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Research in brief

Is splitting tablets dangerous?

  • 3 Comments

This study examined the different methods of tablet-splitting to establish which one was likely to be most accurate

In this article…

  • Why tablet-splitting is common practice
  • Potential dangers of tablet-splitting
  • How different methods compare

Keywords: Nursing homes, Practice guideline, Tablet-splitting

  • This article has been double-blind peer reviewed

Splitting tablets is daily practice in nursing homes where nurses are responsible for administering medication to residents safely. However, the practice can lead to medication errors because the tablet parts are often not equal in size, and a substantial amount of tablet can be lost as a result of splitting. If it is performed without the correct device splitting may be inaccurate and can result in a dosing error, which may result in harm for residents.

In most cases, dose deviations do not have clinical consequences for the patients but in the few cases (mostly medications with a narrow therapeutic index) that a small dose deviation has a clinical consequence, it can be serious, especially in older people.

The study

The aim of this study was to investigate the differences in the weight of tablets and the average weight loss, after being split using three different splitting methods.

We asked five volunteers to mimic the situation in nursing homes and to split eight tablets of different sizes and shapes using three different routine methods: a splitting device (Pilomat), scissors for unscored tablets or manual splitting for scored tablets, and a kitchen knife. No specific splitting guidelines or instructions were given. Tablets and tablet parts were weighted before and after splitting.

Eight commercially available tablets of different sizes and shapes, which are commonly split in nursing homes were selected for the experiment. We assessed the initial weight of 10 tablets of each formulation per volunteer and per method, using an electronic analytical balance and also recorded the mass of each tablet. After splitting, each half or quarter tablet – depending on the formulation – was individually weighed.

Findings

With all the tablets, using a splitting device resulted in less of a difference in weight compared with the two other methods. The device also resulted in significantly less weight loss than splitting by hand (for scored tablets) or with scissors (for unscored tablets), or splitting with a kitchen knife. The differences between using scissors for unscored tablets or manual splitting for scored tablets, and using a kitchen knife was not statistically significant.

Splitting tablets can lead to major differences in both fragment weights and weight losses. Using a splitting device appeared to be the best method for splitting tablets since it resulted in smaller weight weight losses than the other two methods.

Conclusion

While tablet-splitting might be common practice in nursing homes, not all formulations are suitable for splitting, and even when they are, weight losses can occur. This could have serious clinical consequences for medications with a narrow therapeutic-toxic range.

We would recommend using a splitting device as a routine method when splitting cannot be avoided, for example when the prescribed dose is not commercially available, or when there is not an alternative formulation, such as a liquid.

Nursing home staff performing the splitting should be educated in splitting as accurately as possible, and they should be aware of the possible clinical consequences of dose deviations.

We also recommend that pharmacists should give clear messages about the risks related to splitting.  Manufacturers could avoid the need for splitting by introducing a wider range of tablet doses or liquid formulations.

*This article is a summary of a paper published in the Journal of Advanced Nursing. Verrue Cet al (2010) Tablet-splitting: a common yet not so innocent practice. Journal of Advanced Nursing; 67: 1, 26-32.

Charlotte Verrue, Els Mehuys and Koen Boussery are post-doctoral researchers, Jean-Paul Remon is professor of pharmaceutical technology; all at the pharmaceutical care unit, faculty of pharmaceutical sciences, Ghent University, Belgium. Mirk Petrovic is professor of geriatrics, department of geriatrics, Ghent University Hospital, Belgium

  • 3 Comments

Readers' comments (3)

  • working on a ward that has a high ratio of polypharmic patients who very ofetn find it difficult to swallow their medication whole it is a problem and one that really need to be addresses.1) how many of these patients undergo a review of their meds and are all the medications essential or can they be reviewed for the sake of the patient, and very often if the patient is lucid will sometimes tell you that they even crush their tablets to make them easier to swallow. I digress, very often we have patients who are fed and have their medications via an nasogastric feeding tube, sometimes the medications come in loquid form but not always and as a staff nurse you find yourself crushing tablets or taking them out of their capsules so they can still be given. Surely this alters the way the medications work and do the medications still work as efficiently. Its not just a matter of cutting the tablets with a crusher is it still safe to give or is this a patients safety issue does the pharmacology alter when the tablet is crushed or dispersed in water? after all this is my registration on the line

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  • Even with a spiltting device there are still problems. Normally the local pharmacy that has to be used does this for us, but there have been times where this is not the case. Using a device supplied by the pharmacy has resulted in unequal amounts, which results in odd quantities being administered. All parties are aware of the problem yet nothing more has been done to reduce this.

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  • eileen shepherd

    Reply to Anonymous | 4-Mar-2011 1:24 am

    Your comments are very interesting and there are issues associated with crushing tablets and opening capsules to administer via a feeding tube. We will look into your questions and publish a response. It may be useful to seek advice immediately from your pharmacist and nutrition nurse specialist. BAPEN have a useful guide on this topic. I have copied the link below
    http://www.bapen.org.uk/res_drugs.html

    I hope this is helpful

    Eileen Shepherd
    Deputy Practice Editor

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