Lecture 11 & 12: Drug Shortages & Errors

drug shortage

when demand for a medically necessary drug exceeds its supply

national drug shortage trends

• going down since 2011

• most common cause is unknown

• slightly more than half of drugs on shortage are injectables

4 drug shortage impacts on healthcare system

• financial burden - increased drug budget, lost revenue

• safety concerns - increased risk for med errors made by interprofessional team

• pt care compliance

  • economic - increases med costs

  • clinical - txt delays, decreased QoL, more rehospitalizations

  • humanistic - more emotional impact on pt/families

• operational disruptions - pharm staff time spent, managing shortage disrupts other areas of productivity

drug shortage implementation tasks

1. awareness

   1. identify

2. internal assessment

   1. operational - severity, impact on workflow, alt method

   2. clinical - alt meds, allocate resources

   3. severity evaluation

3. preparation

   1. planning

4. implementation & evaluation

   1. implement & communicate

   2. re-evaluate - impact on pt care & work processes

   3. resolution - what’s a safe level of inventory to return to previous state -

potential errors

• prescribing, transcribing & documenting → decision-making failure

• dispensing → failure in execution

• administering → failure in execution

• monitoring → decision making/execution

define error

inappropriate or undesirable decision/behavior that has potential to reduce effectiveness, safety, or system performance

types of errors

• latent

• active

latent vs active errors

latent - built into the system in which you’re operating in

active - human errors that occur during operation through cognitive decisions

types of active error

failures in execution:

• slips - actions not carried out as intended

• lapses - missed actions usually forgetfulness

failures in judgement/inferential processes

• mistakes

Reason’s Swiss Cheese model

• errors occur when multiple failures/weaknesses in different layers of defense align

• emphasizes importance of double checking, resilience and multiple layers of defense to prevent errors

define med error

preventable event that may cause or lead to inappropriate med use or pt harm while med is in control of healthcare professional, pt, or consumer

med error types

• compliance

• prescribing

• omission - fails to receive ordered med

• wrong time

• unauthorized med

• wrong dose

• admin technique

• monitoring

causes of med errors

• expired

• wrong duration

• wrong preparation

• wrong strength

• wrong rate

• wrong time

• wrong dose

• wrong form

• wrong pt action

• allergy

• CI

harms of med errors

pharmacy error categories

• judgemental

• mechanical (dispensing/preparation)

system/process issues

• similar drug names

• workplace interruptions

• lack staff

• workload demand

• insufficient time to counsel