When a patient in the ICU needs a life-saving shot of epinephrine or a chemotherapy drip of cisplatin, and the vial isn’t there, the problem doesn’t start with the doctor or the nurse. It starts in a factory-often overseas-where a single machine breakdown, a quality control failure, or a natural disaster can ripple through the entire U.S. healthcare system. Injectable medication shortages aren’t just inconvenient-they’re life-threatening, and hospital pharmacies are the ones forced to clean up the mess.
Why Hospitals Feel the Pain Most
Hospital pharmacies don’t just fill prescriptions. They manage the entire drug supply for critical care, surgery, emergency response, and intensive treatment. That means they rely heavily on sterile injectables-medications that must be made in ultra-clean environments to avoid contamination. These aren’t pills you can swallow or creams you can apply. These are liquids injected directly into veins, muscles, or spinal fluid. One mistake in manufacturing, and the whole batch is destroyed. About 60% of all active drug shortages in the U.S. are sterile injectables. That’s not a coincidence. They’re harder to make, harder to store, and harder to replace. Retail pharmacies can switch a patient to a pill version of a drug. Hospitals can’t. A patient in septic shock doesn’t get better with an oral antibiotic. They need it intravenously, right now. A 2025 survey of 350 hospital pharmacy directors found that 35-40% of their essential inventory is affected by shortages. For comparison, retail pharmacies deal with shortages in only 15-20% of their stock. The difference isn’t just numbers-it’s urgency. When a hospital runs out of normal saline, they don’t just delay a refill. They cancel surgeries, delay dialysis, and scramble to find alternatives that may not work as well.The Top Medications in Shortage
Some drugs are more critical than others-and more likely to disappear. The most affected categories are:- Anesthetics (87% shortage rate): Drugs like propofol and lidocaine. Without them, surgeries get postponed. Patients wait longer. Hospitals lose revenue. Staff burn out.
- Chemotherapeutics (76% shortage rate): Cisplatin, doxorubicin, vincristine. These aren’t optional. For cancer patients, delays can mean the difference between remission and progression.
- Cardiovascular injectables (68% shortage rate): Epinephrine, norepinephrine, amiodarone. These keep hearts beating in emergencies. No backup. No substitute.
Why Do These Shortages Keep Happening?
It’s not one problem. It’s a perfect storm. First, low profit margins. Most injectables are generic drugs. Manufacturers make only 3-5% profit on them. That’s barely enough to cover costs. When a factory has to upgrade equipment, hire more quality inspectors, or deal with an FDA inspection, the math doesn’t add up. Many companies just stop making them. Second, manufacturing is concentrated. About 80% of the active ingredients for generic injectables come from just two countries: China and India. A single tornado in North Carolina in 2023 shut down 15 critical drugs because one Pfizer plant was damaged. A quality issue in an Indian facility in early 2024 stopped all cisplatin production in the U.S. for months. Third, quality control is brutal. Sterile injectables require aseptic manufacturing-no bacteria, no particles, no contamination. One tiny error, and the whole batch gets tossed. The FDA says about 55% of all drug shortages start with a manufacturing defect. That’s not bad luck. It’s systemic risk. And here’s the kicker: the government can’t fix it fast. The FDA only gets notified after a shortage is already happening. Even then, they can’t force a company to restart production. Only 14% of shortage notifications lead to a timely fix, according to internal FDA data.
What Hospitals Are Doing to Survive
Hospitals aren’t waiting for Washington to act. They’re building their own emergency systems. - Therapeutic interchange programs: Pharmacists work with doctors to swap one drug for another that’s similar but not identical. It’s risky. A 2025 ASHP survey found that 42% of pharmacists have had to use a less effective alternative-and knew it could hurt the patient. - Consolidating stock: Instead of keeping shortages spread across 10 units, hospitals now centralize what little supply they have. One locked cabinet. One person in charge. No more guessing. - Alternative sourcing: Some hospitals are turning to smaller, non-traditional suppliers. Not all are FDA-approved. Some are gray-market vendors. It’s a gamble. But when you’re out of epinephrine, you take the risk. - Protocol changes: In some places, nurses are now giving oral fluids instead of IV saline for mild dehydration. It’s not ideal. But when IV bags are gone, it’s the only option. A nurse at Massachusetts General Hospital recorded 37 surgeries postponed in just three months because of anesthetic shortages. That’s not an outlier. It’s becoming the norm.The Human Cost
Behind every shortage is a patient. An elderly man waiting for his potassium shot. A child needing an antibiotic drip. A cancer patient whose treatment is delayed because the last vial was used last week. The American Society of Health-System Pharmacists found that 78% of hospital pharmacists have seen treatment delays directly linked to shortages. Nearly 70% have faced ethical dilemmas-choosing who gets the last dose. One pharmacist on Reddit wrote: “Running out of normal saline for 3 weeks straight forced us to get creative with oral rehydration for post-op patients-never thought I’d see the day.” This isn’t a supply chain issue. It’s a care crisis.
Why Nothing’s Changing
There have been promises. In 2023, Congress passed a law requiring earlier shortage notifications. It reduced duration by just 7%. In 2024, the Biden administration pledged $1.2 billion to bring drug manufacturing back to the U.S. But experts say it will take 3-5 years to see results. Only 12% of sterile injectable makers have adopted new technologies like continuous manufacturing-systems that could make production faster and more reliable. Most still use old, fragile equipment. The FDA’s 2025 strategic plan offers incentives for better quality. But no penalties. No enforcement. No requirement to build backup capacity. It’s like asking a fire station to be more prepared… without giving them more hoses.The Outlook: No Quick Fix
As of July 2025, there were 226 active drug shortages-down from 270 in April. That sounds like progress. But 89% of those shortages were carried over from 2023. They’re not new. They’re persistent. The same drugs. The same factories. The same delays. Hospital pharmacy directors surveyed in late 2024 said 68% expect shortages to stay the same-or get worse-through 2026. Without major changes in how these drugs are made, priced, and regulated, the cycle will keep repeating. For now, hospital pharmacies are doing the impossible: keeping patients alive with half the tools they need. They’re working 11.7 extra hours a week just to find drugs. They’re making split-second decisions with no safety net. And they’re doing it without fanfare, without pay raises, and without a clear end in sight. This isn’t a temporary glitch. It’s the new reality of American healthcare.Why are injectable drugs more likely to be in shortage than pills?
Injectable drugs require sterile, contamination-free manufacturing, which is far more complex and expensive than making pills. They need clean rooms, aseptic techniques, and strict quality controls. One error can destroy an entire batch. Plus, many are generic drugs with low profit margins, so manufacturers don’t invest in backup systems or extra capacity. Pills can be made in bulk, stored longer, and easily substituted. Injectables can’t.
What are the most common injectable drugs in shortage right now?
As of mid-2025, the most frequently shortages affect anesthetics like propofol and lidocaine, chemotherapy drugs like cisplatin and doxorubicin, and cardiovascular agents like epinephrine and norepinephrine. These are all essential for emergency care, surgery, and critical care units. Normal saline (0.9% sodium chloride) has also been in short supply for months at a time, forcing hospitals to use oral rehydration when possible.
Can hospitals just order more from other countries?
It’s not that simple. The U.S. imports about 80% of the active ingredients for generic injectables from China and India. But if a factory there fails an FDA inspection, all imports from that site are blocked-even if other products are fine. The FDA doesn’t allow substitutions from unapproved suppliers. Even if a hospital finds a foreign vendor, the drug must go through full U.S. approval, which can take months. There’s no quick global workaround.
How do pharmacists decide who gets the last dose?
There’s no official national protocol. Hospitals create their own triage rules, often based on clinical guidelines. For example, if there’s only one vial of epinephrine left, it might go to the patient in cardiac arrest rather than someone with a mild allergic reaction. These decisions are made by pharmacy and therapeutics committees, often under extreme pressure. A 2025 survey found that 42% of hospital pharmacists have had to use a less effective drug because the better one wasn’t available-knowing it might compromise patient outcomes.
Is the government doing anything to fix this?
There have been efforts, but they’re not working fast enough. The FDA now requires manufacturers to notify them of potential shortages earlier, but this only reduced shortage duration by 7%. A $1.2 billion federal investment to boost U.S. manufacturing was announced in 2024, but experts say it will take 3-5 years to show results. The FDA’s current plan relies on voluntary quality improvements, not mandates. Without financial incentives or penalties, most companies won’t change how they operate.
Written by Guy Boertje
View all posts by: Guy Boertje