t i n f o r m a t i o n f r o m the o r i g i n a l a r t i c l e i n c l u d i n g the s a m p l e s i z e , d u r a t i o n of the s t u d y , d o s a g e  informa-  t i o n and the s t a t i s t i c a l s t u d y p e r f o r m e d as w e l l as the r e s u l t s a n d m e n t s o f the a u t h o r .  International P h a r m a c e u t i c a l A b s t r a c t s ,  com-  published  b y the A m e r i c a n S o c i e t y o f H o s p i t a l P h a r m a c i s t s , i s a s e m i - m o n t h l y b u l l e t i n c o n t a i n i n g a b s t r a c t s f r o m o v e r 1000  p e r i o d i c a l s dealing with  4  p h a r m a c y , m e d i c i n e a n d r e l a t e d f i e l d s (18).  The  International P h a r m a -  c e u t i c a l A b s t r a c t s p u b l i c a t i o n c o m p i l e s the t i t l e of the o r i g i n a l a r t i c l e  and  a n i n f o r m a t i v e a b s t r a c t w h i c h i s c a t e g o r i z e d u n d e r one o r m o r e o f the  25  s e c t i o n s w h i c h c o v e r the p r a c t i c a l , t h e o r e t i c a l , e c o n o m i c a n d  scientific  aspects of p h a r m a c y l i t e r a t u r e .  In c o n t r a s t to the a b s t r a c t i n g s e r v i c e s , the Iowa D r u g Service presents  the c o m p l e t e o r i g i n a l a r t i c l e on m i c r o f i l m , i n d e x e d b y  64 t w o - d i g i t " d e s c r i p t o r s " on a c c o m p a n y i n g f i l e c a r d s . a r e t e r m s u s e d to d e f i n e the c o n t e n t s , The  Information  The  "descriptors"  s t r u c t u r e a n d r e s u l t s o f the  study.  s i g n i f i c a n t i t e m s o f e a c h p a p e r a r e c o d e d b y the " d e s c r i p t o r s " b e f o r e  the a r t i c l e i s m i c r o f i l m e d .  T h i s p r o c e s s a l l o w s the u s e r to p i n p o i n t h i s  a r e a s o f i n t e r e s t f i r s t l y f r o m the i n d e x c a r d a n d f i l m e d a r t i c l e (19).  s e c o n d l y o n the m i c r o -  It a l s o m a k e s a v a i l a b l e the c o m p l e t e a r t i c l e f o r  i m m e d i a t e e v a l u a t i o n b y the u s e r .  One  d r a w b a c k o f t h i s s y s t e m i s that a  m i c r o f i l m r e a d e r o r r e a d e r - p r i n t e r i s r e q u i r e d to m a k e u s e o f the  infor-  mation.  The  a d v a n t a g e o f s y s t e m s s u c h a s t h o s e d e s c r i b e d a b o v e l i e s i n the  f a c t that t h e y c o v e r a l a r g e n u m b e r of i n f o r m a t i o n s o u r c e s ,  organizing  t h e m into a u s a b l e f o r m a t a n d m a k i n g t h e m a v a i l a b l e to the u s e r s o f d r u g information.  One  d i s a d v a n t a g e i s that t h e y do not p r e s e n t e v a l u a t e d  infor-  m a t i o n (14) but r a t h e r p r e s e n t a l l i n f o r m a t i o n r e g a r d l e s s o f the v a l i d i t y or significance. A p p e n d i x I).  The  A n o t h e r d i s a d v a n t a g e of t h e s e s y s t e m s is the c o s t (see p r i c e , the s t o r a g e a r e a n e e d e d a n d the e q u i p m e n t  5  n e c e s s a r y to m a k e u s e o f s y s t e m s s u c h a s the Iowa D r u g I n f o r m a t i o n S e r v i c e l i m i t the a b i l i t y o f the i n d i v i d u a l h o s p i t a l to a c q u i r e a n d m a i n t a i n them.  As  explained by Burkholder  (14) a n d s u p p o r t e d b y o t h e r s (12, 16,  20, 21) the p r o b l e m i s to m a k e a v a i l a b l e to m e m b e r s o f the h e a l t h p r o f e s s i o n s v a l i d and useful drug i n f o r m a t i o n when and where it i s needed. A c o r o l l a r y to the p r o b l e m c o u l d b e that the i n f o r m a t i o n a l s o s h o u l d b e u n b i a s e d (1).  II.  Hospital Drug  (a)  Definition  The  Formularies  m a j o r a p p r o a c h t a k e n b y h o s p i t a l s to o v e r c o m e the p r o b l e m  o f not h a v i n g the r i g h t d r u g i n f o r m a t i o n a v a i l a b l e at the r i g h t t i m e i s the d e v e l o p m e n t o f h o s p i t a l d r u g f o r m u l a r i e s i n c o n j u n c t i o n w i t h the P h a r m a c y a n d T h e r a p e u t i c s C o m m i t t e e s o f the i n d i v i d u a l i n s t i t u t i o n s (23-31).  A  f o r m u l a r y i s d e f i n e d b y the A m e r i c a n S o c i e t y o f H o s p i t a l P h a r m a c i s t s a s :  ". ..a continually r e v i s e d compilation of p h a r m a c e u t i c a l s w h i c h r e f l e c t s the c u r r e n t c l i n i c a l j u d g m e n t o f the m e d i c a l s t a f f " (34).  " M i r r o r to H o s p i t a l P h a r m a c y " i n d i c a t e s that a b o u t 60 p e r c e n t o f h o s p i t a l s i n the U n i t e d S t a t e s o p e r a t e u n d e r a f o r m u l a r y s y s t e m , d e f i n i n g a formulary system as:  6  " . . . a m e t h o d w h e r e b y the m e d i c a l s t a f f o f a hospital, working through a p h a r m a c y therapeutics appraises  and  committee...,  and  evaluates,  s e l e c t s f r o m a m o n g the  numerous medicinal that a r e c o n s i d e r e d  agents a v a i l a b l e those m o s t useful i n patient  c a r e , t o g e t h e r w i t h the p h a r m a c e u t i c a l preparations  i n w h i c h they may  be  adminis-  t e r e d m o s t e f f e c t i v e l y . " (32).  The  usefulness  o f the f o r m u l a r y s y s t e m i s a c k n o w l e d g e d b y b o t h the  C a n a d i a n S o c i e t y of H o s p i t a l P h a r m a c i s t s a n d the A m e r i c a n S o c i e t y o f H o s p i t a l P h a r m a c i s t s i n p u b l i s h i n g s t a t e m e n t s o f g u i d e l i n e s f o r the u s e the h o s p i t a l f o r m u l a r y s y s t e m (33, 34).  In a d d i t i o n a l s u p p o r t o f the  m u l a r y s y s t e m , the C a n a d i a n C o u n c i l on H o s p i t a l A c c r e d i t a t i o n  of  for-  (35)  r e q u i r e s p a r t i c i p a t i o n i n the d e v e l o p m e n t o f a h o s p i t a l f o r m u l a r y as  part  o f the r e q u i r e m e n t s f o r p h a r m a c e u t i c a l s e r v i c e s of a h o s p i t a l s e e k i n g accreditation.  The  use  of f o r m u l a r i e s  i s not a new  concept.  T h e y have been u s e d  i n N o r t h A m e r i c a s i n c e the e a r l y n i n e t e e n t h c e n t u r y (36).  Some f o r m u l a -  r i e s , f o r e x a m p l e the p r e v i o u s V a n c o u v e r G e n e r a l H o s p i t a l f o r m u l a r y (37), w e r e l i s t s of d r u g s and Other formularies  dosage f o r m s a v a i l a b l e for use  i n the h o s p i t a l .  c o n t a i n e d a d d i t i o n a l i n f o r m a t i o n on t h e r a p e u t i c i n d i c a -  t i o n s , side e f f e c t s , and  s t a n d a r d d o s e s as i n the f o r m u l a r y o f the O t t a w a  C i v i c H o s p i t a l (25) a n d the f o r m u l a r y o f the U n i v e r s i t y o f P e n n s y l v a n i a H o s p i t a l (28).  A  t h i r d f o r m a t i s that o f the L i o n s G a t e H o s p i t a l D r u g  F o r m u l a r y (see F i g u r e  1) w h i c h c o n t a i n s i n d i c a t i o n s , s i d e e f f e c t s  and  d o s a g e s as w e l l as a d d i t i o n a l i n f o r m a t i o n on c o n t r a i n d i c a t i o n s , d r u g i n t e r -  7  F i g u r e 1.  E x a m p l e o f the f o r m a t a n d c o n t e n t o f the d r u g m o n o g r a p h s o f the L i o n s G a t e H o s p i t a l Drug Formulary.  8 GLUTETHIMIDE  DORIDEN  28:24  ACTION A s e d a t i v e - h y p n o t i c s t r u c t u r a l l y s i m i l a r to b a r b i t u r a t e s . G r e a t e r d e g r e e of h y p o t e n s i o n than b a r b i t u r a t e s . Onset:  20 m i n u t e s .  Duration:  Approximately  6 hours.  INDICATIONS Sedative, hypnotic. CONTRAINDICATIONS None known.  U s e with caution when impending d e p r e s s i o n o r  suicidal tendencies exist. DOSAGE ADULTS:  Daytime sedation: Insomnia:  - . 5 gm.  125-250 m g .  t.i.d.  h . s., m a y be r e p e a t e d n o t l e s s  than 4 h o u r s b e f o r e a r i s i n g .  In l o n g t e r m u s e the  total d a i l y dose s h o u l d not e x c e e d 1  gm.  SIDE E F F E C T S Nausea, vomiting, anorexia, headache, dizziness, confusion, g e n e r a l i z e d skin r a s h . R a r e l y acute a l l e r g i c r e a c t i o n s , blood d y s c r a s i a s , p o r p h y r i a and jaundice. Hypotension and c i r c u l a t o r y s h o c k r e p r e s e n t the m a j o r p r o b l e m i n t o x i c d o s e s . P s y c h i c a n d p h y s i c a l dependence with prolonged u s e . DRUG  INTERACTIONS I n h i b i t s a c t i o n o f o r a l a n t i c o a g u l a n t s i n c r e a s i n g the r i s k o f t h r o m b u s f o r m a t i o n d u r i n g therapy and b l e e d i n g tendency on w i t h d r a w a l . C N S depressant effects of glutethimide a r e potentiated by n a r c o t i c s , alcohol, phenothiazines ( L a r g a c t i l , Stelazine, Phenergan, etc.), M A O inhibitors (Parnate, N a r d i l , etc.), anaesthetics, and R e s e r p i n e . G l u t e t h i m i d e i n h i b i t s (by e n z y m e i n d u c t i o n ) a n a l g e s i c s , antihistamines (Benadryl, P e r a z i n e ) , phenylbutazone, diphenlyhydantoin, griseofulvin ( G r i s a c t i n , F u l v i c i n ) , meprobamate, (Equanil), c o r t i c o s t e r o i d s (oral c o n t r a c e p t i v e s , h y d r o c o r t i s o n e , etc. ) other hypnotics.  NURSING IMPLICATIONS P e r i o d i c b l o o d counts and l i v e r function tests a r e a d v i s a b l e .  With  p r o l o n g e d u s e , w i t h d r a w l f r o m d r u g s h o u l d be g r a d u a l to m i n i m i z e withdrawal  reactions.  G i v e w i t h f o o d to r e d u c e g a s t r i c i r r i t a t i o n .  M o n i t o r v i t a l signs i f being taken r e g u l a r l y . tion b y a l c o h o l .  D o e s not p r o d u c e sedation i n h i g h l y d i s t u r b e d  patients o r those i n p a i n .  M a y produce p h y s i c a l and p s y c h o l o g i c a l  dependence. PRESENTATION Tablets:  500  Exaggerated potentia-  mg. FIGURE 1  9  actions and nursing i m p l i c a t i o n s .  As  w e l l a s d e v e l o p m e n t s i n the f o r m a t a n d c o n t e n t o f f o r m u l a r i e s ,  a d v a n c e s h a v e b e e n m a d e i n the f i e l d o f f o r m u l a r y p r o d u c t i o n .  Electronic  Data P r o c e s s i n g (E.D. P . ) i s being u s e d i n f o r m u l a r y production i n both C a n a d a a n d the U n i t e d S t a t e s (25, 2 7 , 28, 38, 39, 40, 4 1 ) . T h e I o w a D r u g I n f o r m a t i o n S e r v i c e u s e d E . D . P . to p r o d u c e a d r u g f o r m u l a r y f r o m t h e i r a u t o m a t e d d r u g i n f o r m a t i o n f i l e (27).  A t the U n i v e r s i t y o f P e n n s y l v a n i a  H o s p i t a l (28) a n d t h e O t t a w a C i v i c H o s p i t a l (25, 38) f o r m u l a r i e s w e r e  pro-  d u c e d f r o m d e c k s o f c o m p u t e r c a r d s o n w h i c h the i n f o r m a t i o n h a d b e e n key-punched.  A t p r e s e n t , the O t t a w a C i v i c H o s p i t a l h a s c o n v e r t e d  p r o d u c t i o n o f the f o r m u l a r y  their  to a u t o m a t e d p h o t o c o m p o s i t i o n a n d m a g n e t i c  tape f o r i n f o r m a t i o n s t o r a g e (38).  T h e s e o p e r a t i o n s h a v e d e m o n s t r a t e d that  i n the s e v e r a l w a y s o f a p p l y i n g E . D . P . to f o r m u l a r y p r i n t i n g (28), the c o s t o f l o n g - t e r m p r o d u c t i o n o f the f o r m u l a r i e s b y E . D . P . w a s l e s s than the c o s t o f c o n v e n t i o n a l p r i n t i n g m e t h o d s (27, 3 8 ) . E d i t i n g a n d u p d a t i n g o f d r u g i n f o r m a t i o n c o n t a i n e d i n the f o r m u l a r i e s a l s o w a s f a s t e r a n d e a s i e r (25, 28,  (b)  38).  Limitations  F r o m the w i d e - s p r e a d u s e o f d r u g f o r m u l a r i e s i t a p p e a r s that t h e y h a v e b e e n f a i r l y s u c c e s s f u l i n p r o v i d i n g d r u g i n f o r m a t i o n to the h e a l t h p r a c t i t i o n e r s at the p o i n t o f u s e i n t h e i r r e s p e c t i v e h o s p i t a l s . there a r e also some specific limitations i n their e f f e c t i v e n e s s .  However,  10  It h a s b e e n r e c o g n i z e d that a t r u e f o r m u l a r y p r e h e n s i v e t h a n m e r e l y a d r u g l i s t (27).  com-  It h a s b e e n i d e n t i f i e d a l s o that  the c o s t o f the d r u g i n f o r m a t i o n r e s o u r c e s  ( s e e A p p e n d i x I) r e q u i r e d to  evaluate and c o m p i l e i n f o r m a t i o n for a f o r m u l a r y i n d i v i d u a l h o s p i t a l to m a i n t a i n  h a s to b e m o r e  the r e s o u r c e s  with additional i n f o r m a t i o n when n e c e s s a r y .  l i m i t s the a b i l i t y o f e a c h  to b a c k - u p t h e i r  formulary  It s h o u l d be n o t e d that the  s m a l l e r n o n - t e a c h i n g h o s p i t a l i s p e r h a p s ate.a g r e a t e r d i s a d v a n t a g e i n t h i s r e g a r d s i n c e a c c e s s to l a r g e m e d i c a l l i b r a r i e s i s l i m i t e d (42).  Neverthe-  l e s s , these s m a l l e r hospitals r e q u i r e drug i n f o r m a t i o n as m u c h as, o r m o r e t h a n the l a r g e t e a c h i n g i n s t i t u t e s ( 3 1 ) .  A s e c o n d o b s t a c l e to the e f f e c t i v e p r o d u c t i o n o f i n d i v i d u a l f o r m u l a r i e s i s the c o n s i d e r a b l e t i m e a n d e x p e r t i s e r e q u i r e d to e v a l u a t e the l i t e r a t u r e a n d p r o d u c e the d r u g m o n o g r a p h s (43).  The responsibility for  p r o d u c i n g the d r u g m o n o g r a p h s r e s t s w i t h the p h a r m a c i s t s who i n t h e i r s p a r e t i m e e v a l u a t e the l i t e r a t u r e a n d p r o d u c e the d r u g m o n o g r a p h s ( 4 3 ) .  F r a n c k e r e c o g n i z e d t h e s e o b s t a c l e s to the p r e p a r a t i o n o f a d r u g formulary  i n h i s o w n h o s p i t a l (43).  the c o s t l y i n f o r m a t i o n s o u r c e s , the f o r m u l a r y w h e r e (43).  H e a l s o r e c o g n i z e d that the p u r c h a s e o f  a n d the t i m e a n d e f f o r t r e q u i r e d to p r o d u c e  were being duplicated many times by pharmacists  every-  F r a n c k e s u g g e s t e d that m u c h o f the d u p l i c a t i o n m e n t i o n e d  a b o v e c o u l d b e e l i m i n a t e d i f the A m e r i c a n S o c i e t y o f H o s p i t a l P h a r m a c i s t s would sponsor a national hospital f o r m u l a r y to the h o s p i t a l s a t a r e a s o n a b l e c o s t (43).  s e r v i c e and m a k e it a v a i l a b l e T h i s p e r h a p s w a s the f i r s t s t e p  11  to r e g i o n a l i z e d f o r m u l a r y p r o d u c t i o n .  III.  Regional Drug Formularies  (a) T h e  A m e r i c a n Hospital F o r m u l a r y  Service  A l t h o u g h the P h y s i c i a n s ' D e s k R e f e r e n c e * ( P . D . R . ) h a d s e r v e d the general m e d i c a l p r a c t i t i o n e r s ' needs for drug information for m a n y y e a r s (47),  it r e p r e s e n t s a national c o m p i l a t i o n of drug m a n u f a c t u r e r s ' l i t e r a -  t u r e (44).  P e r h a p s the f i r s t , a n d s t i l l m o s t p o p u l a r r e g i o n a l d r u g  formu-  l a r y that p r o v i d e s a c c u r a t e a n d u n b i a s e d i n f o r m a t i o n i s the A m e r i c a n Hospital F o r m u l a r y A.H. F.S.  S e r v i c e * * ( A . H . F . S. ).  The  d r u g m o n o g r a p h s o f the  a r e p r e p a r e d b y the C o m m i t t e e o n P h a r m a c y a n d  c a l s o f the A m e r i c a n S o c i e t y o f H o s p i t a l P h a r m a c i s t s .  The  Pharmaceutid i r e c t o r of  the c o m m i t t e e e d i t s the m o n o g r a p h s to e n s u r e a c o n s t a n t f o r m a t a n d t h e y are  r e v i e w e d by three s u b c o m m i t t e e s of p r a c t i t i o n e r s , p h a r m a c i s t s  manufacturers A.H. F.S.  f o r suggestions and c o m m e n t s .  and  S u p p l e m e n t s to the  a r e p u b l i s h e d a n d d i s t r i b u t e d to the s u b s c r i b e r s at r e g u l a r  i n t e r v a l s c o n t a i n i n g b o t h new existing monographs.  d r u g m o n o g r a p h s a n d u p d a t e d i n f o r m a t i o n on  T h e m o n o g r a p h s p r o d u c e d a r e b e l i e v e d to r e p r e s e n t  a c c u r a t e , e v a l u a t e d a n d u n b i a s e d i n f o r m a t i o n (46).  *The P h y s i c i a n s ' Desk R e f e r e n c e , 23rd. edition, M e d i c a l E c o n o m i c s , Inc.,  s u b s i d i a r y of L i t t o n P u b l i c a t i o n s , I n c . , O r a d e l l , New  **The A m e r i c a n Hospital F o r m u l a r y  S e r v i c e , C o m m i t t e e on  Jersey,  1969.  Pharmacy  a n d P h a r m a c e u t i c a l s o f the A m e r i c a n S o c i e t y o f H o s p i t a l P h a r m a c i s t s ; The H a m i l t o n P r e s s , H a m i l t o n ,  Illinois.  12  The  C o m m i t t e e on P h a r m a c y and P h a r m a c e u t i c a l s  recognized  two  i m p o r t a n t u s e s f o r the A . H . F . S. : (1)  As  a basis for p r e p a r i n g individual hospital f o r m u l a r i e s ;  (2)  As  a c o m p a r a t i v e l y c o m p l e t e d r u g r e f e r e n c e u s e f u l to  p r a c t i t i o n e r s a n d t e a c h e r s i n a l l the h e a l t h p r o f e s s i o n s concerned The  w i t h d r u g s (46).  f i r s t o b j e c t i v e i n t e n d e d that e a c h h o s p i t a l P h a r m a c y a n d  Therapeutics  C o m m i t t e e w o u l d a c c e p t the r e s p o n s i b i l i t y to a d a p t the A . H . F . S. to the s p e c i f i c n e e d s o f the i n d i v i d u a l h o s p i t a l (57). Francke  P r o m o t i n g this concept  s u g g e s t e d that the r e s p e c t i v e p h a r m a c i s t s  also might maintain  f i l e a l l a d d i t i o n a l d r u g m o n o g r a p h s s u p p l i e d b y the A . H . F . S . drug i n f o r m a t i o n .  on  as a d d i t i o n a l  T h i s p r a c t i c e w o u l d e n a b l e the p h a r m a c i s t to p r o v i d e  i n f o r m a t i o n to the P h a r m a c y a n d T h e r a p e u t i c s C o m m i t t e e i n v e s t i g a t i n g a new lary  f o r m u l a r y a d d i t i o n o r to o t h e r s t a f f m e m b e r s r e q u e s t i n g a n o n - f o r m u drug.  (b) H o s p i t a l D r u g I n f o r m a t i o n  The  Centres  s e c o n d p r o j e c t e d u s e o f the A . H . F . S . b e c a m e m o r e p o p u l a r  w i t h the d e v e l o p m e n t o f h o s p i t a l d r u g i n f o r m a t i o n c e n t r e s (24, 30, 31, 50).  T h e s e c e n t r e s w e r e i n i t i a t e d to p r o v i d e a c c u r a t e , d e t a i l e d a n d  49,  up-to-  date i n f o r m a t i o n on d r u g s to a l l m e m b e r s o f the p a t i e n t c a r e s t a f f o f the h o s p i t a l s (31) a n d  " . . .to s u p p o r t , a s s i s t a n d p r o m o t e a r a t i o n a l d r u g  t h e r a p y p r o g r a m " (24).  A l t h o u g h o t h e r f o r m u l a r i e s s u c h as the A . H .  F.S.  (51, 52) a d e q u a t e l y p r o v i d e d e v a l u a t e d , a c c u r a t e a n d u n b i a s e d i n f o r m a t i o n  13  (46), i t w a s  d i f f i c u l t f o r t h e s e s e r v i c e s to p r o v i d e u p - t o - d a t e i n f o r m a t i o n .  T h i s p r o b l e m was  due l a r g e l y to the t i m e l a g b e t w e e n the o r i g i n a l p u b l i c a -  t i o n o f the l i t e r a t u r e a n d the p r o d u c t i o n o f the r e s p e c t i v e s u p p l e m e n t s .  An  a c t i v e d r u g i n f o r m a t i o n c e n t r e o n the o t h e r h a n d w i t h i n f o r m a t i o n r e s o u r c e s s i m i l a r to t h o s e l i s t e d b y B u r k h o l d e r p r o v i d e up-to-date  (6), b e t t e r e n a b l e d the p h a r m a c i s t to  i n f o r m a t i o n , to a n s w e r q u e s t i o n s that w e r e b e y o n d the  s c o p e o f the f o r m u l a r y a n d to p r o v i d e i n f o r m a t i o n o n n o n - f o r m u l a r y (27, 29, 30, 31, 42, 48, 49,  drugs  50).  A g a i n , as w i t h the p r o d u c t i o n o f h o s p i t a l f o r m u l a r i e s , the s m a l l e r c o m m u n i t y h o s p i t a l w i t h l i m i t e d a c c e s s to l i t e r a t u r e r e s o u r c e s , f a c i l i t i e s a n d s t a f f i s at a d i s a d v a n t a g e 53).  i n o p e r a t i n g a d r u g i n f o r m a t i o n c e n t r e (42,  In o r d e r to o v e r c o m e d u p l i c a t i o n a n d i n a d e q u a t e  h o s p i t a l s i n t h i s r e s p e c t , i t was  efforts by  small  r e c o g n i z e d that s u c h n e e d s f o r d r u g  m a t i o n m i g h t b e t t e r be s e r v e d b y d e v e l o p i n g one  infor-  large drug information  c e n t r e at a u n i v e r s i t y - a f f i l i a t e d h o s p i t a l to s e r v e a s p e c i f i c r e g i o n of s m a l l e r i n s t i t u t i o n s (42).  (c) R e g i o n a l D r u g I n f o r m a t i o n  The  Centres  d e v e l o p m e n t o f R e g i o n a l D r u g I n f o r m a t i o n C e n t r e s , l i k e the  p r o d u c t i o n o f the r e g i o n a l A m e r i c a n H o s p i t a l F o r m u l a r y S e r v i c e , r e s u l t e d i n a c e n t r a l i z e d s e r v i c e s u p p o r t i n g s m a l l e r s e r v i c e s at the l o c a l l e v e l (42, 7, 3 4 ,  55,  56) a n d ,  consequently,  of c o s t s , f a c i l i t i e s , and staff.  the e l i m i n a t i o n o f s o m e o f the d u p l i c a t i o n  T h e r e h a v e b e e n two m a j o r t r e n d s i n the  14  d e v e l o p m e n t o f R e g i o n a l D r u g I n f o r m a t i o n C e n t r e s b a s e d on and c e n t r a l i z e d a p p r o a c h e s .  These may  decentralized  be e x e m p l i f i e d b y the  Michigan  R e g i o n a l D r u g I n f o r m a t i o n N e t w o r k a n d the K e n t u c k y R e g i o n a l D r u g I n f o r mation Centre  The  respectively.  M i c h i g a n Regional D r u g Information Network with its m a i n  c e n t r e at the U n i v e r s i t y o f M i c h i g a n  s u p p l i e s d r u g i n f o r m a t i o n to n i n e  a f f i l i a t e d h o s p i t a l s t h r o u g h o u t the s t a t e .  V a r i o u s s o u r c e s of drug  infor-  m a t i o n i n c l u d i n g the A m e r i c a n H o s p i t a l F o r m u l a r y S e r v i c e , the d e H a e n s y s t e m s , the F e d e r a l D r u g A d m i n i s t r a t i o n ( F . D . A . ) C l i n i c a l  Experience  A b s t r a c t s , the F . D . A . S u s p e c t e d A d v e r s e R e a c t i o n , I n t e r n a t i o n a l P h a r m a c e u t i c a l A b s t r a c t s a n d s e v e r a l j o u r n a l s s e r v e as r e s o u r c e s (57, 58). E a c h affiliated centre is responsible for answering drug information r e q u e s t s f r o m i t s own  a r e a w h e n e v e r p o s s i b l e (58).  The  main centre is  available as a r e f e r r a l centre o r c l e a r i n g house for m o r e c o m p l e x requests that c a n n o t be a n s w e r e d a d e q u a t e l y at the l o c a l c e n t r e (59) as w e l l as a n s w e r i n g r e q u e s t s f r o m the U n i v e r s i t y o f M i c h i g a n M e d i c a l C e n t r e .  This  s y s t e m h a s a t t e m p t e d to m a i n t a i n a s m u c h a u t o n o m y as p o s s i b l e at e a c h a f f i l i a t e d c e n t r e w i t h i n the f r a m e w o r k o f a r e g i o n a l s y s t e m a n d i s t h e r e f o r e a n e x a m p l e o f the d e c e n t r a l i z e d t r e n d i n R e g i o n a l D r u g I n f o r m a t i o n  The  s y s t e m i n o p e r a t i o n at the U n i v e r s i t y o f K e n t u c k y a n d ,  Centres.  simi-  l a r l y , i n the A p p a l a c h i a n R e g i o n a l H o s p i t a l s S y s t e m i s d e s i g n e d to p r o v i d e m e d i c a l l i b r a r y and d r u g i n f o r m a t i o n s e r v i c e s on a r e g i o n a l b a s i s f r o m a s i n g l e c e n t r a l i z e d s o u r c e (55, 56).  In the K e n t u c k y R e g i o n a l D r u g I n f o r -  15  mation  C e n t r e , the c e n t r a l i n f o r m a t i o n s o u r c e i s a v a i l a b l e to the h e a l t h  p r o f e s s i o n a l s i n the state b y a t o l l - f r e e , d i r e c t - d i a l t e l e p h o n e l i n e (called a Wide A r e a Telephone S e r v i c e o r W A T S ) for i n c o m i n g  calls.  W h e n a r e t u r n c a l l i s n e c e s s a r y the i n f o r m a t i o n i s p r o v i d e d v i a the e x i s t ing telephone l i n e s .  B y u s i n g the e x i s t i n g t e l e p h o n e s y s t e m i n s t e a d o f the  W A T S n e t w o r k f o r o u t - g o i n g c a l l s the K e n t u c k y R e g i o n a l D r u g I n f o r m a t i o n C e n t r e h a s r e d u c e d the h i g h c o s t o f c o m m u n i c a t i o n i n h e r e n t i n a c e n t r a l i z e d s y s t e m (55, 6 8 ) .  In the A p p a l a c h i a n r e g i o n , c o m m u n i c a t i o n b e t w e e n the  m a i n c e n t r e a n d the r e g i o n a l h o s p i t a l s i s m a i n t a i n e d b y a t e l e t y p e n e t w o r k , n e w s l e t t e r s , a n d t e l e p h o n e c o n f e r e n c e s (56).  T h e p o p u l a r i t y o f the A . H . F . S . general,  and D r u g Information Centres i n  i s r e f l e c t e d b y the i n c r e a s i n g u s e a n d d e v e l o p m e n t o f b o t h o f  t h e s e c o n c e p t s (24, 3 1 , 38, 4 5 , 51, 59, 6 0 , 6 1 , 6 2 , 6 3 , 64). c o m b i n a t i o n o f the A . H . F . S .  A l t h o u g h the  and a D r u g Information Centre has resulted  i n the D r u g I n f o r m a t i o n C e n t r e b e i n g l a b e l l e d a s the " . . . g u a r d i a n o f the f o r m u l a r y " (48), the A . H . F . S .  alone still has definite limitations for u s e  in g e n e r a l and, m o r e s p e c i f i c a l l y , i n C a n a d a .  (d) L i m i t a t i o n s o f the A . H . F . S .  S o m e o f the g e n e r a l l i m i t a t i o n s o f the A . H . F . S . w h i c h h a v e b e e n cited include: 1.  T h e A.H. F.S. 1030  h a s e x p a n d e d to i n c l u d e , (as o f 1967)  d r u g m o n o g r a p h s a n d 2766 p a g e s i n a t w o - v o l u m e  s e t (43).  A s a r e s u l t o f the s i z e , the A . H . F . S .  v e r y b u l k y a n d a w k w a r d b o o k to u s e (47, 65).  is a  The  16  b u l k i n e s s alone can i m p e d e r a p i d i n f o r m a t i o n r e t r i e v a l (47); 2.  M a n y p r o d u c t s c o v e r e d i n the A . H . F . S. m a y be u s e d i n a s p e c i f i c h o s p i t a l .  Burkholder  not showed  that the a v e r a g e n u m b e r o f d r u g m o n o g r a p h s r e q u i r e d b y a h o s p i t a l i s about 400 A.H.  F.S.  c o n t a i n s 1030  (43).  (66) w h i l e  the  T h i s i m p l i e s that  a s e t o f the A . H . F . S. i n the a v e r a g e h o s p i t a l i s about two 3.  The  and o n e - h a l f t i m e s l a r g e r than n e c e s s a r y ;  f o r m a t o f the A . H . F . S .  problem.  The  is a third potential  f o r m a t of p a r a g r a p h s r a t h e r than  p o i n t f o r m r e q u i r e s that the u s e r r e a d w h o l e s e n t e n c e s to f i n d the r e q u i r e d i n f o r m a t i o n .  Also,  the i n f o r m a t i o n d o e s not s e e m to be d i v i d e d into enough s u b s e c t i o n s .  T h i s r e q u i r e s that the u s e r  m u s t r e f e r to the s u b s e c t i o n on  "pharmacology  a n d a c t i o n " to f i n d i n f o r m a t i o n on s i d e e f f e c t s . 4.  F i n a l l y , the d r u g m o n o g r a p h s a r e not r e f e r e n c e d a n d to s u p p l y a d d i t i o n a l i n f o r m a t i o n on a s p e c i f i c p o i n t of i n t e r e s t b e c o m e s q u i t e d i f f i c u l t w i t h o u t the s t a r t i n g p o i n t of the o r i g i n a l r e f e r e n c e . *  In the U n i t e d S t a t e s , a t t e m p t s to o v e r c o m e the b u l k i n e s s o f the A . H . F . S. h a v e t a k e n the f o r m of m o d i f i e d f o r m u l a r i e s as s u g g e s t e d b y the p r o d u c e r s o f the A . H . F . S. (46).  H o w e v e r , this i s a v e r y t i m e c o n s u m i n g task  a n d the r e s u l t i n g f o r m u l a r y  p r i n t e d o n s m a l l p a g e s to m a t c h the A . H .  (46) F.S.  i s s t i l l b u l k y (65).  In a d d i t i o n to the a b o v e , t h e r e a r e at l e a s t two  d r a w b a c k s to the  of the A m e r i c a n H o s p i t a l F o r m u l a r y S e r v i c e i n C a n a d i a n h o s p i t a l s : 1.  The  A . H . F . S. u s e s A m e r i c a n b r a n d n a m e s w h i c h i n  m a n y i n s t a n c e s do not c o r r e s p o n d to the b r a n d n a m e s c o m m o n l y in use in Canada. problem are:  Some e x a m p l e s of this  chlorpromazine which is T h o r a z i n e ^ in  R the U n i t e d S t a t e s a n d  Largactil  in Canada;  cyclophos-  p h a m i d e w h i c h i s Cytoxan-"- i n the U n i t e d S t a t e s a n d R R Procytox in Canada; isoniazid which is D i n a c r i n in * Presently being undertaken.  use  17  the U n i t e d S t a t e s a n d R i m a f o n  in Canada; and d i e t h y l R • stilboestrol diphosphate which i s M i l e s t r o l i n the U n i t e d States and H o n v o l i n C a n a d a (70.67). '  2.  A  s e c o n d p r o b l e m o f the u s e o f a n y A m e r i c a n  drug  r e f e r e n c e i n a C a n a d i a n h o s p i t a l i s the p o s s i b i l i t y o f d i f f e r e n t f o r m u l a t i o n s o f p r o d u c t s b e a r i n g the same brand name.  This problem is represented  b y the d i f f e r e n t f o r m u l a t i o n s o f a C a n a d i a n  and  an A m e r i c a n p r o d u c t w h i c h b o t h h a v e the b r a n d name Infantol. supplement  The  Canadian product is a dietary  containing v i t a m i n A, v i t a m i n  D,  thiamine, r i b o f l a v i n , v i t a m i n C, n i a c i n a m i d e a n d p y r i d o x i n e (70) w h i l e the A m e r i c a n p r o d u c t is an a n t i d i a r r h e a l containing, p e c t i n ,  zinc  phenosulphonate, b i s m u t h s u b s a l i c y l a t e and I r i s h M o s s E x t r a c t ( 6 7 ) . T h i s i s p o s s i b l y one o f the m o s t s i g n i f i c a n t f o r m u l a t i o n d i f f e r e n c e s .  A l t h o u g h t h e r e i s no r e g i o n a l f o r m u l a r y i n C a n a d a c o m p a r a b l e to the A . H . F . S . , one p u b l i c a t i o n w h i c h o v e r c o m e s s o m e o f the a b o v e l i m i t a t i o n s i s the C o m p e n d i u m o f P h a r m a c e u t i c a l s a n d S p e c i a l t i e s * ( C . P . S . ). T h e C . P . S . i s a c o m p i l a t i o n of i n f o r m a t i o n on p h a r m a c e u t i c a l p r o d u c t s and i s c o m m o n l y u s e d i n C a n a d i a n h o s p i t a l s , c l i n i c s , c o m m u n i t y p h a r m a c i e s a n d p h y s i c i a n s ' o f f i c e s ( 6 8 ) . H o w e v e r , s o m e o f the c h a r a c t e r i s t i c s o f the C . P . S . m a k e i t s o m e w h a t i n a d e q u a t e i n a h o s p i t a l s e t t i n g : 1.  T h e f o r m a t of the C . P . S . i s not thought to be suitable for r a p i d r e f e r e n c e since it is p r e p a r e d i n p a r a g r a p h s r a t h e r than point f o r m ;  2.  T h e i n f o r m a t i o n i n the d r u g m o n o g r a p h s i s not d i v i d e d into e n o u g h s u b s e c t i o n s to e n a b l e the u s e r s to r a p i d l y f i n d the d e s i r e d i n f o r m a t i o n ;  3.  T h e m o n o g r a p h s o f the C . P . S . a r e a r r a n g e d a l p h a b e t i c a l l y by both b r a n d and g e n e r i c n a m e s . A s a r e s u l t of this p r a c t i c e , there m a y  *  be  C o m p e n d i u m of P h a r m a c e u t i c a l s and S p e c i a l t i e s , R o t e n b e r g , G.N. H u g h e s , F . N.,  ed. Canadian P h a r m a c e u t i c a l Association, Toronto  and 1972.  18  s e v e r a l s e p a r a t e m o n o g r a p h s for one g e n e r i c name drug.  A n e x a m p l e of this p r o b l e m i s  A m p i c i l l i n which is monographed five times u n d e r d i f f e r e n t b r a n d n a m e s a n d o n c e a s the g e n e r i c n a m e d r u g (70); 4.  T h e C . P . S . does not contain any r e f e r e n c e s for the m o n o g r a p h s so that i t i s n o t p o s s i b l e to e v a l u a t e the o r i g i n a l i n f o r m a t i o n s o u r c e o n a specific statement o r point of interest;  5.  T h e C . P . S . does not include s p e c i f i c  subsec-  tions r e g a r d i n g drug a d m i n i s t r a t i o n and u s e .  The  p o p u l a r i t y o f u s e o f the A . H . F . S .  a n d the C . P . S . i n C a n a d a  e n d o r s e the n e e d f o r a r e g u l a r l y p r o d u c e d f o r m u l a r y information.  on current drug  R e c o g n i z i n g the l i m i t a t i o n s o f the a b o v e two s e r v i c e s , h o w -  e v e r , i t w o u l d a p p e a r that a n e e d s t i l l e x i s t s f o r a C a n a d i a n h o s p i t a l formulary  IV.  service.  Provincial Hospital Drug  The  Formulary  d e v e l o p m e n t o f c l i n i c a l p h a r m a c y s e r v i c e s a n d the i n c r e a s e d  i n v o l v e m e n t o f the L i o n s G a t e H o s p i t a l * p h a r m a c y s t a f f i n d r u g l e d to the r e c o g n i t i o n o f the l i m i t a t i o n s o f the A . H . F . S . this h o s p i t a l (71, 72).  information  a n d the C . P . S . i n  B e t w e e n the y e a r s 1965-1970, the p h a r m a c i s t s at  the L i o n s G a t e H o s p i t a l p r e p a r e d a d r u g f o r m u l a r y  c o n t a i n i n g o n e o r two  t y p e w r i t t e n p a g e s o f c l i n i c a l l y r e l e v a n t i n f o r m a t i o n o n a b o u t 300 d r u g s i n u s e at the h o s p i t a l (37).  Working f r o m many sources of drug information,  the a u t h o r s w e r e a b l e to c o m p i l e f o r t h e i r d r u g m o n o g r a p h s i n f o r m a t i o n o n  * L i o n s Gate H o s p i t a l , N o r t h V a n c o u v e r , B r i t i s h  Columbia.  19  p e d i a t r i c d o s a g e s , d o s a g e s i n k i d n e y and l i v e r f a i l u r e , i n t r a v e n o u s patibilities,  incom-  d r u g i n t e r a c t i o n s a n d n u r s i n g i m p l i c a t i o n s w h i c h f o r the m o s t  p a r t h a d b e e n u n a v a i l a b l e i n the m o n o g r a p h s of the A . H . F . S. and the C . P . S . T h i s i n f o r m a t i o n was  a d d e d to the b a s i c d r u g i n f o r m a t i o n c o m m o n l y a v a i l -  a b l e on i n d i c a t i o n s , d o s a g e s , s i d e e f f e c t s a n d c o n t r a i n d i c a t i o n s to p r o d u c e the d r u g m o n o g r a p h s o f the L i o n s G a t e H o s p i t a l D r u g F o r m u l a r y F i g u r e 1).  A l t h o u g h m u c h o f t h i s i n f o r m a t i o n was  available in journals,  t e x t b o o k s a n d h a n d b o o k s , the r e s u l t i n g f o r m u l a r y was a l l of t h i s i n f o r m a t i o n into one u s a b l e  (see  unique i n c o m p i l i n g  s o u r c e of d r u g i n f o r m a t i o n f o r the  h e a l t h p r o f e s s i o n a l s i n the h o s p i t a l (71,  72).  F o r the L i o n s G a t e H o s p i t a l , the p r o d u c t i o n o f the L i o n s  Gate  H o s p i t a l D r u g F o r m u l a r y * a l s o o v e r c a m e the c o n f l i c t b e t w e e n C a n a d i a n a n d A m e r i c a n b r a n d n a m e s that i s i n h e r e n t i n u s i n g an A m e r i c a n s u c h as the A . H . F . S .  in a Canadian hospital.  The  reference  authors also attempted  to r e d u c e the s e a r c h t i m e f o r i n f o r m a t i o n b y p r e p a r i n g t h e i r f o r m u l a r y i n p o i n t f o r m r a t h e r t h a n p a r a g r a p h s a n d b y d i v i d i n g the m o n o g r a p h s into s u b sections of s p e c i f i c i n f o r m a t i o n .  The  subsections included action, i n d i c a -  tions, c o n t r a i n d i c a t i o n s , dosage, side effects, intravenous t i e s , d r u g i n t e r a c t i o n s and n u r s i n g i m p l i c a t i o n s .  incompatibili-  With these  a n d a d d i t i o n s to the f o r m a t a n d c o n t e n t o f the A . H . F . S .  alterations  a n d the C . P . S . ,  s o m e o f the l i m i t a t i o n s p r e v i o u s l y m e n t i o n e d w e r e o v e r c o m e .  However,  the L i o n s G a t e H o s p i t a l D r u g F o r m u l a r y s t i l l h a d one m a j o r d r a w b a c k to  * L i o n s Gate H o s p i t a l D r u g F o r m u l a r y , L i o n s Gate H o s p i t a l , P h a r m a c y Department, North Vancouver,  1971.  20  its continuing u s e as a s o u r c e o f d r u g i n f o r m a t i o n .  T h e r e w a s no e s t a b -  l i s h e d m e c h a n i s m f o r r e g u l a r l y u p d a t i n g the d r u g m o n o g r a p h s .  The  p r e v i o u s w o r k o f u p d a t i n g the m o n o g r a p h s a n d the p r o d u c t i o n o f n e w m o n o graphs when n e c e s s a r y  s o o n p r o v e d to be a m o n u m e n t a l t a s k (71).  R e c o g n i z i n g the u n i q u e f e a t u r e s o f the L i o n s G a t e H o s p i t a l D r u g F o r m u l a r y to the p r o v i n c e a s a w h o l e , the B r i t i s h C o l u m b i a H o s p i t a l A s s o c i a t i o n ( B . C H . A . ) a d o p t e d the text a s a p r o v i n c i a l D r u g a n d i t w a s m a d e a v a i l a b l e to a p p r o x i m a t e l y (37).  Formulary  100 B r i t i s h C o l u m b i a h o s p i t a l s  A l s o r e c o g n i z i n g that the m o n o g r a p h s r e p r e s e n t e d o n l y t h o s e d r u g s  u s e d at o n e h o s p i t a l a n d that a r e g u l a r u p d a t i n g m e c h a n i s m w a s r e q u i r e d to m a i n t a i n t h e p o t e n t i a l o f the n e w D r u g F o r m u l a r y , the B . C . H . A . a s t u d y at the F a c u l t y o f P h a r m a c e u t i c a l  supported  S c i e n c e s , U n i v e r s i t y of B r i t i s h  C o l u m b i a , d i r e c t e d at d e s i g n i n g a m e c h a n i s m to o v e r c o m e t h e s e  limita-  tions .  V.  Academic  One  Role  o f the m a j o r a s s i g n m e n t s f o r s e n i o r p h a r m a c y s t u d e n t s at the  Faculty of P h a r m a c e u t i c a l  S c i e n c e s , U n i v e r s i t y of B r i t i s h  Columbia,  r e q u i r e s a n e x t e n s i v e l i t e r a t u r e e v a l u a t i o n o f the s c i e n t i f i c a n d c l i n i c a l validity o f new drug i n f o r m a t i o n .  A c c o r d i n g l y , the i n f o r m a t i o n r e l a t i v e to  about 100 d r u g s i s e v a l u a t e d a n n u a l l y .  Although these a s s i g n m e n t s were  not e x t e n d e d to p r o d u c e the r e s u l t s i n d r u g m o n o g r a p h f o r m a t ,  it became  a p p a r e n t that m u c h o f the t i m e a n d e f f o r t e x p e n d e d b y s t u d e n t s a n d  21  i n s t r u c t o r s r e p r e s e n t e d the type o f r e s o u r c e u p d a t i n g r e q u i r e d to a n n u a l l y r e v i s e the p r o v i n c i a l D r u g  It w a s  Formulary.  f u r t h e r r e c o g n i z e d that to r e v i s e , c o n d e n s e , e d i t a n d  the a c a d e m i c a s s i g n m e n t s into u s e f u l F o r m u l a r y  monograph format,  compile some  " s e r v i c e " c o m m i t t m e n t i n t e r m s of p h a r m a c i s t and s t e n o g r a p h i c p e r s o n n e l w o u l d be r e q u i r e d . T h e  degree of this c o m m i t t m e n t i n t e r m s of " s e r v i c e "  to a n n u a l l y u p d a t e a n d r e v i s e the D r u g F o r m u l a r y present study.  i s the o b j e c t i v e o f the  22  STATEMENT OF  The  OBJECTIVES  d i s t r i b u t i o n o f the D r u g F o r m u l a r y , o r i g i n a l l y p r o d u c e d at  the L i o n s G a t e H o s p i t a l , to the p r o v i n c i a l h o s p i t a l s b y the B r i t i s h H o s p i t a l A s s o c i a t i o n r e f l e c t s the n e e d f o r a f o r m a l p r o v i n c i a l D r u g lary.  T h e o b j e c t i v e s o f the p r e s e n t s t u d y a r e to: 1.  I d e n t i f y how  the p r e s e n t D r u g F o r m u l a r y  may  b e c o m e m o r e u s e f u l on a p r o v i n c i a l b a s i s through m o d i f i c a t i o n o f the m o n o g r a p h a n d  Formulary  formats; 2.  D e f i n e a m e c h a n i s m w h e r e b y the F o r m u l a r y  may  be e v a l u a t e d a n d u p d a t e d o n a r e g u l a r b a s i s ; 3.  P r o j e c t p e r s o n n e l r e q u i r e m e n t s to a c h i e v e the above.  Columbia Formu-  23  METHODOLOGY  T h i s r e s e a r c h was  i n s t i t u t e d w i t h the r e a l i z a t i o n that the D r u g  F o r m u l a r y w h e n a d o p t e d a n d d i s t r i b u t e d b y the B r i t i s h C o l u m b i a  Hospital  A s s o c i a t i o n ( B . C . H.A. ) would p o s s i b l y r e q u i r e s o m e a l t e r a t i o n s i n f o r m a t a n d c o n t e n t to m a k e i t m o r e a c c e p t a b l e a n d u s e f u l to the p r o v i n c i a l h o s p i t a l s . It was  r e c o g n i z e d a l s o that the D r u g F o r m u l a r y s h o u l d be u p d a t e d at r e g u l a r  i n t e r v a l s f r o m the c u r r e n t l i t e r a t u r e w i t h i n f o r m a t i o n that i s b o t h s c i e n t i f i c a l l y and c l i n i c a l l y v a l i d .  I.  I d e n t i f y i n g the P r o v i n c i a l N e e d s  In a n a t t e m p t to d e t e r m i n e the a c c e p t a b i l i t y o f the p r e s e n t D r u g F o r m u l a r y a n d w h a t m o d i f i c a t i o n s w e r e d e s i r a b l e i n r e g a r d to f o r m a t content, three studies w e r e u n d e r t a k e n .  F i r s t l y , a questionnaire  and  was  d i s t r i b u t e d to the c h i e f p h a r m a c i s t s o f the p r o v i n c i a l h o s p i t a l s to d e t e r m i n e the e x t e n t o f u s e o f the D r u g F o r m u l a r y a n d t h e i r o p i n i o n s i n r e g a r d to the f o r m a t a n d c o n t e n t s . o f the p r o v i n c e was  S e c o n d l y , a s u r v e y of four m a j o r h o s p i t a l s  c o n d u c t e d to d e t e r m i n e how  many additional drug  m o n o g r a p h s w e r e d e s i r e d w h i c h w o u l d e v e n t u a l l y i n f l u e n c e the s i z e o f the Formulary.  T h i r d l y , a s t u d y was  c o n d u c t e d o f the d r u g u s a g e p a t t e r n s i n  s p e c i f i c c a r e a r e a s o f f i v e h o s p i t a l s to d e t e r m i n e i f a c o n d e n s e d v e r s i o n o f the F o r m u l a r y c o u l d be m a d e to f a c i l i t a t e a m o r e e f f e c t i v e u s e o f the D r u g F o r m u l a r y at the w a r d l e v e l .  24  (a)  P o p u l a r i t y of U s e  A  q u e s t i o n n a i r e was  s e n t to the c h i e f p h a r m a c i s t s o f a l l B r i t i s h  C o l u m b i a h o s p i t a l s w h i c h l i s t e d a c h i e f o r d i r e c t o r o f p h a r m a c y i n the 1971  e d i t i o n o f the " C a n a d i a n H o s p i t a l D i r e c t o r y " * .  The  questionnaire  d e s i g n e d to g i v e the F o r m u l a r y u s e r s the o p p o r t u n i t y to e x p r e s s t h e i r  was own  o p i n i o n s a n d t h o s e o f t h e i r c o l l e a g u e s o n the c o n t e n t a n d f o r m a t o f the present Drug F o r m u l a r y .  It a l s o g a v e t h e s e p r o f e s s i o n a l s a c h a n c e to  s u g g e s t c h a n g e s i n the f o r m a t a n d c o n t e n t a n d a d d i t i o n a l d r u g m o n o g r a p h s f o r i n c l u s i o n i n the F o r m u l a r y .  F i g u r e 2 i l l u s t r a t e s the q u e s t i o n n a i r e .  A l l q u e s t i o n n a i r e s that w e r e c o m p l e t e d a n d r e t u r n e d w e r e r e v i e w e d to d e t e r m i n e the n u m b e r o f h o s p i t a l s that w e r e u s i n g the F o r m u l a r y a n d to o b t a i n s u g g e s t i o n s f o r f u t u r e c h a n g e s i n the F o r m u l a r y f o r m a t a n d the monograph format. the  The lists of additional drug monographs requested by  c h i e f p h a r m a c i s t s f o r i n c l u s i o n i n the F o r m u l a r y w e r e i n c l u d e d i n the  r e s u l t s o f the A d d i t i o n a l D r u g s S u r v e y .  (b) N u m b e r o f D r u g M o n o g r a p h s  Before requesting which additional drug monographs were needed b y the F o r m u l a r y u s e r s , i t was  d e e m e d n e c e s s a r y to d e t e r m i n e the n u m b e r  of d r u g m o n o g r a p h s i n the e x i s t i n g D r u g F o r m u l a r y a n d the n u m b e r o f C "**Canadian H o s p i t a l D i r e c t o r y , V o l . 19, T h e Association, Toronto,  1971.  Canadian Hospital  25  F i g u r e 2.  E x a m p l e o f the q u e s t i o n n a i r e s e n t to the c h i e f p h a r m a c i s t s o f the p r o v i n c i a l hospitals.  26 THE  UNIVERSITY OF BRITISH COLUMBIA VANCOUVER  8, C A N A D A  FACULTY OF PHARMACEUTICAL SCIENCES  November 21st, 1972  Dear Fellow  Pharmacists:  The Faculty of Pharmaceutical Sciences i s undertaking a provincially sponsored study to "update" and make "more provincial" the present Drug Formulary (Lion's Gate) being distributed by the B.C.H.A. The objective here is to design and maintain on a regular basis a provincial formulary for a l l hospitals in British Columbia. Accordingly, so that the design might represent "provincial" thinking, we are asking for your support and the contribution of your ideas as related to the following questions: 1. Is the Drug Formulary i n general use i n your hospital?  .  2. If the answer to question 1 i s no, please comment i n regard to the reasons in your hospital for not using the Drug Formulary.  Did you previously have a formulary of your own i n your hospital? If yes, i s i t s t i l l being used? Is the formulary satisfactory i n regard to: (a) overall format  '  (b) monograph format (c) introductory information (d) monograph information (e) other as related to the physicians, pharmacists and nursing views i n your hospitals. Are there any additional monographs you would like to see included? i f yes, please l i s t them .  As the information that you supply to us w i l l be used to determine the cost and usefulness of regular updating and making the formulary more provincially useful, we request that you reply before the 15th of December, 1972. A reply by that date w i l l enable us to evaluate your comments and to incorporate your ideas into our project in early 1973. Thank you for any assistance which you can give to us and for your interest in promoting better drug information to your hospital i n the future. Yours sincerely,  EAP/cs  Elizabeth A. Page, B.Sc.(Pharm). Division of C l i n i c a l Pharmacy  cc. Dr. J . Hlynka, chairman, Division of C l i n i c a l Pharmacy  FIGURE 2  27  d r u g s a n d d r u g p r o d u c t s l i s t e d i n the F o r m u l a r y a l p h a b e t i c a l i n d e x .  The  d r u g m o n o g r a p h s i n the F o r m u l a r y w e r e c o u n t e d , e x c l u d i n g  the s p e c i a l i z e d m o n o g r a p h s o n " E a r , E y e , N o s e a n d T h r o a t P r e p a r a t i o n s " , "Skin and M u c o u s M e m b r a n e P r e p a r a t i o n s " , and "Intravenous and I r r i g a tion S o l u t i o n s " .  T h e a b o v e l i s t e d s e c t i o n s w e r e e x c l u d e d b e c a u s e the  monographs r e p r e s e n t specialized uses of drugs which are usually monog r a p h e d i n the m a i n s e c t i o n o f the F o r m u l a r y u n d e r g e n e r i c n a m e s .  To  d e t e r m i n e the n u m b e r o f d r u g s a n d d r u g p r o d u c t s l i s t e d i n the F o r m u l a r y a l p h a b e t i c a l i n d e x , m o s t o f the b r a n d n a m e s o f the d r u g s w h i c h a r e i n c l u d e d i n the i n d e x a s a c r o s s - r e f e r e n c e to the g e n e r i c d r u g n a m e w e r e e l i m i n a t e d . The  r e m a i n i n g drug names were counted and a r r a n g e d i n alphabetical o r d e r .  The  r e s u l t i n g d r u g l i s t w a s l a t e r u s e d i n the s t u d y o f d r u g u s a g e p a t t e r n s  in special care a r e a s of five p r o v i n c i a l hospitals.  Additional Drugs  Survey  T o d e t e r m i n e w h i c h , i f any, additional drug m o n o g r a p h s w e r e n e e d e d to m a k e the D r u g F o r m u l a r y m o r e a d e q u a t e l y r e f l e c t the d r u g i n f o r m a t i o n n e e d s o f the p r o v i n c i a l h o s p i t a l s , a s a m p l e s u r v e y w a s d u c t e d i n f o u r m a j o r h o s p i t a l s o f the p r o v i n c e .  Vancouver  con-  General  H o s p i t a l , St. Paul's Hospital (Vancouver), V i c t o r i a G e n e r a l H o s p i t a l and R o y a l J u b i l e e H o s p i t a l ( V i c t o r i a ) w e r e c h o s e n b e c a u s e they a l l o f f e r h o s p i t a l p h a r m a c y r e s i d e n c y p r o g r a m m e s a n d t h e r e f o r e e x p e c t e d to h a v e s u f f i c i e n t s t a f f to c o m p l e t e the s u r v e y .  28  T h e h o s p i t a l p h a r m a c y r e s i d e n t i n e a c h h o s p i t a l w a s a s k e d to r e v i e w the d r u g s s t o c k e d i n h i s h o s p i t a l a n d to l i s t a l l d r u g s u s e d w h i c h w e r e n o t m o n o g r a p h e d i n the p r e s e n t D r u g F o r m u l a r y .  They were  asked  a l s o to i n d i c a t e w h e n e v e r p o s s i b l e w h i c h d r u g s i n the l i s t s t h e i r h o s p i t a l w o u l d l i k e to s e e i n c l u d e d i n the F o r m u l a r y .  T h e r e s u l t s of this  survey  w e r e c o r r e l a t e d w i t h the l i s t s o f a d d i t i o n a l d r u g m o n o g r a p h s r e q u e s t e d b y the c h i e f p h a r m a c i s t s .  The additional drug monographs requested  w e r e c a t e g o r i z e d a c c o r d i n g to the f r e q u e n c y o f r e q u e s t s r e c e i v e d f o r e a c h d r u g f r o m the f o u r h o s p i t a l s a n d the c h i e f p h a r m a c i s t s . r e s u l t s , the e v e n t u a l s i z e a n d c o n t e n t o f the D r u g F o r m u l a r y e s t i m a t e d p r o v i d i n g that the a d d i t i o n a l d r u g s  F r o m the c o u l d be  suggested above were r e p r e -  s e n t a t i v e o f the o t h e r p r o v i n c i a l h o s p i t a l n e e d s a s w e l l .  (c<) F o r m a t o f the D r u g M o n o g r a p h s  In c o m p l e t i n g the c h i e f p h a r m a c i s t s q u e s t i o n n a i r e ( s e e p a g e 26) the c h i e f p h a r m a c i s t s w e r e a s k e d to c o m m e n t o n the a c c e p t a b i l i t y a n d u s e f u l n e s s o f the d r u g m o n o g r a p h f o r m a t .  Suggestions for changes and  a d d i t i o n s w e r e r e v i e w e d i n a d d i t i o n to t h o s e that w e r e i d e n t i f i e d f r o m a n a n a l y s i s o f the l i t e r a t u r e a n d f r o m the c o m m e n t s o f the m e m b e r s o f the Faculty of P h a r m a c e u t i c a l Sciences, University of B r i t i s h Columbia w e r e i n v o l v e d i n the c u r r e n t r e v i s i o n s .  who  A l l of these w e r e noted and some  of t h e m w e r e a d o p t e d f o r f u r t h e r e v a l u a t i o n s i n the p r e s e n t s t u d y .  29  Canadian D r u g Identification Code The  r e c e n t p u b l i c a t i o n b y the f e d e r a l H e a l t h P r o t e c t i o n B r a n c h  o f the C a n a d i a n D r u g I d e n t i f i c a t i o n C o d e s t i m u l a t e d i n t e r e s t i n a d d i n g to the d r u g m o n o g r a p h s a d r u g c o d e w h i c h was nature.  specifically Canadian in  T h i s w o u l d s u p p l e m e n t the e x i s t i n g A m e r i c a n H o s p i t a l F o r m u l a r y  S e r v i c e ( A . H . F.S.)  therapeutic classification number.  S i n c e the C a n a d i a n  D r u g Identification Code contains four unique drug codes, t e c t i o n B r a n c h p u b l i c a t i o n was  the H e a l t h  Pro-  s t u d i e d to d e t e r m i n e w h i c h o f the f o u r c o d e s  w o u l d be m o s t u s e f u l to the F o r m u l a r y u s e r s f o r d r u g i d e n t i f i c a t i o n as w e l l as s t o c k c o n t r o l a n d o t h e r  procedures.  Ambulatory Considerations In r e c e n t y e a r s , h o s p i t a l s a n d h o s p i t a l p h a r m a c i s t s h a v e b e c o m e i n c r e a s i n g l y i n v o l v e d i n a m b u l a t o r y a n d o u t p a t i e n t s e r v i c e s (60).  In  a t t e m p t i n g to p r o d u c e a D r u g F o r m u l a r y w h i c h m i g h t be u s e f u l to a l l h e a l t h p r o f e s s i o n a l s o f the p r o v i n c e , c o n s i d e r a t i o n was  g i v e n to t h o s e  a r e a s w h i c h d e a l w i t h a m b u l a t o r y p a t i e n t s i n an o u t p a t i e n t c l i n i c as w e l l a s i n the i n p a t i e n t s e t t i n g .  F o r t h i s r e a s o n a n a t t e m p t was  m a d e to s u p p l y  i n f o r m a t i o n on the d r u g m o n o g r a p h s to a s s i s t the h e a l t h c a r e p r o f e s s i o n a l s i n i n s t r u c t i n g the a m b u l a t o r y p a t i e n t s about the p r o p e r h a n d l i n g and of their m e d i c a t i o n s .  The  use  m e c h a n i s m that i s b e i n g e v a l u a t e d a s a m e a n s  of u p d a t i n g the D r u g F o r m u l a r y m o n o g r a p h s was  a d o p t e d as the b a s i s f o r  a l s o a c c o m p l i s h i n g the o b j e c t i v e o f s u p p l y i n g i n s t r u c t i o n s to the p a t i e n t s .  30  E l e c t r o n i c Data P r o c e s s i n g and F o r m u l a r y P r o d u c t i o n Because  the p r e s e n t m e t h o d o f p r i n t i n g the D r u g  Formulary  r e q u i r e s that the w h o l e m o n o g r a p h be r e - t y p e d e a c h t i m e that i t i s upd a t e d , i t was s h o u l d be  d e c i d e d that a n o t h e r m e a n s o f p r o d u c i n g the F o r m u l a r y  investigated.  T h e use of e l e c t r o n i c data p r o c e s s i n g ( E . D . P . ) and c o m p u t e r i zation i s b e c o m i n g m o r e c o m m o n i n m e d i c a l and p h a r m a c y p r a c t i c e s e v e r a l drug f o r m u l a r i e s have been p r o d u c e d by these m e a n s . tigate the p o s s i b i l i t y o f c o m p u t e r i z e d p r o d u c t i o n o f the D r u g i n f u t u r e y e a r s , the r e c e n t l i t e r a t u r e on t h i s s u b j e c t was letter was  a l s o s e n t to M r .  To  and  inves-  Formulary  reviewed.  A  H . S m y t h e , D i r e c t o r o f P h a r m a c y at the O t t a w a  C i v i c H o s p i t a l , ( O t t a w a , O n t a r i o ) r e q u e s t i n g i n f o r m a t i o n o n the c o s t s , s t o r a g e o f i n f o r m a t i o n , a n d the m e t h o d u s e d to u p d a t e the m o n o g r a p h s b y E.D.P.  T h e O t t a w a C i v i c H o s p i t a l was  c h o s e n a s the s o u r c e o f t h i s  i n f o r m a t i o n b e c a u s e i t i s a C a n a d i a n h o s p i t a l u s i n g E . D . P . to p r o d u c e a d r u g f o r m u l a r y a n d i t was  thought that the c o s t s a n d p r o c e d u r e s at a  C a n a d i a n h o s p i t a l w o u l d m o r e c l o s e l y r e s e m b l e the p o s s i b l e c o s t s a n d methods also available in B r i t i s h C o l u m b i a .  A c o m p a r i s o n b e t w e e n the  costs of E . D . P . f o r m u l a r y p r i n t i n g as supplied by M r .  S m y t h e a n d the  c o s t s o f the c o n v e n t i o n a l m e t h o d s a s u s e d to p r o d u c e the B r i t i s h D r u g F o r m u l a r y was  done.  Columbia  31  (d) M o n o g r a p h U t i l i z a t i o n SurveyOne  o f the l i m i t a t i o n s o f the A m e r i c a n H o s p i t a l  Formulary  S e r v i c e i s that the t w o - v o l u m e set i s too b u l k y f o r e a s y u s e (47, 65). S i m i l a r l y , the p r e s e n t D r u g F o r m u l a r y a l s o i s a w k w a r d due to i t s s i z e . F o r t h i s r e a s o n a n d b e c a u s e the c o n t e n t o f the F o r m u l a r y m a y  h a v e to be  f u r t h e r i n c r e a s e d to c o v e r the d r u g i n f o r m a t i o n n e e d s o f the p r o v i n c e , attempt was  an  m a d e to f i n d a m e t h o d ( s ) b y w h i c h the w a r d s o f the h o s p i t a l s  c o u l d be s u p p l i e d w i t h u s e f u l , c o m p a c t f o r m u l a r i e s t h r o u g h i d e n t i f y i n g the unique drug use patterns i n each patient c a r e a r e a .  A  s t u d y was  conducted i n this r e g a r d i n five p r o v i n c i a l hospitals  to d e t e r m i n e the f r e q u e n c y o f u s e o f the d r u g s a n d d r u g p r o d u c t s l i s t e d i n the a l p h a b e t i c a l i n d e x o f the F o r m u l a r y a c c o r d i n g to s p e c i a l t y w a r d s . c o m p l e t e d r u g l i s t was t r i b u t e d to V a n c o u v e r  t y p e d ( f i r s t p a g e e x e m p l i f i e d i n F i g u r e 3) a n d G e n e r a l H o s p i t a l , St. Paul's H o s p i t a l , L i o n s  The dis-  Gate  H o s p i t a l , V i c t o r i a G e n e r a l H o s p i t a l and R o y a l Jubilee H o s p i t a l .  I n f o r m a t i o n i n this r e s p e c t was  g e n e r a t e d o n the f r e q u e n c y of  u s e o f the l i s t e d d r u g s i n the s p e c i f i c c a r e a r e a s o f P e d i a t r i c s , P s y c h i a t r y and E x t e n d e d C a r e .  Emergency,  T h e s e a r e a s w e r e c h o s e n to e x e m p l i f y  s p e c i a l t i e s b e c a u s e o f the w i d e v a r i e t y o f d r u g s that m i g h t b e u s e d i n e a c h of t h e m .  F o r e a c h l i s t e d d r u g the f r e q u e n c y o f u s e was  d e t e r m i n e d as  " f r e q u e n t l y " , " o c c a s i o n a l l y " o r " r a r e l y " i n e a c h o f the f o u r a r e a s .  "Fre-  q u e n t l y U s e d D r u g s " w e r e d e f i n e d a s t h o s e d r u g s w h i c h w e r e s u p p l i e d to  32  F i g u r e 3.  S a m p l e of D r u g L i s t s u s e d f o r Monograph Utilization Survey.  33  DRUG  EMERGENCY  PEDIATRICS  F  0  i. F  R  i  0  R  EXTENDED CARE  PSYCHIATRIC  F  0  i  R  F  I  i Acetaminophen Acetazolamide Acetycholine Acetylcysteine A c e t y l s a l i c y l i c acid Achromycin ACTH Adephinine Adrenalin Aerosporin A e r o s p o r i n (Ear) Agarol Airbron Alcohol Alkeran Allopurinol Alpha-Chymotrypsin  i  j  I 1  1  i  R  I  0  i  1  i  1 1  | I1 1  i  ii • i  !•  1  i  | 1  !  Alpha-Tocopherol Aluminum Hydroxide Americaine Amesec Amethopterin Aminocaproic a c i d ii Aminophyllin |j A m i n o p h y l l i n Compounds|| Amitriptyline Ammonium Carbonate Mixture Ammonium C h l o r i d e Ammonium C h l o r i d e Mixture Amobarbital Sodium Amphotercin Amphyl Ampicillin Amyl N i t r i t e Artectine Anileridine Annanase Antepar Anusol i Apresoline Argyrol Ascorbic acid A t r o p i n e (eye)  I  1  t1t '  1 1  |  i  !  .i  i  !  1  • 1  1 1  i !  FIGURE 3  1  •  34  an a r e a a s w a r d s t o c k , u s e d d a i l y o r s e v e r a l t i m e s a w e e k .  "Occasional  U s e d D r u g s " w e r e t h o s e u s e d i n an a r e a o n l y o n c e o r t w i c e a m o n t h , " R a r e l y U s e d D r u g s " w e r e i n t e r p r e t e d a s t h o s e d r u g s u s e d i n an only once or twice a y e a r , or n e v e r . w e r e r e v i e w e d and p h a r m a c i s t s  To  and  area  obtain this i n f o r m a t i o n ,  records  a n d n u r s e s w e r e i n t e r v i e w e d a c c o r d i n g to  s p e c i f i c d r u g u s e p a t t e r n s (see F i g u r e 4 ) .  The  l i s t s f r o m e a c h h o s p i t a l w e r e a n a l y s e d a c c o r d i n g to the  s p e c i f i c t r e a t m e n t a r e a s to d e t e r m i n e the n u m b e r o f d r u g s a n d  the  a p p r o x i m a t e p e r c e n t a g e o f the d r u g s u s e d " f r e q u e n t l y " , " o c c a s i o n a l l y " and  " r a r e l y " for each hospital.  It was  a n t i c i p a t e d that the r e s u l t s c o u l d  then be u s e d to p r o p o s e a s y s t e m w h e r e b y the m o n o g r a p h s o f the  "Fre-  q u e n t l y U s e d D r u g s " c o u l d be m a d e m o r e r e a d i l y a v a i l a b l e to the h e a l t h p r o f e s s i o n a l s o n the n u r s i n g w a r d w i t h o u t s a c r i f i c i n g the a v a i l a b i l i t y of the r e m a i n i n g in each a r e a .  m o n o g r a p h s f o r d r u g s u s e d " O c c a s i o n a l l y " and It was  "Rarely"  h o p e d a l s o to k e e p the p o t e n t i a l b u l k o f a p r o v i n c i a l  D r u g F o r m u l a r y to a m i n i m u m .  II.  E v a l u a t i o n a n d U p d a t i n g the F o r m u l a r y  F o r the p a s t two y e a r s a l i m i t e d n u m b e r o f s e n i o r y e a r s t u d e n t s at the F a c u l t y o f P h a r m a c e u t i c a l  pharmacy  S c i e n c e s , U n i v e r s i t y of B r i t i s h .  C o l u m b i a have been p a r t i c i p a t i n g i n a p r o g r a m m e of l i t e r a t u r e evaluation in conjunction with a pilot course in C l i n i c a l P h a r m a c y . that the w o r k done b y the s t u d e n t s was  It was  recognized  v a l u a b l e a n d that m u c h o f t h i s w o r k  35  FIGURE 4  INSTRUCTIONS FOR MONOGRAPH UTILIZATION SURVEY  O F DRUG USE FOR SPECIALTY  SURVEY  FORMULARIES  Hospital Name Resident's N a m e INSTRUCTIONS: 1.  C o m p l e t e the f o l l o w i n g c h a r t s w i t h r e g a r d to the f r e q u e n c y o f d r u g use i n s p e c i a l i z e d c a r e a r e a s in your  2.  F  =  hospital.  F r e q u e n t l y - f l o o r s t o c k to a r e a o r u s e d d a i l y ,  s e v e r a l times  a week? O  =  O c c a s i o n a l l y - u s e d i n s p e c i f i c a r e a only once o r twice a month.  R  =  R a r e l y - u s e d i n s p e c i f i c a r e a only once o r twice p e r y e a r o r never..  Other  than f l o o r s t o c k , f r e q u e n c y o f u s e i s to be d e t e r m i n e d b y  Resident's experience, pharmacists' opinions and nurses' opinions. 3.  A s e c t i o n o n the l a s t p a g e i s p r o v i d e d f o r e v a l u a t i o n o f the f r e q u e n c y of u s e o f d r u g s that a r e n o t l i s t e d h e r e , b u t a r e u s e d i n y o u r h o s p i t a l .  4.  D r u g s a r e l i s t e d b y g e n e r i c n a m e o n l y , to p r e v e n t c o n f u s i o n w i t h b r a n d s that m a y n o t be u s e d i n a l l h o s p i t a l s . ( E x c e p t i o n : t h o s e medications which a r e combination products).  5.  P l e a s e c o m p l e t e a n d r e t u r n f o r m s b e f o r e D e c e m b e r 20, 1972.  36  c o u l d be f u r t h e r a p p l i e d to a p r a c t i c a l u s e i n f u l f i l l i n g the n e e d o f u p d a t i n g the p r e s e n t D r u g F o r m u l a r y .  A c c o r d i n g l y a m e c h a n i s m w a s p r o p o s e d to  the M e d i c a l S e r v i c e s F o u n d a t i o n o f B r i t i s h C o l u m b i a w h e r e b y the m o n o g r a p h s o f the D r u g F o r m u l a r y educational assignment  c o u l d be u p d a t e d a s a c l i n i c a l l y r e l a t e d  to the s e n i o r y e a r p h a r m a c y c l a s s i n 1 9 7 2 - 7 3 .  T h e p r o p o s e d m e c h a n i s m o f u p d a t i n g the d r u g m o n o g r a p h s to b e e v a l u a t e d i n the p r e s e n t s t u d y r e p r e s e n t s a s e q u e n c e o f s e n i o r y e a r C l i n i c a l P h a r m a c y student a s s i g n m e n t s  and i n s t r u c t o r r e v i e w , both as an  " a c a d e m i c " r e s p o n s i b i l i t y a n d o n a " s e r v i c e " b a s i s to e n s u r e the a c c u r a c y of the s t u d e n t w o r k .  T h e i n s t r u c t o r " s e r v i c e " input r e p r e s e n t s the  r e v i s i o n a n d c o n d e n s i n g o f the l i t e r a t u r e e v a l u a t i o n r e p o r t to s u i t a b l e monograph format.  T h e above Foundation approved a one-year  g r a n t to  e n a b l e the f i n a n c i n g o f t h i s " s e r v i c e " c o m p o n e n t b y the i n s t r u c t o r a s w e l l as s o m e s t e n o g r a p h i c a s s i s t a n c e .  The  q u e s t i o n s that w e r e to b e a n s w e r e d b e f o r e a c o n t i n u i n g p r o -  g r a m m e o f this n a t u r e c o u l d be u n d e r t a k e n on an annual b a s i s i n c l u d e : 1.  Is t h e r e a n e e d f o r r e g u l a r u p d a t i n g o f the d r u g monographs ?  2.  W h a t a r e the t i m e r e q u i r e m e n t s o f the s t u d e n t s a n d what i s the e x t e n t o f t h e i r c o n t r i b u t i o n to the u p d a t i n g m e c h a n i s m ?  3.  W h a t i s the t i m e r e q u i r e m e n t o f the i n s t r u c t o r s beyond their a c a d e m i c  4.  involvement?  W h a t i s the t i m e r e q u i r e m e n t of; the s t e n o g r a p h i c s t a f f to type the u p d a t e d m o n o g r a p h s o n a n a n n u a l basis ?  37  (a)  M e c h a n i s m of Updating  Student A s s i g n m e n t E a c h s t u d e n t i n the s e n i o r y e a r p h a r m a c y c l a s s w a s a s s i g n e d t h r e e d r u g s (see A p p e n d i x III) to c o m p l e t e l y e v a l u a t e the e x i s t i n g m o n o graph i n f o r m a t i o n and r e f e r e n c e f r o m o r i g i n a l literature a l l statements i n the m o n o g r a p h s e c t i o n s o f " D r u g I n t e r a c t i o n s " a n d " I n t r a v e n o u s Incompatibilities".  T h e s t u d e n t s w e r e s u p p l i e d w i t h a s t a t e m e n t o f the  type o f p a p e r s a n d r e f e r e n c e s w h i c h w e r e a c c e p t a b l e l i t e r a t u r e  sources  a n d w e r e i n s t r u c t e d to u s e o n l y s c i e n t i f i c a l l y v a l i d i n f o r m a t i o n to u p d a t e the m o n o g r a p h s .  In a d d i t i o n the s e c t i o n o f the m o n o g r a p h  concerning  " A c t i o n " w a s to b e e x p a n d e d to i n c l u d e the m e c h a n i s m o f a c t i o n , t i o n , d i s t r i b u t i o n , m e t a b o l i s m a n d e x c r e t i o n o f the d r u g .  absorp-  A new s e c t i o n  o f " I n s t r u c t i o n s to the P a t i e n t " w a s a d d e d a l s o to f u l f i l l the o b j e c t i v e o f s u p p l y i n g d r u g i n f o r m a t i o n to a m b u l a t o r y c a r e a r e a s .  T h r o u g h o u t the  a s s i g n m e n t the s t u d e n t s w e r e r e q u i r e d to a d d a n y new i n f o r m a t i o n f r o m the l i t e r a t u r e o f the p a s t y e a r a s w e l l a s to e v a l u a t e e x i s t i n g m o n o g r a p h information from earlier years.  T h e s t u d e n t s a l s o w e r e d i r e c t e d to  r e c o r d a n y c h a n g e s o r c o r r e c t i o n s that w e r e f o u n d f r o m the l i t e r a t u r e a n d to r e f e r e n c e t h e s e a l t e r a t i o n s o n a C h a n g e S h e e t ( s e e F i g u r e 5) w h i c h w e r e p r e s e n t e d to the i n s t r u c t o r w i t h b o t h the o r i g i n a l a n d e v a l u a t e d m o n o graphs.  T h r o u g h o u t the a s s i g n m e n t the s t u d e n t s r e c o r d e d the t i m e r e q u i r e d to u p d a t e e a c h m o n o g r a p h .  T h e r e s u l t s o f the t i m e s t u d y w e r e  38  F i g u r e 5.  S a m p l e of a Change Sheet as d i s t r i b u t e d to the s t u d e n t s , w i t h s e c t i o n s f o r the u p d a t e d i n f o r m a t i o n s i m i l a r to the monograph format.  39  Pharmacy 403 Drug and Poison Information Centre Revisions and Updating of Drug Monograph  GENERIC NAME O F DRUG  1. General Information 2.  Action  3. Spectrum of Activity 4.  Indications  5.  Contraindications  6. Cautions 7.  Dosage  8. Side Effects 9. Drug Interactions 10. Intravenous Incompatibilities 11. Nursing Implications 1 2.  Instructions to the Patient  13.  Presentation  FIGURE 5;  40  u s e d to p r o j e c t the s t u d e n t i n v o l v e m e n t i n a n n u a l u p d a t i n g a n d a t i m e schedule for future r e v i s i o n s .  Pharmacist The  Involvement r e q u i r e d i n s t r u c t o r i n v o l v e m e n t i n t o t a l r e v i s i o n o f the d r u g  m o n o g r a p h s r e p r e s e n t s the p a r t i c i p a t i o n o f the i n s t r u c t o r s b e y o n d t h e i r "academic"  responsibility.  The "academic"  responsibility included being  p r e s e n t at the s t u d e n t p r e s e n t a t i o n s o f the e v a l u a t e d m o n o g r a p h s a n d g r a d i n g the w o r k o n the b a s i s o f a c a d e m i c m e r i t .  F o r F o r m u l a r y purposes,  the i n s t r u c t o r s t h e n r e v i e w e d the r e v i s e d m o n o g r a p h s f o r a l l  changes,  a d d i t i o n s a n d c o r r e c t i o n s m a d e b y the s t u d e n t s , a n d e v a l u a t e d the w o r k and c i t e d r e f e r e n c e s f o r s c i e n t i f i c v a l i d i t y on a " s e r v i c e " b a s i s .  When  the i n s t r u c t o r s h a d c o m p l e t e d the e v a l u a t i o n o f the r e v i s e d m o n o g r a p h s t h e y t h e n e d i t e d a n d c o n d e n s e d the m o n o g r a p h s into the s t a n d a r d f o r m a t o f the D r u g  Formulary.  T h e i n s t r u c t o r s w e r e r e q u e s t e d to m a i n t a i n a r e c o r d o f t h e i r time r e q u i r e m e n t s beyond their "academic"  involvement.  These  time  r e c o r d s w e r e u s e d to p r o j e c t the p h a r m a c i s t " s e r v i c e " r e q u i r e m e n t s f o r u p d a t i n g the m o n o g r a p h s o n a f u t u r e a n n u a l b a s i s .  Stenographic The  Requirements r e v i s e d , c o r r e c t e d and condensed monographs were r e q u i r e d  to b e t y p e d i n a u n i f o r m f o r m a t f o r d u p l i c a t i o n a n d d i s t r i b u t e d to the  41  participating hospitals. Accordingly, a stenographic service input was required for this purpose. As for other personnel, the time required for the stenographic work was recorded to enable a projection of this service on a potential annual basis.  (b) Nature and Frequency of Changes  One hundred completed Change Sheets (see Figure 5, page 39) were selected and reviewed to estimate the need for regular revision of the Drug Formulary monographs. These one hundred Change Sheets were analyzed to show the average total number of changes in each monograph and the average number of changes which appeared specifically in the sections of "Drug Interactions" and "Intravenous Incompatibilities". The latter two sections were segregated since it was expected that the majority of the future updating time might be required in these areas.  (c) Time Evaluation  F r o m each of the time records of the above three groups (students, instructors and stenographers) one hundred records were evaluated. These records were used to determine the average approximate time needed for updating the monographs on a "service" basis, to propose a schedule for future revisions and to project the personnel that might be needed to accomplish this objective.  42  R E S U L T S AND  DISCUSSION  T h e t h r e e b a s i c i s s u e s to b e r e s o l v e d i n the p r e s e n t studyi n c l u d e d the d e f i n i t i o n o f the d r u g m o n o g r a p h a n d F o r m u l a r y  format  c h a n g e s r e q u i r e d to p r e s e n t a m o r e p r o v i n c i a l l y u s e f u l r e f e r e n c e ,  the  p r o j e c t i o n o f a n e v a l u a t i o n m e c h a n i s m w h i c h c o u l d e f f e c t i v e l y u p d a t e the F o r m u l a r y o n a r e g u l a r b a s i s , a n d a d e s c r i p t i o n o f the t y p e a n d n u m b e r of p e r s o n n e l r e q u i r e d to p r o d u c e  I.  such updated drug m o n o g r a p h s .  I d e n t i f y i n g the P r o v i n c i a l N e e d s  T h r e e a p p r o a c h e s w e r e u s e d to d e t e r m i n e the n e c e s s a r y f o r m a t c h a n g e s a n d how provincially useful Drug  to i m p l e m e n t t h e s e c h a n g e s to p r o d u c e a m o r e Formulary.  (1) A q u e s t i o n n a i r e w a s s e n t to the c h i e f p h a r m a c i s t s o f all B r i t i s h Columbia hospitals which listed a chief or d i r e c t o r of p h a r m a c y i n the 1971 e d i t i o n o f the C a n a dian Hospital D i r e c t o r y * . (2) A s a m p l e o f f o u r h o s p i t a l s o f the p r o v i n c e w e r e s u r v e y e d to d e t e r m i n e w h i c h , i f a n y , a d d i t i o n a l d r u g monographs were needed. (3) A n e v a l u a t i o n o f the d r u g u s e p a t t e r n s o f the d r u g s l i s t e d i n the a l p h a b e t i c a l i n d e x o f the F o r m u l a r y i n s p e c i a l t y c a r e a r e a s o f f i v e p r o v i n c i a l h o s p i t a l s was c o n d u c t e d to d e t e r m i n e i f m o r e e f f e c t i v e u s e c o u l d be m a d e o f the F o r m u l a r y at the w a r d l e v e l .  * C a n a d i a n H o s p i t a l D i r e c t o r y , V o l . 19, T h e Toronto,  1971.  Canadian Hospital Association,  B y r e v i e w i n g the r e s u l t s o f t h e s e t h r e e a p p r o a c h e s , f o r m a t a n d c o n t e n t c h a n g e s that w o u l d m a k e the D r u g F o r m u l a r y  some more  u s e f u l to a l l h o s p i t a l s o f the p r o v i n c e w e r e i d e n t i f i e d .  (a) P o p u l a r i t y o f U s e  O f the 46 h o s p i t a l s m o n i t o r e d i n the c h i e f p h a r m a c i s t s q u e s t i o n n a i r e , 32 o r a p p r o x i m a t e l y 70 p e r c e n t r e p l i e d to the q u e s t i o n n a i r e a n d o f t h e s e , 19 o r a p p r o x i m a t e l y 60 p e r c e n t r e p o r t e d u s i n g the D r u g F o r m u l a r y ( s e e T a b l e I).  T h e m a j o r r e a s o n s f o r n o t u s i n g the F o r m u l a r y a n d  the i n c i d e n c e o f t h e s e r e a s o n s a r e p r e s e n t e d i n T a b l e II. - S i n c e the m a j o r i t y o f the r e s p o n d e n t s a p p e a r to b e u s i n g the F o r m u l a r y  a n d s i n c e the  l i m i t a t i o n s f o r w a r d e d c a n b e o v e r c o m e , i t w o u l d a p p e a r to b e w o r t h w h i l e to p u r s u e a n a t t e m p t to m a k e the F o r m u l a r y m o r e p r o v i n c i a l l y a c c e p t a b l e .  T h o s e h o s p i t a l s u s i n g the D r u g F o r m u l a r y  submitted  some  e x c e l l e n t r e c o m m e n d a t i o n s f o r i m p r o v e m e n t s and the f o l l o w i n g l i s t o f r e c o m m e n d e d m o d i f i c a t i o n s r e p r e s e n t a s u m m a r y o f these as w e l l as those f r o m the o t h e r s o u r c e s m e n t i o n e d o n p a g e 4 2 : (1)  (2)  that a d d i t i o n a l d r u g m o n o g r a p h s , b e a d d e d to the F o r m u l a r y to c o v e r the d r u g i n f o r m a t i o n n e e d s o f the p r o v i n c e ; that the m o d e o f a c t i o n b e i n c l u d e d o n the d r u g m o n o g r a p h s a n d that m o r e e x t e n s i v e i n f o r m a tion on s o m e drugs be added;  (3)  that c o n s i d e r a t i o n b e g i v e n to s u p p l y i n g i n f o r m a t i o n to t h o s e a r e a s o f p r a c t i c e that d e a l w i t h the a m b u l a t o r y p a t i e n t i n a h o s p i t a l s e t t i n g  44  TABLE I  DRUG F O R M U L A R Y UTILIZATION As Determined By a Survey of Chief Pharmacists  Number of Hospitals Hospitals in British Columbia  Percentage^  104  Hospitals Surveyed  46  44  Hospitals which replied  32  70  19  60  Hospitals which use the Provincial Drug Formulary  2  1. Determined to the nearest percentage point. 2. Of those hospitals which replied.  45  T A B L E II  REASONS FOR NOT USING T H E DRUG F O R M U L A R Y  Reason  1  Number of Hospitals  Using American Hospital Formulary Service Using Compendium of Pharmaceuticals and Specialties Do not have sufficient Copies for all areas (more on order) Specialized Hospitals (Mental Health, Rehabilitation) Use it but as Back-up Reference only  Total  1. Acs determined from the survey of chief pharmacists.  13  46  s u c h a s the O u t p a t i e n t C l i n i c , N u r s i n g S t a t i o n s i n r e m o t e a r e a s a n d the M e n t a l H e a l t h C l i n i c s ; (4)  that r e f e r e n c e s o f the d r u g m o n o g r a p h s w o u l d a s s i s t the u s e r s i n o b t a i n i n g a d d i t i o n a l i n f o r m a t i o n as r e q u i r e d ;  (5)  that a C a n a d i a n D r u g C o d e be i n c l u d e d o n the monographs for drug identification;  (6)  that the D r u g F o r m u l a r y i s too b u l k y a n d c u m b e r s o m e for quick reference;  (7)  that e l e c t r o n i c d a t a p r o c e s s i n g ( E . D . P . ) be c o n s i d e r e d a s a m e a n s o f p r o d u c i n g the D r u g F o r m u l a r y w h i c h m i g h t be c h e a p e r f a c i l i t a t e q u i c k e r u p d a t i n g and  (8)  and  editing;  that the F o r m u l a r y s h o u l d be u p d a t e d at r e g u l a r i n t e r v a l s so that i t r e m a i n s a n a c c u r a t e , u p - t o date s o u r c e o f d r u g i n f o r m a t i o n to the u s e r s .  • S o m e o f the a b o v e r e c o m m e n d a t i o n s w e r e i m p l e m e n t e d i n the c u r r e n t r e v i s i o n o f the F o r m u l a r y .  O t h e r s h a v e b e e n i n v e s t i g a t e d i n the  p r e s e n t study f o r p o s s i b l e future adaptations. are  The  results in each area  c o n s i d e r e d a s f o l l o w s u n d e r the s u b - h e a d i n g s o f " N u m b e r o f D r u g  M o n o g r a p h s " , " F o r m a t o f D r u g M o n o g r a p h s " , " F o r m a t o f the F o r m u l a r y " a n d " E v a l u a t i o n a n d U p d a t i n g of the F o r m u l a r y " .  (b) N u m b e r o f D r u g M o n o g r a p h s  B e f o r e r e q u e s t i n g w h i c h a d d i t i o n a l d r u g m o n o g r a p h s m i g h t be n e e d e d b y the p r o v i n c i a l h o s p i t a l s , the n u m b e r o f d r u g m o n o g r a p h s i n c l u d e d i n the p r e s e n t D r u g F o r m u l a r y w a s  determined.  T h i s was  done to e n a b l e a  47  p r o j e c t i o n o f the p o s s i b l e s i z e o f the F o r m u l a r y i f a d d i t i o n a l d r u g m o n o graphs a r e r e q u i r e d . ing  Formulary  The  T h e t o t a l n u m b e r o f d r u g m o n o g r a p h s i n the e x i s t -  i s 306.  a l p h a b e t i c a l i n d e x o f the F o r m u l a r y ,  drugs and drug p r o d u c t s .  h o w e v e r , l i s t s 483  T h e d i s c r e p a n c y that e x i s t s i s due to the f a c t  that the l a t t e r n u m b e r i n c l u d e s the v a r i o u s s a l t s o f the g e n e r i c n a m e  drugs  as w e l l a s s o m e b r a n d n a m e s o f c o m b i n a t i o n p r o d u c t s w h i c h m a y be m o n o g r a p h e d i n the F o r m u l a r y u n d e r a s i n g l e g e n e r i c n a m e .  In r e c o g n i t i o n o f the f a c t that the p r e s e n t D r u g F o r m u l a r y t a i n s m o n o g r a p h s o f o n l y t h o s e d r u g s u s e d at o n e h o s p i t a l , a s u r v e y  conwas  c o n d u c t e d i n f o u r a d d i t i o n a l p r o v i n c i a l h o s p i t a l s o f v a r y i n g s i z e to d e t e r m i n e w h a t a d d i t i o n a l d r u g m o n o g r a p h s m i g h t be r e q u i r e d to s u p p l y c o m p r e h e n s i v e d r u g i n f o r m a t i o n i n the p r o v i n c e .  The hospitals included in  this s t u d y ( s e e M e t h o d o l o g y , p a g e 27) w e r e r e q u e s t e d to l i s t the d r u g s that they s t o c k w h i c h a r e not i n c l u d e d p r e s e n t l y i n the D r u g  Formulary  It w a s f e l t that b y c o r r e l a t i n g t h e s e l i s t s w i t h t h o s e s u b m i t t e d b y f i v e c h i e f p h a r m a c i s t s o n the c h i e f p h a r m a c i s t s q u e s t i o n n a i r e ( s e e M e t h o d o l o g y , p a g e 24), the f i n a l r e s u l t w o u l d r e f l e c t m o s t o f the d r u g m o n o g r a p h s n e e d e d b y the p r o v i n c i a l h o s p i t a l s .  O f a t o t a l o f 904 d r u g m o n o g r a p h s e v e n t u a l l y r e q u e s t e d i n a d d i t i o n to the e x i s t i n g m o n o g r a p h s , 592 r e c e i v e d one r e q u e s t , 204 w e r e r e q u e s t e d b y two h o s p i t a l s ,  71 w e r e r e q u e s t e d b y t h r e e h o s p i t a l s , 32 o t h e r s  48  were r e q u e s t e d b y four institutions and five drug m o n o g r a p h s were r e q u e s t e d b y f i v e h o s p i t a l s (see A p p e n d i x II).  In t e r m s o f p r i o r i t i e s f o r  n e w d r u g m o n o g r a p h s to b e p r o d u c e d i n the f u t u r e , i t i s r e c o m m e n d e d that t h o s e d r u g s w h i c h r e c e i v e d two o r m o r e r e q u e s t s s h o u l d be c o n s i dered firstly.  O n this b a s i s , a future p r o v i n c i a l D r u g F o r m u l a r y m i g h t  be e x p e c t e d to c o n t a i n i n e x c e s s o f 600 d r u g m o n o g r a p h s ; 306 e x i s t i n g m o n o g r a p h s , p l u s a p p r o x i m a t e l y 300 n e w m o n o g r a p h s r e q u e s t e d b y two or m o r e institutions.  (c)  F o r m a t o f the D r u g M o n o g r a p h s  A m o n g the m a n y w a y s i n w h i c h the f o r m a t o f the p r e s e n t d r u g m o n o g r a p h s w e r e r e c o m m e n d e d to b e c h a n g e d to o b t a i n a m o r e p r o v i n c i a l F o r m u l a r y , the i n c l u s i o n o f " M o d e o f A c t i o n " , a m b u l a t o r y u s e i n s t r u c t i o n s , b i b l i o g r a p h y r e f e r e n c e s a n d the C a n a d i a n D r u g I d e n t i f i c a t i o n C o d e w e r e s o m e w h i c h w e r e a d o p t e d d u r i n g the c u r r e n t F o r m u l a r y r e v i s i o n .  Figure  6 and F i g u r e  res-  7 p r e s e n t c o p i e s o f the m o n o g r a p h s o f E r y t h r o m y c i n ,  pectively, before  a n d a f t e r r e v i s i o n f e a t u r i n g the a b o v e a d d i t i o n s .  Mode of A c t i o n A l t h o u g h the e x i s t i n g m o n o g r a p h s h a v e a s e c t i o n f o r i n f o r m a t i o n o n the a c t i o n o f the d r u g , it i s o f t e n o n l y a s t a t e m e n t o f the t h e r a p e u t i c c l a s s i f i c a t i o n o f the d r u g (see F i g u r e 6 ) .  In v i e w o f the r e q u e s t that  the m o d e o f a c t i o n b e i n c l u d e d o n the m o n o g r a p h s , e a c h r e v i s e d m o n o g r a p h now c o n t a i n s i n f o r m a t i o n o n the m e c h a n i s m , a b s o r p t i o n ,  distribution.  49  Figure 6. Sample monograph of Erythromycin from the existing Drug Formulary before revision.  so ERYTHROMYCIN  ILOSONE ERYTHROCIN  8:12:12 ACTION: P r i m a r i l y b a c t e r i o s t a t i c a n t i b i o t i c . S p e c t r u m s i m i l a r to P e n i c i l l i n , i . e . , m a i n l y g r a m p o s i t i v e b a c t e r i a . E x c r e t e d m a i n l y i n b i l e . P e a k of A c t i o n : 2-4 h o u r s . D u r a t i o n 6 h o u r s . N o r m a l s e r u m h a l f - l i f e : 1.5 h o u r s . S e r u m h a l f - l i f e i n r e n a l f a i l u r e : 5 h o u r s . BACTERIAL SPECTRUM: S t a p h y l o c o c c i , B - h e m o l y t i c s t r e p t o c o c c i , C l o s t r i d i a , D. p n e u m o n i a e , H . p e r t u s s i s , * C . d i p h t h e r i a e , t r e p o n e m a , * M y c o p l a s m a p n e u m o n i a e ( E a t o n agent)., v i r u s e s c a u s i n g t r a c h o m a and l y m p h o g r a n u l o m a v e n e r e u m . ( ^ G e n e r a l l y c o n s i d e r e d a n t i b i o t i c of 1st c h o i c e . ) O t h e r p r i n c i p a l u s e i s a g a i n s t g r o u p A , b e t a - h e m o l y t i c s t r e p t o c o c c i and p n e u m o c o c c a l i n f e c t i o n s i n p a t i e n t s a l l e r g i c to P e n i c i l l i n . INDICATIONS: . B a c t e r i o s t a t i c against staphylocci, pneumococci, beta-hemolytic s t r e p t o c o c c i . t i s s u e , r e s p i r a t o r y and s k i n i n f e c t i o n s .  U s e d i n soft  CONTRAINDICATIONS: H y p e r s e n s i t i v i t y . E r y t h r o m y c i n e s t o l a t e (Ilosone) i s c o n t r a i n d i c a t e d i n c h o l e s t a t i c j a u n d i c e o r l i v e r d i s e a s e . K i d n e y d i s f u n c t i o n i s not a c o n t r a i n d i c a t i o n to use of E r y t h r o m y c i n . DOSAGE: O R A L : A D U L T S AND  . I. V . : A D U L T S :  C H I L D R E N o v e r 23 k g : 250 m g . e v e r y 6 h o u r s . S e v e r e i n f e c t i o n s : 500 m g . e v e r y 6 h o u r s . T a k e n 1-1-1/2 h o u r s p r i o r to o r a f t e r m e a l s . D o s a g e r a n g e 1-4 gm. d a i l y . C H I L D R E N 11. 5-23 k g : 125 m g . q.6.hl C H I L D R E N 4. 5-11. 5 k g : 11 m g . / k g . q.6.h.  R e s e r v e d f o r s e v e r e i n f e c t i o n s : 1-4  CHILDREN:  gm.  d a i l y i n d i v i d e d d o s e s q. 6.h.  1 2 - (24)- 48 mg./kg/24 h o u r s d i v i d e d q. 8. h . M a x i m u m s i n g l e d o s e : 0.5 gm. M a x i m u m d a i l y d o s e : 1.5 In r e n a l f a i l u r e ( c r e a t i n i n e c l e a r a n c e 10 m l . / m i n . o r l e s s ) : i n i t i a l dose f o l l o w e d by h a l f - d o s e s at i n t e r v a l s o f 8 h o u r s .  gm. Normal  SIDE E F F E C T S : N a u s e a , v o m i t i n g , d i a r r h e a , s k i n r a s h , j a u n d i c e , I.M. i n j e c t i o n of m o r e than 100 m g . s e v e r a and p e r s i s t e n t p a i n . I.V. i n f u s i o n of 1 gm. d o s e s f r e q u e n t l y c a u s e s p h l e b i t i s .  produces  DRUG INTERACTIONS: E r y t h r o m y c i n antagonizes action of P e n i c i l l i n s . NURSING IMPLICATIONS: O r a l s o l u t i o n s m u s t be r e f r i g e r a t e d , s t a b i l i t y v a r i e s w i t h p r o d u c t . I n j e c t i o n s t a b l e 14 d a y s u n d e r r e f r i g e r a t i o n . I.V. i n j e c t i o n m u s t be m i x e d w i t h w a t e r f o r i n j e c t i o n w i t h o u t p r e s e r v a t i v e o t h e r w i s e the d r u g p r e c i p i t a t e s . It i s a d v i s a b l e to g i v e o r a l p r e p a r a t i o n s b e t w e e n m e a l s u n l e s s g a s t r i c i r r i t a t i o n i s too s e v e r e . P e r i o d i c b l o o d c e l l counts a r e a d v i s a b l e . Liver f u n c t i o n t e s t s a r e a d v i s a b l e i n p r o l o n g e d t h e r a p y w i t h the e s t o l a t e s a l t . I.V. I N C O M P A T I B I L I T I E S : L o s s of a c t i v i t y i n s o l u t i o n i s r a p i d at a p H b e l o w 5. C o m p a t i b l e w i t h m o s t I.V. s o l u t i o n s but m a y be p r e c i p i t a t e d by a d d i t i o n of h i g h c o n c e n t r a t i o n s of i n o r g a n i c s a l t s . I n c o m p a t i b l e w i t h B c o m p l e x w i t h C, b a r b i t u r a t e s , h e p a r i n . T e t r a c y c l i n e , C e p o r a n , D i p h e n y l h y d a n t o i n (Dilantin). Chloramphenicol, Aminophyllin, Streptomycin. PRESENTATION: Capsules or Tablets: Suspension:  250 m g . 125mg./5cc.  Drops: Vial:  100 m g . / c c . 1 gm.  51  Figure 7. Sample monograph of Erythromycin including the bibliography after revision, showing the Canadian Drug Identification Code Active Ingredient Group Number in the top left-hand corner and the American Hospital Formulary Therapeutic Classification number in the top right-hand corner.  52 00431  ERYTHROCIN (STEARATE) ILOSONE (ESTOLATE) E - M Y C I N (BASE)  ERYTHROMYCIN AND ITS E S T E R S 8:14:12  ACTION: Bacteriostatic Antibiotic. M e c h a n i s m : P r i m a r i l y b a c t e r i o s t a t i c . I n h i b i t s p r o t e i n s y n t h e s i s at r i b o s o m a l l e v e l (1). Absorption: O r a l - readily, p r i m a r i l y f r o m upper part of s m a l l intestine. The base and s t e a r a t e s a l t a b s o r p t i o n d e c r e a s e s i f t a k e n w i t h f o o d b u t the e s t o l a t e s a l t i s u n a f f e c t e d ( 3 ) . H i g h l y p r o t e i n b o u n d , p e a k b l o o d l e v e l s i n about two h o u r s w i t h e s t o l a t e s a l t , i n a b o u t f o u r h o u r s w i t h s t e a r a t e salt o r w i t h base i n a c i d r e s i s t a n t coated tablets (3). B l o o d l e v e l s a r e at l e a s t t w i c e a s h i g h (1), m o r e p r e d i c t a b l e a n d m o r e p r o l o n g e d (3) w h e n a n e q u i v a l e n t d o s e of estolate given as c o m p a r e d with base o r s t e a r a t e . D i s t r i b u t i o n : A l l t i s s u e s e x c e p t b r a i n c o n t a i n h i g h e r c o n c e n t r a t i o n s than i n b l o o d (1); i n t o p e r i t o n e a l , p l e u r a l , a s c i t i c and a m n i o t i c f l u i d s ; into s a l i v a ; a c r o s s mucous m e m b r a n e o f the t r a c h e o - b r o n c h i a l t r e e ; i n t o p l a c e n t a l c i r c u l a t i o n ( 3 ) . P o o r l y i n t o s p i n a l f l u i d u n l e s s m e n i n g e s i n f l a m e d (3). M e t a b o l i s m : N o r m a l s e r u m h a l f - l i f e 1. 5 h o u r s . H a l f - l i f e i n r e n a l i m p a i r m e n t u p to f i v e h o u r s ( l 1). E x c r e t i o n : T h e d r u g i s c o n c e n t r a t e d i n the l i v e r a n d i s m a i n l y e x c r e t e d i n the a c t i v e f o r m i n the b i l e ( 1 ) . A l s o e x c r e t e d i n the u r i n e , f e c e s a n d m i l k ( 3 ) . SPECTRUM OF ACTIVITY: ' S i m i l a r to p e n i c i l l i n s , i . e . , m a i n l y G r a m p o s i t i v e b a c t e r i a . B a c t e r i o s t a t i c a g a i n s t S t a p h y l o c o c c i , B - h e m o l y t i c s t r e p t o c o c c i , C l o s t r i d i a , D. pneumoniae, H. p e r t u s s i s , *C. diphtheriae, t r e p o n e m a , ^ M y c o p l a s m a pneumoniae (Eaton agent), v i r u s e s causing t r a c h o m a and l y m p h o g r a n u l o m a v e n e r e u m . * - g e n e r a l l y c o n s i d e r e d antibiotic of 1st c h o i c e . No c r o s s r e s i s t a n c e with p e n i c i l l i n . C r o s s resistance with c a r b o m y c i n , oleandomycin and s p i r a m y c i n . Staphyloc o c c i s t r a i n s develop r e s i s t a n c e f a i r l y r a p i d l y (3). INDICATIONS: ' P r i n c i p a l use i s i n group A beta-hemolytic streptococcal and pneumococcal infections i n p a t i e n t s who a r e a l l e r g i c to p e n i c i l l i n ( 2 ) . P r o p h y l a c t i c a l l y - f o r p r e v e n t i o n o f b a c t e r i a l e n d o c a r d i t i s p r i o r to d e n t a l o r o t h e r o p e r a t i v e p r o c e d u r e s o n p a t i e n t s w i t h a h i s t o r y o f r h e u m a t i c r e f e v e r o r congenital heart disease (2). U s e d i n soft t i s s u e , r e s p i r a t o r y i n f e c t i o n s . CONTRAINDICATIONS: H y p e r s e n s i t i v i t y . Estolate salt i s contraindicated i n cholestatic jaundice o r l i v e r disease, and i n c h r o n i c d i s o r d e r s ( e . g . , a c n e a n d f u r u n c u l o s i s ) ( 3 ) . K i d n e y d y s f u n c t i o n i s not a c o n t r a i n d i c a t i o n to u s e ( 1 ) . CAUTIONS: P a t i e n t s w i t h p r e - e x i s t i n g l i v e r d y s f u n c t i o n (4). DOSAGE: O r a l : A d u l t s a n d c h i l d r e n o v e r 23 K g . 250 m g e v e r y 6 h o u r s . S e v e r e i n f e c t i o n - 500 m g e v e r y 6 h o u r s . T a k e n 1 h o u r p r i o r to o r 2 h o u r s a f t e r m e a l s . D o s a g e r a n g e 1-4 G m d a i l y . C h i l d r e n : 11. 5 to 23 K g : 125 m g q. 6. h.; 4. 5 to 1 1 . 5 K g : 11 m g / K g q . 6 . h . I V . : R e s e r v e d f o r s e v e r e i n f e c t i o n s . A d u l t s : 1-4 G m d a i l y i n d i v i d e d d o s e s q. 6.h. Maximum s i n g l e d o s e : 0.5 G m . M a x i m u m d a i l y d o s a g e : 1,5 G m . In r e n a l f a i l u r e ( c r e a t i n i n e c l e a r a n c e 10 m l / m i n o r l e s s ) : N o r m a l i n i t i a l d o s e f o l l o w e d by h a l f d o s e a t i n t e r v a l s o f 8 h o u r s . SIDE E F F E C T S : R a r e l y s e r i o u s a d v e r s e r e a c t i o n s (5), i n f r e q u e n t l y n a u s e a , v o m i t i n g , d i a r r h o e a , s k i n r a s h , j a u n d i c e (only w i t h e s t o l a t e s a l t a n d e x t e n d e d t h e r a p y ( 3 , 8 ) ) . I . M . i n j e c t i o n o f m o r e than 100 m g m produces s e v e r e and p e r s i s t e n t p a i n . I.V. infusion o f l G m doses f r e q u e n t l y causes phlebitis.  53 00431  - 2 -  ERYTHROMYCIN  INTERACTIONS: E r y t h r o m y c i n antagonizes action of penicillin (12). Antibacterial effect in the urine appears to be enhanced by agents which alkalinize the urine - e.g., acetazolamide, sodium bicarbonate ( 6 , 7 ) . The drug should not be administered p r i o r to fruit juice o r other acid drink - activity of drug greatly decreases in acid solution ( 3 ) . I.V. I N C O M P A T I B I L I T I E S : E r y t h r o m y c i n is extremely pH dependent - most stable above pH 6-8. L o s s of activity in solution is rapid at a pH below 5 - avoid concurrent use of additives which will result in an admixture pH below 5 (9). Compatible with most I.V. solutions but may be precipitated by addition of high concentrations of inorganic salts. Incompatible with: Vitamin B complex with C, barbiturates, heparin, tetracycline, cephaloridine, diphenylhydantoin, chloramphenicol, aminophyllin, streptomycin, ascorbic acid, dextrose in lactated Ringer's injection (10). NURSING I M P L I C A T I O N S : O r a l solutions must be refrigerated, store in a cool place, protected f r o m light (4); stability v a r i e s . Injection stable 7 days under refrigeration (4). I.V. injection must be mixed with water for injection without preservatives, otherwise the drug precipitates. I. M . injections i r r i t a t i n g and too painful and should not exceed 100 mg. It is advisable to give o r a l preparations between meals unless gastric irritation is too severe. Antacid may be given for gastric i r r i t a t i o n . P e r i o d i c blood counts are advisable in prolonged therapy with the estolate salt. Venous irritation and thrombosis may occur if I.V. solution extravasates - watch site of infusion, stop flow before removing needle (4). Observe for symptoms of overgrowth of nonsus- . ceptible organisms (black furry tongue, enteritis) during prolonged therapy (4). The commercial I . M . product is not m i s c i b l e with water, so only a d r y syringe and needle should be used (2). INSTRUCTIONS T O P A T I E N T : Take one tablet one hour before meals (or two hours after) and at bedtime - 4 a day. Take antacid i f stomach gets upset after taking medication. Don't drink fruit juice or any acid drink with or after taking tablet. Store medication in a cool place, protected f r o m light. PRESENTATION:  ^ Capsules or Tablets Suspension Drops Vial  Date P r e p a r e d :  March, 1973  250 125 100 1  mgm mgm/5 cc mgm/cc Gm  54 00431  Erythromycin  REFERENCES: 1.  2.  G o o d m a n , L . a n d G i l m a n , A.:  The  p e u t i c s , 4th e d i t i o n .  1274-7.  C o m p e n d i u m o f P h a r m a c e u t i c a l s a n d S p e c i a l t i e s , 6th e d i t i o n . 1972 .  3.  (1970) p.  Canada,  Canadian P h a r m a c e u t i c a l A s s o c i a t i o n , Inc.  American  Hospital F o r m u l a r y Service.  P h a r m a c i s t s , Washington, D.C. 4.  P h a r m a c o l o g i c a l B a s i s of T h e r a -  American  Society of H o s p i t a l  (1971).  Govoni, L . E . and H a y e s , J . : D r u g s and N u r s i n g I m p l i c a t i o n s , edition,  p.  2nd  128.  5.  AMA  D r u g E v a l u a t i o n s , 1 st e d i t i o n (1971).  6.  Savath, L.D.,  p.  402.  et a l . : E x c r e t i o n o f e r y t h r o m y c i n a n d i t s e n h a n c e d  activity i n urine against g r a m negative b a c i l l i with alkalinization.  J.  Lab. Clin. Med.  ~  72:916 (1968).  7.  Z i n n e r , S.H., et a l . : E r y t h r o m y c i n a n d a l k a l i n i z a t i o n i n t h e r a p y o f b a c t e r i u r i a . A n t i m i c r o b . A g e n t s C h e m o t h e r . 9th c o n f . (1969) 36 A b s t . 85, 1969.  8.  FDA  R e p o r t s o f s u s p e c t e d a d v e r s e r e a c t i o n s to d r u g s , 1967,  No.  671103-002-00501. 9. 10.  Anon., Compatibility Digest, A m e r . J . Hosp. P h a r m . 26:410, Intravenous Additive Incompatibilities. . Health, Education, Welfare.  J a n u a r y (1970).  U.S.  1969.  Dept.  11.  F r a n c k e , D . E . and Whitney, H. A . K. : P e r s p e c t i v e s i n C l i n i c a l P h a r m a c y . D r u g I n t e l l i g e n c e P u b l i c a t i o n s , H a m i l t o n , I l l i n o i s (1972).  12.  Jawetz, E . : The use of a n t i m i c r o b i a l d r u g s . 8:151 (1968).  Date P r e p a r e d :  March,  1973  Ann.  Rev.  Pharmacol.  55  m e t a b o l i s m and  e x c r e t i o n of the d r u g w h e r e a p p l i c a b l e ( s e e F i g u r e  7).  As  w e l l as a d d i n g the a b o v e i n f o r m a t i o n to the m o n o g r a p h s , the r e v i s e d m o n o g r a p h s now  also include m o r e extensive  i n f o r m a t i o n i n e a c h o f the o t h e r  s e c t i o n s of the m o n o g r a p h on " I n d i c a t i o n s " , " S i d e E f f e c t s " , c a t i o n s " and  Contraindi-  "Intravenous I n c o m p a t i b i l i t i e s " . Such additional information  c o n t a i n e d i n the d r u g m o n o g r a p h s s h o u l d b e t t e r m e e t the n e e d s o f m o s t u s e r s i n the f u t u r e .  Ambulatory Use  Instructions  S i n c e the D r u g F o r m u l a r y i s i n u s e the p r o v i n c e ,  and  i n h o s p i t a l s i n a l l p a r t s of  since s o m e of these h o s p i t a l s a r e a c t i v e i n m a n y s e r v i c e s  i n c l u d i n g o u t p a t i e n t c l i n i c s , it was  d e t e r m i n e d that a s e c t i o n s h o u l d be  a d d e d to t h i s y e a r ' s r e v i s e d m o n o g r a p h s on " I n s t r u c t i o n s to the (see F i g u r e  7).  T h i s s e c t i o n a l s o i s e x p e c t e d to be o f u s e  within  Patient" the  h o s p i t a l s e t t i n g i t s e l f to a s s i s t i n the i n s t r u c t i o n o f p a t i e n t s r e c e i v i n g d i s charge medications.  The  addition of this s e c t i o n may  further prove useful  i f a n A m b u l a t o r y D r u g F o r m u l a r y i s p r o d u c e d at s o m e f u t u r e date f o r in Community Health C e n t r e s .  In a n A m b u l a t o r y F o r m u l a r y the s e c t i o n on  " I n s t r u c t i o n s to the P a t i e n t " c o u l d be u s e d i n p l a c e o f the s e c t i o n s on travenous I n c o m p a t i b i l i t i e s " and  use  "In-  " N u r s i n g I m p l i c a t i o n s " w h i c h at p r e s e n t  d e a l p r i m a r i l y w i t h i n f o r m a t i o n r e q u i r e d i n the h o s p i t a l s e t t i n g .  R e f e r e n c e s and  Bibliography  F r o m p r e v i o u s e x p e r i e n c e w i t h the A m e r i c a n H o s p i t a l F o r m u -  56  l a r y S e r v i c e ( A . H . F . S . ) a n d o t h e r r e f e r e n c e s o u r c e s s u c h as  standard  textbooks, difficulty is experienced frequently in conducting additional i n f o r m a t i o n s e a r c h e s on the p r e s e n t e d i n f o r m a t i o n b e c a u s e t h e s e s o u r c e s c o n t a i n no i n d i c a t i o n o f w h e r e the o r i g i n a l i n f o r m a t i o n w a s  found.  Although it is  p o s s i b l e to o b t a i n the r e f e r e n c e s to the A . H . F . S . b y w r i t i n g to the A m e r i c a n S o c i e t y o f H o s p i t a l P h a r m a c i s t s , e x p e r i e n c e d i c t a t e s that t h i s s y s t e m i s too a w k w a r d and t i m e c o n s u m i n g f o r efficient u t i l i z a t i o n . was  F o r these r e a s o n s , it  d e c i d e d to r e f e r e n c e the c o n t e n t s o f the d r u g m o n o g r a p h s a n d to p r o v i d e  a c o m p l e t e b i b l i o g r a p h y f o r e a c h m o n o g r a p h i n the D r u g F o r m u l a r y F i g u r e 7).  The  (see  p r e s e n c e o f the. r e f e r e n c e s a n d b i b l i o g r a p h y i s e x p e c t e d to  e n a b l e the u s e r to f u r t h e r r e s e a r c h i n f o r m a t i o n and to i d e n t i f y the i n f o r m a tion s o u r c e  quickly.  Canadian D r u g Identification Code The  H e a l t h P r o t e c t i o n B r a n c h o f the C a n a d i a n g o v e r n m e n t h a s  r e c e n t l y p u b l i s h e d the C a n a d i a n D r u g I d e n t i f i c a t i o n C o d e .  The  publication  c o n t a i n s f o u r s e c t i o n s o f d i f f e r e n t c o d e s - the S e q u e n t i a l I d e n t i f i e r ; a n a l p h a b e t i c a l l i s t i n g b y T r a d e n a m e s ; the M a n u f a c t u r e r s ' A s s i g n e d C o d e  and  the A c t i v e I n g r e d i e n t G r o u p N u m b e r .  A f t e r r e v i e w i n g the a b o v e f o u r c o d e s , i t was  d e c i d e d to a d o p t the  A c t i v e I n g r e d i e n t G r o u p N u m b e r f o r i n c l u s i o n i n the d r u g m o n o g r a p h s b e c a u s e it a p p e a r e d to be the m o s t u s e f u l c o d e w i t h o u t l i m i t i n g i d e n t i f i c a t i o n to o n l y one m a n u f a c t u r e r ' s  p r o d u c t ( s e e F i g u r e 7,  top l e f t ) .  It was  f e l t that as w e l l  57  a s h a v i n g the C a n a d i a n D r u g I d e n t i f i c a t i o n C o d e A c t i v e I n g r e d i e n t G r o u p Number  h o w e v e r , the A m e r i c a n H o s p i t a l F o r m u l a r y S e r v i c e ( A . H . F . S . )  T h e r a p e u t i c C l a s s i f i c a t i o n n u m b e r (8:12:12) s h o u l d be r e t a i n e d on the m o n o g r a p h ( s e e F i g u r e 7, top r i g h t ) as a c o r r e l a t i o n to the A . H . F . S . f o r t h o s e h o s p i t a l s w h i c h w i s h to f i l e the m o n o g r a p h s b y the A . H .  and  F.S.  Therapeutic Classifications.  (d) F o r m a t o f the F o r m u l a r y  T h e m a j o r c r i t i c i s m o f the p r e s e n t D r u g F o r m u l a r y f o r m a t a s d e t e r m i n e d f r o m the c h i e f p h a r m a c i s t s q u e s t i o n n a i r e , f r o m the m e m b e r s o f the F a c u l t y o f P h a r m a c e u t i c a l S c i e n c e s who  w e r e i n v o l v e d w i t h the c u r r e n t  r e v i s i o n s a n d f r o m the c o m m e n t s o f the F o r m u l a r y u s e r s , i s that i t i s too bulky.  The  F o r m u l a r y , i f e x p a n d e d i n i t s p r e s e n t f o r m a t to a p p r o x i m a t e l y  600 m o n o g r a p h s a s a n t i c i p a t e d ( s e e p a g e  48) w o u l d be f u r t h e r r e d u c e d i n  u s e f u l n e s s , p a r t i c u l a r l y o n the n u r s i n g s t a t i o n w h e r e l i m i t e d t i m e a n d  space  i s a v a i l a b l e . . It w o u l d a p p e a r that the l a r g e r the r e f e r e n c e b o o k , the l e s s i t i s l i k e l y to be  used.  Monograph Utilization Survey In a n a t t e m p t to r e d u c e the b u l k a n d to i n c r e a s e the u s e f u l n e s s o f the D r u g F o r m u l a r y , a s u r v e y was  c o n d u c t e d to d e t e r m i n e the f r e q u e n c y  of u s e o f the 483 d r u g s a n d d r u g p r o d u c t s l i s t e d i n the F o r m u l a r y a l p h a b e t i c a l i n d e x (see p a g e s  31-35).  T h i s a p p r o a c h s h o u l d r e f l e c t the f r e q u e n c y  58  o f m o n o g r a p h r e q u i r e m e n t s i n s p e c i a l t y a r e a s w i t h i n the h o s p i t a l s a c c o r d i n g l y , the m i n i m u m n u m b e r ^ r e q u i r e d i n e a c h / .  The  survey  conducted i n five B r i t i s h C o l u m b i a hospitals (see Methodology, The  and  page  s t u d y r e q u e s t e d i n f o r m a t i o n o n the f r e q u e n c y o f u s e o f the d r u g s  was 31 ). and  t h e r e f o r e d r u g m o n o g r a p h s i n the f o l l o w i n g f o u r s p e c i a l i z e d c a r e a r e a s : P e d i a t r i c s , E m e r g e n c y , P s y c h i a t r y and E x t e n d e d C a r e . e v a l u a t e d at the f i v e h o s p i t a l s was  The  information  c o m p i l e d into the f o l l o w i n g t a b l e s u n d e r  the h e a d i n g s o f " F r e q u e n t l y " , " O c c a s i o n a l l y " a n d " R a r e l y " u s e d d r u g s . It was  a s s u m e d that s h o u l d s o m e f o r m a t o f the D r u g F o r m u l a r y e v e n t u a l l y  be d e s i g n e d f o r s p e c i f i c w a r d a r e a s , o n l y t h o s e d r u g s i d e n t i f i e d a s " F r e q u e n t l y " a n d / o r " O c c a s i o n a l l y " u s e d m i g h t be i n c l u d e d f o r u s e i n t h o s e areas.  T h e a n t i c i p a t e d a d v a n t a g e o f s u c h a s y s t e m w o u l d be to r e d u c e the  b u l k o f the F o r m u l a r y w h i l e s u p p l y i n g the r e q u i r e d d r u g i n f o r m a t i o n o n the d r u g s m o s t f r e q u e n t l y u s e d i n the w a r d a r e a .  In the a r e a o f P e d i a t r i c s , f i v e h o s p i t a l s r e p l i e d w h e r e a s i n E x t e n d e d C a r e a n d P s y c h i a t r y o n l y t h r e e h o s p i t a l s s u p p l i e d the n e c e s s a r y i n f o r m a t i o n b e c a u s e the o t h e r two h o s p i t a l s do not h a v e f a c i l i t i e s f o r t h e s e services.  In r e g a r d to E m e r g e n c y c a r e , one i n s t i t u t i o n , t h e R o y a l J u b i l e e  H o s p i t a l , was  u n a b l e to s u p p l y c o m p l e t e i n f o r m a t i o n o n d r u g u s a g e a n d  t h e r e f o r e was  not i n c l u d e d i n the r e s u l t s .  T a b l e III s h o w s the f r e q u e n c y o f u s e o f the 483 d r u g s l i s t e d i n the F o r m u l a r y a l p h a b e t i c a l index on P e d i a t r i c w a r d s .  T h e n u m b e r of drugs  59  " F r e q u e n t l y " u s e d r a n g e d f r o m 63 at L i o n s G a t e H o s p i t a l to 111 at the Vancouver  General Hospital.  T h e difference i n these figures m a y b e  b u t a b l e to the l a r g e t e a c h i n g a t m o s p h e r e  o f the l a t t e r h o s p i t a l .  attri-  The average  n u m b e r o f " F r e q u e n t l y " u s e d d r u g s i n the f i v e h o s p i t a l s w a s 86 o r a p p r o x i m a t e l y 18 p e r c e n t o f the t o t a l n u m b e r o f d r u g s l i s t e d .  T h i s w o u l d s e e m to  i n d i c a t e that a F o r m u l a r y o f 600 m o n o g r a p h s w o u l d n o t o n l y b e c u m b e r s o m e but o f l i t t l e v a l u e f o r u s e o n P e d i a t r i c w a r d s .  T a b l e I V s h o w s s i m i l a r r e s u l t s f o r f o u r h o s p i t a l s o n the s t u d y o f E m e r g e n c y W a r d drug use.  L i o n s G a t e H o s p i t a l a g a i n h a d the l o w e s t n u m b e r  o f " F r e q u e n t l y " u s e d d r u g s at 68 w h i l e S t . P a u l ' s H o s p i t a l i n d i c a t e d that 178 drugs were "Frequently" used.  T h e r e a s o n f o r this d i f f e r e n c e was  difficult  to d e t e r m i n e b u t m a y h a v e b e e n due to the u r b a n , c e n t r a l s e t t i n g o f the l a t t e r hospital which might r e q u i r e a m o r e d i v e r s e pattern of e m e r g e n c y c a r e .  In  E m e r g e n c y W a r d s the a v e r a g e n u m b e r o f '".Frequently" u s e d d r u g s i n the f o u r h o s p i t a l s w a s 122 o r a p p r o x i m a t e l y 25 p e r c e n t o f the t o t a l n u m b e r o f d r u g s l i s t e d i n the c u r r e n t F o r m u l a r y a l p h a b e t i c a l i n d e x .  A g a i n , the l i m i t e d  n u m b e r o f m o n o g r a p h s a p p a r e n t l y u s e d i n t h i s a r e a f u r t h e r s u p p o r t s the a p p a r e n t n e e d l e s s n e s s o f the c o m p l e t e D r u g F o r m u l a r y i n a n y s p e c i a l t y a r e a .  In E x t e n d e d C a r e ( T a b l e V ) , V a n c o u v e r G e n e r a l H o s p i t a l r e c o r d e d the l o w e s t n u m b e r o f " F r e q u e n t l y " u s e d d r u g s at 4 3 , a n d L i o n s G a t e H o s p i t a l h a d the h i g h e s t n u m b e r at 106.  It i s thought that the V a n c o u v e r  General  H o s p i t a l h a d the l o w e s t n u m b e r i n t h i s c a t e g o r y b e c a u s e t h e y h a d j u s t o p e n e d  60  T A B L E III  FREQUENCY  O F USE O F PROVINCIAL F O R M U L A R Y  DRUGS (483) IN PEDIATRIC WARDS O F VARIOUS HOSPITALS FREQUENTLY Hospital  Number (%)  1  OCCASIONALLY  4  Number (%)  4  111 (23)  2  RARELY  3  Number (%)  Vancouver General  93 (19)  St. Paul's  75 (16)  88 (18)  320 (66)  Lions Gate  63 (13)  40 (8)  387 (79)  111 (23)  134 (27)  238 (50)  86 (18)  103 (21)  294 (61)  86 (18)  93 (20)  304 (62)  Victoria General Royal Jubilee 5 Average  1. Drugs used daily. 2. Drugs used once or twice a month. 3. Drugs used once or twice a year or never. 4. To nearest percentage point, of total 483 drugs. 5. Averaged to nearest whole number and percentage point.  279 (58)  4  61  T A B L E IV  FREQUENCY  O F USE O F PROVINCIAL F O R M U L A R Y  DRUGS (483) IN E M E R G E N C Y WARDS OF VARIOUS HOSPITALS  FREQUENTLY Hospital  Number (%)  4  1  OCCASIONALLY Number (%)  4  2  RARELY  3  Number (%  St. Paul's  178 (37)  53 (11)  252 (52)  Vancouver General  137 (28)  112 (23)  234 (49)  68 (14)  65 (13)  350 (73)  Lions Gate Victoria General  103 (21)  Average^  122 (25)  125 (26)  255 (53)  89 (18)  272 (57)  1. Drugs used daily. 2. Drugs used once or twice a month. 3. Drugs used once or twice a year or never. 4. To nearest percentage point, of total 483 drugs. 5. Averaged to nearest whole number and percentage point.  4  62  t h e i r new f a c i l i t y a n d t h e r e f o r e m e d i c a t i o n r e q u i r e m e n t s w e r e quite l o w . T h e a v e r a g e n u m b e r o f " F r e q u e n t l y " u s e d d r u g s f o r the t h r e e h o s p i t a l s w i t h E x t e n d e d C a r e f a c i l i t i e s w a s 83 o r a p p r o x i m a t e l y 17 p e r c e n t o f the 483 drugs.  S h o u l d a f u t u r e D r u g F o r m u l a r y c o n t a i n a s m a n y a s 600 m o n o g r a p h s ,  some m e c h a n i s m f o r separating those m o n o g r a p h s " F r e q u e n t l y " u s e d i n s p e c i a l t y a r e a s , s u c h as E x t e n d e d C a r e , s h o u l d be d e s i g n e d f o r e a s e o f u s e .  In the f i e l d o f P s y c h i a t r y ( T a b l e V I ) , L i o n s G a t e H o s p i t a l a n d the Vancouver  G e n e r a l H o s p i t a l h a d s i m i l a r d r u g u s e n e e d s w i t h 50 a n d 53  drugs "Frequently" used respectively. 193 d r u g s " F r e q u e n t l y " u s e d .  The R o y a l Jubilee Hospital listed  T h e l a r g e d i f f e r e n c e s e e n h e r e m a y be due  to the f a c t that the R o y a l J u b i l e e H o s p i t a l o p e r a t e s a v e r y l a r g e P s y c h i a t r i c f a c i l i t y w h i l e b o t h L i o n s G a t e H o s p i t a l a n d the V a n c o u v e r operate considerably s m a l l e r units.  General Hospital  The average number of "Frequently"  u s e d d r u g s f o r the t h r e e h o s p i t a l s w a s 98 o r a p p r o x i m a t e l y 20 p e r c e n t o f the n u m b e r o f d r u g s l i s t e d i n the a l p h a b e t i c a l i n d e x o f the p r e s e n t D r u g mulary.  For-  A g a i n , the c o m p l e t e D r u g F o r m u l a r y o n p s y c h i a t r i c w a r d s w o u l d  a p p e a r to p r o v e u n n e c e s s a r y a n d a w k w a r d a s d e m o n s t r a t e d t h r o u g h o u t T a b l e s III to V I .  T h e m a j o r c r i t i c i s m o f the p r e s e n t F o r m u l a r y i s that i t i s too b u l k y f o r c o n v e n i e n t u s e at the w a r d l e v e l .  A t t e m p t s to m a k e the F o r m u l a r y  m o r e p r o v i n c i a l i n n a t u r e ( s e e p a g e 46 ) s u g g e s t that t h i s p r o b l e m m a y b e i n c r e a s e d w i t h the a d d i t i o n o f a p p r o x i m a t e l y 300 a d d i t i o n a l m o n o g r a p h s i n the  future.  T h e d a t a p r e s e n t e d i n T a b l e s III to V I , h o w e v e r , r e v e a l that  63  TABLE V  F R E Q U E N C Y O F USE O F PROVINCIAL F O R M U L A R Y DRUGS (483) IN E X T E N D E D C A R E WARDS O F VARIOUS HOSPITALS  FREQUENTLY Hospital Vancouver General  Number (%)  4  1  OCCASIONALLY Number (%)  4  2  RARELY  3  Number (%)  43 (9)  73 (15)  367 (76)  Lions Gate  106 (22)  67 (14)  310 (64)  Victoria General  100 (20)  120 (25)  463 (55)  83 (17)  86 (18)  314 (65)  Average^  1. Drugs used daily. 2. Drugs used once or twice a month. 3. Drugs used once or twice a year or never. 4. To nearest percentage point, of total 483 drugs. 5. Averaged to nearest whole number and percentage point.  4  64  T A B L E VI  F R E Q U E N C Y O F USE O F PROVINCIAL F O R M U L A R Y DRUGS (483) IN PSYCHIATRIC WARDS OF VARIOUS HOSPITALS  FREQUENTLY Hospital  Number (%)  4  1  OCCASIONALLY Number (%)  4  2  RARELY  3  Number (%)  Vancouver General  53 (11)  116 (24)  314 (65)  Lions Gate  50 (10)  49 (10)  384 (80)  91 (19)  199 (41)  85 (18)  300 (62)  Royal Jubilee 5 Average  193 (40)  98 (20)  1. Drugs used daily. 2. Drugs used once or twice a month. 3. Drugs used once or twice a year or never. 4. To nearest percentage point, of total 483 drugs. 5. Averaged to nearest whole number and percentage point.  4  65  c o n s i d e r a b l y f e w e r d r u g s t h a n t h o s e that m i g h t a p p e a r i n a f u t u r e F o r m u l a r y a r e u s e d w i t h a n y d e g r e e o f f r e q u e n c y i n any g i v e n s p e c i a l t y w a r d . w o u l d s u g g e s t that t h e r e i s no n e e d f o r the b u l k o f the c o m p l e t e in these a r e a s . areas may  This  Formulary  It a l s o s u g g e s t s that " S p e c i a l t y F o r m u l a r i e s " f o r s p e c i a l t y  f u n c t i o n w e l l i n r e l a t i o n to a " M a s t e r F o r m u l a r y " f o r the e n t i r e  hospital.  Master-"Mini" The  Formulary p r e v i o u s r e s u l t s p r o j e c t that e a c h h o s p i t a l m i g h t h a v e a  M a s t e r F o r m u l a r y of a l l p r o v i n c i a l d r u g m o n o g r a p h s as w e l l as " M i n i " Formularies  d e s i g n e d f o r and c o n t a i n i n g m o n o g r a p h s for o n l y those  "Frequently" used in specialty ward areas.  T h e s e two  drugs  types of F o r m u l a r i e s  w i t h i n a h o s p i t a l w o u l d be f u r t h e r d i f f e r e n t i a t e d a c c o r d i n g to the i n d i v i d u a l m o n o g r a p h content.  F o r e x a m p l e (see F i g u r e 7, p a g e  5 1 ) , the M a s t e r  F o r m u l a r y w o u l d c o n t a i n the c o m p l e t e m o n o g r a p h p l u s the b i b l i o g r a p h y w h e r e a s the " M i n i " F o r m u l a r y i n u s e on the w a r d w o u l d not be  encumbered  b y the b i b l i o g r a p h y .  A n o t h e r f e a t u r e that m i g h t be i n c l u d e d i n a f u t u r e M a s t e r (but not " M i n i " ) F o r m u l a r y i s a c r o s s - i n d e x .  In r e c o g n i t i o n of the l a r g e n u m b e r  of different m a n u f a c t u r e r s and b r a n d n a m e s for e a c h g e n e r i c n a m e drug or drug product,  i t i s s u g g e s t e d that a c o m p l e t e c r o s s - i n d e x o f b r a n d to g e n e r i c  n a m e s be p r o d u c e d .  In t h i s i n d e x i t i s s u g g e s t e d a l s o that the C a n a d i a n D r u g  I d e n t i f i c a t i o n C o d e A c t i v e I n g r e d i e n t G r o u p N u m b e r s h o w n on the  present  r e v i s e d m o n o g r a p h s be i n c l u d e d to f a c i l i t a t e the u s e o f n a t i o n a l e l e c t r o n i c  66  data p r o c e s s i n g indexing and stock c o n t r o l s y s t e m s when these a r e i n t r o d u c e d into the h o s p i t a l s at s o m e f u t u r e d a t e .  It i s r e c o m m e n d e d f u r t h e r  that t h i s c r o s s - i n d e x b e p r o d u c e d a s s o o n a s p o s s i b l e a n d u p d a t e d a s b r a n d n a m e d r u g s a r e i n t r o d u c e d a n d a s new i n c l u s i o n i n the D r u g  new  monographs are produced for  Formulary.  A s c a n b e d e d u c e d f r o m the i n c r e a s e d a m o u n t o f i n f o r m a t i o n p r o p o s e d f o r a d d i t i o n to the F o r m u l a r y a s w e l l a s a c o m p l e t e b i b l i o g r a p h y f o r e a c h m o n o g r a p h a n d a c r o s s - i n d e x , the M a s t e r D r u g F o r m u l a r y c o u l d become a massive volume.  T h e v a l u e of s u c h a v o l u m e f o r r e s o u r c e i n f o r -  m a t i o n and r e s e a r c h , h o w e v e r , b e c o m e s a p p a r e n t .  O n the o t h e r h a n d , i t  b e c o m e s a p p a r e n t a l s o that the M a s t e r F o r m u l a r y a s d e s c r i b e d h e r e w o u l d not b e e f f e c t i v e l y u s e d at the w a r d l e v e l due to i t s b u l k .  F r o m t h i s s t u d y t h e r e a p p e a r to be f o u r w a y s to r e d u c e the b u l k i n e s s o f the D r u g F o r m u l a r y o n the w a r d b y u s i n g a " M a s t e r " - " M i n i " F o r mulary arrangement.  F i r s t l y , b y r e m o v i n g the b i b l i o g r a p h y f r o m the " M i n i "  F o r m u l a r i e s l o c a t e d at the w a r d l e v e l the b u l k s h o u l d be d e c r e a s e d b y t h i r d to o n e - h a l f .  one-  In t h i s r e s p e c t , i t i s p r o p o s e d that the m o n o g r a p h s w i t h  the r e f e r e n c e n u m b e r s be k e p t o n the w a r d w h i l e the b i b l i o g r a p h i e s be m a i n t a i n e d i n the M a s t e r F o r m u l a r y i n the C e n t r a l P h a r m a c y o r D r u g I n f o r m a tion C e n t r e .  T h i s w o u l d e n a b l e the r e d u c t i o n o f the D r u g F o r m u l a r y o n the  w a r d w h i l e s t i l l a l l o w i n g the u s e r s a c c e s s to the b i b l i o g r a p h i e s w h e n n e c e s s a r y b y c o n t a c t i n g the p h a r m a c y .  67  A  s e c o n d a p p r o a c h to r e d u c i n g t h e . b u l k o f the F o r m u l a r y w o u l d  be to p r o d u c e " M i n i " F o r m u l a r i e s f o r e a c h s p e c i f i c w a r d , i n c l u d i n g o n l y those drugs which a r e " F r e q u e n t l y " u s e d i n each a r e a .  U n f o r t u n a t e l y , this  s o l u t i o n i f u n d e r t a k e n b y the p r o d u c e r s o f the D r u g F o r m u l a r y w o u l d p r o b a b l y be too c o s t l y to b e c o m e f e a s i b l e . was  If a s p e c i f i c " M i n i "  Formulary  to b e p r o d u c e d f o r e a c h w a r d o f e a c h h o s p i t a l o f the p r o v i n c e (100  p r o v i n c i a l h o s p i t a l s w i t h an a v e r a g e o f 8 to 10 w a r d s each) t h e r e c o u l d be f r o m 800 to 1000  s p e c i f i c f o r m u l a r i e s to c o l l a t e s e p a r a t e l y .  g r e a t l y i n c r e a s e the p e r s o n n e l r e q u i r e d to p r o d u c e the D r u g  This would Formulary  a n d i n c r e a s e the c o s t s p o s s i b l y b e y o n d the p r e s e n t c o s t s .  A t h i r d a p p r o a c h to p r o d u c i n g  a " M i n i " F o r m u l a r y could o v e r -  c o m e t h i s p r o b l e m b y h a v i n g the p h a r m a c i s t s o f e a c h h o s p i t a l c o n d u c t s u r v e y s s i m i l a r to the M o n o g r a p h U t i l i z a t i o n S u r v e y ( s e e p a g e s  31-34) o n the  w a r d s o f t h e i r h o s p i t a l to d e t e r m i n e t h o s e d r u g s m o s t f r e q u e n t l y u s e d i n each patient c a r e a r e a .  O n c e t h i s h a s b e e n d e t e r m i n e d , i t i s s u g g e s t e d that  the m o n o g r a p h s f o r t h e s e d r u g s (without the b i b l i o g r a p h y ) c o u l d be  removed  f r o m a c o m p l e t e F o r m u l a r y a n d be p l a c e d i n c l e a r p l a s t i c e n v e l o p e s a n d i n s e r t e d i n a t h r e e - r i n g b i n d e r w h i c h c o u l d be p e r m a n e n t l y a f f i x e d to e i t h e r a c o u n t e r o r w a l l at the l o c a t i o n o f g r e a t e s t u s e .  In t h i s m a n n e r , the m o n o -  g r a p h s w o u l d be a v a i l a b l e to the u s e r s but c o u l d not be r e m o v e d f r o m the p l a c e o f u s e , r e s u l t i n g i n l e s s p o s s i b i l i t y o f the m o n o g r a p h s b e i n g l o s t . r e m a i n i n g m o n o g r a p h s c o u l d be m a i n t a i n e d i n the o r i g i n a l b i n d e r a n d o n the n u r s i n g s t a t i o n i n a d r a w e r o r c u p b o a r d .  The  stored  These monographs should  be k e p t o n the n u r s i n g s t a t i o n so that t h e y a r e a v a i l a b l e w h e n o c c a s i o n a l l y  68  or r a r e l y u s e d d r u g s a r e b e i n g a d m i n i s t e r e d and i n f o r m a t i o n on these m e d i c a t i o n s i s r e q u i r e d b y the m e d i c a l o r n u r s i n g  staff.  T h e a b o v e p r o p o s e d s y s t e m m i g h t be e x p e c t e d to c o s t a p p r o x i m a t e l y $ 1 0 . 00 p e r w a r d b e y o n d the c o s t o f the b a s i c D r u g F o r m u l a r y . ( T h i s i s b a s e d o n $ 2 . 50 f o r a h a r d c o v e r , t h r e e - r i n g b i n d e r a n d $ 0 . 15 x 50 = $ 7 . 50 f o r 50 p l a s t i c e n v e l o p e s ) .  T h i s s y s t e m would allow between  50 a n d 100 m o n o g r a p h s to b e p l a c e d i n the " M i n i " F o r m u l a r y . s y s t e m a l o n g s i m i l a r l i n e s was  Another  investigated using K a r d e x f r a m e s of  x 11 i n c h s i z e to c o n t a i n the m o n o g r a p h s .  The  8-1/2  cost of this type of s y s t e m  was  a p p r o x i m a t e l y 40 t i m e s g r e a t e r t h a n the a b o v e s y s t e m a n d t h e r e f o r e  was  thought to be p r o h i b i t i v e f o r w i d e s p r e a d u s e .  T h e f o u r t h s u g g e s t i o n f o r r e d u c i n g the b u l k o f the F o r m u l a r y i s to p r i n t the m o n o g r a p h s o f two p a g e s o r m o r e i n l e n g t h o n b o t h s i d e s o f a p a g e ( s e e F i g u r e 7, p a g e  51 ).  T h e b i b l i o g r a p h i e s o f two o r m o r e p a g e s  a l s o c o u l d be p r i n t e d o n b o t h s i d e s o f a p a g e .  T h i s suggestion could have  the p o s s i b l e e f f e c t o f r e d u c i n g the s i z e o f the F o r m u l a r y b y up to o n e - h a l f .  U n d e r the p r o p o s e d c o n d i t i o n s , the M a s t e r F o r m u l a r y w o u l d be m a i n t a i n e d i n the p h a r m a c y ( c o n t a i n i n g the m o n o g r a p h s o f a l l d r u g s u s e d i n the h o s p i t a l , the b i b l i o g r a p h i e s f o r e a c h m o n o g r a p h a n d the c o m p l e t e i n d e x o f the F o r m u l a r y ) . T h e  cross-  " M i n i " F o r m u l a r y w o u l d c o n t a i n o n l y the  d r u g m o n o g r a p h s o f the d r u g s f r e q u e n t l y u s e d o n the w a r d w i t h the r e m a i n i n g m o n o g r a p h s b e i n g s t o r e d i n the o r i g i n a l b i n d e r i n a d r a w e r o r c u p b o a r d o n the w a r d .  69  P r e s e n t P u b l i c a t i o n and E l e c t r o n i c D a t a P r o c e s s i n g .  As Ray  E l e c t r o n i c D a t a P r o c e s s i n g ( E . D . P . ) a n d the u s e of C a t h o d e  T u b e (C.R. T.) r e a d e r - p r i n t e r s b e c o m e m o r e acceptable i n h o s p i t a l s ,  a n o t h e r m e a n s o f r e d u c i n g the b u l k o f the p r e s e n t D r u g F o r m u l a r y w i l l become feasible.  T h i s would enable the r e m o v a l of the p r i n t e d F o r m u l a r y  c o m p l e t e l y f r o m the w a r d a r e a s a n d the m a i n t e n a n c e of a l l d r u g i n f o r m a t i o n i n a c e n t r a l d a t a b a n k w h i c h w o u l d be c o n n e c t e d to e a c h a r e a b y a C . R . T . reader-printer.  The  p r e s e n t c o s t o f t h i s s y s t e m i s p r o h i b i t i v e , but a s the  s y s t e m b e c o m e s m o r e available and less expensive, reader-printers may  the u s e o f C . R . T .  b e c o m e a m o r e f e a s i b l e m e a n s of supplying drug  i n f o r m a t i o n to h e a l t h p r a c t i t i o n e r s .  A n o t h e r a p p r o a c h to E . D . P . h o w e v e r , m i g h t r e d u c e the cost of F o r m u l a r y p r o d u c t i o n .  The  p r o d u c t i o n o f the D r u g  present  Formulary  p r e s e n t l y i s b e i n g u n d e r t a k e n b y the B r i t i s h C o l u m b i a H o s p i t a l A s s o c i a t i o n at a c o s t to the h o s p i t a l s o f a b o u t $ 1 5 . 00 p e r c o p y o r a p p r o x i m a t e l y cents a page.  T h i s c o s t r e p r e s e n t s o n l y the d u p l i c a t i o n a n d  four  distribution  c o s t s a n d d o e s not i n c l u d e p e r s o n n e l a n d s t e n o g r a p h i c e x p e n s e s i n r e s e a r c h i n g a n d p r e p a r i n g the i n f o r m a t i o n f o r e a c h m o n o g r a p h . H o s p i t a l was  Ottawa C i v i c  c o n t a c t e d i n r e g a r d to the p r o d u c t i o n c o s t s o f E . D . P . F o r m u -  lary printing. H o s p i t a l was  The  The  c o s t of p r o d u c i n g e a c h F o r m u l a r y at the O t t a w a C i v i c  $ 5 . 00 o r a b o u t two  approximately tional method.  cents per page.  T h i s cost represents  o n e - h a l f the c o s t o f p r i n t i n g the D r u g F o r m u l a r y b y a c o n v e n It i s f e l t that the c o s t d i f f e r e n c e c a n be a t t r i b u t e d to t h r e e  70  factors:  the m e t h o d o f p r o d u c t i o n ; the n u m b e r o f p a g e s ; a n d f i n a l l y , the  n u m b e r of f o r m u l a r i e s p r i n t e d .  The  Ottawa C i v i c Hospital F o r m u l a r y is  p r i n t e d b y E . D . P . m e t h o d s w h i c h , f r o m the l i t e r a t u r e (27, 38) w e r e n o t e d to be l e s s e x p e n s i v e f o r l o n g - t e r m p r i n t i n g , w h i l e the p r o v i n c i a l D r u g F o r m u l a r y is produced by conventional methods. H o s p i t a l p r i n t s a b o u t 600  c o p i e s of a p p r o x i m a t e l y  The  Ottawa C i v i c  270 p a g e s e a c h , w h e r e a s  the c u r r e n t D r u g F o r m u l a r y c o n t a i n s 400 p a g e s a n d the n u m b e r o f F o r m u l a r i e s p r i n t e d i s a b o u t 250. f o r the  A c c o r d i n g l y , the a d o p t i o n of E . D . P . p r i n t i n g  P r o v i n c i a l F o r m u l a r y s h o u l d not be c o n s i d e r e d b e f o r e the m a j o r  r e v i s i o n s a r e m a d e a n d the r e g u l a t i o n p u b l i c a t i o n i s  The  decided upon.  a b o v e s t u d i e s r e f l e c t that s e v e r a l m o d i f i c a t i o n s o f the  p r e s e n t D r u g F o r m u l a r y s h o u l d be c o n s i d e r e d i n a d d i t i o n to u p d a t i n g , i n m a k i n g i t m o r e u s e f u l on a p r o v i n c i a l b a s i s .  The  future n u m b e r of m o n o -  g r a p h s , a d d i t i o n a l i n f o r m a t i o n i n e a c h , an e x t e n s i v e b i b l i o g r a p h y , a Master-"Mini"  f o r m a t f o r m o r e e f f e c t i v e h o s p i t a l u s e and p r o d u c t i o n a i d s  s u c h as e l e c t r o n i c d a t a p r o c e s s i n g , a l l w o u l d a s s i s t i n p r o d u c i n g a F o r m u l a r y of a m o r e valuable f o r m a t .  II.  E v a l u a t i n g and U p d a t i n g the  Formulary  P e r h a p s the g r e a t e s t l i m i t a t i o n of the p r e s e n t D r u g F o r m u l a r y i s that no m e c h a n i s m e x i s t s f o r u p d a t i n g and e v a l u a t i n g the d r u g m o n o g r a p h s o r f o r r e v i e w i n g the s c i e n t i f i c a n d c l i n i c a l v a l i d i t y o f the i n f o r m a t i o n  con-  71  tained therein.  T h e p r o p o s e d m e t h o d that w a s e v a l u a t e d i n the p r e s e n t s t u d y i s the o n e w h i c h w a s u s e d to p r o d u c e 100 e x i s t i n g m o n o g r a p h r e v i s i o n s b a s e d on a s e n i o r p h a r m a c y s t u d e n t a s s i g n m e n t ( s e e M e t h o d o l o g y , p a g e 37 ) d u r i n g 1972-73.  T o e v a l u a t e the p r o p o s e d m e c h a n i s m , two p o i n t s w e r e (1)  studied:  T h e n u m b e r a n d n a t u r e o f c h a n g e s i n the m o n o g r a p h s a s s u g g e s t e d f r o m the s t u d e n t u p d a t i n g a s s i g n m e n t ( s e e M e t h o d o l o g y , p a g e 37 );  (2)  T h e time r e q u i r e m e n t f o r student, i n s t r u c t o r and s t e n o g r a p h e r input f o r m o n o g r a p h updating ( s e e M e t h o d o l o g y , p a g e 41 ) ,  F r o m the r e s u l t s o f t h e s e s t u d i e s , p r o j e c t i o n s w e r e m a d e r e g a r d i n g a s c h e d u l e f o r u p d a t i n g the m o n o g r a p h s o n a n a n n u a l c o m b i n e d e d u c a t i o n a n d " s e r v i c e " b a s i s a n d r e g a r d i n g the p e r s o n n e l w h i c h m i g h t b e r e q u i r e d to c o n t i n u e the a n n u a l u p d a t i n g o f the F o r m u l a r y .  (a) N a t u r e a n d F r e q u e n c y  of Changes  F o r e a c h u p d a t e d m o n o g r a p h the s t u d e n t s c o m p l e t e d a C h a n g e Sheet (see M e t h o d o l o g y , page  39) w h i c h i n d i c a t e d a l l a d d i t i o n s ,  a n d c h a n g e s to the o r i g i n a l m o n o g r a p h . w e r e a n a l y z e d to d e t e r m i n e monographs.  corrections  One h u n d r e d of these Change  Sheets  the n e e d f o r a n n u a l u p d a t i n g o f the e x i s t i n g  T h e r e s u l t s o f this study a r e p r e s e n t e d i n T a b l e V I I .  B e c a u s e i n s o m e c a s e s , t h r e e to f i v e y e a r s h a d e l a p s e d s i n c e the o r i g i n a l m o n o g r a p h was p r o d u c e d ,  a g r e a t deal of new i n f o r m a t i o n and,  72 I  T A B L E VII  MONOGRAPH  CHANGES  1  B a s e d o n I n f o r m a t i o n F r o m the L i t e r a t u r e i n 1969-73  Average Total Changes  2  Range  13.26  3-30  Changes i n sections on D r u g Interactions and  .,. 3 Intravenous Incompatibilities T  4.  T  - „„ 5. 77  „ 2-18  1.  A s d e t e r m i n e d b y r e v i e w i n g the C h a n g e S h e e t s f o r 100 r a n d o m l y s e l e c t e d e x i s t i n g m o n o g r a p h s d u r i n g the u p d a t i n g a s s i g n m e n t .  2.  T h e a v e r a g e n u m b e r o f r e q u i r e d c h a n g e s f o u n d o n one m o n o g r a p h .  3.  T h e n u m b e r o f c h a n g e s f o u n d o n the m o n o g r a p h s e c t i o n s thought to be m o s t r e q u i r e d i n annual u p d a t i n g s .  73  t h e r e f o r e , c h a n g e s a p p e a r e d i n the u p d a t e d m o n o g r a p h s . a p p a r e n t w h e n the C h a n g e S h e e t s w e r e  Due  This became  studied.  to the s i g n i f i c a n t n u m b e r o f c h a n g e s r e q u i r e d , two  f o r m s of  u p d a t i n g s h o u l d be i d e n t i f i e d i n the t o t a l r e v i s i o n r e q u i r e m e n t s - c o m p l e t e e v a l u a t i o n and annual updating.  Complete evaluation includes referencing  o f the e x i s t i n g m o n o g r a p h i n f o r m a t i o n , a d d i t i o n o f the new "Mode of A c t i o n " and  and  c u r r e n t l i t e r a t u r e to the e x i s t i n g  m o n o g r a p h ( s e e M e t h o d o l o g y , p a g e s 37-38).  T h i s definition of c o m p l e t e  i s c o n s i s t e n t w i t h the a s s i g n m e n t c o m p l e t e d b y the s e n i o r p h a r m a c y  students i n 1972-73.  O n c e t h i s c o m p l e t e e v a l u a t i o n h a s b e e n done on a l l  m o n o g r a p h s , o n l y a n n u a l u p d a t i n g f r o m c u r r e n t l i t e r a t u r e w o u l d be in future  on  " I n s t r u c t i o n s to the P a t i e n t " , a n d the a d d i t i o n o f any-  additional information f r o m previous  evaluation  sections  required  years.  The  p r o p o s e d a n n u a l u p d a t i n g , a p a r t o f the t o t a l r e v i s i o n ,  s i s t s of p r o o f r e a d i n g  the r e v i s e d m o n o g r a p h a g a i n s t s t a n d a r d  con-  reference  s o u r c e s s u c h as the A m e r i c a n H o s p i t a l F o r m u l a r y S e r v i c e , t e x t b o o k s  and  the C o m p e n d i u m of P h a r m a c e u t i c a l s a n d S p e c i a l t i e s , as w e l l as u p d a t i n g the m o n o g r a p h f r o m the l i t e r a t u r e o f the p r e v i o u s the s e c t i o n s of " D r u g I n t e r a c t i o n s " a n d determination  year only, with emphasis  "Intravenous Incompatibilities".  to p l a c e the e m p h a s i s o n t h e s e s e c t i o n s was  n u m b e r of changes w h i c h o c c u r r e d  on  i n t h e s e two  The  m a d e b e c a u s e the  s e c t i o n s was  greater  than  o n e - t h i r d o f the t o t a l n u m b e r o f c h a n g e s p e r m o n o g r a p h i n m o s t c a s e s (see T a b l e VII).  74  (b) T i m e E v a l u a t i o n  T h e p u r p o s e o f s t u d y i n g the t i m e r e q u i r e m e n t s o f the s t u d e n t s , i n s t r u c t o r s a n d s t e n o g r a p h e r s f o r u p d a t i n g a n d t y p i n g the d r u g m o n o g r a p h s w a s to d e t e r m i n e a n a p p r o x i m a t e p e r s o n n e l r e q u i r e m e n t f o r u p d a t i n g the D r u g F o r m u l a r y o n a c o n t i n u i n g " s e r v i c e " b a s i s i n the f u t u r e .  The indivi-  d u a l as w e l l a s c o l l e c t i v e t i m e s w e r e a n a l y z e d to e n a b l e f l e x i b i l i t y i n a n y suggested  system.  O n e h u n d r e d t i m e s h e e t s a g a i n w e r e a n a l y z e d f o r e a c h o f the three groups (students, i n s t r u c t o r s , and stenographers) f o r i n c l u s i o n i n the t i m e e v a l u a t i o n s .  T h e r e s u l t s of this study a r e p r e s e n t e d i n T a b l e VIII.  75  T A B L E VIII  REVISION TIMES  A V E R A G E TIME FOR MONOGRAPHS - Standard Deviation (Hours) A.  STUDENTS 1. Total Revision 2. Annual Updating  B.  13.13 - 9.09 4.50 t 3. 72  2  INSTRUCTORS' REVIEW  t l . 06  1.  Review and Evaluate  3.26  2.  Edit and Condense for monograph format  0.84 t 0.31  C. . S E C R E T A R I A L WORK Typing  0.68 t 0.44  3  1. As determined from 100 randomly selected updating time sheets. 2. Portion of the Total Revision time requirement representing "Drug Interactions" and "Intravenous Incompatibilities" as described on page 73 . 3.  Does not consider time required to make corrections or typographical errors.  76  As  c a n be s e e n f r o m the T a b l e o f R e v i s i o n T i m e s , a p p r o x i m a t e l y  13 h o u r s p e r m o n o g r a p h was lete m o n o g r a p h .  r e q u i r e d b y the s t u d e n t s to e v a l u a t e the c o m p -  T o u p d a t e o n l y the s e c t i o n s on " D r u g I n t e r a c t i o n s " a n d  " I n t r a v e n o u s I n c o m p a t i b i l i t i e s " , the s t u d e n t s r e q u i r e d b e t w e e n f o u r five h o u r s .  By  and  c o r r e l a t i n g t h e s e r e s u l t s w i t h the d e f i n i t i o n s o f c o m p l e t e  e v a l u a t i o n a n d a n n u a l u p d a t i n g on p a g e 73 , i t s e e m s r e a s o n a b l e to e s t i m a t e that the a n n u a l u p d a t i n g w o u l d r e q u i r e d a p p r o x i m a t e l y o n e - t h i r d o f the t i m e r e q u i r e d f o r the i n i t i a l c o m p l e t e  The  e v a l u a t i o n o f the m o n o g r a p h .  d e t e r m i n a t i o n o f i n s t r u c t o r t i m e r e q u i r e d c o n c e r n s o n l y the  t i m e n e c e s s a r y to c o m p l e t e the " s e r v i c e " p o r t i o n o f t h e i r w o r k a n d d o e s not c o n s i d e r t h e i r a c a d e m i c i n p u t to the u p d a t i n g a s s i g n m e n t M e t h o d o l o g y , page  37).  (see  T h i s " s e r v i c e " p a r t i n c l u d e s the e v a l u a t i o n o f the  o r i g i n a l r e f e r e n c e as c i t e d b y the s t u d e n t f o r s c i e n t i f i c v a l i d i t y , e d i t i n g c o n d e n s i n g the u p d a t e d m o n o g r a p h f o r t y p i n g . o f the i n s t r u c t o r s ' c o m m i t m e n t  and  It c a n be s e e n that t h i s p o r t i o n  r e q u i r e d about f o u r h o u r s p e r m o n o g r a p h .  O n c e a l l o f the F o r m u l a r y m o n o g r a p h s h a v e b e e n c o m p l e t e l y e v a l u a t e d h o w e v e r , i t c a n be e x p e c t e d that a p p r o x i m a t e l y one h o u r w i l l b e  required  to r e v i e w the a n n u a l u p d a t i n g done b y the s t u d e n t s .  The  t i m e r e q u i r e d b y the s t e n o g r a p h i c s t a f f to type e a c h m o n o g r a p h  i n the s t a n d a r d f o r m a t ( s e e F i g u r e 7, p a g e 51), w i t h i t s c o r r e s p o n d i n g b i b l i o g r a p h y , was  a p p r o x i m a t e l y 40 m i n u t e s .  T h i s f i g u r e d o e s not i n c l u d e  the t i m e n e c e s s a r y to c o r r e c t a n y t y p o g r a p h i c a l e r r o r s w h i c h w e r e d i s c o v e r e d w h i l e p r o o f r e a d i n g the e v a l u a t e d m o n o g r a p h s .  77.  In t o t a l , the t i m e r e q u i r e d f o r s t u d e n t , i n s t r u c t o r , a n d s t e n o g r a p h e r i n p u t w a s about 18 h o u r s f o r e a c h m o n o g r a p h b a s e d o n the 1972-73  complete  evaluation format.  P r o p o s e d F u t u r e R e v i s i o n Schedule B y u s i n g the r e s u l t s o f the t i m e e v a l u a t i o n , a s c h e d u l e o f c o m p l e t e e v a l u a t i o n a n d a n n u a l u p d a t i n g o f the r e m a i n i n g a n d f u t u r e m o n o g r a p h s m i g h t be m a d e on a c o m b i n e d e d u c a t i o n a n d " s e r v i c e " b a s i s .  This proposal is  m a d e o n the a s s u m p t i o n that the e d u c a t i o n a l t i m e a n d c r e d i t v a l u e o f the s t u d e n t a s s i g n m e n t w i l l b e c o n t i n u e d . It i s m a d e a l s o o n the a s s u m p t i o n that a " s e r v i c e " c o m p o n e n t o f i n s t r u c t o r t i m e w i l l b e m a d e a v a i l a b l e .  The  proposed schedule i s presented in Table IX.  A s s u m i n g that the e d u c a t i o n a l a s s i g n m e n t w i l l b e s i m i l a r i n 1973-74, i t i s p r o p o s e d that the s e n i o r y e a r p h a r m a c y s t u d e n t s b e a s s i g n e d c o m p l e t e e v a l u a t i o n s ( a n d a n n u a l u p d a t i n g ) o f the r e m a i n i n g 88 m o n o g r a p h s not done i n 1972-73 a s w e l l a s the a n n u a l u p d a t i n g o f the 218 m o n o g r a p h s evaluated i n 1972-73.  O n t h i s p r o p o s e d s c h e d u l e , the r e v i s i o n o f the e x i s t i n g  monographs will r e a c h a maintenance 1973-74.  l e v e l b y the e n d o f the a c a d e m i c  term  T h e r e a f t e r , the s t u d e n t a s s i g n m e n t w o u l d c o n s i s t o n l y o f a n n u a l  u p d a t i n g o f the e x i s t i n g d r u g m o n o g r a p h s a n d p e r h a p s the c o m p l e t e e v a l u a t i o n of n e w m o n o g r a p h s .  In 1 9 7 2 - 7 3 , the i n s t r u c t o r s r e v i e w e d , e d i t e d a n d c o n d e n s e d 100 o f the  218 e v a l u a t e d m o n o g r a p h s .  It i s p r o p o s e d that i n 1973-74, the i n s t r u c t o r s  78  TABLE  IX  F U T U R E REVISION  SCHEDULE  for D r u g F o r m u l a r y Monographs  Number of Revised Monographs Academic  Terms  Complete  Evaluation 7  1972-73 218  1973-74 88 (306)  Annual Updating  218  306  Instructor R e v i e w and Condense3  100  206 (306)  Total 306  306  1.  On a p r o p o s e d education and " s e r v i c e " b a s i s .  2.  A s r e l a t e d to s t u d e n t a s s i g n m e n t i n 1972-73 a n d a s d e f i n e d o n p a g e 73 .  3.  Instructor c o m m i t t m e n t on a " s e r v i c e " b a s i s  4.  T h e t o t a l n u m b e r o f d r u g m o n o g r a p h s i n the p r e s e n t F o r m u l a r y .  only.  79  complete  the r e m a i n i n g 118 m o n o g r a p h s e v a l u a t e d i n 1972-73 a n d r e v i e w  a n d c o n d e n s e the 88 m o n o g r a p h s e v a l u a t e d i n 1 9 7 3 - 7 4 . a s s i g n m e n t s , the " s e r v i c e " c o m m i t m e n t  o f the i n s t r u c t o r s w o u l d r e a c h a  m a i n t e n a n c e l e v e l b y the e n d o f the a c a d e m i c t e r m a d d i t i o n a l m o n o g r a p h s be a d d e d . instructors' commitment  A s w i t h the s t u d e n t  1973-74 s h o u l d no  H o w e v e r , i t i s p r o p o s e d that the  t h e r e a f t e r s h o u l d b e to p r o d u c e n e w  monographs  as r e q u e s t e d i n the A d d i t i o n a l D r u g s S u r v e y ( s e e M e t h o d o l o g y , p a g e s  27 , 28  a n d A p p e n d i x II).  Future Personnel Requirements T o c o n t i n u e the u p d a t i n g o f the F o r m u l a r y o n a " s e r v i c e " b a s i s f o r d i s t r i b u t i o n to the h o s p i t a l s o f B r i t i s h C o l u m b i a , m e n t s m u s t be quantitated.  certain personnel require-  T h i s p r o j e c t i o n i s b a s e d on a c o n t i n u e d student  i n v o l v e m e n t a n d , t h e r e f o r e , no p r o f e s s i o n a l s t a f f r e q u i r e m e n t w i l l be a s s i g n e d to the p o r t i o n o f e v a l u a t i o n p r e s e n t l y u n d e r t a k e n b y the s t u d e n t s . H o w e v e r , " s e r v i c e " s t a f f w i l l b e n e e d e d to c o n t i n u e the i n s t r u c t o r s ' r e v i e w a n d c o n d e n s i n g o f the u p d a t e d m o n o g r a p h s a s w e l l a s the t y p i n g o f the s a m e .  F r o m the T i m e E v a l u a t i o n s t u d i e s , i t w a s n o t e d that the i n s t r u c t o r s r e q u i r e d a n a v e r a g e o f f o u r h o u r s to r e v i e w a n d c o n d e n s e e a c h m o n o g r a p h (see T a b l e V I I I ) .  T h e r e f o r e , i t m i g h t be e x p e c t e d that a p p r o x i m a t e l y 800  h o u r s w o u l d b e r e q u i r e d f o r the i n s t r u c t o r s to r e v i e w a n d c o n d e n s e the r e m a i n i n g 206 m o n o g r a p h s ( f o u r h o u r s t i m e s 206 m o n o g r a p h s ) .  O n this  b a s i s i t i s e x p e c t e d that a b o u t o n e to o n e a n d o n e - h a l f a d d i t i o n a l h o u r s p e r m o n o g r a p h w i l l b e n e c e s s a r y to r e v i e w the 218 m o n o g r a p h s w h i c h w i l l r e q u i r e  8G  annual updating i n 1973-74. 300 h o u r s .  T h e r e f o r e , to f u l f i l l the " s e r v i c e " c o m m i t t m e n t a s p r o j e c t e d , a  total of a p p r o x i m a t e l y 1973-74.  T h i s r e p r e s e n t s a p p r o x i m a t e l y an additional  1100 i n s t r u c t o r " s e r v i c e " h o u r s w i l l b e n e e d e d i n  F o r t h i s r e a s o n , i t i s a n t i c i p a t e d that o n e - h a l f o f a p h a r m a c i s t ' s  t i m e w i l l b e r e q u i r e d i n 1973-74 f o r t h i s c o m m i t t m e n t .  R e c o g n i z i n g that t h e r e m i g h t be 206 a d d i t i o n a l m o n o g r a p h s  prepared  f o r t y p i n g i n 1973-74 ( s e e T a b l e I X ) , a n d that e a c h m o n o g r a p h took a p p r o x i m a t e l y 40 m i n u t e s to type d u r i n g 1972-73 ( s e e T a b l e VIII), i t i s p r o j e c t e d that about 140 h o u r s o f s t e n o g r a p h i c t i m e m i g h t be r e q u i r e d i n 1973-74. S i n c e this e x t r a p o l a t i o n does not a c c o u n t f o r c o r r e c t i o n s o f t y p o g r a p h i c a l e r r o r s , i t i s r e c o g n i z e d that t h i s t i m e e s t i m a t e i s a v e r y m i n i m u m .  The  r e s u l t s o f the a b o v e s t u d i e s i d e n t i f y that the m o n o g r a p h s o f the  e x i s t i n g D r u g F o r m u l a r y r e q u i r e c o m p l e t e e v a l u a t i o n o f the p r e s e n t i n f o r m a t i o n as w e l l a s a n n u a l u p d a t i n g o f n e w i n f o r m a t i o n .  Student,  instructor  a n d s t e n o g r a p h i c t i m e r e q u i r e d to e v a l u a t e a n d u p d a t e 100 m o n o g r a p h s d u r i n g the 1972-73 a c a d e m i c t e r m w e r e r e c o r d e d a n d a n a l y z e d .  S u c h a n a l y s e s a r e u s e d to p r o j e c t a c o n t i n u e d e v a l u a t i o n a n d u p d a t i n g r e v i s i o n o f the r e m a i n i n g m o n o g r a p h s d u r i n g 1 9 7 3 - 7 4 . it i s e x p e c t e d that at l e a s t o n e - h a l f o f a p h a r m a c i s t ' s  O n this b a s i s ,  t i m e w i l l h a v e to be  m a d e a v a i l a b l e o t h e r than f o r a c a d e m i c i n s t r u c t i o n , a n d that a b o u t 140-150 h o u r s o f s t e n o g r a p h i c t i m e , s i m i l a r l y , w i l l b e r e q u i r e d to c o m p l e t e the  81  r e v i s i o n o f the r e m a i n i n g D r u g F o r m u l a r y m o n o g r a p h s It c a n b e e x p e c t e d that a n n u a l u p d a t i n g committment.  thereafter,  d u r i n g the n e x t y e a r .  will require a  similar  82  RECOMMENDATIONS  If the p r e s e n t D r u g F o r m u l a r y d i s t r i b u t e d f o r u s e i n B r i t i s h C o l u m b i a h o s p i t a l s i s to r e t a i n i t s p r e s e n t v a l u e , a n d p e r h a p s r e a l i z e a g r e a t e r p o t e n t i a l , s e v e r a l changes i n f o r m a t and a r e g u l a r updating m e c h a n i s m s h o u l d be e f f e c t e d .  1.  B a s e d o n the p r e s e n t s t u d y , t h e s e i n c l u d e :  The addition of a p p r o x i m a t e l y another  300  d r u g m o n o g r a p h e n t r i e s to m a k e the F o r m u l a r y m o r e u s e f u l to a l l h o s p i t a l s ; 2.  The  addition of m o r e i n f o r m a t i o n under  each  m o n o g r a p h , s p e c i f i c a l l y i n the " M o d e o f A c t i o n " a n d " I n s t r u c t i o n s to the P a t i e n t " ; 3.  4.  T h e e v a l u a t i o n a n d r e f e r e n c i n g o f the e x i s t i n g i n f o r m a t i o n a n d the a n n u a l u p d a t i n g o f the same; T h e adoption of a M a s t e r F o r m u l a r y  containing  all provincially used drugs, a complete  biblio-  graphy for each m o n o g r a p h and a c r o s s - i n d e x o f g e n e r i c to m a n u f a c t u r e r s ' b r a n d n a m e s ; 5.  The adoption of a " M i n i " F o r m u l a r y d e r i v e d f r o m the M a s t e r a n d c o n t a i n i n g o n l y the m o n o g r a p h s for those drugs frequently u s e d i n the i n d i v i d u a l h o s p i t a l w a r d a r e a s ;  6.  T h e a r r a n g e m e n t f o r a p r i n t i n g r a t h e r than t y p i n g p r o d u c t i o n o f the F o r m u l a r y ;  7.  T h e p r o v i s i o n o f at l e a s t o n e - h a l f t i m e p h a r m a c i s t o n a " s e r v i c e " b a s i s to e d i t , r e v i s e and condense student d r u g l i t e r a t u r e e v a l u a t i o n p r o j e c t s to F o r m u l a r y  8.  format;  T h e p r o v i s i o n o f a m i n i m u m of 200 h o u r s p e r year stenographer time;  83  9.  The  arrangement for a Medical Review B o a r d  to j u d g e the c l i n i c a l s i g n i f i c a n c e o f p r o p o s e d  10.  new  i n f o r m a t i o n to be  added;  The  e s t a b l i s h m e n t of a c e n t r a l D r u g I n f o r m a -  t i o n C e n t r e i n the p r o v i n c e to c o o r d i n a t e the a b o v e f u n c t i o n s a n d to s e r v e as a r e s o u r c e centre for additional information r e q u i r e d on a d a i l y b a s i s f o r the e f f e c t i v e u s e o f the Formulary.  84'  BIBLIOGRAPHY  1.  A n o n . , D r u g I n t e l l . C l i n . P h a r m . , 4, 109  (1970).  2.  R e p o r t P r e p a r e d f o r the Study of ' I n t e r a g e n c y  Coordination in Drug  R e s e a r c h a n d R e g u l a t i o n s ' b y the S u b c o m m i t t e e o n R e o r g a n i z a t i o n I n t e r n a t i o n a l O r g a n i z a t i o n of the S e n a t e C o m m i t t e e on Operations. Appendix 3.  Government  U . S.. G o v e r n m e n t P r i n t i n g O f f i c e , A u g u s t 30,  1963.  C.  R e p o r t P r e p a r e d f o r the S t u d y o f ' I n t e r a g e n c y  Coordination in Drug  R e s e a r c h a n d R e g u l a t i o n s ' b y the S u b c o m i t t e e o n R e o r g a n i z a t i o n I n t e r n a t i o n a l O r g a n i z a t i o n of the S e n a t e C o m m i t t e e o n Operations. pp. 4.  and  U.S.  and  Government  G o v e r n m e n t P r i n t i n g O f f i c e , A u g u s t 30,  1963.  1-3.  R e p o r t P r e p a r e d f o r the S t u d y o f ' I n t e r a g e n c y  Coordination in Drug  R e s e a r c h a n d R e g u l a t i o n s ' b y the S u b c o m m i t t e e on R e o r g a n i z a t i o n I n t e r n a t i o n a l O r g a n i z a t i o n of the S e n a t e C o m m i t t e e o n  5.  Government  Operations,  U . S.. G o v e r n m e n t P r i n t i n g O f f i c e , A u g u s t 30,  A p p e n d i x A-  1.  1963.  R e p o r t P r e p a r e d f o r the S t u d y o f ' I n t e r a g e n c y C o o r d i n a t i o n i n D r u g R e s e a r c h a n d R e g u l a t i o n s ' b y the S u b c o m m i t t e e o n R e o r g a n i z a t i o n a n d I n t e r n a t i o n a l O r g a n i z a t i o n of the S e n a t e C o m m i t t e e o n G o v e r n m e n t O p e r a t i o n s . U . S . G o v e r n m e n t P r i n t i n g O f f i c e , A u g u s t 30, 1963. pp.  6.  6-7.  W e l t , I. D.,  e d . D r u g I n f o r m a t i o n II F o r the H e a l t h P r o f e s s i o n s , G o r d o n  and B r e a c h , S c i e n t i f i c P u b l i s h e r s , N e w  Y o r k , 1970,  pp.  324-325.  7.  P e a r s o n , R. E . , S a l t e r , F . J . , B o h l , J . C., T h u d i u m , V . F . , P h i l l i p s , G. L . , A m . J . H o s p . P h a r m . , 27, 911 (1970).  8.  T a n e n b a u m , H.,  9.  Boyd, C.E.,  10.  , and  D r u g I n f o r m a t i o n B u l l . , 4, p p .  D r u g I n f o r m a t i o n B u l l . , Z, 112  1-12  and  ( J a n / J u n e , 1970).  ( J u l y / S e p t , 1968).  S a d u s k , J . F . , J r . , D r u g I n f o r m a t i o n B u l l . , 3, p p .  66-72, ( J u l y / S e p t . ,  1968). 11.  K e e f e r , C.S.,  Am.  J . H o s p . P h a r m . , 23,  55 (1966).  12.  W a l t o n , C.A.,  Am.  J . H o s p . P h a r m . , 22, 459  (1965).  85  13.  W e s t o n , J . K., D r u g I n f o r m a t i o n B u l l . ,  3, 121 ( J u l y / S e p t . , 1968).  14.  W e l t , I.D., e d . D r u g I n f o r m a t i o n II f o r the H e a l t h P r o f e s s i o n s , and B r e a c h , S c i e n t i f i c P u b l i s h e r s , New Y o r k ,  1970, p p . 3 0 1 - 3 0 3 .  15.  Pellegrino, E., Am.  16.  Editorial, Am.  17.  W e l t , I.D., e d . D r u g I n f o r m a t i o n II f o r the H e a l t h P r o f e s s i o n s ,  J . H o s p . P h a r m . , 22, 40 (1965).  J . H o s p . P h a r m . , 2 0 , 353 (1963).  and B r e a c h , S c i e n t i f i c P u b l i s h e r s , New Y o r k , 18.  American 1972,  19. 20.  Gordon  Gordon  1970, p . 4 8 .  S o c i e t y o f H o s p i t a l P h a r m a c i s t s N e w s R e l e a s e #25, S e p t . 22,  Washington, D. C. .  T e s t e r , W.W.,  a n d O l e s o n , C . H . , H o s p i t a l s , 4 5 , (1971).  W e l t , I.D., e d . D r u g I n f o r m a t i o n II f o r the H e a l t h P r o f e s s i o n s , and B r e a c h , S c i e n t i f i c P u b l i s h e r s , New Y o r k ,  21.  H e n l e y , S., T e s t e r , W. W.,  22.  T h o m p s o n , C O . , S c h w a r t a u , N.W., J. F., Am.  Gordon  1970, p. 329-332.  K n o p p , R., H o s p i t a l s , _42, 99 (1968). Trites,  D.K., a n d L e c k w a r t ,  J . H o s p . P h a r m . , 2 7 , 276 (1970).  23.  p o x , N . , T h e H o s p i t a l P h a r m a c i s t , 2 0 , 67-70 (1970).  24.  D r u g Information S e r v i c e s : Two O p e r a t i o n a l M o d e l s , Department of H e a l t h , E d u c a t i o n a n d W e l f a r e P u b l i c a t i o n s # ( H S M ) 7 2 - 3 0 3 0 , 7(197).  25.  Smythe, H. A., B o u g h e r , D . J . , and B a c h y n s k y , J . , T h e H o s p i t a l P h a r m a c i s t s , _21_, 267-276 (1968).  26.  N a y l o r , M . J . V . , C a n . J . H o s p . P h a r m . , X X I V , 131 (1971).  27.  F r a n k e n f e l d , F . M . B l a c k , H . J . , a n d D i c k , R.W., P h a r m . , 28, 155 (1971).  28.  F l a c k , H. L . , Downs, G . E . , and Lanning, L . E . , A m . 24,  A m . J . Hosp.  J . Hosp. Pharm.,  5 (1967).  29.  B u r k h o l d e r , D., A m .  J . H o s p . P h a r m . , 2 2 , 48 (1965).  30.  R o s e n b e r g , J . M . H o s p . P h a r m . , 3, 5 (1968).  86-  31.  L i g u o r i , Sister  M.,  D r u g I n f o r m a t i o n S e r v i c e s , p r e s e n t e d at S t .  M i c h a e l ' s H o s p i t a l , T o r o n t o , A u g u s t 20, 1968. ( u n p u b l i s h e d ) . 32.  F r a n c k e , D.E.,  J L a t i o l a i s , C . S . , F r a n c k e , G . N . , H o , N . F . H.,  M i r r o r To Hospital Pharmacy, American  Society of H o s p i t a l P h a r m a -  c i s t s , W a s h i n g t o n , 1964, p p . 1 4 0 - 1 5 0 . 33.  S t a t e m e n t o f G u i d e l i n e s f o r the U s e o f the H o s p i t a l F o r m u l a r y S y s t e m , C a n a d i a n S o c i e t y o f H o s p i t a l P h a r m a c i s t s , T o r o n t o , A u g u s t , 1968.  34.  Anon., A m .  35.  J . H o s p . P h a r m . , 21_, p p . 40-41 (1964).  G u i d e to H o s p i t a l A c c r e d i t a t i o n , 1972, C a n a d i a n C o u n c i l o n H o s p i t a l A c c r e d i t a t i o n , T o r o n t o , 97.  36.  S o n n e d e c k e r , G., D r u g I n t e l l . C l i n . P h a r m . , 6, p p . 425-432 (1972).  37.  Hlynka, J.M.,  " T o D e v e l o p the F i r s t Stage o f a D r u g I n f o r m a t i o n  Service for British Columbia", 38.  A p p e n d i x I, J u l y 20, 1972.  S m y t h e , H . A . , C a n . J . H o s p . P h a r m . , X X I V , p p . 169-171 ( S e p t . / O c t . 1971).  39.  T o b e r , T.W.,  Am.  J . H o s p . P h a r m . , _21, p p . 105-111 (1964).  40.  L a m y , P . P . , B o u r n , I. F . a n d F l a c k , H . L . , A m .  J . H o s p . P h a r m . , 18,  p p . 641-649 (1961). 41.  D a n i e l s o n , F . , H o s p . P h a r m . , 5, p p . 21-24 (1970).  42.  Anon., Am.  43.  F r a n c k e , D . E . , D r u g I n t e l l . C l i n . P h a r m . , j>, p p . 448-455 (1972).  44.  M i l l e r , A . B . , D r u g I n f o r m a t i o n B u l l . , _5, 157 ( J u l y / D e c . 1970).  45.  Hetherington, C , (1970).  46.  H e l l e r , W.M.,  47.  Seim, H. C ,  J . H o s p . P h a r m . , 23, p p . 293-303 (1966).  T h e J o u r n a l o f H o s p i t a l P h a r m a c y , 28, p p . 152-155  Am.  J . H o s p . P h a r m . , _l€>, p p . 519-523 (1959).  and Kabat, H. F . , A m .  4 8 . . B u r k h o l d e r , D., A m . 49.  Anderson, (1965).  R.D.,  J . H o s p . P h a r m . , _23, 241 (1966).  J . H o s p . P h a r m . , 22, 50 (1965).  and L a t i o l a i s , C . J . , A m .  J . H o s p . P h a r m . , 22, 55  87-:  50.  Parker, P.F.,  Am.  J . H o s p . P h a r m . , _22, p p . 42-47 (1965).  51.  V i s c o n t i , J . , D r u g I n f o r m a t i o n S e r v i c e s P o l i c y , O h i o State U n i v e r s i t y H o s p i t a l , D e p a r t m e n t o f P h a r m a c y , 14 (1962, r e v i s e d 1968).  52.  Munro, F . J . , J r . , Am.  53.  R o s e n b e r g , J.M., 270 (1971).  54.  J . H o s p . P h a r m . , 24, 574  and P e r i t o r e , S.P.,  Am.  P e a r s o n , R. E . , S a l t e r , F . J . , B o h l , J . C., P h i l l i p s , G. L . , A m .  55. - A m e r s o n , A . B . , (1971).  B a u m g a r t e r , R.P.,  57.  P e a r s o n , R. E . , S a l t e r , F . J . , B o h l , J . C . ,  58.  59.  Am..  Am.  56.  P h i l l i p s , G.L.,  J . Hosp. Pharm.,  Thudium, V.F.,  J . H o s p . P h a r m . , 29, 229  and W a l t o n , C.A.,  Am.  (1967). 28,  and  (1972).  J . H o s p . P h a r m . , 28,  J . H o s p . P h a r m . , 28, 670  (1971).  Thudium, V. F . ,  J . H o s p . P h a r m . , _29, 312  267  and  (1972).  P e a r s o n , R. E . , P h i l l i p s , G . L . , a n d T h u d i u m , V . F . , " P r o j e c t to D e v e l o p , E v a l u a t e and D e m o n s t r a t e a P i l o t D r u g I n f o r m a t i o n and D r u g T h e r a p y A n a l y s i s a n d R e p o r t i n g S y s t e m " . A p r o j e c t o f the U n i v e r s i t y of M i c h i g a n C o l l e g e o f P h a r m a c y , p p . 8-12 (1971). P e a r s o n , R. E . , P h i l l i p s , G . L . , a n d T h u d i u m , V . F . ,  " P r o j e c t to  D e v e l o p , E v a l u a t e and D e m o n s t r a t e a P i l o t D r u g I n f o r m a t i o n and T h e r a p y A n a l y s i s and R e p o r t i n g S y s t e m " .  Drug  A p r o j e c t o f the U n i v e r s i t y  of M i c h i g a n C o l l e g e o f P h a r m a c y , 17 (1971).60.  C o u p e r , I. A . ,  The  61.  Anon., The  62.  D u r o n t , W.J.,  63.  Reilly,  64.  W i t t r u p , R.D.,  65.  R a p p o r t , H.,  66.  B u r k h o l d e r , D.,  67.  Wilson, C O . ,  J o u r n a l o f H o s p i t a l P h a r m a c y , 30, 125  P h a r m a c e u t i c a l J o u r n a l , 209,  M.J.,  The  159  (1972).  (1972).  Hospital Pharmacist, XXI,  213 ( S e p t . / O c t . 1968).  D r u g I n f o r m a t i o n B u l l . , _5, 154 ( J u l y / D e c . , 1970). Am.  J . H o s p . P h a r m . , 22, 59 ( 1 9 6 5 ) .  H o s p . P h a r m . , 4, 17 (1969). D r u g I n t e l l . , 1, 321  and J o n e s , T . E . ,  J . B. Lippincott Co.,  ed.  Philadelphia,  (1967). American  174.  D r u g Index  1967,  .88  68.  R o t e n b e r g , G . N.,  D r u g I n f o r m a t i o n B u l l . , _5, 181  69.  W e l t , I.D., e d . D r u g I n f o r m a t i o n II F o r the H e a l t h P r o f e s s i o n s , G o r d o n a n d B r e a c h , S c i e n t i f i c P u b l i s h e r s , N e w Y o r k , 1970, p p . 336-341.  70.  R o t e n b e r g , G.N.,  and H u g h e s , F . N . ,  c a l s a n d S p e c i a l t i e s 7th e d i t i o n , T h e tion, Toronto,  ( J u l y / D e c . 1970).  ed. C o m p e n d i u m of  Pharmaceuti-  Canadian Pharmaceutical A s s o c i a -  1972.  71.  Zacharis, E., Personal Communication.  72.  d u P l e s s i s , D.,  Personal Communication.  89  APPENDIX I  COST O F T H R E E MAJOR DRUG INFORMATION  SERVICES  1. d e H a e n S e r v i c e s , P a u l d e H a e n I n c . , 11 W e s t 4 2 n d S t r e e t , N e w Y o r k , N . Y.,  2.  10036.  A.  "Drugs in U s e and Combination"  $700.00/year  B.  "Drugs in R e s e a r c h "  $150.00/year  C.  " D r u g s i n U s e P r o d u c t P r o f i l e Index"  $100.00/year  D.  "Drugs in Prospect"  $450.00/year  International P h a r m a c e u t i c a l A b s t r a c t s , A m e r i c a n Society of H o s p i t a l P h a r m a c i s t s , 4630 M o n t g o m e r y A v e . , Washington, D.C., 20014. $150.00/year  3.  Iowa D r u g I n f o r m a t i o n S e r v i c e s , C o l l e g e o f P h a r m a c y ,  Iowa State  U n i v e r s i t y , Iowa C i t y , I o w a .  *  A.  C u r r e n t S u b s c r i p t i o n Y e a r (1973)  B.  R e t r o s p e c t i v e F i l e (1966-1972)  $900. 0 0 / y e a r * $1500.00*  S u b s c r i p t i o n C h a r g e s , Iowa D r u g I n f o r m a t i o n S e r v i c e s , C o l l e g e o f Pharmacy,  I o w a State U n i v e r s i t y , Iowa C i t y , I o w a , F e b r u a r y , 1 9 7 3 .  APPENDIX II LISTS O F DRUGS RECEIVING TWO OR M O R E REQUESTS FOR INCLUSION IN T H E DRUG F O R M U L A R Y  Drugs receiving 5 requests Ethacrynic acid Ethchlorvinyl Perphenazine Protriptyline Vinblastine  Drugs receiving 4 requests Clofibrate Cycloserine Cycrimine Cytosine Arabinoside Dehydrocholic acid Dienestrol Dihydroergotamine Echothiophate Iodide Erythrityl Tetranitrate Ethambutal Ethanolamine Oleate Fluocinolone Fluphemazine Hydroxychloroquine Iron-Sorbitol Complex Meclizine Methallenestril Methsuximide Methyltestosterone Nitrofurazone Nortriptyline Orciprenaline Orphenadrine Hydrochloride Oxacillin Oxazepam  A P P E N D I X II ( C o n t i n u e d )  Drugs receiving 4 requests  (Continued)  Oxytetracycline Phenelzine Pseudoephedrine Hydrochloride T e r p i n Hydrate Triethylenethio Phosphoramide (Thio-tep Trimethadione Vancomycin  Drugs receiving 3 requests Acenocoumarol Alphaprodine Hydrochloride A l u m i n u m Acetate Ambenonium Chloride Ammoniated Mercury Bendroflumethiazide B l o o d and B l o o d C o m p o n e n t s Butabarbital Sodium Carbinoxamine Carisoprodol Chlorcyclizine C hlo r m e z a n o n e Chlorphenoxamine Maleate Chlorprothixene Chlorthalidone C h l o r o t r i a n i s ene Clindamycin Cyclahdelate Cyclizine Hydrochloride Cyclopentolate Dactinomycin Dapsone Dextrose Dextrothyroxine Dichlorphenir amine Dicloxacillin Dicyclomine Dimethylpolysiloxane Dioxyline Phosphate Doxycycline Estradiol Valerate Ethamival.  A P P E N D I X II ( C o n t i n u e d )  Drugs receiving 3 requests  (Continued)  Ethinyl Estradiol Ethisterone Fludrocortisone Gitalin Glycerin Enema Hydroxyprogesterone Caproate Indomethacin Influenza V a c c i n e (Polyvalent) Inositol Niacinate Isopropamide I s o p r o t e r e n o l Sulphate L i o thyronine Methdilazine Hydrochloride Methocarbamol Methylprednisolone Methysergide Bimalate Metapryone Nandrolone Phenpropionate Nicotinamide Novobiacin Oxymetholone Paramethadione Phenmetrazine Prednisolone Procarbazine Pyrimethamine Quinacrine Quinidine Phenylethyl Barbaturic A c i d Saccharin Sodium S o d i u m T e t r a d e c t y l Sulphate Stanozolol Succinylsulfathiazide Sulfamethiazole Sulfinpyrazone Tetanus Antitoxin T h i o m e r sol T riamcinolone T r ifluopromazine T r i m e p r amine Trimethobenzamine T r i m i p r amine T r i p l e Sulfa C r e a m (equivalent) Trolnitrate Phosphate Witch Hazel  A P P E N D I X II (Continued)  Drugs receiving 2 requests Acetic Acid Acetohexamide Acnomel Alcaroid Pulvules Alkavervir Allylbarbaturic Acid Alophen Alphosyl Lotion Amaranth Aminopryine Amphetamine Sulphate Antivert Atasorb Azapetine Phosphate Azuresin (Diagnex Blue) Belladonna Leaf Benzoate Benzononate Benzyl Peroxide Betahistine Biperiden Bismuth Formic Acid Compound Bismuth Sodium Triglucollamate Blephamide Brucellergan Butaserpine Butobarbitone Calcium Bromodolactobionate Calcium Undecylenate Carcholin Cassia Oil Chlorophylline Chlorophenesin Chlor quinaldol Chorionic Gonadotropin Citri-cerose Climacterone Clindinium Bromide Coccidioidan Collodion Cophylac Drops Creta Pulvules Cremosuximide Cyclamate  A P P E N D I X II ( C o n t i n u e d )  Drugs receiving 2 requests  (Continued)  Cyclobarbitone Cyclomethylcaine Cyclopentamine Dextromethorphan Diasol Diatroate  Sodium  Dihexylverine Hydrochloride Dihydrotachysterol Dill Oil Diperidolate Diperidon Dipianone Dimethisoquin D i m e thy Is t e r one Disodium Hydrogen  Citrate  Doxylamine Dromoran Duo-C V P Entoral Eosine Estradiol Lipropionate Etrafedrine Ethopropazine Ethylenediamine Ethylene Glycol  Tetra-acetate  Etrafon Eucalyptus O i l Euflavine Evans Blue Fat Emulsion Festol Fibrinogen Flucinonide Fluoescite Fiurandrenolone Folinic Acid Framycetin  Sulphate  Furazalidone G a l l and O p i u m Ointment Glauber  Salts  Glycothmoline G o l d Salts  A P P E N D I X II ( C o n t i n u e d )  D r u g s r e c e i v i n g 2 r e q u e s t s (Continued) Hemocebrin Heptobarbital Hetacillin Histamine Azoprotein Histoplasmin Hydromorphone Hygroton-Reserpine  Ichthyl Immune Serum  Globulin  Imuvac Iodoform  Compounds  Iopanoic A c i d Iophendylate Isoflurophate Isometheptene Itramine Tosylate Ketamine Lactated Pepsin Elixir Lactostat (Testosterone Estradiol) Lanatoside C Levopromazine Magenta Magnesium Mefenamic  Trisilicate Acid  Menadione Mepenzolate Mephenytoil Mephobarbital Mepivacaine Mercuric Mercury  Oxide Bichloride Ointment  Metaxalone Methacholine Methanthe line Methycellulos e Metimyd Myocrysine Nandrolone  Decanoate  Neomedrol Nifuroxime Norethandrolone Norisodrine O i l of Cajaput Oral Proteolytics  A P P E N D I X II ( C o n t i n u e d )  D r u g s r e c e i v i n g 2 requests (Continued) O x a l i c and M a l o r i c  Acid  Para-amino Benzoic Acid Papain  Pulvules  Penicillamine Penthienate  Methobrorriide  Pentylenetetrazole Pericyazine P e r t u s s i s Immune Globulin Phenaglycodol Phenol Phenoxymethylpenicillin Pimacrin  Compound  Piperoxan Podophyllin Potassium Bromide P o t a s s i u m Phosphate Proflavine Progfesterone Proguanil Protamide Protein Hydrolysate Pyrimethamine Pyrithen Pyrrobutamine  Compound  Quandrinal Quinidine  Compound  Raudixin R a u t r a c t y l #2  #4  Resorcinol Monoacetate Resteclin Restropin Restropinal Rimactane Roniacol Salbutamol Salicylamide Ser-Ap-Es Silver Nitrate Sodium  Citrate  Sodium  Iodide  S o d i u m F r e e Salt Sulfa suxidine Sodium Oxychlorosene  APPENDIX  II ( C o n t i n u e d )  Drugs receiving 2 requests Sodium Para-amino Staphlococcus  (Continued)  Hippurate  Antitoxin  Stilboestrol Diphosphate Sodium Sulfamerazine Surfacaine Testolactone T etrahydr azoline Theobromine Calcium  Salicylate  Theophylline T hyroglobulin Thyrotropin Trichloroacetic Acid T r ifluoper azine T r i p r o l i d i n e and Compounds Troxidone Trypsin Tuberculin  PPD  T y p h o i d , P a r a t y p h o i d and Tetanus Tyrothricin Urethan Vagisec V a l e r i a n Root V i t a m i n A and D  Ointment  Viomycin White P i n e Syrup Xanthinol Niacinate Zeobarb Zincafrin Zylene  98 A P P E N D I X III  S T U D E N T M O N O G R A P H U P D A T I N G A S S I G N M E N T - 1972-73 D r u g and P o i s o n I n f o r m a t i o n  Centre  Monograph Assignment  Pharmacy  403  1.  E a c h s t u d e n t w i l l be a s s i g n e d to p r e p a r e t h r e e d r u g m o n o g r a p h s a n d poison monograph.  one  2.  T h e c o m p l e t e d m o n o g r a p h s w i l l be t y p e w r i t t e n ( d o u b l e - s p a c e d r e f e r e n c e s ) on 8-1/2" x 11" w h i t e b o n d p a p e r .  3.  E a c h p a g e o f the m o n o g r a p h s h a l l h a v e the n a m e o f the d r u g o r p o i s o n a n d the n a m e o f the s t u d e n t .  4.  DRUG  - including  MONOGRAPHS  (a)  U p d a t e the L i o n ' s G a t e H o s p i t a l F o r m u l a r y m o n o g r a p h u s i n g the m o s t r e c e n t m o n o g r a p h o f the A m e r i c a n H o s p i t a l F o r m u l a r y S e r v i c e . R e f e r e n c e a l l changes or additions.  (b)  S e a r c h Index M e d i c u s f o r a l l new i n f o r m a t i o n on the p a r t i c u l a r d r u g o r p o i s o n w h i c h h a s b e e n p u b l i s h e d d u r i n g the p r e v i o u s 12 m o n t h s . R e f e r e n c e a l l new i n f o r m a t i o n w i t h o r i g i n a l r e f e r e n c e s o u r c e s . R e s t r i c t the s e a r c h to p e r t i n e n t c l i n i c a l d a t a (do N O T include animal data) - d e H a e n i n f o r m a t i o n c a r d s m a y be u s e d but not q u o t e d as reference source.  (c)  The  f o l l o w i n g s e c t i o n s m u s t be c o m p l e t e l y r e f e r e n c e d with o r i g i n a l  reference  sources: S e c t i o n IX:  Drug Interactions  Section  I.V.  X:  Incompatibilities  O n l y c l i n i c a l l y s i g n i f i c a n t d r u g i n t e r a c t i o n s s h o u l d be i n c l u d e d i n the m o n o g r a p h .  ( " D r u g I n t e r a c t i o n s " b y H a n s t e n c a t e g o r i z e s the c l i n i c a l  s i g n i f i c a n c e o f the v a r i o u s d r u g i n t e r a c t i o n s q u i t e w e l l ) .  " H a z a r d s of M e d i c a t i o n " by M a r t i n and  "Drug Interactions" by  H a n s t e n a r e t e r t i a r y r e f e r e n c e s o u r c e s a n d the s t u d e n t m u s t r e v i e w o r i g i n a l a r t i c l e a n d u s e the o r i g i n a l a r t i c l e as the r e f e r e n c e  (d)  the  source.  S e c t i o n XI: N u r s i n g I m p l i c a t i o n s . E v e r y s t a t e m e n t s h o u l d be r e f e r e n c e d .  The A m e r i c a n Hospital F o r m u l a r y S e r v i c e and/or r e f e r e n c e s used i n p r e p a r i n g S e c t i o n s I - X m a y be r e p e a t e d .  (e)  S e c t i o n XII:  I n s t r u c t i o n s to P a t i e n t  E v e r y s t a t e m e n t s h o u l d be  referenced.  A u s e f u l r e f e r e n c e i s " D r u g s and N u r s i n g I m p l i c a t i o n s 1 1 by and H a y e s .  The  reference sources may  Govoni  be e i t h e r p r i m a r y ( o r i g i n a l a r t i c l e s )  or t e r t i a r y (textbooks and f o r m u l a r i e s ) .  (f)  6.  S e c t i o n XIII:  Presentation  A.  Dosage F o r m s Available - "CPS"  is recommended reference.  B.  Identi-Code  C.  C o s t - the c o s t to the c o m m u n i t y p h a r m a c i s t f o r 100 t a b l e t s o r c a p s u l e s i s o b t a i n e d f r o m the D r u g B e n e f i t L i s t i n the Student H e a l t h S e r v i c e P h a r m a c y , C u n n i n g h a m B u i l d i n g , U.B.C.  Number - if applicable.  General (a)  The  m e t r i c a n d c e n t i g r a d e s c a l e s s h o u l d be  (b)  The  f o l l o w i n g f o r m a t s h o u l d be u s e d f o r the b i b l i o g r a p h y :  JOURNAL:  B i l l i g , N.,  used.  Propoxyphene Hydrochloride  (Darvon) Poisoning  in a T h r e e Y e a r Old Child, A m e r . J . P i s . Child. 189  116:  187-  (August).  T E X T B O O K : Goodman, L.S.  a n d G i l m a n , A.,  The  T h e r a p e u t i c s , 4th e d i t i o n , M a c M i l l a n  Pharmacological C o . : New  York,  Basis 1970.  10*0  T h e a b b r e v i a t i o n s o f j o u r n a l n a m e s s h o u l d c o n f o r m to that o f I n d e x M e d i c u s .  In r e v i e w i n g c l i n i c a l c a s e r e p o r t s , the s t u d y s h o u l d h a v e a r a n d o m ized double-blind  t r i a l with a s a m p l e s i z e of a p p r o x i m a t e l y Z 0  p a t i e n t s b e f o r e the r e s u l t s c a n be c o n s i d e r e d One  exception  statistically significant.  i s a d v e r s e d r u g r e a c t i o n s i n w h i c h c a s e , the  s i z e c a n be r e d u c e d to o n l y one  sample  patient.  In c l i n i c a l c a s e r e p o r t s , i t i s i m p o r t a n t to c o n s i d e r p e r t i n e n t p a t i e n t factors: i) ii)  kidney function l i v e r function  iii)  age,  iv)  other coinciding  v) vi)  weight,  diseases  placebo effect spontaneous r e m i s s i o n i.e.,  vii)  sex  of the d i s e a s e ( i f a p p l i c a b l e )  rheumatoid  arthritis  s e a s o n a l v a r i a t i o n of the d i s e a s e i . e . , hay f e v e r  (if applicable)  101  P H A R M A C Y 403 DRUG AND  POISON INFORMATION F o r m a t for D R U G  1.  II.  General  CENTRE  (DPIC)  MONOGRAPH  Information:  A.  Heading:  A H F S Pharmacologic - Therapeutic  B.  Non-propriatory  C.  Trade name or synonyms.  Classification Number.  name.  Action : A.  Absorption - includes absorption by usual routes of a d m i n i s t r a t i o n b u t s h o u l d not be c o n f i n e d o n l y to r o u t e s u s e d f o r c o m m e r c i a l l y a v a i l a b l e p r e p a r a t i o n s ; onset; duration of action; peak blood levels following various routes; factors affecting absorption.  B.  D i s t r i b u t i o n - usual distribution in body t i s s u e s and fluids; indicate protein binding, penetration of blood-brain b a r r i e r , across placental b a r r i e r .  transfer  C.  M e t a b o l i s m - half-life and factors affecting; sites of b i o t r a n s f o r mation; metabolic products and their activity.  D.  E x c r e t i o n - r o u t e ( s ) o f e l i m i n a t i o n f r o m the b o d y ; f a c t o r s a f f e c t i n g elimination; form in which eliminated.  III.  S p e c t r u m of A c t i v i t y : ( i f a p p l i c a b l e ; e.g.,  b a c t e r i a l , fungal, etc.).  IV.  Indications: Statement of indications and use (Indicate p r o p h y l a c t i c , t h e r a p e u t i c , p a l l i a t i v e , c u r a t i v e , s u p p o r t i v e u s e , e t c . ).  V. VI.  C o n t r a i n d i c a t i o n s : (include p r e g n a n c y if i n f o r m a t i o n known). Cautions:  e.g. u s e i n patients with c e r t a i n d i s e a s e s o r under conditions.  certain  102  VII.  Dosage: A.  Include m i n i m u m , m a x i m u m and m a i n t e n a n c e d o s a g e .  B.  State r o u t e s of a d m i n i s t r a t i o n a n d  C. . G i v e adult and  VIII.  IX.  X.  XI.  dose schedule.  children's dosage.  . Side E f f e c t s A.  Include incidence (if a v a i l a b l e ) .  B.  Group according  C.  R e p o r t changes i n r e n a l or hepatic changes - function, blood dyscrasins, etc.  Drug Interactions:  to b o d y s y s t e m ( e . g . , G .  (include OTC's)  A.  Drug - drug.  B.  Drug - food.  C.  Drug - lab. test.  I.V.  1.).  I n c o m p a t i b i l i t i e s : (if a p p l i c a b l e )  Nursing Implications:  (not a l l c a t e g o r i e s w i l l be a p p l i c a b l e ) .  A.  Observation for a d v e r s e r e a c t i o n s , hypersensitivity reactions, toxicity.  B.  M o n i t o r i n g of v i t a l s i g n s , c a r d i a c  C.  L a b . tests for r e n a l , and/or hepatic function, blood counts, blood chemistry, etc.  D.  O b s e r v a t i o n f o r p h y s i c a l c h a n g e s i n d r u g - e.g.,  E.  M e t h o d , route, t i m e of a d m i n i s t r a t i o n .  F.  Storage.  status.  discolouration.  103  XII.  XIII.  XIV.  XV.  I n s t r u c t i o n s to P a t i e n t : A.  C o r r e c t m e t h o d s of a d m i n i s t r a t i o n .  B.  D r u g - f o o d and  C.  "Selected"  D.  Contraindications for continued  E.  Specific storage instructions.  drug-drug (including OTC)  side e f f e c t s .  Presentation: A.  Dosage forms available.  B.  Identi-code n u m b e r .  C.  Cost.  References:  Date P r e p a r e d :  use.  interactions,