Drug shortages are a public health crisis that has persisted for many years in the U.S. health system. The daily struggle of shortage management by healthcare providers has led to negative downstream effects on patients, including instances of unsafe or compromised practice and potentially harmful medication errors. A total of 448 medication error event reports associated with drug shortages were submitted to the Pennsylvania Patient Safety Authority from July 2004 through June 2018.

Pennsylvania Patient Safety Authority analysts reviewed medication errors associated with drug shortages submitted through PA-PSRS from July 2004 through June 2018.

When stratified by PA-PSRS harm score, the majority (71.0%; n = 318 of 448) of drug shortage events reached the patient (harm score category, C to I; Figure 1).

The number of reports submitted per year can be seen in Figure 2.

A total of 173 unique drugs were reported to the Authority, which analysts subcategorized into 57 drug classes (Figure 3).

Analysts categorized each report into one of three nodes of the medication use system—prescribing, dispensing, or administering—then further categorized each report into node-specific event subtypes (Figure 4).

Excerpted from: Cierniak KH, Gaunt MJ, Grissinger M. Drug shortages: shortchanging quality and safe patient care. Pa Patient Saf Advis 2019 Mar. http://patientsafety.pa.gov/ADVISORIES/Pages/201903_DrugShortages.aspx.