Drug Shortages Adversely Affect Patient Care, ISMP Survey Findings Suggest

Most respondents to an Institute for Safe Medication Practices’ (ISMP) national survey on drug shortages for hospital pharmacy directors or their designees conducted from August to October 2017 confirmed that drug shortages during the previous 6 months continue to be a daily struggle.¹

They suggested that providing appropriate and safe drug therapy has become extremely challenging during shortages and has led to numerous instances of compromised care, potentially harmful errors, and unsafe practices.

ADVERSE PATIENT OUTCOMES AND ERRORS

Nearly 300 respondents completed the survey on drug shortages. A majority said that drug shortages had compromised patient care. Most (71%) were unable to provide patients with the recommended drug or treatment for their condition, because of shortages, and nearly half (47%) said that this resulted in receiving a less effective drug. Also, three-quarters (75%) of respondents said that patient treatments had been delayed because of drug shortages. One example involved a delay in treating acidosis and sepsis using sodium bicarbonate that may have contributed to a patient’s death. An additional 5% of respondents reported other types of adverse outcomes related to drug shortages, such as increased discomfort or pain during a procedure, because of the unavailability of a required analgesic or sedation agent.

Nearly a quarter (21%) of all respondents said that they were aware of the occurrence of at least 1 medication error related to a drug shortage in the previous 6 months. Respondents provided descriptions of close to 100 errors. Most (67%) were associated with the wrong dose or concentration. Examples of errors reported through the survey are:

• Ordered HYDROmorphone prefilled syringes from a different manufacturer; nurse gave the medication orally because the syringe looked like an oral syringe, though it was clearly labeled for intravenous use.
• A patient received no treatment when a drug known to be unavailable was ordered verbally, and the nurse did not notify the pharmacy about the order or request an alternative.
• The wrong concentration of sodium acetate injection was added to an automated compounder; several patients received the wrong dose in their parenteral nutrition.

INTERDISCIPLINARY TENSION

About two-thirds (62%) of all respondents reported that leadership, medical staff, nurses, patients, and employees from other clinical departments always or frequently expressed frustration with pharmacy staff members because of drug shortages. Few dif- ferences were seen among respondents from different settings.

CONCLUSIONS

The findings from ISMP’s survey suggest that the impact of drug shortages on health care providers and patients continues to be significant. Although numerous agencies and organizations continue to develop more effective early warning systems for impending shortages, keep clinicians informed about shortages and potential alternatives, work to provide oversight regarding the availability of drug products, and reduce the overall adverse effects of drug shortages, progress is slow.

In the meantime, communication, monitoring, preparation, and standardization are key to safely managing drug shortages. Although it may be impractical to prepare for every potential drug shortage, proper planning can minimize the adverse effects on both patients and providers. Be sure to update and standardize any processes associated with alternative medications and communicate information to clinicians about the steps taken to extend or limit products in short supply. Use adverse event and error reporting systems, as well as discussions during rounds, focus group meetings, or other means to learn about adverse events associated with drug shortages, close calls, and hazardous conditions associated with drug shortages so that actions can be taken to limit further harm and risk.

Michael J. Gaunt, PharmD, is a medication safety analyst and the editor of ISMP Medication Safety Alert! Community/ Ambulatory Care Edition

REFERENCE

Institute for Safe Medication Practices. ISMP survey on drug short- ages for hospital pharmacy directors or their designees only. ISMP Medication Safety Alert! 2017;22(17):5-6.