01 | 23 | 2008 Posted By Regan Zambri & Long

Chewing Some Medications Can Be Fatal: Patient Safety Organization Issues Warning

The Institute for Safe Medication Practices (ISMP), a non-profit patient safety organization, has issued an alert that some medications should never be chewed, cut, crushed, or diluted. The group advises all patients to read medication label instructions carefully and to ask pharmacists or physicians specifically how each drug should be taken. The group reports that unfortunately, not all patients read pharmaceutical directions or receive and follow the advice of health providers.

In its patient safety alert, ISMP relates the story of an 83-year-old patient who was prescribed Cardizem CD® (sustained release diltiazem capsules) for blood pressure control, but who chewed her medication because the capsules were too large to swallow.  Because the pills were not designed to be chewed, her pulse twice slowed to low levels and the family contacted the pharmacist for advice. Upon learning that she was chewing the medication, the pharmacist suggested that the physician substitute immediate release diltiazem tablets, which are easier to swallow. The prescription was changed and the patient did well for several months.

Months later, however, the same patient returned to her physician for a check up, and was again put on Cardizem CD®.  Since the patient had either forgotten or never been warned about the danger of chewing Cardizem CD, she once again began chewing the large capsules. She became progressively weaker and died three weeks later.  According to her family, the patient had been alert and intelligent but had too much faith in her health providers to question their instructions.

ISMP reminds all patients that a complete medication list reviewed with health providers on every visit is an invaluable protection against such medication-related problems.  Additionally, the organization has published a roster of oral dosage medications that should never be crushed.

Previously on the DC Metro Area Medical Malpractice Law Blog, we have posted articles related to:

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