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Five questions nurses should ask prior to crushing medication:Legal implications

An estimated 55% of drugs are administered unsafely according to 2015 Australian study Downey et al “Don’t rush to crush:audit of modifications to oral medicines for patients with swallowing difficulties”.

In the UK and Australia most drugs are “authorised for marketing” (licenced). The drug must be given (form, dose,ranges) according to its licence. Medical officers and pharmacists have legal authority to prescribe and dispense medication outside the drug license. Nurses do NOT have such authority. 

Altering the form of a drug (ie crushing) for many drugs is operating outside its licence. There are five questions nurses need to ask before proceeding with crushing medication.

1. Is there a valid clinical reason for the need to crush medications?

Patients experiencing difficulty with swallowing medication is common especially in the elderly. A nurse’s role in medication management is to ensure the patient receives their drugs as per the medication regime prescribed by a medical officer.

Crushing medications can destroy the physical and chemical properties of the drug. This can impact on the drugs effectiveness and potentially increase toxicity causing harm to the patient.

Individual preference, family pressure and ‘taking too long to swallow I don’t have enough time to stand here and wait’ are some reasons nurses might crush medications. These are NOT valid clinical reasons to crush.

Difficulty with swallowing (dysphagia) is a valid clinical reason considered appropriate for crushing medication. Nasogastric and PEG tubes being in situ are other valid reasons. If a patient is experiencing dysphagia they should be referred to a speech language pathologist for a swallow review and assessment. 

2. Is the doctor prescribing the medication aware of the nurses intent   to crush the drug?

Nursing concerns regards a patients swallow or requests from patient/family for crushing medication should be escalated appropriately. Assuming the medical officer and pharmacist are aware is not an acceptable response if decision to crush is challenged legally or professionally.

Medication management is a team effort. Patient/family, medical officer, nurse,
pharmacist and speech language pathologist are involved. Assessing and providing treatment for swallowing difficulties is important. A patient with a nasogastric or PEG tube for feeding purposes requires a comprehensive review of their medication regime.

Once a drug is prescribed and supplied outside of its licence (ie crushing in most
instances) the pharmaceutical company is no longer liable for potential side effects or harm. Clinicians making the decision to crush the drug is now liable for potential side effects or harm.

3. Are there alternatives preparations of the drug or alternative drugs available negating the need to crush?

Many drugs are not suitable for crushing ie slow release, enteric coated etc. With
increased technology and manufacturing processes it has become more difficult to determine visually if a drug is suitable to be crushed or not.

In many instances there are alternative preparations of a drug which bypasses the
necessity for crushing. Within each class of drugs are options a prescriber has in treating a condition. This allows the prescriber to choose a drug which has an alternative preparation which may be more suitable.

A conversation between the nurse, prescriber and pharmacist in most instances will be able to problem solve the issues involved without needing to crush the drug concerned.

4. Is the drug suitable to be crushed?

Some drugs are able to be crushed. The prescribing medical officer must be made aware the intent is to administer it by crushing. This needs to be clearly documented by the medical officer preferably on the patient’s medication order.

A valuable resource in Australia is a document “Don’t Rush To Crush”. This was developed in 2011 (and recently revised) by Society of Hospital Pharmacists of Australia. Additionally this text has been added to MIMS Online providing quick and easy access to all clinicians involved in medication management.

“Don’t Rush To Crush” provides comprehensive information of all oral solid drugs
available in Australia including if they can be crushed, the risks associated and how they should be prepared for administration to the patient.

5. Has the patient/family been informed of the risks associated with crushing of medications and provided consent?

Providing treatment and care outside of what is considered “usual care” requires patient consent. Consent includes providing the patient with the rationale/reason for the variance of care, the risks associated and alternative options available. Cushing medications would be considered outside usual care given the legal implications and risk for potential harm. 

The discussion and provision of consent should be well documented in the patients medical notes. The prescribing medical officer is responsible for the gaining of consent. Once a drug is NOT prescribed or administered in the form according to the marketing licence the pharmaceutical company is no longer liable legally for drug reactions.

The prescribing medical officer prescribing a drug outside of the marketing licence is legally liable for drug reactions.

A pharmacist providing a drug in the full knowledge it has been prescribed and/or administered outside of the marketing licence is additionally held liable for any drug reactions.

Nursing staff who crush medications without the knowledge of the medical officer and pharmacist is liable solely for any drug reactions potentially causing patient harm.

Providing safe nursing practice and care to patients is a nurse’s top priority. By asking these five questions of themselves or their colleagues prior to crushing any medication safeguards and protects patients and nurses equally.

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