Abstract
Background: Medication shortage is a serious issue affecting public health and patient care. It causes a major burden on the medical team of a healthcare organization in the delivery of quality care. Objectives: This study aims to assess the perception of ambulatory care pharmacist about formulary medication shortage as well as to assess the rate of medication shortage and explore the highest classes of the not-available (NA) medication. Methods: A cross-sectional survey was performed to assess pharmacist perception regarding medication shortage. The data for NA medication was collected from the hospital health information system “HIS” (Best care) to investigate the type and classes of medication shortage. Results: The overall survey response rate was 92.7%. The majority (61%) of participants encountered 5 to 15 labels of NA medication per day, 43% of participants encountered unpleasant behavior from patients usually due to NA medication and the main reason of patient dissatisfaction was the negative effect of NA medication on their course of therapy. Ninety-seven percent of participants agreed that medication shortage adds extra pressure/workload and 66% agreed that medication shortage increases the chance of medication error. A total of 113 medication shortage was recorded between January and March 2020. The 2 drug classes, which showed maximum shortage, were gastrointestinal and cardiovascular medications. The most prevalent type of medication shortage was for drugs administered by oral route (91.2%). Conclusions: The study provides insights into the frequency, management, and problems confronted due to medication shortage from the pharmacist perception. The study findings highlight the classes and type of medication shortage in the hospital which needs intervention to enhance patient care. The findings of the study would help the higher administration to implement an effective strategy to mitigate the shortage of medication, improve patient satisfaction, and to reduce pharmacist workload.
Keywords: ambulatory care, drug class, medication shortage, perception, pharmacist, Saudi Arabia
Introduction
Medication shortage is a well-known topic to pharmacists and pharmacy team members also involving medical supply officers. It is a serious issue that affects public health and patient-care, causing a major impediment to the medical team of a healthcare organization in delivery of quality care. The American Society of Health-System Pharmacists (ASHP) defines medication shortage as “a supply issue that affects how the pharmacy prepares or dispenses a drug product or influences patient care when prescribers must use an alternative agent.” 1
Medication shortage is considered a global problem, whether influenced by the organizational level or through international factors. There are many reasons behind medication shortage globally including but not limited to, significant demand changes that affect the international marketplace or supply-side related problems. Saudi Arabia is equally affected by this growing issue and the main domestic causes of drug shortages in Saudi Arabia include poor medication supply chain management, lack of government regulation that mandates early notification of drug shortages, low-profit margins of some essential drugs, weak and ineffective law-violation penalties against pharmaceutical companies. 2
European Association of Hospital Pharmacists’ survey, 2018, done across 39 countries revealed that 90% of hospital pharmacists indicate medication shortage as an existing issue in delivering optimal healthcare to patients. 3 On the other hand, a cross-sectional study conducted in Saudi Arabia in 2017 explored the prevalence and characteristics of drug shortages. 4 The study found that a higher percent of pharmacists from the ministry of health-affiliated medical cities reported medication shortages on daily basis at 42.11% compared to 15.09% at non-MOH hospitals.
Several studies suggested that not-available (NA) medications are directly linked to patient dissatisfaction due to out-of-pocket expenses, treatment changes, and treatment delays.4-10 In order to manage medication shortage, pharmacist has to go beyond his domain to perform various activities, through identifying therapeutic alternatives, compounding pharmaceutical preparations, communicating with healthcare providers, hospital staff education, updating electronic information system, and contacting vendors or manufacturers. Therefore, pharmacist perceptions about the drug shortage are valuable in resolving the issue. In this regard, presently only few studies are available from the Saudi Arabia and to fill this gap, present study was planned to assess the perception of ambulatory care pharmacists about formulary medication shortage as well as to assess the rate of medication shortage and explore the highest classes of the NA medication.
Methods
Study Instrument
A survey questionnaire was developed based on previously published work.4,7 The questionnaire was reviewed by the research team to select appropriate questions and then the questions were modified according to the study settings and local factors. The questionnaire comprised of 2 parts, first part included 4 questions to explore participant demographics, and second part had 10 questions to assess pharmacist perception about medication shortage and the effect it had on their workload, quality of delivered care, and patient dissatisfaction. It also had a section for their recommendations to improve current practice. The questions selected for present study were evaluated by the experts in the field of pharmacy; their suggestions were valued and the questionnaire was revised. The survey questionnaire clarity, unambiguity of the questions, and time needed to complete the survey was assessed by conducting a pilot study on 15 pharmacists. The participants did not face any trouble in understanding the questions and took about 3 to 5 minutes to complete the survey.
Study Design
A cross-sectional survey was performed to assess pharmacist perception regarding medication shortage. The data for NA medication was collected from the hospital health information system “HIS” (Best care) to investigate the type and classes of medication shortage.
Setting
The study was conducted in 3 outpatient pharmacies of one of the Ministry of National Guard Health Affairs (NGHA) Medical City, which is an academic tertiary care referral center.
Sample Size Calculation
The sample size was calculated using online Raosoft sample size calculator, available at http://www.raosoft.com/samplesize.html. The total population of pharmacists was estimated as 20 000, margin of error 10% with 95% Confidence Interval. The minimum sample size for the study was calculated to be 96 and study population of 110 taking into consideration some dropouts and incomplete responses.
Data Collection
Pharmacist perception
Convenience sampling technique was utilized due to logistic limitations. Researcher visited pharmacies once weekly for 3 consecutive weeks in December, 2019. Pharmacists available in the pharmacy of the hospitals were explained about study objective and the importance of their perception along with the information that only 5 minutes will be needed for completing the survey. After getting verbal consent, link of online Google form that had questionnaire was sent to their mobile number. Pharmacists were working at outpatient pharmacy in a NGHA hospital, NGHA children’s hospital, and Health Care Specialty Center (HSCS).
Not available (NA) medication data
A complete list of NA medication was retrieved from Health Information System (HIS, Best Care) between January and March 2020. The data includes generic name of NA medication, route of administration (oral, injection, inhaler, topical), and number of prescriptions with NA medication per month. Moreover, NA medications were classified into drug class to describe the shortage.
Statistical Analysis
Descriptive analysis was performed using IBM SPSS version 23, New York, USA. Descriptive statistics were used to compare the opinions of pharmacists about the drug shortages in the 3 pharmacies using the categories and percentage distribution of responses in each category. Cronbach’s alpha test was conducted to check inter-correlation between 3 parameters which were graded on 5-Point Likert scale and the alpha value was found to be .73.
Ethical Consideration
The study is approved by the Institutional Review Board of the Medical City, Saudi Arabia.
Result
Overall survey response rate was 92.7% (102/110). Table 1 shows the demographic characteristics of the participants. The majority of participants were female 60/102 (58.8%), in the age group of 23 to 35 years 78/102 (76.5%), and with a working experience of fewer than 5 years 43/102 (42.2%). HCSC outpatient pharmacy had significantly higher participants in the age group more than 35 years 12/16 (75.0%) and a working experience above 10 years 11/16 (68.7%) than participants from NGHA hospital (11/54 [20.4%]; 9/54 [16.7%], respectively) and from NGHA children’s hospital (1/32 [3.1%]; 4/32 [12.5%], respectively] (P = .0001).
Table 1.
Demographics of Participants.
| Demographics | Location of outpatient pharmacy | P-value | Total (n = 102) | ||
|---|---|---|---|---|---|
| NGHA hospital (n = 54) | NGHA children’s hospital (n = 32) | HCSC (n = 16) | |||
| Gender (%) | |||||
| Male | 18 (33.3) | 11 (34.4) | 13 (81.3) | .002* | 42 (41.2) |
| Female | 36 (66.7) | 21 (65.6) | 3 (18.7) | 60 (58.8) | |
| Age (years) (%) | |||||
| ≤35 | 43 (79.6) | 31 (96.9) | 4 (25.0) | <.0001* | 78 (76.5) |
| >35 | 11 (20.4) | 1 (3.1) | 12 (75.0) | 24 (23.5) | |
| Experience (years) (%) | |||||
| <5 | 21 (38.9) | 21 (65.6) | 1 (6.3) | <.0001* | 43 (42.2) |
| 5-10 | 24 (44.4) | 7 (21.9) | 4 (25.0) | 35 (34.3) | |
| >10 | 9 (16.7) | 4 (12.5) | 11 (68.7) | 24 (23.5) | |
P-value significant.
All the participants from NGHA hospital outpatient pharmacy reported having dealt with NA medication over the past 3 months while “1” participant each from NGHA children’s hospital and HCSC outpatient pharmacies reported no encounter with NA medication. The participants who reported no encounter NA medication were excluded from further analysis. Table 2 presents responses of 100 participants to question about medication shortage. Sixty-one (61%) participants reported encounter with 5 to 15 labels of NA medication per day, 49 (49%) participants reported that their first action to NA medication was to ask the patient to check the pharmacy later for the availability of medication, and 37 (37%) said they contact the prescriber for an alternative. Furthermore, 21 (21%) participants reported to contact prescriber 3 to 5 times per day to recommend an alternative for NA medication.
Table 2.
Responses of Participants to Questions About Drug Shortage.
| Questions | Location of outpatient pharmacy | P-value | Total (n = 100) # | ||
|---|---|---|---|---|---|
| NGHA hospital (n = 54) | NGHA children’s hospital (n = 31) | HCSC (n = 15) | |||
| How many times usually you encounter NA medication per day? (%) | |||||
| <5 label | 17 (31.5) | 9 (29.0) | 3 (20.0) | .636 | 29 (29) |
| 5-15 label | 33 (61.1) | 18 (58.1) | 10 (66.7) | 61 (61) | |
| >15 label | 4 (7.4) | 4 (12.9) | 2 (13.3) | 10 (10) | |
| What is the first action you usually do if NA medication in the prescription? | |||||
| Contact prescriber to write alternative | 19 (35.2) | 11 (35.5) | 7 (46.7) | .628 | 37 (37) |
| Ask patient to check pharmacy later to check availability | 29 (53.7) | 13 (41.9) | 7 (46.7) | 49 (49) | |
| Other | 6 (11.1) | 7 (22.6) | 1 (6.6) | 14 (14) | |
| How many times you contact prescriber per day to recommend to prescribe alternative for the NA medication? (%) | |||||
| <3 times | 7 (13.0) | 5 (16.1) | 0 (0) | .610 | 12 (12) |
| 3-5 times | 9 (16.7) | 5 (16.1) | 7 (46.7) | 21 (21) | |
| >5 times | 2 (3.7) | 1 (3.2) | 0 (0) | 3 (3) | |
| No response | 36 (66.6) | 20 (64.6) | 8 (53.3) | 64 (64) | |
| How often do you encounter unsatisfied behavior from the patient due to NA medication? (%) | |||||
| Always | 16 (29.6) | 10 (32.3) | 4 (26.7) | .022* | 30 (30) |
| Usually | 23 (42.6) | 17 (54.9) | 3 (20.0) | 43 (43) | |
| Often | 8 (14.8) | 2 (6.4) | 0 (0) | 10 (10) | |
| Sometimes | 6 (11.1) | 2 (6.4) | 8 (53.3) | 16 (16) | |
| Never | 1 (1.9) | 0 (0) | 0 (0) | 1 (1) | |
| From your opinion what is the main reason that leads to patient dissatisfaction regarding medication shortage? (%) | |||||
| Delay on receiving medication | 14 (25.9) | 9 (29.0) | 5 (33.3) | .845 | 28 (28) |
| Affecting negative course therapy | 27 (50.0) | 12 (38.7) | 6 (40.0) | 45 (45) | |
| Other | 13 (24.1) | 10 (32.3) | 4 (26.7) | 27 (27) | |
| From your opinion, medication shortage adds extra pressure/workload on you as a pharmacist dealing with a patient? (Select the most appropriate answer) (%) | |||||
| Strongly agree | 31 (57.4) | 24 (77.4) | 11 (73.3) | .066 | 66 (66) |
| Agree | 20 (37.0) | 7 (22.6) | 4 (26.7) | 31 (31) | |
| Disagree | 2 (3.7) | 0 (0) | 0 (0) | 2 (2) | |
| Strongly disagree | 0 (0) | 0 (0) | 0 (0) | 0 (0) | |
| Not applicable | 1 (1.9) | 0 (0) | 0 (0) | 1 (1) | |
| From your opinion, medication shortage has high chance to medication error (Select the most appropriate answer) (%) | |||||
| Strongly agree | 13 (24.1) | 8 (25.8) | 7 (46.7) | .153 | 28 (28) |
| Agree | 17 (31.5) | 15 (48.4) | 6 (40.0) | 38 (38) | |
| Disagree | 21 (38.9) | 5 (16.1) | 0 (0) | 26 (26) | |
| Strongly disagree | 0 (0) | 3 (9.7) | 2 (13.3) | 5 (5) | |
| Not applicable | 3 (5.5) | 0 (0) | 0 (0) | 3 (3) | |
| In your opinion, in which step dispensing NA medications will take longer time than expected (Select all and multiple option apply) ## (%) | |||||
| Checking the store | 6 (10.2) | 5 (14.3) | 1 (6.7) | — | 12 (11.0) |
| Contacting prescriber for alternative | 10 (16.9) | 7 (20.0) | 3 (20) | 20 (18.3) | |
| Discussing the issue with patient | 6 (10.2) | 3 (8.6) | 2 (13.3) | 11 (10.1) | |
| All the above | 37 (62.7) | 20 (57.1) | 9 (60.0) | 66 (60.6) | |
| From your experience dealing with NA medications will increase the patient waiting time in ambulatory pharmacy by (%) | |||||
| 15 minutes | 20 (37.0) | 11 (35.5) | 14 (93.3) | .0001* | 45 (45) |
| 30 minutes | 30 (55.6) | 8 (25.8) | 1 (6.7) | 39 (39) | |
| >30 minutes | 4 (7.4) | 12 (38.7) | 0 (0) | 16 (16) | |
| From your opinion, what do you recommend to lessen the impact of NA medications on the pharmacy workload? (Select all and multiple option apply) ## (%) | |||||
| Ask prescriber to shorten the duration of prescribed item | 4 (6.0) | 4 (9.5) | 3 (17.6) | — | 11 (8.7) |
| Receive regular emails/updates regarding NA medications from administration | 27 (40.3) | 16 (38.1) | 7 (41.2) | 50 (39.7) | |
| Improve workflow for dealing with NA medication efficiently | 25 (37.3) | 15 (35.7) | 2 (11.8) | 42 (33.3) | |
| Other | 7 (10.4) | 1 (2.4) | 1 (5.9) | 9 (7.1) | |
| All the above | 4 (6.0) | 6 (14.3) | 4 (23.5) | 14 (11.1) | |
P-value significant.
One participants each from children hospital pharmacy and HSCS pharmacy was removed from the analysis as their response was “No” for “Have you encountered medication shortage over the past 3 months,” so n = 100.
The total number of responses are different from number of participants due to multiple option selection availability.
Forty-three (43%) participants reported to have encountered unpleasant behavior from the patients usually due to NA medication and as per the opinion of a majority of them, the main reason for patient dissatisfaction is the negative effect of NA medication on their course of therapy and delay on receiving the medication. Ninety-seven (97%) participants agreed that medication shortage adds extra pressure/workload and 66 (66%) participants agreed that medication shortage increases the chances of medication error, reasons for which are enumerated in the discussion. Sixty-six (66%) participants reported encounter with NA medication increases the time taken for dispense as extra time is required for checking the store, contacting the prescriber, and discussing the issue with the patient. Fifty (50%) participants recommend regular emails/updates on NA medication from administration will reduce the pharmacy workload and improve workflow.
Participants from NGHA hospital and NGHA children’s hospital outpatient pharmacy encountered unpleasant behavior from patients in higher frequency than HCSC outpatient pharmacy (P = .022). The increase in patient waiting time is approximate 15 minutes according to 14/15 (93.3%) participants from HCSC while it is significantly higher at 30 minutes or more according to 34/54 (63%) participants from NGHA hospital and 20/31 (64.5%) participants from NGHA children’s hospital (P = .0001).
Table 3 shows frequency of medication shortage for different medication classes in NGHA hospital and NGHA children’s hospital outpatient pharmacies. In the duration of 3 months (January-March, 2020), 16 806 prescribed medication were not available. Gastrointestinal drug class shows higher number of NA medications with total number of 6005 (35.7%), cardiovascular 4544 (27.0%), therapeutic/nutrients/minerals/electrolytes 1886 (11.2%), and antibacterial 756 (4.5%).
Table 3.
Distribution of Month Wise Medication Shortage.
| Drug class | Location of outpatient pharmacy (no. of NA prescribed medication) | Total patients refused in 3 months | |||||||
|---|---|---|---|---|---|---|---|---|---|
| NGHA hospital | NGHA children’s hospital | ||||||||
| January | February | March | Total | January | February | March | Total | ||
| Analgesic | 0 | 0 | 42 | 42 | 0 | 0 | 2 | 2 | 44 |
| Anti-bacterial | 304 | 181 | 21 | 506 | 30 | 190 | 30 | 250 | 756 |
| Anti-coagulant | 126 | 334 | 270 | 730 | 0 | 2 | 1 | 3 | 733 |
| Anti-convulsant | 21 | 24 | 0 | 45 | 6 | 0 | 2 | 8 | 53 |
| Anti-dementia | 0 | 0 | 45 | 45 | 0 | 0 | 0 | 0 | 45 |
| Anti-depressant | 185 | 0 | 12 | 197 | 0 | 0 | 0 | 0 | 197 |
| Anti-diabetic | 82 | 29 | 19 | 130 | 11 | 5 | 9 | 25 | 155 |
| Antidote | 17 | 26 | 15 | 58 | 5 | 13 | 11 | 29 | 87 |
| Anti-fungal | 1 | 3 | 1 | 5 | 0 | 0 | 0 | 0 | 5 |
| Anti-inflammatory | 22 | 0 | 0 | 22 | 0 | 0 | 0 | 0 | 22 |
| Anti-migraine | 0 | 0 | 0 | 0 | 4 | 0 | 0 | 4 | 4 |
| Anti-mycobacterial | 10 | 26 | 10 | 46 | 1 | 0 | 4 | 5 | 51 |
| Anti-neoplastic | 38 | 192 | 240 | 470 | 23 | 10 | 15 | 49 | 518 |
| Anti-psychotic | 21 | 0 | 11 | 32 | 0 | 2 | 1 | 3 | 35 |
| Anti-viral | 2 | 0 | 1 | 3 | 0 | 21 | 21 | 42 | 45 |
| Blood formation | 2 | 1 | 0 | 3 | 6 | 1 | 0 | 7 | 10 |
| Cardiovascular | 996 | 1253 | 1485 | 3734 | 210 | 342 | 258 | 810 | 4544 |
| Dermatological | 26 | 264 | 129 | 419 | 2 | 8 | 26 | 36 | 455 |
| Gastrointestinal | 2258 | 426 | 2710 | 5394 | 379 | 35 | 197 | 611 | 6005 |
| Hormonal agent/stimulant/replacement | 48 | 94 | 83 | 225 | 69 | 76 | 11 | 156 | 381 |
| Immunological | 33 | 4 | 0 | 37 | 19 | 0 | 1 | 20 | 57 |
| Inflammatory bowel disease | 0 | 0 | 0 | 0 | 0 | 3 | 0 | 3 | 3 |
| Miscellaneous | 39 | 34 | 91 | 164 | 10 | 3 | 7 | 20 | 184 |
| Ophthalmic | 208 | 38 | 0 | 246 | 93 | 0 | 20 | 113 | 359 |
| Respiratory tract | 20 | 66 | 57 | 143 | 5 | 3 | 21 | 29 | 172 |
| Therapeutic/nutrients/minerals/electrolytes | 93 | 96 | 1258 | 1447 | 102 | 276 | 62 | 439 | 1886 |
| Total | 4552 | 3091 | 6500 | 14 143 | 974 | 990 | 699 | 2663 | 16 806 |
Table 4 shows distribution of route of medication shortage; the most prevalent route of medication shortage was oral 15 336 (91.2%) followed by topical 943 (5.6%) and injectable 372 (2.2%).
Table 4.
Type of Drug Shortage.
| Type of drug | Location of outpatient pharmacy | Total of NA prescribed medication in 3 months | |||
|---|---|---|---|---|---|
| NGHA hospital |
NGHA children’s hospital |
||||
| No. of NA medication | No. of NA prescribed medication in 3 months | No. of NA drugs | No. of NA prescribed medication in 3 months | ||
| Injection | 6 | 186 | 8 | 186 | 372 |
| Inhaler | 3 | 143 | 4 | 12 | 155 |
| Oral | 61 | 13 045 | 59 | 2291 | 15 336 |
| Topical | 9 | 769 | 13 | 174 | 943 |
| Total | 79 | 14 143 | 84 | 2663 | 16 806 |
Discussion
Medication shortage is of great importance as it has an impact on the patient health and increases patient dissatisfaction. The pharmacists are the ones who have to face this situation and their views and opinions on the effect of medication shortage are of immense significance. Through this study it was tried to know about pharmacist perceptions on medication shortage and the study achieved a very high response rate of 92.7% as the pharmacists of the 3 centers were contacted personally and were explained about the importance of their view on the subject. Moreover, the study used a short questionnaire which needed only 5 minutes for completion helped to get a higher interest and increased the participation rate. A previous study from Saudi Arabia which was carried out in large hospital in Riyadh showed comparatively lower response rate of 60%. 4
In the present study it was found that more than 60% of the pharmacists from these hospitals came across on an average 5 to 15 label of NA medication per day suggesting that the problem is very common in these centers. It further highlights that patient care is greatly affected due to it and there is need to initiate an intervention to solve the issue. Similar findings were reported by a survey conducted in Canada, 11 where more than half of the pharmacists experienced a shortage during 1 shift, and 80% experienced drug shortages over a 1-week period. The participants estimated that they spent an average of 17.5 minutes each shift dealing with drug shortages, very similar to our study.
A study from USA, 5 where a national online survey was conducted to quantify the effects of drug shortages on patient care and pharmacy expenses involving Directors of pharmacy in acute care institutions. Nearly all directors (95%) believed that shortages had changed practice, and a majority (61%) believed that drug shortages had compromised patient care, which adds to the finds from the present study.
According to the responses received, nearly all pharmacists agreed that medication shortage puts an extra pressure/workload on them, resulting in physical and mental stress. So to resolve this outstanding problem, a department dedicated to medication shortage may be formed. The responsibility of the department should include bi or tri-weekly review of the medicine stock and get prepared with the arrangement of alternative drug before the medication shortage crisis arises. They should also remain in close contact with drug suppliers and develop coordination with them to sort out the problem of medication shortage on a temporary basis.
It is noteworthy that 43% of the pharmacists reported encounter with unpleasant behavior usually from the patient or attendant due to NA medication. According to their perception, the main cause of patient dissatisfaction is the negative impact of NA medication on their course of therapy or delay/postponement of a planned treatment of procedure. This finding is worth noting as it gives insight that patients are aware about the importance of their medications and complications associated with non-compliance to the treatment. It is expected that these patients would spend time to track down substitute pharmacies in the town to obtain their essential drugs. If they lack medical insurance policy for claim, then they may have to bear the expense out of their pocket. If such conditions are prevalent for long, then the patients would lose their faith in the health care system. On the other hand, patients who did not complain or inform regarding the negative impact of NA medication on their treatment may not take the issue seriously and discontinue treatment till the medications gets available in the pharmacy. This can lead to an increased number of patients reporting to hospital with severe complications or disease progression in the future. Similar to present study findings, a survey from USA reported that 38% of the participant responded shortage of medication leads to patient complaints. 5
Participants from NGHA hospital and NGHA children’s hospital outpatient pharmacies reported more issues related to unsatisfied behavior from patients compared to HCSC outpatient pharmacy. This higher encounter may be due to the long waiting time required by the patients in these pharmacies than the HCSC pharmacy. The long waiting time in NGHA hospital and NGHA children’s hospital pharmacies may be considered judicious as these pharmacies have younger pharmacists with less working experience compared to HCSC pharmacy.
The main medication shortage found in this study was for drugs administered by the oral route. Similar findings of shortages in oral products were reported from Saudi Arabia while the injectable products were the main type of medication shortage in USA. 12 The patient management in Saudi Arabia is usually carried out through oral medication, so it is sensible to encounter with oral medication shortage than injectable products.
Sixty-six percent of pharmacists responded that medication shortage will increase the occurrence of medication error. A number of studies have also reported medication errors due to medication shortage.2,4,5,8,13 Such errors can occur due to drug unavailability as the pharmacist needs to adopt hit-and-trial method when faced with the shortage, compounded by unpleasant reaction of the patient or attendant. This reduces his attention span and productivity at work which may lead to mistakes while dispensing a drug to the same or unrelated patient. In the study done in the USA, 5 only 10% of Hospital directors reported a serious medication error. This difference may be attributed to less number of pharmacists manning each pharmacy in Saudi Arabia as compared to the USA, thereby increasing the workload. To reduce the medication errors, the hospitals can prepare a list of alternative medicines in advance along with the side effects and other complications associated with them that need to be considered before dispensing medicine. This will reduce on the spot selection of an alternative drug by the physician when called about for a drug shortage.
In this study, 113 medication shortages were recorded from medical city during the 3 months period from January to March 2020. Three class of drugs, which showed maximum shortage were cardiovascular (14 drugs), gastrointestinal (12 drugs), and hormonal agent/stimulant/replacement (12 drugs). A number of studies are present in literature which support the present findings of the maximum shortages being for these 3 classes of drugs probably since these category of drugs either have to be taken for long duration, sometimes for lifetime and the prevalence of these conditions is increasing exponentially across the globe.4,7,12-14 A comparative study of medication shortage in USA and Saudi Arabia found that significantly higher percentage of shortages involved injectable drugs in the US hospital setting (78.1%) than the Saudi hospitals (34.43%) (P ≤ .0001). 12 This divergent finding of less shortages of injectables in Saudi Arabia as compared to the USA may be explained by more preference to oral therapies by physicians and patients, better inventory management of life-saving drugs that are mostly given by injection route.
Participants in the study recommended that improvement in the communication among pharmacists and higher administration as well as shortening duration of prescribed medicine by prescriber will help to lessen the burden of shortage. It was also suggested that improved workflow of NA medication with modern IT tools is necessary to help the policy makers and Hospital stakeholders to tackle this growing problem. On the same lines, another study from Saudi Arabia also recommended creating advanced communication tools to help pharmacists act swiftly when encountered with drug shortage. 15 The suggestions provided by the pharmacist to lessen the impact of NA medication on workload are feasible to be accomplished by the health administration, as the health system in Saudi Arabia uses highly advanced digital technologies. A number of published studies have suggested guidelines which highlight that healthcare professionals should develop practical strategies collaboratively with pharmacists in a proactive manner to reduce the impact of medication shortage on patients’ wellbeing.1,16 The best way to manage the problem associated by medication shortage is development of good coordination between pharmacists and physicians to find suitable substitutes and efficient allocation of medicines that are in short supply to the patients with the highest need.1,17,18
Strength
The study achieved a good response rate of 92.7%. The details of medication shortage were retrieved from an electronic HIS (Best Care). The study focuses on outpatient pharmacies of 1 medical city, so the result may help the administration to take necessary action to intervene the issue of medication shortage more effectively.
Limitations
Inpatient setting for drug shortages and comparison of the perceptions, actions in indoor and outdoor patients was not done. The study is related to 1 institution and has used a non-probability sampling technique to select the participants, so caution should be used while applying and attributing the results to general perception of pharmacists in Saudi Arabia. The supply chain management is different among the institutions in Saudi Arabia, so, this research can be advanced by comparing findings to other institutions who have signed contract with “Wasfati” program. The survey can be expanded to other medical staff related to drug shortage like physicians and nurses and a parallel survey can be carried on patients to know their perception on medication shortage.
Conclusion
The study provides insights into the frequency, management, and problems confronted due to medication shortage from the pharmacist perception. It provides valuable information about classes and types of medication shortage in the hospital, which needs intervention to enhance patient care. The findings of the study would help the higher administration to implement an effective strategy to mitigate the shortage of medication, improve patient satisfaction, and to reduce pharmacist workload.
Acknowledgments
We would like to express our gratitude to Deanship of Scientific Research, Saudi Electronic University, Riyadh, Kingdom of Saudi Arabia and we would like to express our sincere thanks Ahmed Alquhaidan, for his valuable contribution to survey development and validation.
Footnotes
Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
Ethics Statement: The study is approved by the Institutional Review Board, King Abdullah International Medical Research Center Riyadh, Saudi Arabia.
ORCID iD: Mohammed AL-Mohaithef 
https://orcid.org/0000-0002-8312-1005
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