Appropriateness of oral dosage form modification for aged care residents: a video-recorded observational study

Abstract

Background Dosage forms of oral medications are frequently modified in aged care facilities (ACFs) by crushing/splitting tablets or opening capsules to facilitate medication administration for residents with swallowing difficulties. These practices pose safety concerns including the risk of adverse events resulting from loss of dose during transfer and alteration in the rate of absorption. Objective To identify the incidence, methods, and appropriateness of oral dosage form (ODF) modification practices in ACFs. Setting A purposive sample of four urban and regional ACFs in Queensland, Australia. Method The processes of ODF modification were observed and video-recorded using an action camera placed on medication trolleys. Each video was then reviewed, and the details of the medication modification processes were recorded in a data collection form. The appropriateness of the practices of dosage form modification was evaluated against existing national guideline (Australian Don't Rush to Crush Handbook). Deviations from the instructions in the guideline were considered as inappropriate practice. Main outcome measure Incidence and characteristics of inappropriate ODF modification. Results ODFs were modified in 25.7% of 810 observed medications. The most common methods of dosage form modification included crushing tablets with a manual crushing device (71.6%), cutting/splitting tablets (20.2%), and opening capsules (4.3%). According to the national guideline, 12.5% of the modification instances were inappropriate.Inappropriate practices were commonly associated with the suboptimal methods of medication preparation where medications were unsuitably modified, mixed, spilled, or incompletely dosed. Conclusion ODF modification is a common practice in ACFs. However, some of these modifications do not comply with the requirements of good practice in existing guidelines. Healthcare workers in ACFs need to be supported and upskilled with effective training to promote the best and safest practices of ODF modification.

A Difficult Pill to Swallow: An Investigation of the Factors Associated with Medication Swallowing Difficulties

“…9,36,37 Modifying medications can result in dose variations, alter drug absorption, and lead to adverse events. 38,39 Understanding and resolving medication swallowing difficulties can potentially prevent the risks associated with modifying dosage forms.…”

Assessment of oral solid dosage forms administration manner and acceptability

“…These coping strategies were addressed not only by patients but also by some caregivers and healthcare practitioners, especially in nursing home care (Caussin et al 2012;Schiele et al 2013;Manrique et al 2014; Almukainzi Sefidani Forough et al 2020). Although only a few of the participants admitted that they modified OSDF medication before its administration by crushing or chewing OSDF, many of them believed these practices do not affect the drug's efficacy or safety.…”

“…Moreover, IR OSDF medicines are designed to disintegrate and dissolve in the gastrointestinal tract (GIT), so crushing these tablets or opening the capsule may result in an alteration of the rate of absorption (Manrique et al 2014). These practices can also cause a loss of part of the dose during crushing and administration to the patient (Sefidani Forough et al 2020;Shane et al 2017). Other concerns related to OSDF modification are the risk of occupational and caregiver exposure (Caussin et al 2012;Forough et al 2018;Forough et al 2020).…”

“…These practices can also cause a loss of part of the dose during crushing and administration to the patient (Sefidani Forough et al 2020;Shane et al 2017). Other concerns related to OSDF modification are the risk of occupational and caregiver exposure (Caussin et al 2012;Forough et al 2018;Forough et al 2020).…”

Factors that affect health‐care workers’ practices of medication administration to aged care residents with swallowing difficulties: An Australia‐wide survey study

“…This was significantly higher than in a previous survey among nurses in ACFs in the UK reporting a 61.3% modification rate 2 . While this figure indicates an extensive use of the practices of dosage form modification in ACFs, there remain concerns around the safety of these practices, especially considering that up to one‐third of modifications in the Australian ACFs were found to be inappropriate and potentially risky 8,9,19 …”