Medication organizers often contain “one pill can kill” (1PCK) medications that can be lethal to children, according to the findings of a retrospective study published in the Journal of Pharmacy Practice.

While known to increase patient compliance, medication organizers, such as blister packs and pill boxes, have also been associated with unintentional pediatric medication exposures due to the lack of child protective packaging. Medications that may be potentially lethal with just a single tablet include tricyclic antidepressants, beta blockers, calcium channel blockers, opioids, buprenorphine, methadone, sulfonylureas, clozapine, olanzapine, chloroquine, hydroxychloroquine, benzonatate, clonidine, chlorpromazine, diphenoxylate-atropine, and theophylline.

To better understand the quantity and type of 1PCK medications present in monthly medication blister packs, this retrospective review obtained data on adult patients who received these medication organizers from 1 outpatient pharmacy between September 1, 2017, and September 30, 2017.

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The primary endpoint of the analysis was the quantity and type of 1PCK medications. Secondary endpoints included quantity of tablets dispensed, formulations, and the mean age of patients dispensed blister packs containing 1PCK medications compared with those without.

Of the total 486 blister packs dispensed to 450 patients, 72.4% were found to contain 1PCK medications. The most common 1PCK medications present in the blister packs were sulfonylureas (17%), beta-blockers (58.5%), and calcium channel blockers (68.2%); delayed- or extended-release formulations represented nearly 40% of the 1PCK medications.

Findings of the analysis also revealed that medication organizers that included 1PCK medications often contained more medications (8.5 ± 2.9 vs 5.7 ± 2.9 medications; P<.0001), and were more likely to be dispensed to older patients (69.1 ± 12.6 vs 62.6 ± 16.7 years old; P<.0001).

“Patients should routinely be asked about the presence of children in the household and counseled on safe medication storage,” the authors concluded. “Further research is needed to determine the extent of medication organizers in unintentional pediatric overdoses.”


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

This article originally appeared on MPR