The Pharmaceutical Journal
Vol 269 No 7208 p132
27 July 2002

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Tablet crushing is a widespread practice but it is not safe and may not be legal

By David Wright

The surprising response from a number of my colleagues working in the secondary care sector when I raised the issue of nurses crushing tablets and opening capsules was a resounding "So what!". Apparently the act of tablet crushing and capsule opening is common practice on hospital wards. Apart from initially devaluing my recent publication,¹ these comments have in reality provided some explanation for my research findings and have put into context some of my concerns.

A total of 540 nurses (out of a potential 763) employed in nursing homes in England completed and returned a questionnaire (PJ, 6 July, p8). Nurses stated that on average 15 per cent of residents in their nursing homes had some form of swallowing difficulty, 5 per cent always chewed their medicines, 5 per cent spat them out and 1 per cent regularly hid them. Considering the morbidity of residents in nursing homes, these results are probably unsurprising. What did interest me, however, was the actions taken by nurses to overcome swallowing problems and their reasoning behind this. Forty per cent admitted to crushing tablets every drug round, 29 per cent every day and 12 per cent at least every week. Nurses admitted to having either crushed or opened felodipine, tamoxifen, lithium and Madopar, to name but a few, in the past 12 months. All of the tablets that the nurses admitted to crushing were available to be administered by other routes, in dispersible formulations or as a liquid. Of even more concern were the 10.2 per cent of nurses who stated that they would never ask for advice before crushing a tablet. However, if advice was needed, 81.9 per cent (much greater than for any other health care professional) stated that they would ask their pharmacist. Reasons for crushing tablets were listed as "the GP tells me to" (58 per cent) and that the GP would be concerned about the cost of changing to a liquid formulation (60.9 per cent).

Before taking any great interest in this practice, and as a practising community pharmacist, I had paid little consideration to the legal implications of this practice and what advice I might provide if faced with the question "Can I crush this?". There are, however, some important legal issues that need to be understood before attempting to answer this question:

• The opening of a capsule or crushing of a tablet before administration will in most cases render its use to be "unlicensed". Consequently the manufacturer may assume no liability for any ensuing harm that may come to the resident

• Under the Medicines Act 1968 only medical and dental practitioners can authorise the administration of "unlicensed" medicines to humans. It is, therefore, strictly illegal to open a capsule or crush a tablet before administration without the authorisation of the prescriber

• When a medicine is authorised to be administered "unlicensed" by a prescriber, a percentage of liability for any harm that may ensue will still lie with the administrating nurse. The balance of this liability would be assessed in a court of law on an individual case basis

Clearly, if one recommends that a medicine be used in an unlicensed manner then one may also assume some liability for the consequences.

Accepting the legal implications, which in reality may be of less importance than the clinical significance of this practice, the overriding issue is whether it will affect the patient. As I stated repeatedly in each radio interview and newspaper article that resulted from the publication of my paper, the person in primary care who is most likely to know whether crushing a tablet is likely to cause any harm and be able to describe the therapeutic alternatives is the community pharmacist. There are no other health care professionals who consider as part of their undergraduate education the science behind dosage formulation in such detail. Furthermore, the community pharmacist is in the best position to identify alternative routes of administration and whether a liquid formulation can be readily obtained.

Although it would clearly be inappropriate to crush modified or enteric-coated preparations, concerns have also been raised regarding the crushing of hormonal, cytotoxic and steroidal preparations. This is due to the small dosage potentially received by the administrator owing either to direct contact or aerosolisation^2,3 and in these situations it has been proposed that Control of Substances Hazardous to Health (COSHH) forms should be completed. I would recommend that in all cases if health care professionals are at all unsure they should contact the medicine's manufacturer for advice on both the effect on the licensing status and the potential clinical consequences. This is apparently a reasonably common request and in many instances manufacturers will have useful information to hand.

In most cases, however, there are alternative options to crushing tablets and opening capsues and for both the patient and carer safety these will often be more appropriate. Although the cost of alternatives is a justifiable concern, it must be viewed in the contexts of patient safety and professional liability.

It has, therefore, become clear to me that what is seen as acceptable nursing practice in secondary care, where pharmaceutical advice and support is immediately at hand, it translates to potentially unsafe practice in primary care. We as a profession can either be reactive, waiting for the questions to arise from nursing homes, or proactive and ask appropriate questions during our routine visits. Support in the development of in-house protocols for dealing with patients with swallowing difficulties would go some way to improving current practice. This is a good example of an area of practice where both the practice and science aspects of our undergraduate education can be expertly applied.

ACKNOWLEDGEMENTS Thanks to my colleagues at the University of Bradford, Anne Page, teacher-practitioner at Northern General Hospital, Sheffield, and Kuljit Thiary, teacher-practitioner at Lloydspharmacy for their guidance