The COVID-19 pandemic posed unprecedented challenges to health care systems worldwide, with medication and equipment shortages emerging as critical issues. To gain insights into how health care organizations navigated these shortages and their impact on patient treatment, CHPSO conducted analyses, drawing from patient safety event records.
The following examines CHPSO’s findings, shedding light on the extent and consequences of these shortages in the health care sector.
Medication and Other Substance Shortage Events
Alongside staffing shortages, the medical community faced medication shortages before the pandemic. These shortages stemmed from various factors, including Food and Drug Administration regulations, just-in-time production practices, raw material scarcity, and quality control issues. The global pandemic further exacerbated these shortages, leading to supply chain disruptions across various industries.
- Amiodarone: Amiodarone, typically used for arrhythmias, saw increased demand as an off-label COVID-19 treatment for severe respiratory failure. Shortages arose due to manufacturing discontinuations and delays. According to the May 2022 shortage alert issued by the American Society of Health-System Pharmacists, there are six amiodarone manufacturers. Of these, AuroMedics discontinued amiodarone in 2021, and Sagent ceased the production of 50 mg/mL 3 mL syringes in June 2019. Baxter continued to experience delays in manufacturing premixed bags. The other three manufacturers did not state the reasons for the shortage.
- Antibiotics: The antibiotic shortage has been a global problem associated with antimicrobial resistance and disease outbreaks for more than a decade. Over 40% of antibiotics listed on Critical Acute Drug and Critical COVID-19 Drug Lists remained in shortage as of May 2022 — this includes both cefazolin and the combo drug ceftazidime and avibactam (Avycaz). Conversely, azithromycin, which has been widely used to treat mild to moderate early COVID-19, thanks to its anti-viral and anti-inflammatory properties, was moved to “resolved” shortage status in December 2020. Sampled safety event reports from 2020 indicated a shortage of intravenous azithromycin, so many patients were switched to oral administration.
- Bronchodilators MDIs (metered dose inhalers): Shortages of bronchodilators like albuterol and Combivent occurred as these were recommended because nebulizer therapy with bronchodilators for presumptive or confirmed COVID-19 patients may not be safe due to the generation of aerosols, which increases the risk that respiratory droplets will remain in the air and spread the virus, according to the Institute for Safe Medicine Practices.
- Antineoplastic Drugs: Azacitidine, decitabine, and ruxolitinib were used off-label to treat hematologic cancer patients with COVID-19. Although it’s unclear if the patients associated with these specific medication event reports were being treated as off-label candidates, any practice change could strain the supply chain further.
- Sedatives, Analgesics, and Vasodilators: Medications such as midazolam, fentanyl, hydromorphone, and vasodilators like epoprostenol (Flolan) were in high demand during the pandemic due to an increase in patients on ventilators. These critical medications — essential for airway management, hypoxemia correction, and patient comfort — experienced precipitous shortages. These medications remain in short supply.
- Blood Products: Global blood donations decreased substantially during the pandemic. The steep decline in donations, specifically plasma, is a major contributing factor to intravenous immunoglobulin (IVIG) shortages. Moreover, many blood products were wasted unnecessarily, resulting in scarce supply.
- Intravenous Injection Dextrose (D50): A shortage of D50, essential for treating hypoglycemic events, has persisted since at least 2013, affecting both pre-hospital and hospital care. Patient safety reports describe the use of oral glucose instead of intravenous D50, due to the shortage, to remedy hypoglycemic events.
- Continuous Renal Replacement Therapy (CRRT): High demand for CRRT to treat acute kidney injury due to circulatory shock from COVID-19 strained the supply of dialysate, which is crucial for the procedure. Multiple safety events describe emergent situations where the proper dialysate was not available to perform timely CRRT. Hospital pharmacists intervened in some cases to dispense substitution products and to implement resource allocation techniques when possible.
- Other Medications: Labetalol, bumetanide, oseltamivir (Tamiflu), and normal saline faced supply issues due to raw material acquisition and manufacturing delays.
Equipment and Supply Shortage Events
- Ventilators and BIPAP Machines: The increased need for ventilators and related supplies impacted acute care, long-term care, and home settings.
- Traditional and New Equipment: Blood pressure monitors, smart pumps, and PPE CAPR head gears faced continuous supply challenges, heightened by the pandemic.
- Procedural Equipment: Reloads (staplers) used in surgery and endoscopes experienced supply issues due to staffing and autoclave delays. Competing factors that intensified the shortage were events related to high-risk bronchoscopies among ventilated patients, which strained resources, raised concerns about potential virus transmission to other patients, and posed a risk of virus exposure to health care workers.
- Technology Disruptions: Defective computer electronic health record systems that did not scan medications inhibited some users from logging into the network, and repeatedly kicked other users out of the system creating disruption to patient flow. This contributed to significant delays in care. Other technology events involved spotty Wi-Fi, which impeded nurses from viewing patient charts on their portable workstations, resulting in delayed care.
- PPE and Testing Supplies: The shortage of personal protective equipment, COVID-19 test kits, swabs, and unexpected items like spinal needles and cervical ripening balloon catheters added to the crisis.
Conclusion
Addressing medication and equipment shortages in health care is essential for ensuring patient safety, especially during crises like the COVID-19 pandemic. CHPSO’s analysis of patient safety event records highlights the critical need for proactive measures, including regulatory reforms and supply chain resilience, to mitigate the impact of these shortages and safeguard patient care.