Drug shortage-associated increase in catheter-related blood stream infection in children.
Approach to Improving Safety
Setting of Care
National drug shortages have increased and emerged as a serious patient safety issue in the United States. Recently, a shortage of medicinal-grade ethanol occurred due to a temporary shutdown of the sole supplier. Ethanol lock therapy is used to reduce the incidence of catheter-related blood stream infections (CRBSI) in pediatric patients receiving parenteral nutrition due to intestinal failure. Although the details leading to the voluntary facility shutdown were not transparent, the authors suggest that it was likely due to the risk of an impending Food and Drug Administration inspection. During the shortage, the rate of CRBSI at one hospital rose dramatically, resulting in increased lengths of stay and hospital costs. This evidence illustrates profound financial and patient safety implications related to a national drug shortage.