Injectable Medication Shortages: Why Hospital Pharmacies Are on the Front Line

When a patient in intensive care needs a life-saving shot of epinephrine or a dose of chemotherapy, they don’t get a warning. They don’t get a substitute from the shelf. And increasingly, they don’t get the medicine at all. Hospital pharmacies are the last line of defense in the U.S. drug supply chain-and they’re running out of options. While community pharmacies might see a few missing pills on the shelf, hospital pharmacies are dealing with entire classes of critical injectable drugs vanishing for months, sometimes years. This isn’t a temporary hiccup. It’s a systemic collapse, and the people paying the price are the sickest patients in the country.

Why Injectables Are the First to Go

Not all drugs are created equal when it comes to supply risk. Sterile injectables-medicines you get through an IV or injection-are the most vulnerable. Why? Because making them is complicated, expensive, and low-margin. Unlike pills you swallow, injectables must be produced in sterile environments. One speck of dust, one flawed seal, one temperature spike during shipping, and the entire batch is destroyed. That’s why 55% of all drug shortages stem from manufacturing quality issues, according to FDA data analyzed by the National Association of Boards of Pharmacy.

The problem gets worse because most of the active ingredients for these injectables come from just two countries: China and India. Eighty percent of the raw materials are sourced there. When a tornado hits a Pfizer plant in North Carolina, or when the FDA shuts down a facility in India over contamination, the ripple effect is immediate. In February 2024, a single quality issue halted production of cisplatin, a key chemotherapy drug. Hospitals across the country scrambled. Patients waited. Some treatments were delayed or changed.

And these aren’t rare events. In 2024, 89% of the drug shortages were carryovers from 2023. That means the same drugs-like normal saline, potassium chloride, and anesthetics-were still missing over a year later. These aren’t new problems. They’re old ones that never got fixed.

Hospital Pharmacies Are Hit Harder Than Anywhere Else

Retail pharmacies might lose 15-20% of their inventory to shortages. Hospital pharmacies? They lose 35-40%. And 60-65% of those missing drugs are sterile injectables. That’s not a coincidence. It’s by design.

Why? Because hospitals rely on these drugs for everything. Anesthesia for surgery. Antibiotics for sepsis. Vasopressors for shock. Chemotherapy for cancer. There’s no oral version of epinephrine that works the same way. You can’t substitute a pill for a lifesaving IV drip. So when these drugs disappear, hospitals don’t just inconvenience patients-they delay surgeries, postpone cancer treatments, and sometimes send people home without proper care.

Academic medical centers, which treat the most complex cases, report being hit 2.3 times harder than community hospitals. A nurse manager at Massachusetts General Hospital documented in June 2025 that 37 surgical procedures were postponed in just one quarter because of anesthetic shortages. That’s not a number. That’s 37 people who had to reschedule, worry, and wait-some with worsening conditions.

The Most Affected Drugs: Anesthetics, Chemo, and Heart Medications

Some categories are hit harder than others. According to the U.S. Pharmacopeia’s 2025 report:

• Anesthetics: 87% shortage rate
• Chemotherapeutics: 76% shortage rate
• Cardiovascular injectables: 68% shortage rate

These aren’t obscure drugs. These are the backbone of emergency and critical care. Propofol, used to put patients under for surgery, has been in short supply for over two years. Doxorubicin, a chemotherapy drug, has been unavailable in many hospitals since early 2024. Norepinephrine, used to keep blood pressure up in septic shock, is often rationed.

When these drugs vanish, pharmacists don’t just sit around waiting. They scramble. They call suppliers. They check other states. They contact manufacturers directly. They talk to doctors about switching to less effective alternatives. And sometimes, they have to make impossible choices.

The Human Cost: Ethical Dilemmas and Burnout

It’s not just about logistics. It’s about morality.

A 2025 survey by the American Society of Health-System Pharmacists found that 68% of hospital pharmacists have faced ethical dilemmas because of shortages. Over 40% admitted they’ve had to use alternatives that weren’t as effective-medicines that might not work as well, or that carry higher risks. One pharmacist on Reddit, posting under the username ‘IVguy2025’, wrote: “Running out of normal saline for three weeks straight forced us to get creative with oral rehydration for post-op patients-never thought I’d see the day.”

This isn’t just stressful. It’s traumatizing. Pharmacists are trained to deliver the right drug, at the right dose, at the right time. When they can’t, they feel like they’ve failed. A nurse at a Texas hospital told a colleague, “I had to tell a mom her child’s chemo was delayed because the drug didn’t arrive. She cried. I cried.”

And the workload? It’s crushing. Hospital pharmacists now spend an average of 11.7 hours a week just managing shortages-tracking inventory, calling suppliers, documenting substitutions, training staff. That’s over two full workdays a week spent not on patient care, but on crisis management.

Why the System Won’t Fix Itself

You’d think with all this pressure, someone would fix it. But the root causes are deeply entrenched.

First, profit. Most sterile injectables are generics. That means manufacturers make very little money on them-often just 3-5% margins. Why invest in expensive sterile equipment, quality control, or backup supply lines when you can barely break even?

Second, concentration. Just three companies control 65% of the market for essential injectables like sodium chloride and potassium chloride. If one fails, the whole system stumbles. There’s no competition. No backup. No safety net.

Third, regulation is toothless. The FDA can’t force companies to make more drugs. They can’t fine them for shortages. They can’t require backup suppliers. The Drug Supply Chain Security Act only tracks where drugs go-it doesn’t make sure they’re made. The 2023 Consolidated Appropriations Act required earlier shortage notifications. But the Government Accountability Office found it only reduced shortage duration by 7%.

Even the $1.2 billion federal investment in domestic manufacturing, announced in 2024, won’t help for years. Industry experts say it’ll take 3-5 years to see any real impact. By then, the damage will be done.

What Hospitals Are Doing-And Why It’s Not Enough

Hospitals aren’t sitting idle. Most have set up shortage management committees. 76% have formal plans. But only 32% feel those plans are properly funded or staffed.

Some strategies are working-sort of:

• Consolidating stock: Keeping all scarce drugs in one central location to prevent waste
• Therapeutic interchange: Getting approval to swap one drug for another, even if it’s less ideal
• Building relationships with alternative suppliers: Calling smaller manufacturers who might have stock

But these are band-aids. They don’t fix the broken system. A University of Michigan study found it takes new pharmacy directors an average of 6.2 months just to learn how to manage shortages effectively. And only 45% of hospitals have written, updated protocols. The rest are making it up as they go-increasing the risk of medication errors.

The Outlook: No Relief in Sight

The number of active shortages dropped from 270 in April 2025 to 226 in July 2025. That sounds like progress. But don’t be fooled.

The same drugs are still missing. The same manufacturers are still struggling. The same patients are still at risk. Experts at IQVIA predict shortages will stay between 200 and 250 through 2027. Climate change is making extreme weather more common-more tornadoes, more floods, more plant shutdowns. Geopolitical tensions are disrupting supply chains from Asia. And generic drug prices? Still falling.

Only 12% of sterile injectable manufacturers have adopted new technologies like continuous manufacturing, which could make production faster and more reliable. The rest are stuck in the same outdated, fragile system.

Hospital pharmacies are doing everything they can. But they’re not manufacturers. They’re not regulators. They’re not policymakers. They’re the ones holding the bag when everything else breaks.

What Needs to Change

Real solutions require systemic change:

• Incentivize production: Pay manufacturers more for making high-risk injectables. Offer tax breaks, guaranteed purchases, or subsidies.
• Require redundancy: Mandate that critical drugs have at least two approved manufacturers.
• Invest in domestic capacity: Fund new sterile manufacturing plants in the U.S.-not just in the next five years, but right now.
• Empower the FDA: Give the agency authority to require quality improvements or temporarily suspend imports from unreliable sources.
• Support hospitals: Fund shortage management teams, not just in theory, but with real staffing and budget.

Without these steps, hospital pharmacies will keep being the canaries in the coal mine. And patients? They’ll keep paying the price.