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Background Although Kentucky pharmacists recently gained authority to provide protocol-driven care for 13 conditions, provision of prescription hormonal contraception (HC) services is not currently authorized. A board-approved protocol allowing for provision of nonprescription over-the-counter (OTC) emergency contraception (EC) was recently approved by the Kentucky Board of Pharmacy but has yet to be implemented. Objectives The objectives of this study were (1) to assess Kentucky pharmacists’ interest in providing prescription HC and OTC EC services via protocol and (2) to identify perceived benefits/barriers regarding provision of prescription HC. Methods An online questionnaire was disseminated electronically to a convenience sample of Kentucky pharmacists. The questionnaire collected (1) demographic information, (2) opinions regarding provision of prescription HC and OTC EC, and (3) perceived benefits and barriers regarding provision of prescription HC. For analysis, responses were limited to pharmacists in community-based practice. McNemar’s test was used to identify statistically significant differences in support by dosage form. In addition, a multivariable logistic regression model was used to examine associations between demographic factors and support for pharmacist provision of prescription HC. Results We received 151 responses from community-based pharmacists. Support for provision of prescription HC was highest for oral (61%) and transdermal (54%) forms. We found no statistically significant differences in support among demographic factors other than number of years in practice, with more recent graduates being at higher odds of support. In addition, time, reimbursement, training, and belief in the need for pelvic exams were the most commonly cited barriers to implementation. With regard to OTC EC provision, pharmacists were largely supportive (62%) and confident in their abilities. Conclusions Community-based pharmacists in Kentucky are supportive of provision of oral, vaginal, and transdermal prescription HC as well as OTC EC via protocol. Barriers, including time, reimbursement, training, and belief in the need for pelvic exams, should be addressed to increase support for prescription HC provision.

Objectives An interprofessional group of health colleges' faculty created and piloted the Barriers to Error Disclosure Assessment tool as an instrument to measure barriers to medical error disclosure among health care providers. Methods A review of the literature guided the creation of items describing influences on the decision to disclose a medical error. Local and national experts in error disclosure used a modified Delphi process to gain consensus on the items included in the pilot. After receiving university institutional review board approval, researchers distributed the tool to a convenience sample of physicians (n = 19), pharmacists (n = 20), and nurses (n = 20) from an academic medical center. Means and SDs were used to describe the sample. Intraclass correlation coefficients were used to examine test-retest correspondence between the continuous items on the scale. Factor analysis with varimax rotation was used to determine factor loadings and examine internal consistency reliability. Cronbach α coefficients were calculated during initial and subsequent administrations to assess test-retest reliability. Results After omitting 2 items with intraclass correlation coefficient of less than 0.40, intraclass correlation coefficients ranged from 0.43 to 0.70, indicating fair to good test-retest correspondence between the continuous items on the final draft. Factor analysis revealed the following factors during the initial administration: confidence and knowledge barriers, institutional barriers, psychological barriers, and financial concern barriers to medical error disclosure. α Coefficients of 0.85 to 0.93 at time 1 and 0.82 to 0.95 at time 2 supported test-retest reliability. Conclusions The final version of the 31-item tool can be used to measure perceptions about abilities for disclosing, impressions regarding institutional policies and climate, and specific barriers that inhibit disclosure by health care providers. Preliminary evidence supports the tool's validity and reliability for measuring disclosure variables.

Objectives To provide a brief history of Facebook and online social networking and discuss how it has contributed and can contribute in the future to a paradigm change in social communications. Setting When student pharmacists complete school and enter practice, they encounter enhanced expectations to act appropriately and professionally. Facebook expands the dilemma of separating private and public life—a challenge for individuals in all professions. From the standpoint of a professional association, Facebook provides a tremendous opportunity to reach out to members in an unprecedented way. Pharmacy organizations are beginning to use these new tools to increase communication and dissemination of information. Conclusion The popularity of Facebook has brought the issue of online social networking to the forefront of professional and organizational discussions. The issues of privacy, identity protection, and e-professionalism are likely to reappear as pharmacists and student pharmacists continue to communicate via online networks. The potential exists for organizations to harness this organizational and communication power for their own interests. Further study is needed regarding the interaction between online social networking applications and the profession of pharmacy.

Policies exist at many levels and impact the practice of pharmacy in a wide variety of ways. Some pharmacists may seek advanced education related to policy development and assessment. In this article, policy is defined and the various ways the term is used with regard to the profession are reviewed with selected examples provided. Sources of information about policy-related degree programs offered both by educational units primarily focusing on pharmacy and units outside the specialty area are emphasized along with points to consider in making a decision. Examples of career opportunities are provided and questions to consider are presented.

Objective: To develop, implement, and evaluate a pilot “Pharmacy 101” seminar designed to provide faculty, staff, and graduate students with an overview and orientation to the pharmacy profession and academic pharmacy. Design: Objectives and specific topics for inclusion for the seminar were developed and refined based on input from the Office of the Dean as well as Chairs of both College Departments. Assessment: The seminar has been offered on three separate occasions. The first two offerings were open to the entire college community, whereas the third session was delivered as part of the college of pharmacy’s new graduate student orientation. At the initial offering, participants voluntarily completed an initial evaluation and a postseminar evaluation 60 days later. For the second and third sessions, all participants were asked to complete an initial evaluation and a 15-item pre and post multiple-choice test instrument. Fourteen individuals completed the initial seminar offering, seven the second, and 15 participants took part in the graduate student section. Responses to initial evaluations from all three cohorts were positive and constructive. The pre and post test instruments used in the second and third cohorts demonstrated consistent learning. Conclusion: This seminar appeared to meet its objectives. Similar seminars can be developed to improve faculty, staff, and graduate student productivity and job satisfaction. Future considerations include expansion into a required component of

A variety of challenges facing the health care system in general and the profession of pharmacy in particular creates a need for pharmacists who have completed advanced education and training in administration. Some may choose to look outside academic pharmacy for graduate degree programs in administration. Four types of administrative degrees — MBA, MHA, MPA, and MPH — are described. A list of factors to be considered by a person thinking about pursuing graduate education in this area is presented and discussed. The admission process is described as it may typically occur for such programs in order to familiarize pharmacists with what criteria are likely to be used. An informed evaluation of the alternatives available will help students select the program best suited to their career goals.

Some pharmacists have used a power of attorney document for quite some time when submitting orders for controlled substances. This is authorized by Drug Enforcement Administration (DEA) regulations. Increasingly pharmacists are encountering power of attorney documents in another context – durable powers of attorney authorizing an Agent to make health care decision for the Principal. Medicare requirements have greatly expanded use of such advance directives. Thus, pharmacists may encounter these documents with both professional and personal issues. Types of power of attorney documents are reviewed with the differences highlighted. A variety of legal requirements that may apply are discussed and situations where such documents may prove helpful are listed. Issues related to the Agent are discussed, because pharmacists may find themselves in this role or in the role of advising someone selecting an Agent. How to revoke such legal documents is described as well.

Pharmacies are a potential site for access to sterile syringes as a means for preventing human immunodeficiency virus (HIV), but the type and extent of their utility is uncertain. To examine pharmacy syringe purchase, we conducted a standardized, multistate study in urban and rural areas of four states in which attempts to purchase syringes were documented. Of 1,600 overall purchase attempts, 35% were refused. Colorado (25%) and Connecticut (28%) had significantly lower rates of refusal than Kentucky (41%) and Missouri (47%). Furthermore, urban settings had higher rates of refusal (40%) than rural settings (31%, P

Objective To examine pharmacists' attitudes and practices surrounding human immunodeficiency virus (HIV) prevention among injection drug users. Design Focus groups. Setting Urban and rural sites in Colorado, Connecticut, Kentucky, and Missouri. Patients or Other Participants: Eight focus groups, with 4 to 11 pharmacists participating in each group. Interventions Transcripts of focus group discussions were evaluated for common themes by the authors and through the use of NUD*IST. Main Outcome Measures Willingness to sell syringes to all customers, views on syringe exchange programs (SEPs), knowledge of laws governing syringe sales and racial, ethnic, or gender biases in syringe selling practices. Results Two pharmacists established their own policies of selling syringes to everyone, and three expressed a willingness to have their pharmacies serve as SEPs. A total of 20% of the pharmacists expressed an interest in learning more about the efficacy of SEPs and distribution of syringes by pharmacists, and were willing to change their views based on this information. Many also indicated a general willingness to work with SEPs or to participate in the effort to curb the spread of HIV. However, a majority of pharmacists opposed having SEPs in their pharmacies and reported selling syringes only within specific limits: to known diabetics, to individuals who looked reasonable, or to individuals who presented a logical explanation. No racial, ethnic, or gender bias was observed. Conclusion Opinions among pharmacists varied across and within sites. While a majority of pharmacists would not establish SEPs in their own pharmacies, nearly all would participate in other HIV-prevention programs. Educational programs for pharmacists may be valuable in HIV-prevention efforts.

Objective To examine injection drug users (IDUs) opinions and behavior regarding purchase of sterile syringes from pharmacies. Design Focus groups. Setting Urban and rural sites in Colorado, Connecticut, Kentucky, and Missouri. Patients or Other Participants: Eight focus groups, with 4 to 15 IDU participants per group. Interventions Transcripts of focus group discussions were evaluated for common themes by the authors and through the use of the software program NUD*IST. Main Outcome Measures Knowledge of human immunodeficiency virus (HIV), pharmacy use, barriers to access from pharmacies, high-risk and risk-reducing behavior, and rural/urban difference. Results Almost all participants knew the importance of using sterile syringes for disease prevention and reported buying syringes from pharmacies more than from any other source. Two IDUs believed pharmacists knew the syringes were being used for injecting drugs and perceived pharmacists' sales of syringes to be an attempt to contribute to HIV prevention. Most IDUs reported that sterile syringes were relativity easy to buy from pharmacies, but most also reported barriers to access, such as having to buy in packs of 50 or 100, being made to sign a book, having to make up a story about being diabetic, or having the feeling that the pharmacists were demeaning them. While the majority of IDUs reported properly cleaning or not sharing syringes and safely disposing of them, others reported inadequate cleaning of syringes and instances of sharing syringes or of improper disposal. There were few differences in IDUs' reported ability to buy syringes among states or between urban and rural sites, although the data suggest that IDUs could buy syringes more easily in the urban settings. Conclusion For the most part, participants understood the need for sterile syringes in order to protect themselves from HIV, hepatitis B virus, and hepatitis C virus and saw pharmacies as the best source of sterile syringes. Although these data are not generalizable, they suggest that pharmacists can and do serve as HIV-prevention service providers in their communities.

Direct-to-consumer advertising of prescription-only medications is big business for pharmaceutical manufacturers and has altered the relationship between patients and health professionals. Seeing promotional messages from the manufacturer of a pharmaceutical can have both positive and negative impacts. These are discussed along with current efforts to control activities in this area as well as possible future developments.

*Objective: The goal of this project was to categorize and classify bulletin board postings pertaining to pharmaceutical policy from both the professional and lay press. Methods: Bulletin board postings were used to supplement in-class discussion to keep students, faculty and staff up-to-date on emerging trends. A bulletin board located in the main classroom area of the College of Pharmacy Building where students would pass by on the way to class and congregate during break periods was used to display articles from various sources concerning topics related to pharmaceutical policy. Information is presented about the primary subject matters addressed in the articles, the types of publications from which they were drawn, and the top ten sources of articles displayed. Results: This project showed that coverage of issues related to pharmacists is predominantly seen in newspapers and most pertinent issues are business related. Conclusions: It can be seen from this analysis that the issues facing pharmacists are varied. The pharmaceutical policy field is transforming and many of these changes are very relevant to the general population. This is seen from the coverage of all of these issues in the lay press.

In the United States, up to 80% of prescription drugs are prescribed for indications not approved by the Food and Drug Administration (FDA).[1][1] Unlabeled use is often the mainstay of therapy in patient populations for whom less conclusive evidence is available, such as pediatric,[2][2] oncology,[

Lethal injection as a method of state-sanctioned capital punishment was initially proposed in the United States in 1977 and used for the first time in 1982. Most lethal injection protocols use a sequential drug combination of sodium thiopental, pancuronium bromide, and potassium chloride. Lethal injection was originally introduced as a more humane form of execution compared with existing mechanical methods such as electrocution, toxic gassing, hanging, or firing squad. Lethal injection has not, however, been without controversy. Several states are considering whether lethal injection meets constitutional scrutiny forbidding cruel and unusual punishment. Recently in the case of Ralph Baze and Thomas C. Bowling, Petitioners, v John D. Rees, Commissioner, Kentucky Department of Corrections et al, the United States Supreme Court upheld the constitutionality of the lethal injection protocol as carried out in the Commonwealth of Kentucky. Most of the debate has surrounded the dosing and procedures used in lethal injection and whether the drug combinations and measures for administering the drugs truly produce a timely, pain-free, and fail-safe death. Many have also raised issues regarding the "medicalization" of execution and the ethics of health care professionals' participation in any part of the lethal injection process. As a result of all these issues, the future of lethal injection as a means of execution in the United States is under significant scrutiny. Outcomes of ongoing legislative and judicial reviews might result in cessation of lethal injection in totality or in alterations involving specific drug combinations or administration procedures.

Widespread use of social media applications like Facebook, YouTube, and Twitter has introduced new complexities to the legal and ethical environment of higher education. Social communications have traditionally been considered private; however, now that much of this information is published online to the public, more insight is available to students' attitudes, opinions, and character. Pharmacy educators and administrators may struggle with the myriad of ethical and legal issues pertaining to social media communications and relationships with and among students. This article seeks to clarify some of these issues with a review of the legal facets and pertinent court cases related to social media. In addition, 5 core ethical issues are identified and discussed. The article concludes with recommendations for pharmacy educators with regard to preparing for and addressing potential legal issues pertaining to social media.

To the Editor. Three pharmacist-lawyers collaborate to offer the course PPS 930: Legal, Ethical and Access Issues in Pharmacy to second-year doctor of pharmacy (PharmD) students at the University of Kentucky during the fall semester. This 4 semester-hour course was offered during 2009-2010 for the fourth consecutive year by this trio of instructors. Each instructor delivers about a third of the lectures and the 1 full-time faculty member in the group serves as the course coordinator, attending all class sessions, composing examinations and quizzes, and grading all examinations, quizzes, and term papers. Content of the course breaks down approximately as follows: Legal Issues, 60%; Ethical Issues, 20%; and Access Issues, 20%. Each summer the instructors meet to plan the impending course offering. These discussions have been influenced by a November 2007 article in the American Bar Association Journal regarding use of laptop computers in law school classrooms: “Profs Kibosh Students' Laptops: More Law Schools Are Banning Them as a Distraction – or Worse.”1 This article focused the instructors' attention on this particular PPS 930 course goal included in the syllabus: A corollary goal that is pervasive throughout the course is to give the student experience in listening to professional communication and discerning points of relevance and importance. Bear in mind that this course is about establishing standards for behavior and having people conform their behavior to those standards. That's the essence of law and ethics.2 Faculty colleagues have reported that when they sit in the rear of the classroom where use of laptops is permitted, they have seen students sending e-mail messages to one another, placing orders with Internet vendors, and doing all sorts of other non-class-related things. All the while the instructor is at the front of the room assuming the students are faithfully recording the information being presented. Banning use of laptops brings to mind a quotation from Diane Sawyer, the television news journalist: “I think the one lesson I have learned is that there is no substitute for paying attention.”3 The professional ramifications of these issues surface because this course is designated a professional practice course. All work in this course is expected to be the student's own, including note taking. Hearing the information, thinking about it, and recording your thoughts should all be done independently as will be expected when you are in practice. Use of ‘scribe notes’ is prohibited in this course; each student is to generate his or her own notes just as would be expected when interacting with a patient to collect information.2 A further reference to the professional nature of this course appears in this component of the syllabus: Students should view their participation in this course as being equal in importance or akin to interacting with a patient. A pharmacist who has scheduled a session with a patient would be expected to honor the commitment by being there, by arriving punctually, and by eliminating any potential for distraction during the interaction. Your classmates and instructors, your present and future professional colleagues, are due at least the same level of respect. The Course Coordinator and instructors reserve the right to exclude from the classroom students whose conduct or behaviors in the sole judgment of the instructors or Course Coordinator interfere with the learning environment for others. It should be noted that one example of such ‘interference with the learning environment for others’ during class is having one's cell phone ring, while other examples would be engaging in disruptive or bothersome communication with others such as text messaging or email communication during class or clicking the keys on a laptop computer. You will be expected to provide your undivided attention to matters being discussed in class just as this would be expected in a professional interaction with a patient. In order to prevent that latter event, use of laptop computers is prohibited during class sessions in this course.2 The decision to ban use of laptops by students and “scribe notes” was not implemented without serious consideration that the policy runs directly contrary to the trend in American higher education. The policy flies in the face of people's infatuation with information technology resources and may even open the instructors to being labeled Neanderthals or dinosaurs! More practically, it could be attributed to the fact that none of the 3 instructors can type, thereby creating a possible bias against students who enjoy an advantage by having that skill. It could be argued that permitting use of laptops gives an advantage to those students who can type over those who cannot. Nearly everyone can write. This course has now been conducted twice with these policies in place and the students survived and even did well. They were attentive and engaged in classroom discussion of issues. Course evaluations reveal the students' acceptance and even support for these course policies. Joseph L. Fink III, BSPharm, JD University of Kentucky College of Pharmacy

To compare the regulations of state boards of pharmacy for pharmacist intern supervision and review publications of service-learning experiences in pharmacy curricula for methods of supervision.Online state pharmacy statutes and board of pharmacy regulations were searched to characterize which states' regulations included provisions for the supervision of pharmacist interns, permitted nonpharmacist supervision for student volunteers, and included provisions on interns participating in the practice of pharmacy. Additionally, a PubMed search was conducted for articles describing the supervision of service-learning experiences of pharmacy students at various colleges and schools of pharmacy.The state boards of pharmacy in all 51 jurisdictions included regulations for the supervision of pharmacist interns. Regulations specifically permitted only pharmacist supervision of interns in 45 (88%) jurisdictions, and 3 (6%) states included provisions allowing nonpharmacist supervision of pharmacist interns. Provisions allowing nonpharmacist supervision on a case-by-case basis existed in 6 (12%) jurisdictions. Among the 32 identified reports of service-learning experiences offered in pharmacy curricula, 14 contained the words "supervision" or "supervise," and 9 indirectly described methods of student supervision.State boards of pharmacy regulations largely prohibited nonpharmacist supervision of pharmacy students, and reports of pharmacy student service-learning experiences frequently omitted descriptions of student supervision. Boards of pharmacy should consider revising existing regulations to address the growing need for service-learning in pharmacy curricula.

The effects of amendments to state antisubstitution laws on the hospital formulary system are discussed. The approaches of four states--California, Michigan, Minnesota and Delaware--are reviewed. It is concluded that the legal basis of the hospital formulary system remains intact regardless of the changes in state antisubstitution laws.

Legal issues associated with the use of pharmacokinetic computer software are discussed. One issue involves the physician's reliance on the pharmacist, as a drug therapy expert, to provide consultation on drug dosages. Another issue is the problem of liability associated with the software and how this relates to the physician, the pharmacist, and those who designed, manufactured, and sold the software. The legal concept of negligence as it relates to medical computer software is discussed. Although the programmer and the manufacturer are responsible for verifying that the program does what it purports to do, the user must exercise due care in identifying any program limitations that might influence the accuracy of a consultation. Clinical perspective, effective validation techniques, and critical selection will help to ensure that pharmacokinetic computer software is developed, purchased, and used safely and effectively.

The law regarding refusal of psychiatric patients to take psychotropic medication is reviewed. The law in this area is traced through its evolution beginning in the 1960s when failure to administer medication to psychiatric patients was considered mistreatment of the patient. The legal basis for forcible administration of drugs is reviewed, and a discussion of cases in which patients refused to accept treatment on religious grounds is presented. When children are involved, the courts are generally in accord that the parents' right to freedom of religion ends where the child's right to life begins or when there is a threat to public health and safety. In cases involving adults, without a threat to public health or safety, relevant opinions rule that medical treatment should not be ordered against the patient's religious beliefs because it would constitute a violation of the First Amendment. Two leading cases involving the forcible administration of medication, Rennie v. Klein and Rogers v. Okin, held that administration should be limited to emergency situations when there is substantial risk of injury to the patient or others in the hospital. The Supreme Court made it clear that the right to refuse must be derived from state law, not from the federal Constitution, apparently giving health-care professionals broad leeway in exercising professional judgment in this area.

The Poison Prevention Packaging Act of 1970 became effective on December 30, 1970, and its provisions and the enforcement efforts of the regulatory agencies charged with administering the Act have caused great consternation among both laymen and health professionals. An understanding of the social policy reflected by this legislation as well as the standards which have been promulgated for child-resistant packaging may go far to ameliorate the frustrations of those who have to deal with the requirements of the Act on a daily basis. A discussion of the historical evolution of the 1970 Act and the controversy surrounding it is followed by a review of the standards for child-resistant packaging and exemptions from the requirements of the Act. A discussion of physician and patient waivers focuses on the desirability of documentation. The role of the Act in a professional liability suit is anticipated. A list of the drugs which are currently under consideration for exemption is provided. A better understanding of this legislation should enable health professionals to better deal with their patients.

The process by which courts determine negligence on the part of a pharmacist is discussed, and important malpractice decisions involving pharmacists and other medical professionals are summarized. Courts expect pharmacists to exercise a high level of "due care." It is unclear whether a hospital pharmacist would be held t a standard created by general practitioners or by specialists in institutional practice; but a good case can be made for a special standard. If the court finds that professional standards are deficient, the court may establish higher standards. Pharmacists should ensure that their performance meet legal expectations by keeping abreast of new developments in pharmaceutical practice.

In the United States the number of elderly and their percentage of the total population continues to increase. The large majority will never require care in an institution, yet they are faced with increasing health problems and decreased mobility, and almost half require prescription drugs to pursue activities of daily living. In this paper selected patterns of pharmacy patronage among a sample of elderly are presented. Overall, the percentage of elderly requiring prescriptions reflects national estimates and no significant difference is found in the expressed need for prescriptions between black and respondents. ‘Neighborhood’ pharmacies are perceived as being very important, but relatively few use the most geographically convenient. Nevertheless, the large majority of elderly are satisfied with distances they presently have to travel to purchase prescriptions. The observed travel patterns for prescription purchases suggest that conventional wisdom pertaining to the nature of the pharmacy journey, the notion of convenience and the traditional concept of neighborhood among the elderly should be reexamined.

Patient package insert regulations by the Food and Drug Administration are discussed, emphasizing the pharmacist's responsibility. The possible criminal and civil liability problems the pharmacist may face under the regulations are considered. Legal implications of alternatives to using PPIs provided by the manufacturer are presented. The prudent pharmacist will examine the alternatives, weighing the administrative, clinical and legal implications of the various approaches.

Court cases in which the Standards of the Joint Commission on Accreditation of Hospitals have been introduced into evidence are reviewed to examine the various legal roles of the Standards and to consider some implications of this for the hospital and for the hospital pharmacist. Following a review of the Darling case, the role of the Standards in establishing a legal duty is examined with emphasis on a case involving medication handling where it was held that a hospital may be liable for damages resulting from failure to comply with JCAH Standards. The Standards have also been used to assist in creating a national standard of due care by abrogating the locality or community rule. Miscellaneous uses of the Standards are also discussed. The product institutional pharmacist will be thoroughly familiar with JCAH Standards applicable to activities related to medication handling and take steps to assure that every effort is made to comply with these requirements.

The legal implications of pharmacists serving as therapeutic consultants to other health professionals are discussed. The legal view of the consultant relationship and the relative liability exposure of the primary practitioner and the consultant are reviewed. The pharmacist's liability when serving as a therapeutic consultant is considered in light of the high standard of care that would probably be used in evaluating the pharmacist's performance. Other legal issues considered include potential criminal liability of the pharmacist, whether responses should be in writing, impact of charging for therapeutic consultation services, and coverage for such activities under professional liability insurance policies. By being aware of the legal implications in these areas, pharmacists may limit their liability exposure to an acceptable level.

The legality of state requirements that professionals participate in continuing professional education is discussed. The historical development of the requirement in pharmacy is reviewed, and the legal doctrine of police power is considered as the basis for legal requirements in this area. The need for a statutory basis for this condition is presented, and court cases wherein such requirements have been challenged are reviewed. There must be statutory authorization for imposing continuing education requirements for professionals, and the statute and regulations affecting the rule must not infringe on an individual's constitutional rights.

Tax issues related to sales of medications to outpatients by pharmacies in nonprofit hospitals are described. Hospitals are increasing their emphasis on development of ambulatory-care programs. Two aspects of the tax implications of such services are (1) whether revenue from sales of medications to ambulatory patients constitutes "unrelated business income" for the nonprofit hospital and thus is taxable and (2) whether engaging in dispensing of medications to ambulatory patients might jeopardize the tax-exempt status of the hospital. Various rulings from the Internal Revenue Service and court cases are reviewed. Sales of medications to members of the general public who are unrelated to the hospital are taxable. Sales of medications for the convenience of hospital patients, and irregular and intermittent sales to the public by a pharmacy that normally serves only "patients," are tax exempt. Sales of medications to the public probably do not jeopardize the tax-exempt status of a hospital so long as the primary purpose of the hospital is consistent with permissible tax-exempt purposes.

The incidence of drug-related liability claims is discussed, and data from a number of studies in this area are reviewed. Drug categories that appear to cause the greatest problems are hormones, anticoagulants, adrenal steroids, and antibiotics. Focusing attention on these categories may enable the pharmacist to function as a liability-reducing factor in the institutional setting.

Issues surrounding the screening and testing of individuals for drug use, including analytical and legal aspects of the procedures and social, political, and ethical problems and concerns, are reviewed. Historically, professional and societal debate regarding drug taking, drug-use problems, and the utility of drug testing programs occurs in cycles. Analytical methods commonly used to test for drug use include breath analysis for alcohol and urine drug assays. Blood alcohol concentrations are determined by laboratory assay methods or by portable devices used in the field. While poor laboratory procedures can invalidate test results for both breath and urine tests, urine screening test results can be further invalidated by improper handling of specimens or by tampering on the part of the subject. Also, test results are meaningful only if they are correlated with a clinical state. Legal issues have been raised concerning the validity of testing procedures used and the reliability of evidence obtained, especially in relation to pre-employment drug screening. From an ethical standpoint, drug testing tends to focus efforts to combat drug abuse on the drugs themselves instead of on the social context of the problem. With a recycled interest in drug-use testing and screening, primarily attributable to technological advances, little attention is being given to other approaches to controlling drug use. Additional research is needed to better describe the nature and extent of our drug-use problems and their impact on society.

Liability issues of hospitals with contract-managed pharmaceutical services are discussed. The number of hospitals with pharmaceutical services operated by outside organizations is rapidly increasing. Because pharmacy personnel are employed by the contractor rather than the hospital, a hospital's liability for the actions of these employees is related to the specific agreement between the hospital and the contractor. Application of the doctrine of respondeat superior to these contractual arrangements and specific factors determining the degree of control that the hospital has over contracted employees are discussed. Hospitals contemplating the use of contract-managed pharmaceutical services should determine the exact nature of their liability for the actions of contracted employees.

The potential for clinical pharmacy services to reduce the liability of institutions and the personnel who practice in them is presented. Several studies are reviewed that identify the characteristics of patients who are at a high risk of developing complications. Based on these data and data gathered on drug-related malpractice claims, pharmacists can concentrate their efforts on those patients who have the greatest liability implications to the institution. Pharmacists' efforts to reduce the liability of their institutions can also provide a justification for their clinical services.

Pharmacists often are called upon to adjust the number of dosage units dispensed pursuant to a prescription. Common examples are requests to dispense half or double the amount requested by the prescriber. In some cases, reductions in quantity may be dictated by the provisions of a prescription drug insurance program, either private or governmental. A review of the literature reveals very little information on the legality of such actions by pharmacists. Focusing on both the federal Food, Drug and Cosmetic Act and the federal Controlled Substances Act, a review of the law in this area is presented. Some states also have provisions, either in statutes or regulations, that address the issue. Specific examples are presented and discussed, with the goal being to clarify the law in this area with which the pharmacist must deal on a daily basis.