Patient safety in your hands

It’s sad and it’s a shame, but it is the direction society and communities are heading, so pharmacists have had to take on a greater role by providing other services which would previously be performed by a nurse or doctor within a health centre. With the ever-changing role of the pharmacist becoming more fragmented within the community, the last thing pharmacists need is more pressure from PCTs regarding their spend on specials, although sadly this has become the case.

Pharmacists’ responsibilities
In January, the National Pharmacy Association reacted to recent reports from pharmacists regarding the fact that “medicines management teams at some PCTs are recommending the dispensing of crushed/dispersed tablets or opened capsules as part of reducing costs to the PCT of unlicensed specials”. It also went on to remind members that “the responsibility for dispensed products lies ultimately with the dispensing pharmacist” and that the NPA insurance does not cover members “who undertake PCT recommended alternatives to dispensing unlicensed specials – particularly where recommendations result in the integrity of a licensed medicinal product being compromised, eg by crushing, dispersing or breaking open (capsules) or which otherwise interfere with products in any other way.”

The Pharmacists’ Defence Association supports the professional autonomy of pharmacists regarding dispersing tablets/capsules where these are to be administered via crushing, splitting, dispersing or otherwise interfering with the integrity of the dosage unit by publishing a document for their members. It states that citing the PCT or the prescriber’s recommendations as a defence should anything go wrong would not absolve a pharmacist from their own personal professional responsibility towards patient care. After all, patient care is the primary concern of pharmacists, prescribers, PCTs and the NHS.

The reality is that prescribers and pharmacists should be able to make a professional judgement about whether a special is needed. For example, if someone needs to take a tablet, at the whole dose, but has trouble swallowing a whole tablet, then it could be deduced that splitting the tablet in half and taking two halves instead of the whole would work just as well. In some events, this is the case. However, depending on the bioavailability of the drug, its toxicity risk if airborne, as well as other factors such as any loss of the active drug during the splitting process, this may not always be the best option, particularly if advising patients, carers or anyone other than a pharmacist to carry out this process at home.

Crushing, splitting and opening capsules and tablets
The main concerns regarding crushing, splitting and opening capsules and tablets as reported by the Royal Pharmaceutical Society are:

• Healthcare professionals or carers being exposed to health risks through powder aerosolisation;
• Irritation if the drug is inhaled or comes into contact with eyes, skin or other mucous membranes and, in some cases, causing skin toxicity;

Negative impact on the stability of the drug substance;

• Less drug available to produce the desired clinical effect (eg through powder loss or uneven split);

Loss of protection of the drug from the effects of light;

• Changes in the drug pharmacokinetics and bioavailability, resulting in underdosing or adverse effects;
• May cause oesophageal or stomach irritation or ulceration if tablets are crushed or capsules opened;
• Refusal to take the medication due to unpleasant taste;
• Possible anaesthetic effect on the tongue, particularly if sertraline is given in a powdered form;
• Potential for an unintended large bolus dose to be delivered rather than controlled release over the intended timescale, resulting in a potentially toxic dose with an increased risk of adverse effects;
• Crushing enteric coated tablets may result in the drug being released too early, destroyed by stomach acid, or irritating the stomach lining.