Considerations when crushing tablets or opening capsules in a care home setting

The U.K. Specialist Pharmacist Service has released updated guidelines on the crushing of tablets or opening of capsules in care homes.

Tablets and capsules are the most commonly prescribed formulation of medicine. However swallowing difficulties is a common problem. Patients who have problems swallowing or those who are fed via feeding tubes (e.g. nasogastric (NG), nasojejunal (NJ), percutaneous endoscopic gastrostomy (PEG) tubes) cannot use tablets or capsules in their whole solid form. When administering medication via feeding tubes (PEG, NG, NJ) other issues need to be considered. If medicines are given via the feeding tubes without the correct advice, drug bioavailability may be altered, tubes may become occluded or drugs may bind to the feeding tube. Before giving medicines via feeding tubes always obtain advice from a pharmacist or prescriber.

In a care home setting, there may be a need to identify alternative ways of giving solid oral dose formulations and consider the consequences of manipulating formulations. In these circumstances, medication may need to be administered off-licence e.g. crushing or opening solid dose forms.

Incorrect crushing of medication is a common source of medication error in care homes. Crushed medication is nearly eight times more likely than tablets to give rise to a medication administration error in a care home. Prescription medications should only be taken according to the directions of a prescriber. Medicines used in a different way from what the manufacturers have stated are being used off-licence which means the manufacturer does not accept responsibility for any harm caused by taking the medicine in this way. A person giving crushed tablets or opened capsules to a patient without directions from the prescriber and without making the appropriate checks could be held liable for any harm caused.

But what issues need to be considered before medicine is administered in this way in a care home setting?

• How essential is the medication? Are there alternative formulations (e.g. liquids, patches or sublingual tablets) or medications that can be used
• Before a person crushes or opens a medication, a pharmacist should always be consulted to find out if this is possible and this should be approved by the prescriber and documented in patient records.
• There are solid dose formulations that should never be crushed or opened without appropriate advice from a pharmacist such as some enteric coated tablets or capsules, modified release preparations, hormone, steroid, antibiotic or chemotherapy (cytotoxic) medicines
• Additional patient monitoring may be required which the pharmacist will advise on
• When administering medication via feeding tubes (PEG, NG, NJ) other issues need to be considered. If medicines are given via the feeding tubes without the correct advice, drug bioavailability may be altered, tubes may become occluded or drugs may bind to the feeding tube.

A fuller discussion, with associated disclaimers, is available here. Anyone who intends to use this information in a clinical setting is strongly advised to refer to it.