Background Crushing tablets is an important risk factor for medicines administration errors in patients with swallowing problems and feeding tubes. Information regarding patients requiring crushed medicines does not routinely reach the hospital pharmacist. Measures to improve crushing practice may consist of introducing guidelines, training nurses or giving pharmacy advice.
Purpose To describe an integrated multifaceted approach using an audit and feedback strategy to improve crushing practice on hospital wards in a 500-bed general hospital.
Materials and methods After baseline assessments, the following interventions to do with prescribing, administration and training were gradually introduced:
mention ‘to crush’ on drug prescriptions
order tube feeding using a specific order form
a pharmacist provides an information form listing the substitutions and discusses the situation with the caregivers involved
audit: retrospective analysis of prescriptions to identify the most commonly crushed drugs
introduction of oral syringes and disintegration testing for commonly crushed tablets (dispersible defined as disintegration within one minute in 20 ml cold water)
standardise working instructions
feedback: educational sessions and poster.
Results Pre-intervention questionnaires and disguised observations revealed that nurses’ knowledge regarding correct crushing is limited. We analysed 160 prescriptions mentioning ‘to crush’ for 104 patients (20 on tube feeding). A total of 601 drugs had to be crushed. Proton pump inhibitors and aspirin were among the most commonly prescribed drugs. 18% of prescribed drugs were substituted because of enteric coating (43%), modified-release formulation (25%) or availability of a more suitable alternative (e.g. liquids or dispersible tablets, 32%). 318 recommendations were given and accepted, including two related to hazardous substances. Pharmacists sometimes propose different alternatives for the same drug and patient. We introduced the syringe method (dispersing the tablet in a syringe filled with water) as a closed system for administration of hazardous drugs and dispersible tablets. Commonly crushed tablets such as alprazolam and trazodone were found to disintegrate easily. Crushability, alternatives and recommendations for the 20 most commonly crushed drugs in our hospital were summarised on a poster. Provision of this practice-orientated information and patient-tailored advice can encounter the lack of knowledge of other caregivers.
Conclusions Patients in need of crushed medicines may benefit from a medicines review by a pharmacist. Audit and feedback provide relevant information to other caregivers to prescribe and administer medicines correctly and safety. To evaluate and sustain the impact of our interventions, the clinical pharmacist, as a member of the nutrition support team, will regularly review the drug treatment of patients on enteral tube feeding during their ward visits.
No conflict of interest.
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