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- Drug shortages
- Quality Improvement Strategies
ISMP Medication Safety Alert! Acute Care Edition. November 1, 2018;23:1-5. November 15, 2018;23:1-5.
Errors in the administration of intravenous medications can result in patient harm. This set of articles discusses the results of a nationwide IV push medication survey. The first article reviews unsafe practices in care delivery as defined by inpatient clinicians. The second article recommends ways to improve practice such as assessment of current practices, use of prefilled syringes, and heightened attention to effective labeling.
Tools/Toolkit > Fact Sheet/FAQs
Bethesda, MD: American Society of Health-System Pharmacists and the University of Utah Drug Information Service; 2018.
Journal Article > Study
Alpert A, Jacobson M. Clin Pharmacol Ther. 2019 Feb 10; [Epub ahead of print].
Drug shortages have become more frequent and may lead to delays in treatment or failure to deliver the appropriate drug, an error of omission. This secondary data analysis examined how oncology drug shortages affected use of chemotherapy medications among patients with newly diagnosed cancer as measured by Medicare claims data. The changes in utilization varied by medication; overall, drug shortages had only a modest impact on the delivery of these drugs to patients with newly diagnosed cancer. This finding contrasts with a prior study showing patient harm related to drug shortages, and the authors recommend further study to understand how to identify and mitigate clinically relevant drug shortages. A WebM&M commentary discussed strategies for preventing or minimizing adverse events associated with drug shortages.
Cases & Commentaries
- Web M&M
Steven Plogsted, PharmD; October 2018
A 1-month-old preterm infant in the NICU receiving the standard 500 mL bag of 0.45% sodium chloride (NaCl) with heparin at low rates developed hyponatremia. Clinicians recognized the need to deliver a more concentrated sodium solution and ordered that the IV fluid be changed to a 500 mL bag of 0.9% NaCl with heparin. However, due to a natural disaster affecting the supply chain for IV fluids, 0.9% NaCl 500 mL bags were in short supply, and the order was modified to use 100 mL 0.9% NaCl bags, which were available. Since the total volume was much smaller, a lower concentration formulation of heparin was required. However, the verifying pharmacist discovered that an 10-fold higher concentration had been used to compound the fluids, and further investigation revealed this same error had occurred on five other occasions.
Journal Article > Commentary
Fox ER, McLaughlin MM. Am J Health Syst Pharm. 2018;75:1742-1750.
Drug shortages are a persistent threat to safe patient care. These guidelines provide a structured approach for care teams to develop an action plan to reduce risks when faced with drug shortages in their work. Recommendations include conducting operational assessments, establishing a drug shortage team, and communicating with patients and providers when a shortage occurs.
Horsham, PA: Institute for Safe Medication Practices; August 24, 2017.
Fink S. New York Times. January 29, 2016.
Drug shortages have become a routine challenge in medicine. Reporting on the impact of medication shortages on care delivery and decision making, this newspaper article discusses processes in place to manage patient care as safely as possible and ethical dilemmas health care providers have faced in light of the reduced availability of medications.
Addressing the Global Shortages of Medicines, and the Safety and Accessibility of Children's Medication.
Geneva, Switzerland: World Health Organization; 2015.
Drug shortages have the ability to affect the patient safety in emergency departments, oncology services, and pediatrics. This report discusses the consequences of drug shortages, approaches different countries are taking to reduce their occurrence, and strategies such as proactive identification of potential supply limitations and collective agreements to manage shortages.
Silver Spring, MD: Food and Drug Administration; October 2013.
This report outlines the FDA's plans to address drug shortages, including streamlining tracking processes and developing early warning signals to identify potential shortages.
Journal Article > Review
Rider AE, Templet DJ, Daley MJ, Shuman C, Smith LV. J Pharm Pract. 2013;26:183-191.
Drug shortages have been shown to have serious clinical consequences for affected patients. This review article outlines a systematic approach for managing drug shortages.