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.