Drug shortages affect patient care. Not only are there clinical implications to drug shortages, such as having to use a less optimal medication or rescheduling procedures, there is a financial impact, and resources are required to manage the shortage. The patient safety aspect of drug shortages is not to be underestimated, either, as evidenced by these events reported to the Pennsylvania Patient Safety Authority.
The pharmacist was working on an order for a brand new bag of D10/0.2%NS, as the premade bottles were on back order. The pharmacist had to start from scratch to prepare the solution. The pharmacist did his calculations and noted that he came up with something different than the pharmacist did the previous day. The pharmacist believed that the previous pharmacist had miscalculated and was low by a factor of ten of the sodium chloride. When the other pharmacist came into work on this day, this pharmacist discussed the miscalculation together. It was learned that the order from the previous day was correct, and the miscalculation for today resulted in the sodium chloride content of the IV [intravenous bag] to be ten times higher than what was ordered.
A patient [presented] to the ED [emergency department] for rabies vaccine; the pharmacy informed the ED that the vaccine was not available due to back order.
A patient required 71 mg tissue plasminogen activator (t-PA). [The patient] received 50 mg t-PA related to pharmacy shortage.
Results of a 2010 Institute for Safe Medication Practices survey of pharmacists and other healthcare providers indicated that drug shortages present a clear patient safety threat. Thirty-five percent of respondents indicated they experienced a near-miss event because of a drug shortage. One in four reported an error occurred that reached a patient, and one in five reported an adverse patient outcome occurred due to a drug shortage.
Excerpted from: Bell M. Managing drug shortages. Pa Patient Saf Advis 2011 Dec. http://patientsafety.pa.gov/ADVISORIES/Pages/201112_117.aspx.
