its mechanisms for collecting, recording, and using data and is it cannot afford to sit on its laurels. The report does not find it developing a programe for training staff in crosscultural guilty of racial bias, but neither does it find it not guilty-it can- awareness. It also plans to commission a prospective study to try not because of the parlous state of the organisation's records. to explain the rising proportion of overseas qualified doctors Public bodies have a clear responsibility to maintain records that within the complaints procedure. A major challenge remains: how will allow their processes to be independently monitored. Other- to balance the need for more accountability and visible uni- wise how can an organisation be held accountable to its members formity in decision making with the need to leave room for or to the public? As the authors of the report make clear, interpretation and unforeseen circumstance. inadequate records and obscure decision making processes will The GMC is right to resist imposing a rigid, all embracing leave the GMC open to accusations ofbias until such accusations definition of serious professional misconduct: this could never can be positively disproved. be flexible enough to cope with all eventualities. An alternative FIONA GODLEE approach might be the one developed by the GMC for assess- Assistant editor, BMJ ing seriously deficient professional performance.4 This would London WC1H 9JR still be based in case law, allowing interpretation within the 1 Smith R. Profile of the GMC. The day of judgment comes closer. BMY 1989;298:1241-4. light of current circumstances, but it would provide clearer 2 Esmail A, Everington S. General Medical Council. BMJ 1994;308:1374. articulation of the types of cases to be considered. 3 Allen I, Perkins E,Witherspoon S. The handling ofcomplaints against doctors. Report by the Policy Studies Institute for the Racial Equality Group of the General Medical Council. London: Policy The GMC should be praised for proving its commitment to Studies Institute, 1996. openness, both in commissioning and publishing this report. But 4 Brearley S. Seriously deficient professional performance. BMJ3 1996;312:1180-1.

Naming ofdrugs: pass the epinephrine, please Confusion over international differences mayputpatients at risk

The prescribing, supply, and consumption of medicines are loop diuretic frusemide differs from the recommended common occurrences. In 1994 over 300 million prescriptions international non-proprietary name furosemide because of were issued in Britain.The drugs involved were referred to potential confusion with furamide. About 12 such pragmatic either by their proprietary or approved names. Proprietary solutions exist. names are often catchy and easy to remember, and their Although the system of international non-proprietary biological activity is consistent, as opposed to certain generics, names has proved successful overall, there are important for which considerable biological non-equivalence has been exceptions among medicines that were introduced before the shown.' However, using proprietary names has disadvantages. 1950s. These differences have been highlighted by the imple- Firstly, most of them give little idea of the nature of the active mentation of European Commission directive 92/27.' ingredients, especially in the case of compound preparations. Unfortunately, the interpretation of this directive is that labels Secondly, proprietary names encourage illogical prescribing: and leaflets for medicinal products should use the products whose names begin with the letters in the first half of recommended international non-proprietary name where one the alphabet are prescribed significantly more often than those exists, or if one does not exist, the usual common name. Brit- from the latter half. A third problem is the fact that there is lit- ain's Medicines Control Agency has stated that an immediate tle or no international consistency among proprietary names. change to the use of unfamiliar recommended international By contrast, although the approved name may be more difficult non-proprietary names for medicines in common use would to remember and complex to write, it often reveals the therapeutic cause confusion and a risk to public health.4 Its policy is that category from which the drug is drawn. The approved name can the British approved name should continue to be used on indicate that a drug has more than one active ingredient, and use of labelling and that the recommended international non- generic drugs can lead to significant financial savings. As a conse- proprietary name should be included along with the British quence, the past five years have seen a welcome increase in generic approved name in patient information leaflets. The agency has prescribing in general practice. A further advantage is that the stated an intention to follow this policy until January 1998, approved name is almost always consistent from one country to after which it is expected that the recommended international another. This fortunate situation stems from an initiative taken by non-proprietary name will be used. The agency believes that the World Health Organisation during the 1950s.WHO's original the intervening two years will provide "ample opportunity for intention was to produce the same generic name, the so called rec- information on the future changeover to be disseminated to ommnended international non-proprietary name (rINN), for every industry, professionals and patients."4 However, many profes- medicinal substance across the world. The programme has been sionals take an opposite view. Indeed, objections have been highly successful in achieving harmonisation of drug names for raised by the Royal Pharmaceutical Society of Great Britain. substances developed and marketed in the past 40 years. Nevertheless, in view ofthe potential for confusion, the British The procedure is thatWHO proposes what it believes to be National Formulary started to include the differing inter- an appropriate international non-proprietary name. This national non-proprietary names from issue number 27 name is then published2 and four months are allowed for phar- (March 1994). maceutical companies and others to lodge formal objections In total, 41 drugs have a British approved name that is sig- when, for example, the proposed name might conflict with an nificantly different to their recommended international existing trademark and create unnecessary confusion. non-proprietary name, and of these, 13 are in common use. Examples ofmedicines whose British approved names (BANs) They include adrenaline, amethocaine, bendrofluazide, differ slightly from the recommended international non- benzhexol, chlorpheniramine, dicyclomine, hexachlorophane, proprietary names include mitoxantrone, an anticancer drug, lignocaine, noradrenaline, oestradiol, and phenobarbitone. For which was regarded as being too similar to the proprietary some, such as bendrofluazide (bendroflumethiazide), hex- name of another cancer chemotherapeutic agent, Mitoxana. achlorophane (hexachlorophene), oestradiol (estradiol), and The pragmatic solution was to "convert" mitoxantrone into phenobarbitone (phenobarbital), the differences are small and mitozantrone. Similarly, the British approved name for the are unlikely to cause much difficulty. For others, however, the

BMJ VOLUME 312 25 Y 1996 1315 differences are considerable and may well create problems. cal wards. The situation will not be improved if the names of Among these are the sympathomimetics adrenaline (epine- these agents are changed to trihexyphenidyl and benzatropine phrine) and noradrenaline (norepinephrine); the local respectively. British approved names have served us well over anaesthetics amethocaine (tetracaine) and lignocaine (lido- many years; is this another area in which subsidiarity should be caine); the antimuscarinic dicyclomine (dicycloverine); and allowed? Unless we address the issue now, we will be forced by the antihistamine trimeprazine (alimemazine). January 1998 to ask nurses to "pass the epinephrine please," No doubt, over time, changes of this magnitude can be but at what cost in terms of re-labelling and patient safety? accommodated just as we have coped with the switch from the CF GEORGE old imperial measures to grams, milligrams, and micrograms. Professor of clinical pharmacology However, it must be remembered that both adrenaline and University of Southampton, lignocaine are widely used in cardiovascular emergencies, in Southampton S016 7PX which a delay or a mistake could have serious consequences. 1 George CF. The balance for the patient: a final overview. In: Towse A, ed. Not what the doctor Additionally, I have personally experienced difficulties in ordered. The threat of medicines' substitution. Belfast: Queen's University of Belfast, 1993:97-103. obtaining injectable forms of the anti-parkinsonian prepara- 2 World Health Organisation. Proposed international non-proprietary names: list 74. WHO Drug tions benzhexol or benztropine for patients who have suffered Information 1995;9:236-78. 3 Council directive on the labelling of medicinal products for human use and on package leaflets. dystonic reactions to neuroleptic and anti-emetic compounds Official.Journal of the European Communities 1992;L 113 (31 March):8-12. (92/27/EEC.) because the drugs were unfamiliar to nurses working on medi- 4 Medicines ControlAgency. MedicinesControlAgencyMail 1995;91:5, 15.Airpollution inhomes

Air pollution in homes May be more important than outdoorpollution but is more difficult to monitor

The dangers of air pollution are a regular topic ofdiscussion in gen dioxide from gas cookers and about the effects of high the lay press, much of it ill informed. For example, the increas- counts of house dust mites on people with asthma. Together ing prevalence of asthma in Britain and elsewhere is widely with the survey, this report will help to shape the government's attributed to the rise in pollutants from motor vehicles, programme to promote good air quality in homes. although the balance of scientific evidence suggests that any Improving air quality in private dwellings is a challenge. In the influence of traffic pollutants on the initiation of asthma is control ofoutdoor pollution the government's approach has been small.' Traffic pollutants, especially fine particulates, do seem to set standards based on the advice of an expert panel of scien- to cause illness, but their impact on public health is probably tists. These standards are intended to prevent ill health even in less than that of smoking, diet, and poor housing. vulnerable groups such as asthmatic patients, and the extent to To date, attention has focused mainly on pollutants in out- which they are met is assessed by routine measurements at a net- door air, for which it is easy to blame others rather than work of monitoring stations. Monitoring pollutants in homes is ourselves. Indoor hazards that have attracted publicity have more difficult, and their control must depend in part on also tended to be those caused by someone else-such as individual choices. It may be practical to enforce standards for asbestos in schools and council flats or environmental tobacco ventilation in new houses and for emissions from new gas appli- smoke in offices. It is often overlooked that pollutants such as ances, but it would be unreasonable to limit the availability offur- benzene and nitrogen dioxide are commonly found at higher nishings and household equipment that pose a risk to only a small concentrations indoors than outside. Moreover, in countries minority of the population. Instead, people should be able to like Britain most people spend most of their time inside build- make informed choices depending on their personal circum- ings. Thus, even where outdoor levels of a pollutant are higher, stances. One step in this direction is a guide to controlling mites indoor levels may still be the main determinant of exposure. in the home, which the Department of the Environment Recognising the need for better information about indoor circulated earlier this year to general practitioners and allergy air quality, the Department ofthe Environment commissioned clinics and which is targeted at adults with asthma and parents of a survey by the Building Research Establishment, which pub- asthmatic children. lished its results this week.2 The study measured formalde- In the future we should see similar guides about other hyde, volatile organic compounds, nitrogen dioxide, and indoor air pollutants. In addition, there is an urgent need for biological particulates over a 12 month period in 174 homes in further information about indoor pollutants not covered by the southwest England. Findings included a higher count ofhouse survey. In particular, interpreting epidemiological data about dust mites in living room than bedroom carpets, with non-biological particulates in outdoor air would be much indications that the carpets themselves were a habitat for the enhanced if we knew more about their concentrations within mites as well as mattresses and other soft furnishings. The sur- buildings and how these relate to levels outside. vey also confirmed that levels of nitrogen dioxide are DAVID COGGON determined in part by outdoor concentrations, but are highest Reader in occupational and environmental medicine in kitchens with gas cookers. The mean nitrogen dioxide con- MRC Environmental Epidemiology Unit, centrations in two homes were above the World Health University of Southampton, Organisation's guideline value of 150 pg/m' over 24 hours in at Southampton General Hospital, least one 14 day period. Southampton Also published this week is a report from the Medical S016 6YD Research Council's Institute for Environment and Health, 1 Committee on the Medical Effects of Air Pollutants. Asthma and outdoor air pollution. London which reviewed the health effects ofindoor air pollutants at the HMSO, 1995. levels found in the Building Research Establishment's survey.' 2 Building Research Establishment. Indoor air quality in homes. London: Building Research Establishment, 1996. The conclusions are generally reassuring, but there is some 3 Humfrey C, Shuker L, Harrison P, eds. IEH assessment on indoor air quality in the home. Leices- concern about children's risks ofrespiratory illness from nitro- ter: MRC Institute for Environment and Health, 1996.

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