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I. PURPOSE:
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The purpose of this policy is to outline an appropriate response to current or impending medication shortages in order to provide patients appropriate alternative therapy. In addition, the policy will ensure proper communications among the health system facilities to develop a unified action plan in addressing medication shortages.

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II. DEFINITIONS:
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When used in this policy these terms have the following meanings:

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  1. Shortage: A drug product shortage is 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.

  2. Backorder: A short-term and/or long-term unavailability of drug products.

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III. POLICY:
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  1. It is the policy of the health system that medication shortages and/or backorders shall be handled in an efficient, consistent, and timely manner.

  2. Pharmacy Services shall gather information and work collaboratively to assess alternatives, develop communication plans, and ensure safety when handling medication shortages or backorders.

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IV. PROCEDURE:
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  1. The individual aware of the shortage or backorder will notify the Corporate Pharmacy Contracting Coordinator as soon as it has been identified.

  2. On identification of a medication shortage the Corporate Pharmacy Contracting Coordinator or designee will activate the communications with the pharmacy buyers to obtain an accurate inventory count and site-based utilization data.

  3. The pharmacy buyers will also proceed with the following steps:

    1. Sending a completed Medication Shortage Form (Attachment A) to the site-based Pharmacy Management Team and the Corporate Pharmacy Contracting Coordinator. The entire form must be completed to the extent possible. Any information not readily available may be left blank.

    2. Conduct an accurate and complete inventory inclusive of medication supply in satellite pharmacies, automated dispensing cabinets, storage, main pharmacy, code carts, medication kits, and other procedural areas.

    3. During severe shortages (less than 2-week supply) the decentralized medication stock (ADM, satellite pharmacy, etc.) will be quarantined to the main pharmacy with the approval of the Pharmacy Manager or designee. The Pharmacy Manager or designee must communicate this decision with the pharmacy staff.

    4. Maximize purchasing according to allocation at each site.

    5. Transfer and balance the utilization of the remaining supply with facilities in greatest need and inform site-based Pharmacy Management Team.

  4. For severe and acute shortages a group (Backorder Action Team) will convene under the direction of the Corporate Pharmacy Contracting Coordinator. The group will be responsible for developing a detailed backorder/shortage action plan for alternatives, communications, and a monitoring of the backorder for updates. The group may be inclusive of, but not limited to, the Drug Information Coordinator, Pharmacy Managers, Operations Coordinators, Clinical Coordinators, and when applicable Clinical Specialist, Pyxis® System Specialist, Pharmacy Information Systems Coordinator, Pharmacy Buyer, Pharmacy Educator, and Risk Management.

  5. The Drug Information Coordinator will assist with developing a list of alternatives and a plan for substitution in the event the medication supply becomes depleted. This plan must be forwarded to ...

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