SPLITTING TABLETS CHALLENGES YOU AND YOUR PATIENT

Article reprinted from ISMP Medication Safety Alert! Nurse Advise-ERR (June 2008, Volume 6, Issue 6), with permission by the Institute for Safe Medication Practices and the Kentucky State Board of Nursing.

Most oral medications are available commercially in common dosage strengths, but tablet splitting has become more commonplace for several reasons. Occasionally, a patient may need to take just part of a tablet or more than one tablet when the exact dose isn’t commercially available.  In some cases, the patient may not be able to swallow tablets whole.¹ Financial factors also may play a role.  For example, different strengths of one medication often cost about the same, so patients on a tight budget may be given a prescription for higher strength tablets and told to take a half or even one-fourth of a tablet for each dose.²  Even when patients have healthcare coverage, some insurers deny payment for lower strengths of certain prescribed drugs; to get reimbursement, the patients must get higher strength tablets and split them for each dose.²

Finally, some healthcare organizations don’t purchase all commercially available strengths of oral medications, so some drugs may require staff to split tablets for patient-specific doses.
A study by the Veterans Administration looked at 442 reports related to pill splitting. Of these incidents, 38 percent were considered adverse drug events, with most occurring in outpatient settings (65 percent). The study showed that two-thirds of people who were supposed to split tablets forgot to split them and took too much medication.¹  The errors were discovered when the patients tried to refill their prescriptions too early. A quarter of the medications involved were high-alert drugs, and about 9 percent of patients who took too much medication were harmed by their mistakes; 2 percent required hospitalization. In more than half of the events, the prescribed dosages had been available commercially.

If you work in a hospital, the pharmacy should split tablets and send them to the unit in patient-specific, labeled unit doses. But if you must split tablets or educate patients on how to split their pills, keep in mind the situations that may lead to errors:²
•    A pharmacist or nurse might misread an order written for “½ tablet” as “1-2 tablets.”
•    Nurses may overlook directions on the medication administration record to split the tablet and administer the whole tablet in error (a surprisingly common occurrence). If the tablet is split, the remaining half tablet not administered to the patient is either wasted or maintained in makeshift or unlabeled packaging (often a medication cup or ripped package) until the next dose, risking an error.
•    If a pill splitter is not cleaned between patient uses, pill residue can contaminate the next patient’s medications, risking anaphylaxis if the patient has an allergy to the drug residue.
•    Patients may assume that tablets have already been split when they haven’t, or they may split tablets that have already been split.
•    Patients with visual problems or poor manual dexterity may not be able to split tablets.
•    Patients may get confused and split the wrong tablets.
•    Patients may tire of splitting tablets and stop taking the medication.
•    A patient may be told to split tablets in half, but the directions on the label may indicate “1 tablet” per dose. This can mislead the patient or healthcare providers who use the prescription label to gather information while taking the patient’s medication history.
•    Split tablets crumble easily, so the patient may not get the correct dose.
•    Certain types of medications shouldn’t be split (see Table 1).

REFERENCES:
1)    Sales, MM; Cunningham, FE. Tablet splitting. Veterans Administration. Topics in Patient Safety (TIPS). 2006; 6(3): 1, 4.
2)    Clark, TR. Tablet splitting for cost containment. August 2002. Available at: www.ascp.com/advocacy/briefing/tabletsplittingcontainment.cfm.
Reprinted with permission from the Kentucky Board of Nursing Connection.
 
check it out ✓
To safeguard tablet splitting for you and your patients:
✓    Let pharmacy split. In hospitals, the pharmacy staff should dispense exact doses by either splitting tablets and repackaging them or preparing an oral solution in a unit-dose oral syringe.
✓    Verify suitability. If you must administer half tablets, check drug references or ask a pharmacist to make sure that splitting tablets is safe. For reference, maintain an up-to-date list in patient care units of medications that cannot be crushed or split. If you’re unsure, contact the manufacturer.
✓    Provide the right tools. If patients must split tablets at home, provide them with a tablet-splitting device or advise them to obtain one from their community pharmacy to improve accuracy.
✓    Keep it clean. Patients and healthcare providers should wash their hands before splitting tablets; healthcare workers should also wear gloves. Whenever possible, use a disposable pill cutter labeled with the patient’s name. If disposable cutters are not available, wash the tablet-splitting device with water and dry it after each use to remove powder or particles.
✓   Provide discharge education. Advise patients who are receiving half tablets in the hospital that their community pharmacy might give them a different strength tablet after discharge. Ensure the patient knows the actual dose of the drug, and to ask their pharmacist whether splitting tablets will be required. For patients who will split tablets, make sure they understand what to do and get a return demonstration to make sure they can do it. Enlist the help of a qualified family member if necessary. •