Managing Multi-Dose Vial Workflows During the Midazolam Shortage: A Practical Guide for ASCs

When a medication shortage hits, the pressure falls directly on the people managing the OR schedule. Cases still need to run. Patients still need care. And the clinical team needs to know that the medications they rely on will be there when they need them. 

The ongoing midazolam shortage has created exactly that kind of pressure for ambulatory surgery centers across the country. Midazolam is a go-to sedative for procedural care, and right now, it's in short supply across multiple manufacturers. According to the American Society of Health-System Pharmacists (ASHP), midazolam injection is currently on shortage due to a combination of manufacturing delays and increased demand, with several formulations from Avet, Fresenius Kabi, Hikma, Pfizer, Sagent, and Somerset affected. Some are on long-term back order with no estimated resupply date. 

For ASC clinical leaders, pharmacy staff, and administrators, that uncertainty calls for a practical, organized response. One approach worth considering is the multi-dose vial workflow, a structured process for drawing a single vial down into individual patient syringes over the course of the day. When followed consistently, it stretches available supply, reduces unnecessary waste, and keeps medication accountability intact throughout the process. 

Why Multi-Dose Vial Management Matters During Drug Shortages 

Getting More from What You Have 

When medication supply is limited, how you manage what you have matters as much as how much you have. Multi-dose vials offer a real opportunity to extend available inventory, but only if your OR team has a clear, consistent process for using them. 

Here's why it's worth getting this right: 

Conserving supply 

A single multi-dose vial can serve multiple patients when properly aliquoted. Rather than opening a new vial for each case, perioperative staff can draw precise doses as needed throughout the day. That adds up quickly when supply is tight. 

Maintaining patient care continuity 

Shortages shouldn't mean case delays or last-minute substitutions. A reliable multi-dose vial workflow gives your team a defined process to follow when preferred formulations aren't available, so care can continue without improvisation. 

Medication accountability 

When medication leaves its original packaging, tracking it requires more intentional documentation. With multi-dose vials, your team needs to know what was drawn, when, and for which patient. That level of accountability protects both patients and the surgery center. 

Reducing waste 

Prepared syringes that aren't administered by the end of the day need to be removed and wasted. Having a clear end-of-day process prevents medication from sitting unaccounted for and reduces the waste that comes from over-stocking OR cabinets. 

Operational documentation 

Multi-dose vial workflows introduce documentation steps that don't exist with prefilled syringes or unit-dose products. The more clearly those steps are defined, the easier it is for your team to follow them consistently, and for clinical leadership to verify that they did. 

Step-by-Step Multi-Dose Vial Workflow 

From Main Cabinet to End-of-Day Waste 

The following workflow moves a multi-dose vial from the main cabinet through syringe preparation, per-patient dispensing, and end-of-day waste. Each step includes operational context to help your team understand not just what to do, but why it matters. 

Step 1: Store the multi-dose vial in the main cabinet. 

The workflow starts with the vial secured in your main medication storage device. This is where the medication remains until it's needed for use. Keeping the vial in secured storage until that point supports accurate inventory counts, limits unnecessary access, and gives your team a clear starting point for the day's medication activity. 

Operational note: Before the first case, confirm the vial is in your inventory system and that your on-hand quantities are accurate. Knowing exactly what you have at the start of the day is especially important during a shortage.

Step 2: Remove the vial as floor stock. 

When procedures begin and the medication is needed, the vial is removed from the main cabinet and designated as floor stock. This transition from secured storage to active use should be recorded in your medication management system. It's the first documentation event in the workflow and establishes the chain of custody as the vial moves into circulation. 

Operational note: Floor stock designation signals that this vial is actively being managed by your clinical team. Any gaps between what was removed and what was administered or wasted will show up during reconciliation, so recording this step accurately matters.

Step 3: Using clean technique, aliquot the medication into individual syringes. 

This is the most hands-on step. Using clean technique, qualified perioperative staff draw the medication into individual syringes, typically 1 mL or 2 mL, depending on your surgery center's internal process and dosing standards. 

Why it matters: Aliquoting creates new units of medication that need to be tracked and accounted for. Unlike a prefilled syringe with a manufacturer label, these syringes are prepared on-site. Consistent volumes and organized preparation help reduce the risk of error and support accurate downstream documentation. Follow your surgery center's policies and procedures for syringe preparation.

Step 4: Stock the prepared syringes into OR cabinets. 

Once prepared, the syringes are moved into the procedure room or OR device. This makes the medication accessible at the point of care without requiring staff to return to the main cabinet between cases, a practical efficiency when cases are running back to back. 

Operational note: Stock syringes based on your expected caseload for the day. Over-stocking OR cabinets means more end-of-day waste; under-stocking creates gaps that can slow down room turnover. Matching what you prepare to what you anticipate using is one of the more straightforward ways to manage a limited supply thoughtfully.

Step 5: Dispense syringes per patient as needed throughout the day. 

As cases proceed, syringes are dispensed on a per-patient basis. This is an important distinction from stocking a batch without patient attribution. Dispensing per patient ties medication use to individual cases, which makes it much easier to account for what was administered versus what remained at the end of the day. 

Operational note: Any unused medication at the point of care, including partial syringes or doses that weren't needed, should be handled according to your surgery center's policies and procedures.

Step 6: At the end of the day, remove remaining syringes, document them as patient-expired inventory, and waste them appropriately. 

Prepared syringes that were not administered should not carry over to the next day. At the end of the day, any remaining syringes are removed from OR cabinets, documented as patient-expired inventory, and wasted in accordance with your surgery center's policies and procedures. 

Why it matters: This step closes the loop. It accounts for every syringe that was drawn from the original vial and ensures that no prepared medication is left untracked. A consistent end-of-day waste process helps ensure the workflow remains accurate and accountable. It's the final confirmation that what left the main cabinet has been fully accounted for.

Need a quick reference? Download our Multi-Dose Vial Workflow Guide for a visual overview of the process your team can keep at the point of care.

Managing Documentation and Inventory Visibility 

Turning Workflow Steps into Operational Insight 

The multi-dose vial workflow creates more documentation touchpoints than a standard prefilled syringe workflow. That's not a complication. It's actually a more complete picture of medication activity throughout the day. For ASCs managing a shortage, that visibility is valuable. 

Floor stock tracking 

When a vial leaves the main cabinet, that movement should be tracked in your medication management system. Real-time floor stock tracking gives clinical leadership a clear view of what's in active use and what's still in secured storage, which is critical when supply is limited. 

Accountability across the medication lifecycle 

From the moment a vial is removed from the main cabinet to the moment the last prepared syringe is wasted, there should be a traceable record. The goal is to maintain visibility into medication use throughout the day, including what was administered and what remained unused. 

Inventory visibility for operational planning 

During a shortage, knowing what you have on hand isn't just an administrative function. It directly affects how your OR team plans the day. Real-time inventory awareness helps clinical leadership make better decisions about case scheduling, reordering, and supply allocation before a gap becomes a problem. 

Waste documentation  

Point-of-care waste and end-of-day waste both need to be recorded according to your surgery center's policies. Timely, consistent waste documentation is what keeps your medication records complete and your inventory counts accurate. 

Supporting day-to-day decision-making 

Good documentation isn't only about looking back. It's about staying ahead. During an active shortage, the teams that manage best are often the ones with the clearest picture of their inventory. Knowing how much you've used, how much you have left, and how that compares to tomorrow's case load gives your clinical leadership team the information they need before a gap becomes a problem. 

Supporting Multi-Dose Vial Workflows with Your Medication Management System 

Configure Your System Before the Workflow Begins 

For surgery centers using a dedicated medication management system, setup comes first. Getting the system configured before the team starts using the workflow ensures every transaction is captured from day one rather than reconstructed after the fact. 

If you're using MedServe, here's how to get the workflow configured: 

Adding the medication to your formulary 

Before the medication can be tracked in transactions, it needs to exist in your formulary. In MedServe, navigate to Administration > Formulary, select the appropriate formulary, and use the Add function in the Drugs section to create or locate the medication profile. Once saved, the medication is available to assign to cabinets and include in inventory counts. 

Assigning the medication to a cabinet 

From the cabinet configuration area, select the cabinet where the vial will be stored, typically your main cabinet. Assign the medication to the appropriate compartment and save. If you're also tracking prepared syringes in OR devices, repeat this step for those cabinets. Once assigned, the medication appears in inventory counts and every transaction (floor stock removal, dispensing, waste) gets captured automatically. 

Managing What's Within Your Control 

What Your Team Can Do Right Now 

Drug shortages like the current midazolam situation are largely outside an ASC's control. What is within your control is how your team responds, and having a defined, documented workflow for managing limited medication supply makes a meaningful difference. 

Multi-dose vial workflows allow surgery centers to stretch available inventory across more patients without compromising the accountability that good medication management requires. When each step is followed consistently and documented accurately, you maintain a clear record of what was used, what was wasted, and where every dose went. 

The shortages will resolve. In the meantime, the ASCs that navigate them best will be the ones with the operational clarity to know exactly what they have, how they're using it, and what they need tomorrow. 

Not sure whether your current medication management process can support this workflow?