Drug shortages linked to medication errors, study finds

A French study of adverse drug reaction (ADR) data found a link between drug shortages and medication errors.

In the study, published in the British Journal of Clinical Pharmacology On September 29, 2022, researchers reviewed 462 cases recorded in the French Pharmacovigilance Database between 1985 and 2019 mentioning a drug shortage.

Medication errors were identified in 11% (51) of cases, mostly occurring at the administration stage and involving a human factor. Among these cases, life-threatening situations were reported in three cases and fatal outcomes were reported in four cases.

Overall, the researchers found that the number of drug shortage cases increased over time, accelerating between 2010 and 2019, with the highest number of cases (114) reported in 2019. Almost all pharmacological classes were concerned.

“A drug shortage may lead to the unavailable product being replaced by an alternative,” the researchers wrote. “However, this alternative may have different packaging, labeling, dosage and sometimes route of administration which may increase the risk of medication error.”

The study authors concluded that the findings emphasize the clinical impact of drug shortages in terms of adverse effects, medication errors and ineffectiveness.

“These findings underline the importance of a global health policy program to limit the occurrence of drug shortages and to strengthen information for patients and health professionals in this context to limit the risks.”

In the UK, drug shortages are on the rise. The UK government granted a record 159 price concessions in September 2022 for drugs such as alendronic acid and aripiprazole, due to shortages which pharmacists say are impacting patient care and may cause damage.

Andy Fox, consultant pharmacist in medicine safety and deputy chief pharmacist at Southampton NHS Foundation Trust University Hospital, said the findings of the French study were “relevant” for the UK.

“We have been experiencing an increasing number of shortages in recent years, the reasons for which are well known,” he explained.

“[The study] emphasizes the need for careful management and risk assessment of the product in short supply and the replacement product.

Fox added that “interestingly,” the report mentioned that packaging differences contributed to medication errors.

“The medicine safety officer and the network have a clear role to play in helping to manage local issues and communicate any learning across the network,” he added.

In August 2022, the results of The Pharmaceutical Journal An annual salary and job satisfaction survey showed that 54% of UK-based pharmacists said drug shortages had put patients at risk in the past six months.

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