Safety Risks Associated with Crushing or Altering Medication

Speak up, success analysis, preventing wrong radiology events, and more in the September 2018 Pennsylvania Patient Safety Advisory.

HARRISBURG, Pa., /PRNewswire/ -- The Authority's September 2018 Advisory highlights risks when patients crush or alter their medications, particularly among patients over 65.

While most oral medications are suitable for patients as dispensed, there are times when these medications must be modified to get an exact dose (e.g., breaking a 50 mg tablet in half to get a 25 mg dose). Also, when medications cannot be taken whole (e.g., patient has a feeding tube or can't swallow), tablets are often crushed and mixed with food or diluted in water.

"There are medications that should not be altered, because these changes may affect how the drug is absorbed and works in the body," said Matthew Grissinger, Medication Safety Manager for the Pennsylvania Patient Safety Authority. "For example, some tablets are long-acting formulations that are slowly released into the body and can last for up to 24 hours. Crushing these types of tablets would eliminate the long-acting properties by causing the medication to be absorbed all at once."

Authority analysts identified 621 events involving altered solid dosage forms of medications in reports submitted to the Pennsylvania Patient Safety Authority from January 2006 through September 2017.

Analysis found older patients may be more likely to receive an altered solid dose medication, with more than half of events involving those over 65.

Twenty-eight percent of all reports involved high-alert medications.

Several strategies can be used to protect patients, including limiting oral dosage form alterations to cases in which commercial alternatives are unavailable, dispensing medications in patient-specific doses to minimize preparation on patient care units, and implementing procedures to handle dosage-form alterations and administration via feeding tubes.

Download the full article.

 Also published in this Advisory:

  • Adapting Verification Processes for Preventing Wrong Radiology Events: Wrong radiology studies can expose patients to risks of harm, from unnecessary radiation exposure or contrast doses to delays in diagnosis or treatment. The Pennsylvania Patient Safety Authority analyzed wrong radiology events reported from July 2016through June 2017.
  • Speaking Up for Safety—It's Not Simple: Patient education, engagement, and empowerment have been at the core of many organizations' efforts to make healthcare safer. To measure and focus such efforts, the Pennsylvania Patient Safety Authority developed a patient poll about basic safety practices, such as asking about healthcare worker handwashing.
  • A New Pairing: Root Cause and Success Analysis: Root cause analysis (RCA) is commonly used in attempts to improve the safety of healthcare delivery, but a variation—success analysis—may also be useful.

For more information about the Authority, patient safety topics, Advisory articles, and safety tips for patients, please visit

The Authority's mission is to improve the quality of healthcare in Pennsylvania by collecting and analyzing patient safety information, developing solutions to patient safety issues, and sharing this information through education and collaboration. Its vision is safe healthcare for all patients.

SOURCE Pennsylvania Patient Safety Authority

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Pennsylvania Patient Safety Authority

The Pennsylvania Patient Safety Authority was established under Pennsylvania Act 13 of 2002, the Medical Care Availability and Reduction of Error ("Mcare") Act, as an independent state agency. It operates under an 11-member Board of Directors, six appointed by the Governor and four appointed by the Senate and House leadership. The eleventh member is a physician appointed by the Governor as Board Chair.  Current membership includes six physicians, two attorneys, a nurse, a pharmacist and a non-healthcare worker.