Crushing or Altering Medication Policy

(To be used in conjunction with the ‘GP or pharmacist approval / advice for crushing or altering medication’ form.)

Aim

The aim of this policy is to provide direction and support for the safe and effective management of medications when it is necessary to alter a solid dose medication while administering medication.

Background

This policy covers the alteration of solid oral medication doses during administration in the following ways:

crushing a tablet
opening a capsule.

Cavendish Homecare Professionals recognises that there are times when a client requires that the medication they receive is altered in the above ways so that it can be consumed more easily. This would typically relate to people who are unable to consume solid oral medications, including those with swallowing difficulties and those who have medications administered via an enteral feeding tube.

Cavendish Homecare Professionals is aware that such procedures should only be considered in rare circumstances where there is clinical need and where specialist advice and consent has been obtained. The organisation understands that the routine crushing of medication before it is administered is not considered good practice and in some cases may even be dangerous for the client. This is because crushing a solid tablet designed for oral consumption, or opening a capsule, can potentially change the effectiveness and properties of the medication, in some cases reducing effectiveness and in others increasing side-effects, potential toxicity, etc.

In addition, changing the form of a medication – for example by opening a capsule or crushing a tablet – is effectively a change of the formulation of a tablet and may change the legal status of the administration, moving it outside of a product’s licence or registration arrangements. Consequently, manufacturers may disclaim liability for harm that may occur to the individual receiving an altered medication and this would increase the legal risk to this organisation.

Cavendish Homecare Professionals recognises that it must comply with the following relevant legislation and guidance:

Medicines Act 1968
Misuse of Drugs Act 1971
National Institute for Health and Care Excellence (NICE) guidelines: Managing Medicines in Care Homes, March 2014
Nursing and Midwifery Council standards for the administration of medicines
guidelines of the Royal Pharmaceutical Society.

In addition to the above, this organisation recognises that administration of medication is also an important part of compliance with the registration requirements of the Care Quality Commission.

The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, which include the fundamental standards, apply to health and social care providers from April 2015.

Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 states that care and treatment must be provided in a safe way for clients, including the proper and safe management of medicines.

Policy

All medication should be administered to clients precisely as prescribed and directed by the prescriber. Medication should never be adapted or altered in any way except where it is required for clinical reasons and with the prior written approval of the prescriber.
The provision of safe and effective alteration of solid dose medications prior to administration to clients should only be undertaken by a suitably trained and qualified nurse or care worker who has the appropriate knowledge, skills and competence derived from appropriate training to administer medications.
The needs assessment for a new client should include a medication review. This should identify any cases where medication is being altered in order for the person to be able to take it. Existing clients will have regular case reviews and reviews of medication arrangements where any question that medication may need to be altered should be discussed.
Where a need for medication alteration is identified, specialist advice and guidance should be obtained to ensure that it is done safely and to ensure that there are no safer alternatives.
Where the reason for the alteration is temporary (for example, a temporary difficulty in swallowing) the person responsible for planning the care of the client should contact the GP responsible and ask if the medication can be prescribed in another form or if it can be temporarily discontinued until swallowing improves. The prescriber should always consider the swallowing ability of their patient before prescribing medication.
Where the advice is to crush or alter the medication, checks should be made that the client and their carers are fully aware of the situation and give their consent (note that special arrangements for consent may be required in cases of covert administration). Any concerns should be referred back to the GP prescriber or to the community pharmacist. All cases should be regularly reviewed.
Any changes should be indicated on the client’s MAR (medicine administration record) chart and fully documented in their notes. A written approval should be obtained.
Where the reason for the alteration is longer term, such as longer-term swallowing difficulties or enteral feeding, specialist advice should be obtained regarding medicines management from a speech and language therapist, pharmacist or community nurse specialist as appropriate. Rather than crushing or altering medication, the specialist should be asked if there is any better/safer alternative. Where necessary, additional training/support should be obtained relating to the specific route of administration.
The actual administration should follow all other medication administration policies and guidance and any additional recommendations from a specialist or from the pharmacist. A proprietary tablet crusher should be used wherever possible. In most cases where tablet crushing is required, the crushed medication will be mixed with water to aid swallowing. If uncertain, advice from the pharmacist should always be sought and followed.
Staff should avoid assuming that the dose of a liquid/dispersible formulation will be the same as the solid oral form of a particular product – they should always check dose equivalence.

Management duties

Managers have a duty to:

regularly audit the use of this policy and the effectiveness of procedures to administer medication
monitor complaints and compliments relating to medicines administration
ensure that all medicines are administered safely and that any incidents or errors are investigated and fully documented.

Staff duties

Staff have a duty to:

report any incidents or errors relating to medicines administration
always act in full compliance with this policy
attend appropriate training.

Training

In this organisation:

induction will include training and guidance on basic administration of medication
staff who will be expected to use specialist techniques, such as crushing medication, will be given additional specialist training in the requirements and will be expected to demonstrate their competency.

Date: January 2024

Version: 6 (Review)

Source: Expert Care Manager