Article by Mark Wolfe, Customer Account Representative, GrandView Pharmacy

With apologies to William Shakespeare’s Hamlet it is good question to ask in pharmacy and healthcare, specifically.

Recently a facility asked me about where to notate on their Electronic Health Record when to crush or not to crush a medication.  Since I did not have the answer regarding the EHR, I asked the question that was more in my area of so-called expertise…why do they want to crush the medication?  The answer I got back was, “Well, the resident is having difficulty swallowing and they want to make it easy to swallow”.  As I am not a clinician that made sense.  Let’s reduce the medication in size or form in order that the patient can more easily swallow the medication.  Seems simple enough, right?

But, it is not that simple.  While pharmacies make pill crushers and splitters available to their clients it is equally necessary to assure that the healthcare provider can use them properly and safely and only for appropriate medications that can be crushed.  The Institute for Safe Medication Practices (ISMP) puts out an extensive list of medications that should not be crushed.   There are any number of reasons as to not to crush a medication, (slow-release, Enteric coated, film coated, taste, etc.) but the short answer is the healthcare provider should not be intermittently crushing medications at the nurses’ discretion. That would fall out of bounds of their scope of practice.  Also, pharmacy cannot print medication labels to crush a medication without being directed to do so by a prescribing physician.

Nurses, caregivers and patients themselves should inquire with their physician or pharmacist if they have difficulty swallowing tablets/capsules.  It is also necessary to educate all parties when it is appropriate to crush medications.

As reported in the Apr-2011 issue of Institute of Safe Medication Practices, during a recent visit to a friend’s home a nurse discovered a medication error.  Her friend’s 95-year old mother with Alzheimer’s had experienced rapid decline over the last two months.  She was taking many medications in AM and PM, including potassium chloride extended release, donepezil, and quetiapineER.  Local pharmacy supplied medications with each vial labelled with instructions at given administration time.  At dinner time the nurse witnessed the caregiver retrieve the medication, crush it, it mixed in with chocolate pudding and administer it to the 95-year old.  The nurse asked the caregiver about crushing the medications.  The caregiver replied that the elderly lady was reluctant to swallow the pills, so she took it upon herself, without consulting a healthcare practitioner, to crush the medications.  It was noted that the 95-year old’s decline began about the same time as the new caregiver began crushing the medications.  The quetiapineER is a slow release tablet form of medication.  It should not be crushed.  Even though the medication was given at the appropriate time and the appropriate dose was obtained, the manner of administration was inappropriate.  Therefore, this is a marked medication error.  And preventable.

In conclusion, if a nurse notices that a patient is having difficulty swallowing a prescribed medication, instead of crushing all medications, the better course of action would be for the nurse to request from their GrandView pharmacist if the medication can indeed be crushed; and, if so, to request a new order indicating such.  If the swallowing difficulties persist, it may be necessary to have medications of the patient’s drug regimen switched to a liquid form.

GrandView offers our clients consulting services from Certified Senior Care Pharmacists who are highly specialized in medications and issues affecting older adults.  They can recommend therapeutic alternatives when difficulties swallowing become known.  Additionally, GrandView pharmacists watch for instances of ancillary orders stating, “to crush all meds”.  The number one problem in treating illness today is the patients’ failure to take prescription medications correctly, regardless of their age, and if the medications can be crushed or not.  At GrandView, we offer comprehensive solutions for Senior Care Communities to help residents maintain a high quality of life, whatever level of senior care community they reside.

Click here to read more about our Senior Community Pharmacy Services.