medication coming in inappropriate form for use

[pinkiepieRN]

I work in a SNF/LTC, but I hope this might be applicable across the board. We have many residents who receive crushed medications or medications via g-tube. If that's the case, we're supposed to write that pharmacy send elixir or dissolvable form when available. The problem is that pharmacy isn't always doing so unless the order is re-written as [x] mg/[x] mL, give [x] mL PO or via g-tube. I am the night shift supervisor in my building so I'm not usually giving the meds but I've recently discovered that an overwhelming amount of our patients are receiving medications in capsule form that should not be opened because they're delayed or controlled release, such as Omeprazole. I know that Omeprazole comes in an elixir and that some of our residents do receive the medication that way but I'm not sure how to address this systemic problem. We have residents who have been in our facility for an extended period of time, like > 1 year, and have likely always been receiving the capsule which is opened and either mixed with water for g-tube or apple sauce for PO. I also know that Protonix comes in sprinkle form but we have some patients on Protonix that receive the enteric coated version of it. I know that it shouldn't be crushed and end up feeling stuck: do I give the medication because it's ordered or do I hold it, knowing that they're likely receiving it every other day as a crushed medication and isn't having the desired effect anyway?

My question again goes back to solving this problem across the board and preventing this issue to arise with new patients. Shouldn't pharmacy be reading the diet order (like NPO, pureed, etc.) on new admissions and checking this on current residents? I know it's not their job to know the residents inside and out, but if the pharmacy can call every time a patient displays a potential drug interaction even after a patient has been in the hospital on that combination of medications or even before they were admitted to the hospital, why wouldn't something like this come up? Even when the box on the admission form for "send soluble/crushable form if available" is checked, it seems like this is getting missed by pharmacy and nurses are giving the medication as ordered with the form that is sent. Should we be re-writing the order for all patients who need the soluble form of Protonix or Omeprazole and are receiving the capsule? Is this considered a medication error or am I over-thinking?

[annie.rn]

Don't know how to fix it from a system standpoint but just want to say that I feel your pain. I work in the hospital and see this all the time. It's a big pet peeve of mine. We had one patient getting Seroquel XR crushed through a PEG tube for over a month. I don't understand why pharmacy would have sent the med for that long when it was ordered "via PEG" and why it was being crushed by the nurses. The other thing I see all the time is the crushing of K-Dur when it clearly says "do not crush" on the EMAR and we have K Elixer as an option w/ our potassium replacement protocol.

Omeprazole capsules can be opened and the contents sprinkled on applesauce (or other edible medium) and given immediately. The granules cannot be crushed or chewed. Same goes for similar XR capsules like Adderral XR. You just can't let the granules sit long once mixed w/ food or liquid or they will begin to degrade.

You've probably already done this but I would talk with whoever is in charge of pharmacy and find out what their process is and see if it needs to be amended in order to prevent these situations.

I think it is easier for pharmacy to catch drug to drug interactions because there are computer programs that do that. I imagine they know very little about the diet or swallowing abilities of the patients.

Maybe a system wide inservice with both pharmacy and nursing involved would be helpful. A handout of commonly prescribed meds that cannot be crushed would help out. The list could be posted on the med cart, in the med room, in med books, etc.

I do think it is a med error b/c one makes an XR drug an immediate release drug when one crushes it. I wouldn't go on a write up frenzy but I would definitely educate the offending people on the topic of crushable vs. non crushable meds.