How Specials Can Deliver Value to the NHS | Seite 25

This is not an uncommon problem and is well documented.
Please also refer to Assessing clinical need on page 6.

Cost-effectiveness and quality of life improvements
A recent report published in April 2012 found the most common causes of
medication administration errors were incorrect crushing of medication and
not supervising the intake of medicines42. Although this study was Dutch, it
provides more evidence that the risk-benefits of crushing oral medication
need to be considered very carefully, especially in the elderly with dementia43.
It is well documented that crushing tablets potentially leads to errors43. In
fact, crushed medication is nearly eight times more likely than tablets to give
rise to a medication administration error and this may occur when a patient
has a nasogastric tube inserted43. Liquids or suspensions are obviously more
suitable and less likely to block a nasogastric tube. Despite this, however,
tablet crushing often occurs in practice due to licensed preparations not
being available. The patient was admitted and in practice no tariff would be
charged if re-admitted within a 28-day period. This admission was outside
this period and would have cost £3,29244, as the patient had medical issues
associated with Alzheimer’s disease plus complications. In this specific case,
an unlicensed Special would appear to be the most appropriate option for
the patient and should help keep their blood pressure under control without
blocking their nasogastric tube.
Several cases of issues associated with crushing tablets have been reported
in the literature, such as a crushed extended-release tablet contributed to a
patient fatality45. Recurring chest pain and nausea were reported for a 78-yearold patient, with ECG confirming ischemic changes, when sustained release
tablets were crushed so that they could be administered via a percutaneous
endogastric tube46.

CASE STUDY 9

Assessing clinical need – additional considerations

Management of
blood pressure
in a patient in a
care home

The Royal Pharmaceutical Society has issued guidance when crushing,
opening or splitting oral dosage forms47. This guidance was updated in June
2011 and discusses both the risk and benefits of crushing oral medication.

42 Managing and administering medication in care homes for older people – A report for the project: ‘Working together to develop practical
solutions: an integrated approach to medication in care homes’. Centre for Policy on Ageing October 2011 Revised April 2012
43. Van den Bemt, P. M., Idzinga, J. C., Robertz, H., Kormelink, D. G. and Pels, N. (2009) Medication administration errors in nursing homes using an
automated medication dispensing system, Journal of the American Medical Informatics Association 16 (4) : 486-492
44. 2013-14 tariff – Admitted patient care & outpatient procedures – AA27A, Medical Care of Patients with Alzheimer’s Disease
with CC [date accessed 25/06/14]
45. Schier, J.G., et al. Fatality from administration of labetalol and crushed extended-release nifedipine. Annals of Pharmacotherapy 2003; 37: 1420-1423
46. Hider, J.D., et al. Effectiveness of modified release isosorbide mononitrate affected by incorrect use. British Medical Journal 2000; 320: 483
47. Pharmaceutical Issues when Crushing, Opening or Splitting Oral Dosage Forms June 2011 http://www.rpharms.com/best-practice/
Specials.asp [date accessed Aug 2014]

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