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To Crush or Not To Crush Pills

Consider the following two scenarios:

Case 1: A 65-year-old woman was released from the hospital following a stroke. Diagnosed with dysphagia, she had been placed on a pureed and thickened liquid diet during her stay. The patient also had severe knee pain due to osteoarthritis, for which she had been prescribed oxycodone hydrochloride. While in the hospital following her stroke, she was switched to an equivalent dose of the same drug in an extended-release formulation. The day after discharge, she was found unresponsive in her home.

Case 2: A 70-year-old man underwent endoscopy for complaints of gastrointestinal distress. Due to his severe reflux, he was prescribed omeprazole, to be administered twice a day via feeding tube. On a follow-up visit to his physician, he noted no relief from his symptoms.

These two cases have something in common: both patients received their medications in crushed form.

In the first scenario, the personal care aide crushed the pill because she knew that the client’s dysphagia made swallowing difficult. However, she did not know that the client had been prescribed a different formulation post-discharge. The rapid absorption of the extended-release tablet, which should have been gradually assimilated over a 12-hour period, resulted in respiratory depression, rendering the client unresponsive.

In the second scenario, the omeprazole had an enteric coating to protect the medication from gastric acid. Crushing the tablet neutralized the protective coating, thereby affecting the efficacy of the drug.

Drugs may be produced and marketed in various formulations, but with similar names, which can result in errors and adverse events. The following measures can help enhance compliance and prevent problems stemming from inappropriate use of crushed pills:

Verify that staff members involved in administering medications are legally eligible to do so. The practice of pill crushing presents risks, and therefore is considered a skilled care service. Note that some states specifically prohibit unlicensed staff from administering medications, which would include crushing of pills.

Consult with a licensed pharmacist regarding the appropriateness of crushing prescribed medications for specific clients. The pharmacist may recommend a liquid form of the medication as an alternative to crushing. Pharmacist consultations are required and should be documented in the client record.

Obtain a physician order to crush medications on an individual drug and client basis, if no alternative formulation or mode of administration is available.

Inform staff of any medications that should not be crushed, because of slow-release formulations, enteric coatings, teratogenic potential, potential esophageal irritation or other reasons. (The booklet “Oral Dosage Forms That Should Not Be Crushed,” by John F. Mitchell, lists many such drugs. It is available from the Institute of Safe Medication Practices [ISMP].)

Refer to drug manufacturer recommendations regarding appropriate administration and acceptability of crushing. Care should be taken for medications that must be given on an empty stomach or with a full meal to avoid gastrointestinal effects. In both cases, crushing medications into food may be contraindicated. Manufacturer guidelines also may suggest liquid equivalents, injectables or other alternatives to crushing medications.

If a client is refusing to take a medication, document this fact. Unless deemed incompetent, clients have rights and can refuse medication. However, in some cases, it may be necessary to proceed against client wishes, after first obtaining advice of legal counsel and a court order.

Provide caregivers with training on the appropriate method for crushing medications when indicated, and also on avoiding cross-contamination. Attendance at training sessions must be documented in the caregiver’s personnel file, including date and signature. In addition, maintain a file of instructors’ names and training session dates.

Ensure that caregivers who administer medications through feeding tubes are qualified and aware of state regulations and guidelines. They should receive regular in-services on proper administration methods, signs and symptoms of obstructed feeding tubes, and appropriate response to cases of obstruction. (Note that the rate of feeding tube obstruction after medication administration is over 15 percent, according to research. See Belknap, D.C. et al. “Administration of Medications Through Enteral Feeding Tubes.” American Journal of Critical Care, September 1, 1997, volume 6:5, pages 382-392.)

Inform insurance providers when staff members are expected to crush pills, as this practice is considered a skilled service, and as such may affect premium levels or continued insurability.

Document in the client care record any request by a family member to crush meds, and include the date and signature of the requesting party.

Medication administration is a vital, complex and potentially risky aspect of the healthcare treatment plan. By obtaining information and guidance prior to crushing any pills, caregivers can protect their clients, their employers and themselves.

The information, examples and suggestions presented in this material have been developed from sources believed to be reliable, but they should not be construed as legal or other professional advice. CNA accepts no responsibility for the accuracy or completeness of this material and recommends the consultation with competent legal counsel and/or other professional advisors before applying this material in any particular factual situations. Please note that Internet hyperlinks cited herein are active as of the date of publication, but may be subject to change or discontinuation. This material is for illustrative purposes and is not intended to constitute a contract. Please remember that only the relevant insurance policy can provide the actual terms, coverages, amounts, conditions and exclusions for an insured. All products and services may not be available in all states and may be subject to change without notice. Use of the term “partnership” and/or “partner” should not be construed to represent a legally binding partnership. CNA is a registered trademark of CNA Financial Corporation. Copyright ©2014 CNA. All rights reserved.