Health Care Delivery and Pharmacists During the COVID-19 Pandemic

Medication safety and the prevention of medication errors is always one of several priority safety concerns for pharmacists when treating patients across care settings. Medication error is a broad term used to describe a number of more specific events that may cause, or lead to, inappropriate medication use or patient harm.[1] These include patient receipt of the incorrect prescription (e.g., receiving the wrong drug or the correct drug but at the wrong dosage), harmful drug-to-drug interactions, and errors in medication preparation or delivery. Adverse drug events are harms resulting from medications errors, as well as other negative outcomes associated with medication use, including allergic reactions, side effects, and overmedication.[2]

The COVID-19 pandemic and the response of the healthcare system has affected the ability of pharmacists to ensure medication safety in several ways. These include challenges associated with medication shortages, changes to the pharmacy workflow, an ever-changing evidence base associated with the pharmaceutical treatment of COVID-19 complications, and limited availability of personal protective equipment (PPE).

Challenges

Medication Shortages

Medication shortages during the COVID-19 pandemic is a growing problem in the healthcare system that is expected to worsen before it improves. Shortages are primarily being felt because of two unique scenarios driven by this unprecedented global situation. The first is the sudden, rapid influx of patients with COVID-19 symptoms into the healthcare system. The most serious of these cases require mechanical ventilation, leading to a much higher demand for the medications used in this process. Additionally, drugs that are typically used to treat other conditions, such as lupus and rheumatoid arthritis, are now being tested by medical researchers as potential treatment options for virus symptoms. However, this is becoming less frequent as evidence surrounding other treatment options is becoming more established. The second scenario is the disruption to the global supply chain resulting from decreased or suspended drug exports from manufacturing locations overseas, notably from India and China.[3], [4], [5] While in many clinical settings pharmacists are assisting in developing treatment algorithms to decide how to ration medications, such as remdesivir, for the hospitalized patients, these medication shortages may also force pharmacists to recommend second- or third-line treatment options with which they are less familiar, may be less effective, and/or have more side effects.

Changes to Pharmacy Workflow and Redeployment of Healthcare Personnel

Pharmacists are the best-positioned professionals to ensure safety through the preparation, delivery, and ongoing management of medications. However, like the majority of healthcare providers, the usual pharmacy workflow and operations have been greatly impacted by the response to COVID-19. Factors such as ICU bed expansion and providing care in non-traditional hospital settings (e.g., surge hospitals in repurposed spaces like convention centers and university arenas) have modified the physical settings of care for pharmacists, necessitating changes to their workflows. Additionally, pharmacist workflows may be interrupted or require modification due to increased informatics and technology changes associated with monitoring medication supplies or when systems are operating with a decreased workforce (colleagues are forced to work from home, are sick, or may be furloughed). Lastly, redeployment of healthcare personnel to new areas and specialty of care may introduce safety risks due to unfamiliarity with workflows and processes. For example, the Institute for Safe Medication Practices recently shared a case study in which there was a failure to engage barcode medication administration, a best practice in medication safety, when healthcare staff was assigned to a new patient care area.[6]

Evidence for COVID-19 Treatment

As COVID-19 is a novel virus, there are currently no specific treatments approved by the Food and Drug Administration (FDA).[7] While scientists and the biomedical research community are working to develop vaccines and treatments, short-term solutions for immediate need have focused on the off-label use of existing antivirals approved for other conditions. There are drugs currently undergoing clinical studies to evaluate their effectiveness and safety in the treatment of COVID-19.[8],[9] The National Institutes of Health (NIH) has issued treatment guidelines that are updated frequently as published data becomes available.9 With a treatment landscape that is rapidly changing as more evidence becomes available, it is critical for providers to remain aware of the latest guidance – particularly recommendations against the use of treatments due to potential safety concerns.

Limited Availability of Personal Protective Equipment (PPE)

Hand sanitizer, gloves, and face masks are vital equipment that can ensure the safety of both medical professionals and patients during the COVID-19 pandemic. In addition to their direct patient interactions, pharmacists use this equipment when preparing sterile products for intravenous administration (such as those used in the ventilating process or in many cancer treatments) to ensure the medication remains sterile. With a finite supply of PPE, it is critical to consider how health systems allocate this resource to ensure the safety of all staff and the patients they are interacting with.

Available Resources

Numerous regularly updated electronic resources produced and maintained by federal agencies are available to help clinicians navigate the dynamic and continuously evolving medication safety challenges of the COVID-19 pandemic. Several of these tools were available prior to the emergence of COVID, but have found new significance in the wake of this crisis.

NIH Guidelines

As previously mentioned, the NIH has developed electronic guidelines intended to inform clinicians on how to care for patients with COVID-19. These guidelines are updated frequently as the evidence for specific medication use changes and is maintained by a panel of experts representing federal agencies, academic medical centers, and professional societies in infectious disease, emergency care, and thoracic medicine. The guidance addresses: management for critically ill patients, infection control, the roles of antiviral and immune-based therapy, and includes specific considerations for pediatrics and pregnant women.

Tracking Drug Shortages

The FDA maintains a publicly available database to track current drug shortages.

Peer-to-Peer Learning

In addition to evidence generated through clinical studies, healthcare system providers can greatly benefit from open peer-to-peer communication and the ability to learn from one another. During this time pharmacists may be seeking interactions with colleagues to raise questions associated with COVID care and share lessons learned and best practices. ASHP Connect is an online blog platform that existed before COVID for members to engage with each other around various topics. However, in light of the crisis, the association has created a COVID-19 Connect Community section of the website that is available for both members and non-members to raise questions associated with COVID care and share lessons learned and best practices. Multiple professional organizations have similar professional online forums that can serve as valuable resources for members seeking to connect with peers during these times. For example, the American College of Clinical Pharmacy (ACCP) hosts Practice and Research Networks and the Society of Infectious Diseases Pharmacists host forums for their members.

Reporting Adverse Drug Events

Finally, while there are many pressing demands for healthcare providers during this pandemic, now more than ever it is critical that individuals remain vigilant about reporting suspected ADEs through the FDA MedWatch. Organizations such as the FDA and the Centers for Disease Control and Prevention (CDC) use this information to guide their treatment and prevention recommendations. As we are using medications that are second- or third-line drugs or off-label use of drugs, collecting this ADE information is vital to patient safety.

The abundance of publicly available resources and guidance is critical to ensuring that even in these unprecedented times, pharmacists and other providers are well equipped to manage patient safety concerns.

Authors

Anna Legreid Dopp is an employee of ASHP and serves on committees and initiatives with PQA, NQF, and the National Academy of Medicine.

Anna Legreid Dopp, Pharm. D
Senior Director, Clinical Guidelines & Quality Improvement
American Society of Health-System Pharmacists
Bethesda, MD

Eleanor Fitall, MPH
Research Associate, IMPAQ Health
IMPAQ International
Washington, DC

Kendall K. Hall, MD, MS
Managing Director, IMPAQ Health
IMPAQ International
Columbia, MD

Bryan Gale, MA
Senior Research Analyst, IMPAQ Health
IMPAQ International
Columbia, MD

References

[1] About Medication Errors. National Coordinating Council for Medication Error Reporting and Prevention website. https://www.nccmerp.org/about-medication-errors. Accessed November 18, 2019.

[2] Medication Safety Program: Medication Safety Basics. Centers for Disease Control and Prevention. https://www.cdc.gov/medicationsafety/basics.html. Reviewed September 28, 2010. Accessed June 17, 2020.

[3] Roos, R. Experts say COVID-19 will likely lead to US drug shortages. News & Perspectives. Center for Infectious Disease Research and Policy. https://www.cidrap.umn.edu/news-perspective/2020/03/experts-say-covid-19-will-likely-lead-us-drug-shortages. Published March 27, 2020. Accessed May 7, 2020.

[4] Krans, B. From Pain Meds to Condoms: Other Medical Supply Shortages Under COVID-19. Health News. healthline. https://www.healthline.com/health-news/medical-supplies-that-will-have-shortages-soon-under-covid-19-outbreak#How-manufacturing-is-affected. Published April 2, 2020. Accessed May 7, 2020.

[5] Turner, T. COVID-19 and Drug Shortages: How to Prepare. News. drugwatch. https://www.drugwatch.com/news/2020/04/06/covid-19-drug-shortages-how-to-prepare/. Published April 6, 2020. Accessed May 7, 2020.

[6] Special Edition: Medication Safety Alert! Institute for Safe Medication Practices. https://ismp.org/acute-care/special-edition-medication-safety-alert-may-14-2020/covid-19. Published May 14, 2020. Accessed May 18, 2020.

[7] Coronavirus Disease 2019 (COVID-10): Therapeutic Options. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/hcp/therapeutic-options.html. Updated April 25, 2020. Accessed May 7, 2020.

[8] Dong L, Hu S, Gao J. Discovering drugs to treat coronavirus disease 2019 (COVID-19). Drug Discov Ther. 2020;14(1):58-60. doi: 10.5582/ddt.2020.01012.

[9] Coronavirus Disease 2019 (COVID-19) Treatment Guidelines. National Institutes of Health. https://www.covid19treatmentguidelines.nih.gov/. Updated April 21, 2020. Accessed May 7, 2020.