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Counsel Patients on "One Pill Can Kill" Meds in Common Pill Organizers


A new study reveals that nearly three-quarters of medication organizer packages contain a drug class from which a single pill could be lethal for a child.



Medication "organizers" that help support treatment adherence, particularly in older adults, may prove lethal to children, according to results of a retrospective study published online in the Journal of Pharmacy Practice.

The study focused on the presence in many medication organizers, such as blister packs and pill boxes, of medications that could prove fatal to a child with a single tablet swallowed—the “one pill that can kill” (1PCK). Drugs in that category include tricyclic antidepressants, beta-blockers, calcium channel blockers, sulfonylureas, opioids, and numerous others. According to study authors, the pill organizers have been associated in the past with pediatric exposures caused by lack of child protective packaging.

However, they observe that past reports have not included whether 1PCK medications were involved in the exposures.

Led by Natalija M Farrell, PharmD, BCPS, of the department of pharmacy, Boston Medical Center and department of emergency medicine, Boston University School of Medicine, the team of investigators set out to better understand the quantity and type of 1PCK medications potentially included in monthly medication blister packs. 

The retrospective review included data on adult patients from a single outpatient pharmacy who received blister-packaged medications between September 1 and September 30, 2017.

The primary endpoint of interest was the quantity and type of 1PCK. Secondary outcomes were total number of tablets dispensed, delayed- or extended-release (DR, ER) formulations, and the mean age of patients dispensed blister packs including 1PCK medications vs those without.

Drug classes that may be lethal with a single tablet
Tricyclic antidepressants, beta blockers, calcium channel blockers, opioids, buprenorphine, methadone, sulfonylureas, clozapine, olanzapine, chloroquine, hydroxychloroquine, benzonatate, clonidine, chlorpromazine, diphenoxylate-atropine, and theophylline.


A total of 486 blister packs were dispensed to 450 patients.

75.5% contained 1PCK medications and the most common
1PCK medications included were:

  • calcium channel blockers (68.2%)
  • beta-blockers (58.5%)
  • sulfonylureas (17%)

The authors report that 40% of the 1PCK medications were
DR or ER formulations.

Analysis found that medication organizers with 1PCK were likely to contain more medications than those without (8.5 ± 2.9 vs 5.7 ± 2.9 medications; p<.0001), and that patients who received 1PCK medications were older than those who did not (69.1 ± 12.6 vs 62.6 ± 16.7 years old, p<.0001).

Farrell et al conclude that “The majority of dispensed medication organizers included 1PCK medications.”

Authors call for additional research to help determine how often medication organizers are involved in unintentional pediatric toxic exposures and emphasize that health care professionals should routinely ask patients about the presence of children in the home or other locations where proximity exposures are possible.

Patients and caregivers should always be counseled on safe medication storage.

Reference: Farrell NM, Hamilton S, Gendron BJ, Corio JL, Lookabill SK. Presence of “one pill can kill” medications in medication organizers: implications for child safety. Journal of Pharmacy Practice. Published online May 18, 2021. doi: 10.1177/08971900211017491

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