Sign In
CPSI Share                                                                      
​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​ ​​
Publication Type: Medical Safety Information
Single or Multiple Incident: Multiple
Date: 1/1/2020 12:00:00 AM
Country: Japan

This alert addresses the patient safety issues which can result from crushing a sustained release drug formulation. Four cases were reported in which a sustained-release preparation was ground up and administered to a patient, with the result that the active ingredient was rapidly absorbed into the patient’s bodywith adverse outcomes. Two cases are described. In the first case Nifedipine CR®, a long acting calcium channel blocker, was administered via a nasogastric tube resulting in a sudden drop in blood pressure. In the second case, a patient who had been taking Careload LA® for pulmonary hypertension required a tracheal intubation and a nasogastric feeding tube was inserted. The Careload LA® was a sustained release preparation but the formulation was unknown to the caregiver. The drug was crushed and administered via the nasogastric tube. A sudden drop in blood pressure resulted. The alert provides recommendations to prevent similar incidents.

Additional Details

Device:
nasogastric tube, enterostomy tube
Medication/Gas/Fluid:
calcium channel blocker, nifedipine CR prostacyclin PGI2 derivative beraprost (Careload LA®), oxycodone (Oxycontin®)
Medication/IV List:
narcotics/opiates, IV, transdermal, and oral (including liquid concentrates, immediate and sustained-release formulations)


Administration of a Sustained-Release Preparation in Ground-Up Form