Safety: Managing Medication Shortages

Some of the drugs and fluids used most often in surgical facilities go in and out of shortage daily due to interruptions in the supply chain, a problem exacerbated by the COVID-19 pandemic. Fentanyl for pain control has been in shortage lately, as have some benzodiazepines used for sedation, cardiac medications, diuretics and blood pressure meds. Dextrose and saline fluids are also proving difficult to stock. If your facility doesn't have protocols in place to plan for shortages before they occur, now is certainly the time to create them. Start with these five steps to ensure the drugs needed to provide safe patient care are always on hand, even when supply streams slow to a trickle.

1Monitor supplies
SThe American Society of Health System Pharmacists works closely with the FDA and maintains the most current drug shortage list (ashp.org/drug-shortages). It should be checked daily. The FDA also has daily information on shortages at (osmag.net/RfAAy5). You can also sign up for twice weekly email updates from the FDA on shortages. The Institute for Safe Medication Practices (ismp.org) and our parent organization ECRI Institute (www.ecri.org) has useful information about shortages as well. Check these sites on a regular basis. They're helpful in assessing the current supply levels of your often-used medications and can help you react to potential shortages before they impact your stock.

2Know your inventory
Keep a current list of your most commonly performed procedures and what medications are used for them, and your surgeons' preferred medications. When ordering medications, refer to the list to determine what medications are needed for cases during the upcoming week.

The list should include the primary medication used for all procedures and the second- and third-line options in the event there's a shortage of the medication of choice. Maintain standard order sets (SOS) for your workhorse medications as well as for your facility's secondary and tertiary choices. The order sets are critical clinical tools that have dosage recommendations on them. Many medication errors occur when providers make dosing errors with medications they're not used to administering. If a large orthopedic center typically uses morphine, but pivots to hydromorphone because of a morphine shortage, the dosage is less because the substitute is more powerful. If fentanyl is used as a replacement, it's even more potent, so the dosage is smaller still. These backup medications aren't unsafe. You just have to follow the dosage noted in the SOS so errors don't occur.

3Be flexible
If a medication in the form you generally administer it is in shortage, check to see if oral forms are more easily obtained. It's always more convenient to hang a 50 ml mini-bag of medication, but if you don't have it or it costs a premium to get, find out if that drug can be given by IV push over a three- to five-minute period. Know how to properly dilute the medication and, if it's drawn into a syringe, make sure you have labels on hand to properly identify the contents of the syringes. Commercially available prefilled syringes are often a good, albeit expensive, alternative during shortages.

4Consider workarounds
If you work with a 503B compounding pharmacy, find out if they can compound medications on shortage from active pharmaceutical ingredients, a practice the FDA allows during shortages. Even if you don't currently use a compounding pharmacy, you should establish a relationship with one who can compound from active pharmaceutical ingredients during a shortage. The same principle applies to surgery centers that are part of larger hospital systems. If you work in a hospital-owned facility, communicate with the hospital's pharmacy about pending shortages and determine what their compounding capabilities are, and what medications might be available from them in prefilled syringes.

Also, look into contracting directly with pharmaceutical companies, especially for your workhorse medications. Even if you generally obtain medications through wholesalers and distributors, direct contracts should be considered in this era during which shortages are the norm, because pharmaceutical companies can sometimes offer emergency allotments of medications that are on shortage.

5Communicate clearly
During daily staff huddles, mention what drugs are on or might go on shortage. Also ask your medication supply representatives about what drugs that are anticipated to go on shortage. You may want to have more of these medications on hand, but don't engage in stockpiling or buying alternative agents. Include surgeons in conversations about shortages as well. Just as there might be a shortage of one medication in the Midwest while it's abundant and available on the West Coast, the same could be true locally. A surgeon could arrive at your facility on Tuesday to learn that there's no fentanyl, while the large academic medical center with larger inventory stocks he was at the day before had it. Surgeons don't like inconsistencies or surprises, so keep them in the loop about shortages and your current medication inventories. Maintaining open lines of communication with all stakeholders can prevent finger-pointing when a shortage invariably takes place.

The last thing you want to do is postpone cases, but elective procedures should be rescheduled if you're unable to get the medications needed to provide safe patient care. An overall strategy of staying on top of pending shortages, keeping adequate inventories of your primary and replacement medications, and expanding relationships with suppliers, will keep your facility nimble enough to ensure cases remain on the schedule, regardless of when shortages hit. OSM