Crushing and altering medications in Queensland hospitals.

Abstract

Medications are often altered or crushed for ease of administration in patients with swallowing difficulties, paediatric patients, patients who require non-standard doses or for tube feeding. Modifying a commercially available medication may lead to increased toxicity, undesirable side effects, decreased efficacy, unpalatability, instability of the active ingredient or create potential hazards to health care workers. Further, this practice may breach legal and professional requirements since use of the altered medication will be deemed to be 'unlicensed'. The objective of this study was to identify which medications are most commonly crushed or altered prior to administration to patients in Queensland (QLD) hospitals, including the specific methods involved in altering the medication, and a detailed description of any extemporaneous formulation employed. A self-report survey was distributed to 97 QLD health facilities classified as a 'hospital' according to QLD Health criteria. An equal distribution of rural and metropolitan hospitals responded (39.17%; n=38). 105 different medications were altered at the bedside, primarily for the adult population (83.8%), with most medications being altered on a daily basis (84.0%). Tablets were crushed (288 observations, 75.4%) by a variety of methods and capsules were opened in 65 observations (17.0%). In a majority of cases (262 observations, 68.6%) more than one medication was mixed together, with popular mixers including jam, water and food. 31 different medications were compounded in the pharmacy, primarily for children (84.6%), with the active ingredient obtained principally by crushing tablets (69.2%) and opening capsules (12.8%). A variety of formularies were used, with varying preparation frequency and expiry dates. This survey has identified that altering commercial medications at the bedside and in the pharmacy (i.e. compounding) is common practice in a sample of QLD hospitals. Administering extemporaneous oral liquid formulations is a daily experience and challenge for many hospital pharmacists and this survey has identified some commonly altered medications, thereby providing specific targets for future physicochemical stability studies to ensure that safe, effective and high quality products are delivered to patients.