The impact of manufacturer back orders on the supply chain for pharmaceuticals in the institutional setting was studied. A questionnaire was distributed during May and June 2000 to 600 institutional pharmacies affiliated with a major national drug and supply group purchasing organization. The instrument included questions on basic institutional demographics, perceptions about the frequency of manufacturer back orders for pharmaceuticals, the quality of communication with manufacturers and wholesalers about back orders, the two most significant back orders that had occurred in the 12 months preceding the survey, and the reasons for and impact of back orders. A total of 170 usable surveys were returned (net response rate, 28.3%). Reported manufacturer back orders included an array of drug classes, including blood products, antimicrobials, antiarrhythmics, benzodiazepine antagonists, thrombolytics, corticosteroids, and antihypertensives. Respondents perceived significant back orders as increasing in frequency. Communication by manufacturers and wholesalers about back orders was reported to be relatively poor. A raw-material shortage was the most common reason given by manufacturers for back orders (36.5%), followed by a regulatory issue (23.2%). In most cases (92%), medical staff members had to be contacted, indicating an interruption in the normal drug distribution process. In over a third of instances, respondents stated that the back order resulted in less optimal therapy. A survey found that manufacturer back orders for pharmaceuticals were increasing in frequency and that information flow within the supply chain was insufficient to meet the needs of end users.