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EFFECTIVE DATE:                  5/01                                 REVIEW DATE:                        12/04         

POLICY EDITION:           01                                REVISION DATE:                        12/01     






DEPARTMENT:                        Pharmacy Services                        POLICY NUMBER:     731-416

POLICY TITLE:                        Identifying and Managing                        SUBJECT:    Drug shortages Drug Shortages


 To establish guidelines and procedures for managing drug shortages for Wishard Health Services.


The Department of Pharmacy will have guidelines to safely manage drug shortages. 


 I.       Find out about drug shortages

 The Inventory Pharmacist will regularly search web sites for drug shortage information and will obtain information from Wholesalers.

 II.      Obtain pertinent information

The Inventory Staff will contact the manufacturer for information, a release date, and directions for ordering drugs on allocation or for emergency supplies.  Current inventory will be evaluated to determine if quantity is sufficient.  If not, inventory staff will try to obtain an alternative from another supplier/wholesaler or order allocated or emergency supplies directly from manufac­turer.  A current list is kept to check drug shortage stock and to reorder at the appropriate intervals.

III.    Identify usage and alternatives

A Clinical Specialist, for extreme and/or extended shortages, will undertake any or all of the following steps:

-       identify clinically appropriate uses of the drug

-       ascertain use of the drug in our hospital

-       develop strategies to decrease drug waste

-       determine alternative products

-       prioritize use

IV.    Place limitations on use

Based on the extent of the shortage, availability of alternatives, and our institutions usage, a Clinical Specialist or designee will develop plans to restrict use and reduce wastage.  Plans may include: medication removal from floor stock, A Proof-of-Use@ sheet dispensing, unit dose dispensing, alternative product usage.

V.     Educate departments and Pharmacy Staff

A Clinical Specialist will alert departments to the drug shortage (and reason/duration if known), possible substitutes with dosing information, and any other action plans or recommendations via Pharm-a-gram and/or Memorandum, add information in the gopher drug entry system when appropriate.  Pharmacy Staff is informed of drug shortages along with recommendations at staff meetings, Pharm-A-Grams and/or memorandums.  A Drug Shortage Notebook is updated and kept at the Inpatient Pharmacy Unit Dose Desk.

VI.    Monitor Adverse Effects

Adverse effects from alternatives used because of drug shortages will be monitored through ADR reports, and errors through Medication Error Subcom­mittee and will be reported quar­terly to Pharmacy and Therapeutics Committee. 

____________________________________________                  Date                                 

Director of Pharmacy


____________________________________________                  Date                                 

Chairman Pharmacy and Therapeutics Committee