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Am Fam Physician. 1998;57(11):2615-2616

to the editor: The article1 and editorial2 concerning adverse drug reactions highlight a major problem in medicine today. With the ever-enlarging body of drugs available and a population that is living longer and ingesting an increasing number of prescription and over-the-counter medications, the potential for harm grows.

The article by Drs. Holland and DeGruy suggests that as many as 10 percent of hospital admissions may be attributable to drug-induced disorders. Family physicians see a large proportion of patients and write many of the prescriptions that are ingested. They are thus apt to produce numerous unfavorable results.

I have been interested in this problem for over 15 years, writing and lecturing during this period.35 Despite this focus, I have found myself guilty of failing to detect some important adverse events.

Because of the multiple and varying etiologies of some of these untoward reactions, we can never hope to fully eliminate all such accidents. Nevertheless, constant attention to this problem will help minimize much of the harm we are capable of inadvertently administering during therapy.

While we are all probably aware of the more frequent drug interactions, there are many less common interactions that are difficult for a physician to remember. We must depend on tools other than our memories. In this modern world, many of us are failing to enlist an obvious ally—the computer. Physicians, pharmacists and hospitals should all be required to check with existing computer programs when a patient receives a medication or prescription. Expecting a physician to devote the time necessary to search through the Physicians' Desk Reference or a similar volume is not realistic.

The possibility of your patient adversely reacting to a drug may be only 1 percent, but in that patient the adverse reaction would be 100 percent.

in reply: We appreciate the comments from Dr. Friedman. We agree that it is impossible for a prescribing physician to be aware of all potential problems of medications. The number of drugs available for use increases by one to two each month, and it is preposterous to expect one to memorize all of the potential problems inherent in using these agents.

Numerous computer programs and other resources that review medication lists for potential problems have been developed. Unfortunately, however, many programs are too sensitive and detect clinically irrelevant interactions, while significant interactions are often missed. Nonetheless, these resources can serve as valuable tools for prescribing medications appropriately.

To minimize drug-induced problems, physicians should create a systematic approach to prescribing, giving careful attention to all prescription and nonprescription medications, vitamins, herbs and “health food” products. This approach should include the development of active partnerships between the physician and the clinical pharmacist. Clinical pharmacists, who are trained drug experts, combine their expertise and the information provided from various resources to determine the drug-related issues that need to addressed and modified. Furthermore, clinical pharmacists who are provided with sufficient patient-specific data can identify additional drug-related problems, such as dosing concerns in patients with renal insufficiency and drug-disease interactions.

A deliberate and conscientious approach to prescribing medications, coupled with the full use of a clinical pharmacist's expertise, will enable physicians to use medications with maximum benefit and minimal harm. Providing safe and effective medications for patients is a shared responsibility between the prescribing physician and the clinical pharmacist.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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