Patient Safety and Communication Errors
Lalit Verma, MD, director of the hospital medicine program at Durham Regional Medical Center in North Carolina and assistant professor of medicine at the Duke University School of Medicine, is unaware of any situations in which a shortage put patients in jeopardy at his hospital. He says the pharmacy at Durham Regional, which has seen recent shortages in morphine and heparin, among other drugs, keeps doctors up to date and has adjusted doses appropriately when replacements are used.
“It’s probably been more than I’ve experienced in my 10 years as a hospitalist,” Dr. Verma says. “We have a very good pharmacy program that updates us regularly on drug shortages and offers alternatives.”
Dr. Li also says no patient’s safety has been jeopardized by a shortage.
Others say patient safety has been affected, according to 1,800 healthcare practitioners who participated in a survey last year conducted by the Institute for Safe Medication Practices (ISMP), a nonprofit group. Twenty percent of the respondents said drug-shortage-related errors were made, while 32% said they had “near misses” related to drug shortages. Nineteen percent said there had been adverse patient outcomes as a result of drug shortages.
The study noted two instances in which patients died when they were switched to dilaudid because morphine was in short supply; both patients were given morphine doses instead of adjusted doses for dilaudid.
“It’s about six- or sevenfold more potent than morphine,” says Michael Cohen, ISMP president. “And so when that drug is prescribed in a morphine dose, that would be a massive overdose for some patients.”
He adds that hospitals have tried to stay on top of the drug shortage problem, but that “it’s very difficult.”
“A lot of this happens last-minute,” Cohen says. “Physicians aren’t given a chance to even realize that a certain drug isn’t available, so it causes an interruption in the whole flow of things in the hospital.” Some hospitals have had to hire staffers who handle just the inevitable daily drug shortages, he adds.
A law has been proposed in the U.S. Senate that would require drug manufacturers to notify the FDA when circumstances arise that might reasonably lead to a drug shortage (see “Senate Bill Would Require Advance Notice of Potential Shortages,” p. 41).