How hospitals manage drug shortages

Of the 69 drugs on FDA's current shortage list on Nov. 3, 2026, 49 are injections. Ten fall in FDA's anesthesia category, 17 in its pediatric category, and the median entry was first posted 1,710 days earlier, according to GxRadar's analysis of FDA shortage data from openFDA⁹. Most of those products are given in hospitals, which buy through their own channels, so hospital pharmacy departments do much of the work of absorbing a shortage.

That work is substantial. In a 2017 survey by the Institute for Safe Medication Practices of nearly 300 pharmacy directors, managers and purchasing agents, 71 percent said that in the previous six months they had sometimes been unable to provide the recommended drug or treatment because of a shortage, and 75 percent said treatments had been delayed. FDA summarized those results in its 2019 report on the root causes of shortages².

Hospitals have a shared playbook for this, written by the American Society of Health-System Pharmacists. This piece describes what those guidelines ask hospitals to set up, what researchers have estimated shortages cost in staff time, and why pharmacists treat shortages as a medication-safety problem. It describes institutional practice only. Decisions about any one patient's treatment belong to that patient's clinicians.

The structure ASHP recommends before a shortage hits

ASHP's current guidelines on managing drug product shortages¹ were published in the American Journal of Health-System Pharmacy on Nov. 1, 2018, and replaced a 2009 version. The federal Agency for Healthcare Research and Quality summarizes them as a "structured approach for care teams," with recommendations that include "conducting operational assessments, establishing a drug shortage team, and communicating with patients and providers."

ASHP defines a shortage from the hospital's side of the counter: a supply issue that affects how the pharmacy prepares or dispenses a product, or that forces prescribers to use an alternative. That is broader than FDA's national definition, which turns on whether total supply meets demand, as the agency explains in its shortage FAQ⁵. A drug can be a daily problem for a hospital without ever appearing on FDA's list.

ASHP asks hospitals to have three things in place before any particular shortage starts. The first is an interdisciplinary shortage team with a named point person. At a minimum, the guidelines say, the team should be able to identify who is responsible for:

• gathering and monitoring data on the shortage
• purchasing alternatives
• changing storage, preparation and dispensing procedures
• deciding whether to conserve or ration supply
• making technology changes
• communications

Second comes a resource allocation committee to oversee how scarce drugs are distributed. ASHP says it should include, at a minimum, representatives from pharmacy, nursing, social work and medicine, a patient representative and someone from the hospital's ethics committee. The third is a set of standing processes for approving therapeutic alternatives and handling ethical questions, agreed in advance so that the hardest decisions are not made for the first time at the bedside.

From the first alert to a final plan

Once a shortage is identified, the guidelines lay out a sequence. A flow chart in the 2018 document splits the early work into two tracks, then combines them.

Source: ASHP (2018), Guidelines on managing drug product shortages, Figure 1.

Inventory counts are meant to be exhaustive. The guidelines list pharmacies, inpatient units, clinics, automated dispensing cabinets, floor stock, code carts and prepared trays. Among the inventory measures they list are adjusting par levels, pulling stock back from cabinets and floor stock to a central location, and repackaging into smaller units.

Hospitals are told not to hoard. Stockpiling ahead of an expected shortage "can exacerbate the shortage," the guidelines say, and an early stockpile order usually does not raise a hospital's allocation, because manufacturers and distributors often allocate on the basis of past purchases.

Some of the tools come from FDA. The agency keeps a searchable list of specific lots whose use dates it has extended⁶ to help with supply. It expedited review of 224 submissions tied to shortages in 2025 and prioritized 10 inspections, according to its report to Congress for calendar year 2025⁴. When ASHP's guidelines discuss compounded alternatives, they point either to in-house compounding or to purchase from an FDA-registered outsourcing facility⁷, and they tie any extension of beyond-use dating to approval by FDA and the manufacturer or to a process that complies with USP general chapter 797⁸. GxRadar's piece on compounding during shortages covers the legal side, and our explainer on 503A and 503B compounders explains the two kinds of facilities.

What shortages cost in staff time

Every estimate of the cost is old, and each counts something different. FDA's 2019 report said most hospitals and health systems "have not comprehensively quantified the costs of managing drug shortages and the total cost to the nation's health care delivery system is not known."

The labor figure in the 2011 ASPE issue brief³ came from an ASHP survey of pharmacy directors released in June 2011. The same brief reported that a hospital association survey of 820 hospitals found almost all had faced at least one shortage in the prior six months.

FDA's 2019 report² added survey findings on care itself. Fifty-six percent of community hospitals surveyed said they had changed patient care or delayed therapy during fiscal years 2015 to 2017 because of shortages, and 36.6 percent said they had rescheduled procedures. Almost 80 percent said shortages had raised their drug spending to a moderate or large extent.

ASHP traces the money to off-contract purchases, pricier alternatives, and the staff time needed to develop plans, relocate or compound products and rebuild electronic records. They urge hospitals to track those costs, along with revenue lost to canceled treatments.

Why pharmacists treat shortages as a safety problem

ASHP puts the risk plainly. Medication errors are more likely, the guidelines say, when a pharmacy changes how a product is ordered, prepared or dispensed, or when prescribers switch to less familiar alternatives. Every substitution touches barcode scanning, smart infusion pump libraries, automated cabinets and look-alike, sound-alike procedures, which is why our explainer on look-alike drug names is relevant here too.

ISMP has done most of the measuring. A July to September 2010 ISMP survey drew 1,800 health care practitioners, 68 percent of them pharmacists, and a majority reported problems including less desirable alternatives and the potential for errors, according to the ASPE brief³. In the 2017 ISMP survey that FDA summarized, 47 percent of respondents thought shortages had led to patients receiving a less effective drug. Respondents most often said shortages had affected emergency care (87 percent), anesthesia (85 percent) and pain management (81 percent).

Data on actual harm are thin. The guidelines say evidence of patient harm from shortages is "limited to case reports and survey data," and they call for errors and near misses to be reported internally and externally.

What patients may notice

ASHP asks hospitals to set policies on telling patients when a shortage will delay or compromise care, with particular attention to patients already stabilized on the drug. For people filling prescriptions outside the hospital, FDA's FAQ⁵ says local reports of a missing medicine usually involve temporary distribution problems, and that trouble finding a drug "may be due to a temporary, localized supply issue." It suggests asking a pharmacist or health care provider whether an alternative exists. GxRadar's guides on what to ask when a medicine is in shortage and what to ask about a back order list questions to bring.

The workload is not shrinking as fast as the count of new shortages. FDA recorded four new shortages in 2025, against a peak of 251 in 2011, but 93 shortages were still ongoing at the end of the year, according to its CY 2025 report⁴. The current list and its long-running entries are on GxRadar's shortage tracker and FDA's drug shortages page¹⁰.