Error or Not an Error???

if a pill is scored, has a depressed line across the pill, it can be split in two. the scored tablet has been manufactured to provide equal dosage on both sides of the score of the tablet. for example: coumadin comes in scored tablets where the 5 mg tablet can be cut in half to provide 2.5 mg of medication. you never use a pill splitter to divide an unscored tablet in two. to do so provides an inaccurate dosage and an uncontrolled administration because the pill is not manufactured to provide equal amounts of medication on either side of the pill. the whole pill must be used to administer the correct dosage. if you have a medication order that requires an unscored tablet to be split in two you must bring this to the attention of the physician and the pharmacist.

Gotta love the irony. Lots of people losing sleep over Lunesta. Were the one and one half tabs actually administered ? Was the dose recently increased from two to three mg ? The bottom line is you cannot administer what you don't have and the prescribed medication was not available. Altering non scored tablets may be within the scope of practice of a pharmacist or doctor, but I'm sure it is not within the scope of my practice. If there is not a facility policy in place to adress this issue, this might be a good time to stop throwing fits and device a sound policy.