An audit of drug shortages in a community pharmacy practice

Perceptions, attitudes and experiences of hospital pharmacists working in the private sector regarding drug shortage in Lebanon: a national cross-sectional study

Introduction

Our objective was to assess the perception, attitudes, and experiences of Lebanese hospital pharmacists in everyday practice regarding the drug shortage as well as to identify challenges and propose solutions.

Methods

A cross-sectional survey was conducted between February and June 2021, enrolling 36 Lebanese hospital pharmacists.

Results

The economic crisis and issues with the quality of medicines were ranked as the top two causes of drug shortages in Lebanese hospitals; 88.9% of hospital pharmacists thought that switching to lower doses and using alternatives (97.2%) can be considered viable solutions. To address the issue of drug shortages, efforts made by manufacturers were 36.1%; the availability of alternative drugs in hospitals was 63.9%. All classes of drugs were shorted in hospitals. Hospital pharmacists spent less than 5 h/day to track medicine shortages (44.5%), identifying alternatives (97.3%), purchasing alternatives (91.7%), deliberating with physicians (91.7%). Pharamcists approached 'the parallel import' approach (75%) and contacted other hospitals (52.8%) to insure medicines alternatives.

Discussion

Drug shortages in Lebanon are driven by various factors and have been increasing across governorates. Public health is the most impacted, especially for patients requiring intensive care, which consequently affects their quality of life.

Effective Supply Chain Strategies in Addressing Demand and Supply Uncertainty: A Case Study of Ethiopian Pharmaceutical Supply Services

BACKGROUND

Ensuring the consistent availability of essential medicines is crucial for effective healthcare systems. However, Ethiopian public health facilities have faced frequent stockouts of crucial medications, highlighting systemic challenges such as inadequate forecasting, prolonged procurement processes, a disjointed distribution system, suboptimal data quality, and a shortage of trained professionals. This study focuses on the Ethiopian Pharmaceutical Supply Services (EPSS), known for its highly unstable and volatile supply chain, aiming to identify risks and mitigation strategies.

METHODS

Using a mixed-method approach involving surveys and interviews, the research investigates successful and less successful strategies, key success factors, and barriers related to pharmaceutical shortages.

RESULTS

Proactive measures such as communication, stock assessment, supervision, and streamlined procurement are emphasized as vital in mitigating disruptions, while reactive strategies like safety stock may lack long-term efficacy. The study highlights the importance of aligning supply chain strategies with product uncertainties, fostering collaboration, and employing flexible designs for resilience. Managerial implications stress the need for responsive structures that integrate data quality, technology, and visibility.

CONCLUSIONS

This study contributes by exploring proactive and reactive strategies, elucidating key success factors for overcoming shortages in countries with unstable supply chains, and offering actionable steps for enhancing supply chain resilience. Embracing uncertainty and implementing proactive measures can help navigate volatile environments, thereby enhancing competitiveness and sustainability.

Exploring Drug Shortages in the United Kingdom

Drugs can become short in supply for many reasons including increased demand and reduced production. Drug shortages have the potential to impact patients and pharmacists. This study aimed to highlight the challenges pharmacists face and the constraints of how they manage drug shortages. An online survey was designed with its link distributed electronically to community pharmacists in the UK with the assistance of pharmacy organizations during the period from September to December 2021. Survey data were analysed using descriptive statistics. A total of 83% of the respondents (n= 100) were experiencing drug shortages three or more times per week, and more than 70% of these spent 1-3 h per week dealing with them. A total of 93% of the respondents indicated that the issue of drug shortages was a problem for them, and 61% reported that it has worsened since the start of the pandemic. In addition, 65% of the respondents believed that drug shortages had had an impact on patient care. Drug shortages were shown to impact on the pharmacists' workloads with a potential to affect the quality of patient care. There was a variation between how pharmacists dealt with drug shortages, which needs to be explored further with the reasons behind it.

Reasons for supply side driven drug shortages - A mixed-methods study on first-level, higher-level, and root causes from the perspective of marketing authorization holders

BACKGROUND

Drug shortages impact multiple stakeholders and are detrimental to patient safety. Additionally, drug shortages are an extensive financial burden. In Germany, drug shortages, according to data from the federal ministry for drug and medical products (BfArM), have been increasing by 18% between 2018 and 2021. Studies show that shortages are most frequently supply side driven and that often reasons remain unknown.

OBJECTIVE

The aim is to develop a holistic understanding of supply side causes for drug shortages in Germany from marketing authorization holders' perspectives and to derive implications for shortage mitigation.

METHODS

A mixed-methods research design, with a grounded theory approach based on a structured literature review, BfArM data analysis, and semi-structured interviews, was used.

RESULTS

Input factor supply issues, manufacturing issues, logistics issues, product recalls, and product discontinuations were identified as first-level causes. Furthermore, a theory on their connection to higher-level causes related to business decision-making, as well as root causes linked to regulations, company values, internal processes, market dynamics, external shocks, and macroeconomic factors, was developed.

CONCLUSION

Actions to mitigate drug shortages in Germany (e.g., improving business processes, diversifying tender criteria) were derived. These may thus increase patient safety and decrease the financial burden on the healthcare system.

A Qualitative Study Exploring the Management of Medicine Shortages in the Community Pharmacy of Pakistan

Managing medicine shortages consumes ample time of pharmacists worldwide. This study aimed to explore the strategies and resources being utilized by community pharmacists to tackle a typical shortage problem. Qualitative face-to-face interviews were conducted. A total of 31 community pharmacists from three cities (Lahore, Multan, and Dera Ghazi Khan) in Pakistan were sampled, using a purposive approach. All interviews were audio taped, transcribed verbatim, and subjected to thematic analysis. The analysis yielded five broad themes and eighteen subthemes. The themes highlighted (1) the current scenarios of medicine shortages in a community setting, (2) barriers encountered during the shortage management, (3) impacts, (4) corrective actions performed for handling shortages and (4) future interventions. Participants reported that medicine shortages were frequent. Unethical activities such as black marketing, stockpiling, bias distribution and bulk purchasing were the main barriers. With respect to managing shortages, maintaining inventories was the most common proactive approach, while the recommendation of alternative drugs to patients was the most common counteractive approach. Based on the findings, management strategies for current shortages in community pharmacies are insufficient. Shortages would continue unless potential barriers are addressed through proper monitoring of the sale and consumption of drugs, fair distribution, early communication, and collaboration.

Drug Shortage: Causes, Impact, and Mitigation Strategies

Drug shortage is a global issue affecting low, middle, and high-income countries. Many countries have developed various strategies to overcome the problem, while the problem is accelerating, affecting the whole world. All types of drugs, such as essential life-saving drugs, oncology medicines, antimicrobial drugs, analgesics, opioids, cardiovascular drugs, radiopharmaceutical, and parenteral products, are liable to the shortage. Among all pharmaceutical dosage forms, sterile injectable products have a higher risk of shortage than other forms. The causes of shortage are multifactorial, including supply issues, demand issues, and regulatory issues. Supply issues consist of manufacturing problems, unavailability of raw materials, logistic problems, and business problems. In contrast, demand issues include just-in-time inventory, higher demand for a product, seasonal demand, and unpredictable demand. For regulatory issues, one important factor is the lack of a unified definition of drug shortage. Drug shortage affects all stakeholders from economic, clinical, and humanistic aspects. WHO established global mitigation strategies from four levels to overcome drug shortages globally. It includes a workaround to tackle the current shortage, operational improvements to reduce the shortage risk and achieve early warning, changes in governmental policies, and education and training of all health professionals about managing shortages.

An application of multi-criteria decision-making approach to sustainable drug shortages management: evidence from a developing country

Background

Drug shortage is a significant public health problem, especially for drugs related to life threatening conditions. Almost all countries affected by variety of supply problems and spent a considerable amount of time and resources responding to shortage. The aim of present study is to determine and prioritize strategies to achieve best solutions for these considerable healthcare system challenges and to evaluate this strategies base on practical criteria.

Methods

To achieve the study objectives, the research was conducted in two phases. Determining of the strategies to control drug shortage, and comprehensive assessments of priority of possible strategies. For each phase, a self-design questionnaire was developed. The five main managerial strategies dimensions including: regulatory, financial, supply chain, information system and policy-making were set out. Forty-five alternatives were elicited from literature, and were evaluated and trimmed to 37 strategies based on experts’ opinion. The Multiple criteria decision-making (MCDM) methods were applied in second phase. Five important criteria including cost, time, labor, compliance with law and culture were weighed by Analytic Hierarchy Process (AHP) technique. Then, 37 alternatives have been rated base on the five criteria on the Technique for Order of Preference by Similarity to Ideal Solution (TOPSIS) technique.

Results

“Creating integrated Supply chain information system to manage medicines inventory in the country”, “Creating and using the databases to predict the shortage of medicines”, “Using track and trace system” are alternatives 20th, 24th and 25th, which related to supply chain (SC) and information system (IS) dimensions have higher priority in the experts’ point of view. The results show IS dimension has 100 percentage of priority; following that policy and supply chain have higher priority, respectively.

Conclusion

Health systems rely on consistent supplying of pharmaceuticals to support patient care. The results show that information system, policy-making and supply chain are in the top-ranking priorities. Warning system needs to be improved to the advance system via better collaboration with stakeholders, publish precise and explicit national guidelines for drug shortage management, enforce the guidelines, and improve Iran FDA’s pharmaceutical market control capability.

Medicine Shortages in Serbia: Pharmacists' Standpoint and Potential Solutions for a Non-EU Country

Medicine shortages in Serbia have evidently been present for several decades, but literature data are scarce. The aim of our study was to get an insight on the present situation in Serbia, review the EU actions when managing shortages, and discern a set of potential measures. A short survey was conducted among 500 pharmacists in public pharmacies, in 23 cities in Serbia. The survey questions addressed frequency of drug shortages, professional actions in the event of shortages, main consequences to patients and pharmacies, putative causes, and pivotal measures for the prevention/mitigation of drug shortages under current conditions. Moreover, a Panel of Experts was organized, whose suggestions and opinions were used to analyze the present situation and to form a set of potential solutions and effective measures to mitigate shortages of medicines. In-depth analysis of current Serbian legislation was conducted, with emphasis on specific steps to be made within the actual legal framework. Examples of good practice in the EU, applicable to a country such as Serbia, were examined. Our research showed that although Serbia is, in some aspects, behind EU countries regarding the approaches to overcome medicine shortages, progress can be made within short period of time, by specific well-targeted actions. Both patients and pharmacists would benefit from it.

Medicine Shortages: Gaps Between Countries and Global Perspectives

Introduction: Over the last decade, global health policies and different research areas have focused on the relevance and impact of medicine shortages. Published studies suggest there have been difficulties with access to medicines since the beginning of the 20th century, and there have been advances in our understanding and management of the problem since then. However, in view of global and regional health care concerns with shortages, we believe this phenomenon needs to be characterized and described more fully regarding the types of medicines affected, possible causes, and potential strategies to address these. The aim of this scoping review was to identify, compare if possible, and characterize the recent literature regarding the situation of medicines shortages between countries, and provide different perspectives, including a global context and national approaches.

Methodology: A scoping study presented as a narrative review of the situation and findings principally based on published articles.

Results: Based on the reported cases in the literature, a typology of medicines shortage and supply interruption episodes and their causes were proposed; national approaches to notify and manage the medicines shortages cases were described and classified by update frequency; principal differences between market and supply chain management perspectives of the situation were identified and global and countries’ perspectives were described.

Conclusion: Policy makers require solutions that prevent those cases in which the population’s health is affected by episodes of medicine shortages and/or interruption in the supply chain. There is also a need to generate a glossary related to logistics management and the availability of medicines which will be useful to understand and overcome shortages. In addition, recognize that potential solutions are not only related with actions linked to research, development and innovation, but much wider. Overall, we believe this article can act as a basis for future discussions in this important area.

Medication Exchange and Sharing Network Program (MESNP) initiative to cope with drug shortages in the Kingdom of Saudi Arabia (KSA)

Background

Drug shortages are a major public health concern and remain a persistent problem worldwide. At present, there are no unified existing strategies for managing medicine stocks in the Kingdom of Saudi Arabia (KSA). Here, the aim is to describe our experience with creating a non-profit voluntary national Medication Exchange and Sharing Network Program (MESNP) throughout the KSA.

Methods

A quality improvement process map method was used in this project. The baseline evaluation included a review of possible reasons and strategies for managing medication shortages and recognizing potential associated safety issues. To that end, at the national level, we developed MESNP as a novel project to cope with medication shortages using Telegram social media as the preferred program for connecting with the member institution.

Results

A total of 500 requests were received over one year. Three hundred and fifteen (315) constituted requests for drug supplies due to shortages while the number of reports indicating the availability of overstock drug for re-distribution is (185). Almost 98% of overstocking drug reports was re-distributed in which it covers 75% of drug shortage requests.

Conclusion

This novel project aims to use our current resources by facilitating the medication exchange and sharing between the organizations at national level. The optimistic goal is to proactively mitigate drug wastages and prevent drug shortages toward better patient care.

The current status and effects of emergency drug shortages in China: Perceptions of emergency department physicians

OBJECTIVES

The shortage of emergency drugs in China is severe. This study aimed to characterize emergency drug shortages in China and to measure their effects.

METHODS

An online questionnaire based on a literature review was sent to emergency department physicians in Chinese secondary and tertiary hospitals from November 2016 to February 2017. The survey asked physicians questions about their experiences with emergency drug shortages.

RESULTS

In total, 236 physicians from 29 provinces participated in the survey. According to their responses, 90.7% of the respondents experienced drug shortages during the last year. More than half of the physicians (65.7%) reported that drug shortages occurred at least once a month. Hospitals in the eastern and western regions of China had more emergency drugs in shortage than hospitals in central China, especially those with many inpatient beds (≥800). In addition, the shortage situation was more serious in secondary hospitals than in tertiary hospitals. More respondents agreed that original medicines, injections, essential medicines, medicines without alternative agents and cheap medicines were more susceptible to shortages than generics, oral medicines, nonessential medicines, medicines with alternative agents and expensive medicines, respectively. Most respondents thought that drug shortages always, often or sometimes affected patients [delayed therapy (62.6%), longer rescue and recovery times (58.9%) and higher costs (58.7%)] and physicians [inconvenience (81.0%), higher pressure (76.5%) and harm to patient-doctor relationships (72%)] and compromised hospital reputations (55.1%).

CONCLUSIONS

The shortage of emergency drugs in China is serious, especially in secondary hospitals located in eastern and western China. Emergency drug shortages have significant effects on patients and physicians.

Drug shortages may compromise patient safety: Results of a survey of the reference pharmacies of the Drug Commission of German Pharmacists

Drug shortages are a complex problem and of growing concern. To evaluate implications of drug shortages in terms of outpatient and inpatient safety, the Drug Commission of German Pharmacists surveyed its two nationwide reference pharmacy networks: 865 community and 54 hospital pharmacies. Participants were asked to complete a six-question online survey, covering relevance and challenges of drug shortages in everyday practice as well as consequences for patient safety. Answers were given in the context of the last three months prior to the survey. In total, 482 community (55.7%) and 36 hospital pharmacies (66.7%) participated. Occurrence of drug shortages were confirmed by 88.6% of community and 80.6% of hospital pharmacies. Thus, for example, a substitute was dispensed more than 15 times (60.7% of community, 44.8% of hospital pharmacies) during the 3-month-period. Comparing community and hospital pharmacies, differences in the incidence or severity of consequences for patient safety were apparent. Community pharmacies mainly confirmed adverse effects on patients' medication adherence (60.4%) and treatment discontinuation (25.8%). A delay or deny of a life-saving treatment (39.4%) was largely reported by hospital pharmacies. Medication errors were reported by 20.1% of the community and 21.2% of the hospital pharmacies, respectively. Taken together, sustainable solutions are needed to counteract drug shortages and to ensure adequate treatment for patients.

Systemic Measures and Legislative and Organizational Frameworks Aimed at Preventing or Mitigating Drug Shortages in 28 European and Western Asian Countries

Drug shortages have been identified as a public health problem in an increasing number of countries. This can negatively impact on the quality and efficiency of patient care, as well as contribute to increases in the cost of treatment and the workload of health care providers. Shortages also raise ethical and political issues. The scientific evidence on drug shortages is still scarce, but many lessons can be drawn from cross-country analyses. The objective of this study was to characterize, compare, and evaluate the current systemic measures and legislative and organizational frameworks aimed at preventing or mitigating drug shortages within health care systems across a range of European and Western Asian countries. The study design was retrospective, cross-sectional, descriptive, and observational. Information was gathered through a survey distributed among senior personnel from ministries of health, state medicines agencies, local health authorities, other health or pharmaceutical pricing and reimbursement authorities, health insurance companies and academic institutions, with knowledge of the pharmaceutical markets in the 28 countries studied. Our study found that formal definitions of drug shortages currently exist in only a few countries. The characteristics of drug shortages, including their assortment, duration, frequency, and dynamics, were found to be variable and sometimes difficult to assess. Numerous information hubs were identified. Providing public access to information on drug shortages to the maximum possible extent is a prerequisite for performing more advanced studies on the problem and identifying solutions. Imposing public service obligations, providing the formal possibility to prescribe unlicensed medicines, and temporary bans on parallel exports are widespread measures. A positive finding of our study was the identification of numerous bottom-up initiatives and organizational frameworks aimed at preventing or mitigating drug shortages. The experiences and lessons drawn from these initiatives should be carefully evaluated, monitored, and presented to a wider international audience for careful appraisal. To be able to find solutions to the problem of drug shortages, there is an urgent need to develop a set of agreed definitions for drug shortages, as well as methodologies for their evaluation and monitoring. This is being progressed.

Unavailability of Outpatient Medications: Examples and Opportunities for Management

Drug shortages create significant challenges for patients and health care providers. Pharmacists play important roles in managing medication therapy during drug shortages. The management of drug shortages by the community pharmacist is an expanding role. Adverse drug reactions and delayed treatments are highlighted in the literature as some of the consequences of outpatient drug shortages; it is likely these harms are underreported. This commentary reviews examples and opportunities for the management of outpatient drug shortages.

Toward a European definition for a drug shortage: a qualitative study

BACKGROUND

Drug shortages are currently on the rise. In-depth investigation of the problem is necessary, however, a variety of definitions for 'drug shortages' are formulated in legislations, by different organizations, authorities, and other initiatives. For international comparison, the underlying definition for drug shortages is important to allow appropriate interpretation of national databases and the results of scientific studies. The objective is to identify the different elements which should be considered in a uniform definition for drug shortages in the European Union (EU) and to detect the different conditions for reporting drug shortages.

MATERIALS AND METHODS

Definitions of drug shortages were searched in the scientific databases as well as in the gray literature. Similar topics were identified and organizations were contacted to formulate the reasoning underlying the definitions.

RESULTS

Over 20 different definitions for drug shortages were identified. A distinction is made between general definitions of drug shortages and definitions used for the reporting of drug shortages. Differences and similarities are observed in the elements within the definitions, e.g., when does a supply problem become a drug shortage, permanent and/or temporally shortages, the typology and time frame of a drug shortage. The moment a supply problem is considered as a shortage, can be defined at four levels: (i) demand side, (ii) supply side, (iii) delivery of a drug, and (iv) availability of a drug. Permanent discontinuations of drugs are not always covered in definitions for drug shortages. Some definitions only consider those drugs used for the treatment of serious diseases or drugs for which no alternative is available. Different time frames were observed, varying between 1 day and 20 days.

CONCLUSION

Obtaining a uniform definition for drug shortages is important as well as identifying which conditions are preferable to report drug shortages in order to facilitate international benchmarking. This paper can be used as a guidance to point out all the different elements which should be considered to formulate a uniform definition to be applied in the EU.

Causes of drug shortages in the legal pharmaceutical framework

INTRODUCTION

Different causes of drug shortages can be linked to the pharmaceutical legal framework, such as: parallel trade, quality requirements, economic decisions to suspend or cease production, etc. However until now no in-depth study of the different regulations affecting drug shortages is available. The aim of this paper is to provide an analysis of relevant legal and regulatory measures in the European pharmaceutical framework which influence drug shortages.

METHODS

Different European and national legislations governing human medicinal products were analyzed (e.g. Directive 2001/83/EC and Directive 2011/62/EU), supplemented with literature studies.

RESULTS

For patented drugs, external price referencing may encompass the largest impact on drug shortages. For generic medicines, internal or external reference pricing, tendering as well as price capping may affect drug shortages. Manufacturing/quality requirements also contribute to drug shortages, since non-compliance leads to recalls. The influence of parallel trade on drug shortages is still rather disputable.

CONCLUSION

Price and quality regulations are both important causes of drug shortages or drug unavailability. It can be concluded that there is room for improvement in the pharmaceutical legal framework within the lines drawn by the EU to mitigate drug shortages.