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During the evening shift, a medication nurse used a mortar and pestle to crush a penicillin tablet for one of her patients. When she went off duty, she left the mortar and pestle on top of the drug cart without cleaning them.
On the next shift, another nurse used the same mortar and pestle to crush a tablet for a different patient. Immediately after she administered the crushed tablet, the patient became dyspneic and cyanotic and lost consciousness. The nurse called a code and the patient was successfully resuscitated.
After the crisis was over, the nurse found out that the mortar and pestle hadn't been cleaned after their last use--crushing a penicillin tablet. The tiny bit of penicillin left in the mortar was mixed with the tablet she was crushing. It was enough to put this patient, who was severely allergic to penicillin, into anaphylactic shock.
This error could have been prevented if the mortar and pestle had been thoroughly cleaned after their use. But an even better way to prevent this type of error is to check first with a pharmacist before crushing any tablets.
Many medications today are issued in sustained-release or enteric-coated tablets. If you crush a sustained-release tablet, you'll destroy its long-acting effect. In other words, the patient will get the entire dose all at once instead of over a period of hours. Crushing an enteric-coated tablet causes the drug to be released before it should be, in the stomach rather than the small intestine.
Obviously, you shouldn't crush these tablets. If a patient can't swallow a tablet whole, ask the pharmacist whether a liquid form of the drug is available. If not, the pharmacist may be able to prepare a special formulation or suggest an alternative.