Sunday, April 8, 2012

Getting feedback on drug shortage - Do we need additional measures?

More on SHR's efforts to cope with the national drug shortage.

Last week, we received some positive feedback from our pharmacy about our efforts to conserve injectable medications:
The most recent review revealed an average 37% reduction in usage for the most affected injectable drugs.
That represents the combined efforts of both those prescribing/ordering the medication, and those administering them.  In our department, we've been conscious of the need to order both injectable and oral medications for postoperative patients, so that nurses can make the switch to oral medications as soon as it's appropriate, rather than needing to wait for new orders to be written.

It's encouraging to see this desired change, and I hope that pharmacy will continue to track the drug usage and report back to clinicians.  We're interested in a sustained change in practice, and will need to chart usage over time to see if clinicians need reinforcement, or perhaps some other intervention.

But, is measuring reduction in usage sufficient?  Let's go back to that pesky Model for Improvement.

The Model's first question is answered in an aim statement.  I suggested that our aim statement might be something like:

We will ensure that patients receive appropriate care and access to necessary medication.  We will do this through careful management of the injectable drug supply and by use of alternative medications and administration routes.
The second question relates to how we measure progress.  We currently have one measure - an outcome measure - namely the usage of injectable drugs.  But, any time we change one part of a system, unintended changes may happen in other parts.   Perhaps we should also look at  these possible consequences of our conservation efforts with a balancing measure.  For example, could we be overzealous in our attempts to conserve injectable medication? What if patients had inadequate control of symptoms, like pain or nausea, because oral medication was being used when an injectable form may be more effective?

If you were the pharmacist in charge of this effort, you'd be gnashing your teeth right about now.  "We don't have the time and resources to do comparisons of patients' symptom control with and without injectable drugs," you might say.  That would be a lot of work, so perhaps we could start with a surrogate measure.  How about a survey of physician and nursing staff from various wards to see what their impressions are.  Do they notice a difference in patient comfort?  Are the oral medications giving prompt relief of symptoms?

If staff are noticing that oral medications are less effective, we owe it to our patients to investigate further. (Note: in my own practice, I have not seen any sign that patient care has suffered.  There you go, pharmacist, your first data point is collected!)

P.S. To the Anonymous commenter asking if SHR's medication substitution table is available for wider consumption, I haven't been able to find an external link for you.


  1. I am an Lpn at sch on the gyne ward.. I haven't noticed that my patients are suffering any more since the cut back on IV meds.. the use of gravol supps for nausea, regular use of oral analgesics and pain and nausea rating on rounds has I think ensured patient comfort..Patients seem hesitant at first but are reassured that if the oral or pr routes don't work we will go with the intervenous option. I wonder if Pre op clinic could instruct patients on the shortage so that they are less apprehensive post op when their nurse suggests something other than IV drugs..

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