How to Make Substitutions Safer with Better Workflow and Communication
By Kilee Yarosh, Senior Manager, Clinical Strategists, Omnicell
LinkedIn: Kilee Yarosh
LinkedIn: Omnicell
Most medication shortages don’t manifest as national emergencies. While those extreme occurrences grab the headlines, the more common everyday shortages can also have far-reaching implications. With all the time that goes into establishing a care plan, they can often force change late in the process, leading to avoidable risk. What may seem like a simple medication substitute could actually require a different dose, timing, route, dilution, administration rate, compatibility check, monitoring parameter, or patient counseling point. When those differences are introduced under time pressure, the full care team must be involved to re-coordinate around a moving target, across multiple systems and handoffs, with uneven visibility.
That stacking effect is why medication shortages can create a patient-safety chain reaction. However, when health IT tools are designed around real workflows, they can meaningfully reduce adverse outcomes by making substitutions visible earlier, more standardized, and easier to coordinate across the full medication-use process, including the nursing work areas where retrieval and administration either add risk or reduce it.
With ongoing warnings from the USP that raw materials are becoming a bottleneck for medication supply chains, the organization has identified 100 clinically important medicines that are most at risk of disruption. Given many of these issues start early in the manufacturing or supply chain process, individual local teams cannot outwork the root cause but can get ahead of how early constraints are surfaced and how consistently substitutions are executed once the constraint is known. If the systems and processes are not built for that reality, the organization ends up relying on heroics, memory, and informal messaging to close the gaps.
Shortages quietly create a safety chain reaction
The pattern is consistent across care settings: constraint emerges late, variation increases, and handoffs become more fragile.
It often starts with an inventory reality that is discovered after clinicians have already made a plan based on the usual formulary and standard pathways. The constraint may be visible in a distributor notice, a purchasing platform, a pharmacy tracker, or an inventory count that staff do not fully trust to reflect what is actually available where care is delivered. When that constraint is not surfaced where decisions are made, care teams default to the normal plan until the system forces a change.
The next step often requires a last-minute substitution. The clinical decision may be sound, but the window to execute it shrinks, and the substitute may differ in ways that create downstream work, such as dosing conversions, infusion parameters, administration technique, compatibility checks, or new adverse effect monitoring. Under time pressure, the risk is less about the decision and more about whether every dependency is updated consistently.
Documentation and education gaps then become likely. Orders do not always capture why the change occurred, and medication lists can become confusing when names, strengths, or administration instructions shift. Patient-facing education can lag behind practice when templates are tied to the originally ordered product rather than the dispensed alternative. When patients are told to expect one medication and receive another, their ability to report side effects, track adherence, or recognize warning signs can be diminished – even when the substitute is therapeutically appropriate.
Finally, monitoring and follow-up gaps emerge. Substitutions may require different lab timing, vitals checks, patient monitoring, or outpatient follow-up. If those steps are not embedded in the clinical workflow, they are easier to miss during busy shifts, in times of staffing constraints, or through frequent handoffs. The result is unfortunately more opportunity for delayed detection, inconsistent administration, and avoidable escalation of care.
Make constraints visible before the plan hardens
The best way to prevent late-stage scrambling is to surface constraints at the point of decision before orders are finalized and the patient is already in motion. When clinicians can see that a preferred agent is in short supply, they can choose an alternative intentionally and build the right monitoring and education into the care plan from the start. That posture is fundamentally different from retrofitting a change after workflows have already been triggered.
This is where medication inventory visibility platforms can carry real safety weight, provided they are implemented with discipline:
- Shortage status and formulary guidance should belong inside the ordering workflow, not in a separate dashboard that clinicians rarely open during time-sensitive decisions.
- Therapeutic alternatives should be actionable, with concise guidance on what changes operationally (dose, route, infusion rate, monitoring, patient counseling), rather than a generic warning that simply adds noise.
- Signals must be tuned to reduce alert fatigue, using role-appropriate prompts that appear when they can still change the trajectory of care (for example, at order entry and verification), rather than after administration is imminent.
The operational goal is not perfect prediction. It is fewer late-stage switches because the system helps teams plan with eyes open.
Standardize substitution workflows so variation does not become the hazard
Standardization doesn’t have to mean rigidity, but should include repeatable steps, clear roles, and consistent documentation so the team does not have to reinvent safe practice with every new backorder. Well-designed workflows to prepare for medication changes typically include:
- Therapeutic interchange protocols that specify when pharmacy can substitute, when prescriber approval is required, and how exceptions are handled.
- Dose conversion guidance and default order instructions that incorporate critical operational differences (infusion parameters, monitoring requirements, and hold parameters where appropriate).
- Consistent documentation of the “why” so downstream clinicians and patients understand that the change is shortage-driven and intentional.
- Patient education that stays synchronized with what is actually dispensed and administered, not what was originally selected.
Standardization also has a physical, bedside-adjacent dimension that is easy to underestimate: how medications are stocked and presented in care areas. During shortages, cabinet configurations can vary across units, products may be stored in unfamiliar pockets, and overrides can rise.
Each of these conditions introduces friction into the nurse’s workflow, pulling their attention away from the bedside where it is most valuable. Enterprise-level standardization of stocking practices, paired with disciplined change control and clear communication of cabinet changes, reduces the cognitive burden on nurses and supports reliable performance on the five rights of medication administration.
Closing the loop for consistency across teams and digital platforms
A shortage substitution is only as safe as the alignment it produces. The prescriber, pharmacist, nurse, and patient must share a clear, consistent understanding of what changed and what to watch for. That alignment breaks down if systems stay siloed – when the substitution decision is documented in one place, the dispense record lives in another, administration documentation sits elsewhere, and patient instructions are generated through a separate channel. Closed-loop communication across platforms and teams strengthens reliability by ensuring that substitution decisions and their implications flow cleanly across the medication-use process.
Across all of these interventions, the consistent point is that drug shortages may be outside any single hospital’s control, but the reliability of the medication-use process is not. When inventory visibility, workflow standardization, and closed-loop communication are designed to navigate the variability of the medication supply chain, the care team spends less time chasing the problem and more time delivering safe, consistent care. The measure of success is not eliminating substitutions; it is making substitutions predictable, clearly communicated, and fully supported from order entry through patient education and follow-up.