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ISMP Medication Safety Alert


Some medications should never be chewed, cut, crushed, or diluted. The only way to know is to read label instructions carefully and/or ask your pharmacist or physician how each drug should be taken. Unfortunately, not all patients read the directions or receive and follow this kind of advice from health providers. The following case illustrates the dangers when patients are not given appropriate instructions or do not question how to take medication.

An 83-year-old patient was given Cardizem CDŽ (sustained release diltiazem capsules) for blood pressure control. Because the capsule was too large to swallow, the patient chewed the medication. As a result, 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 the patient returned to her physician for a check up. She was again put on Cardizem CDŽ because the physician apparently did not review the patient's previous medication use and neither the patient nor her caregiver reminded the doctor about the prescription change. Since the patient had either forgotten or never been warned about the danger of chewing Cardizem CD, she again began chewing the larger 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.

Such instances remind us that medication must be taken carefully and always according to specific instructions. It also reminds us that patients can be the last, best check on their own medication use. A complete medication list reviewed with health providers on every visit is an invaluable protection against medication-related problems. Similarly, patients and caregivers should always ask questions aggressively to fully understand the treatment they are receiving, clear up doubts or questions about any aspect of the therapy, and to alert health care providers appropriately if anything seems amiss.


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Throw away your old medicines safely
General Advice on Safe Medication Use
Lessons to Be Learned from Past Errors
Preventing Drug Errors in Children
Safe Medicine: ISMP Medication Safety Newsletter for Consumers
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