Near Misses, Patient Harms, Actual Errors Due to Drug Shortage

A survey of physicians, pharmacists, and nurses working in healthcare facilities found an increasing number of frustrating drug shortages.  Worse:

• One out of three reviewed facilities had a serious error that was caught in time — a near miss.
• One out of four had an actual medication error resulting from the shortages.
• One out of five reported actual adverse outcomes for patients.

This may only be the tip of the iceberg according to the health care professionals surveyed.  Many felt that errors and bad patient outcomes aren’t always shared so there maybe many more.

The Institute for Safe Medication Practices surveyed more than 1,800 healthcare staff, nearly seven out of ten pharmacists, to find out what impact the drug shortage was having in their own facilities.

The September 23, 2010 issue of the ISMP Medication Safety Alert reported that survey respondents were alarmed by the

• ever increasing numbers of critically necessary medications in short supply
• need to use unfamilar alternative drugs — often expensive.
• potential for mistakes and patient adverse events associated with alternative drugs or doses.
• lack of advance warning about impending shortages.
• time lost managing drug shortages that was not available for clinical work with patients.

Finding out about a drug shortage was a particular concern for the survey respondents.  About half of the pharmacists and pharmacy technicians only knew a drug was in shortage when an ordered medicine wasn’t delivered.  Word of mouth, buying groups, wholesale distributors and the American Society of Health-System Pharmacists helped another three out of ten.

Doctors and nurses often found out that a drug was in shortage after ordering it and being told by the pharmacist that it wasn’t available.

Some people who responded to the survey believed drug manufacturers withheld information to avoid hoarding.

Gray markets were another concern, sources of medicines in shortage that were somehow available at exorbitant prices.  Pharmacists worried about the quality and safety of such drugs and the ethical implications of gray markets when a drug is a life-saving medication.

Among reported errors of concern to people with colorectal cancer were:

Physician prescribed the wrong dose when levoleucovorin was substituted for leucovorin.

Substituting XELODA (capecitabine) for leucovorin has resulted in serious gastrointestinal toxicity in many patients.

Cancer patients are also put at risk when supportive medicines like heparin, ondansetron,morphine and antibiotics are in short supply or unavailable completely.  Dosing mistakes can arise from confusion of dose, labeling, and even the bin where the unfamiliar drug is placed for nurses to use.

If you’d like to take action to reduce the impact of the drug shortage, ask your US Senators and members of Congress to support the Preserving Access to Life-Saving Medications Act (S 296 and HR 2245).  Fight Colorectal Cancer has a simple way you can do that directly through our website.