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Background: Medication organizers increased compliance, but they do not contain child protective packaging. Medications organizers have been involved in some pediatric exposures; however, previous reports do not describe if “one pill can kill” (1PCK) medications were involved in the exposures. 1PCK medications may cause toxicity even with a single tablet. Objective: The purpose of this study is to describe the type and presence of 1PCK medications dispensed in medication organizers at a single center. Methods: Adult patients who received blister packed medications from September 1, 2017 to September 30, 2017 were included in this retrospective review. Medications were excluded if dispensed traditionally during this time. The primary outcome described included 1PCK medications (quantity and type). Secondary outcomes included total number of tablets dispensed, delayed- (DR) and extended-release (ER) formulations, average age of those dispensed 1PCK medications versus those without. Results: A total of 450 patients received 486 blister packs and 75.5% of which found to include 1PCK medications. Most commonly included 1PCK medications were beta-blockers and calcium channel blockers (42.4 and 49.4%, respectively). Patients receiving 1PCK medications were older (69.1 ± 12.6 vs 62.6 ± 16.7 years old, p < 0.0001) and included more medications (8.5 ± 2.9 vs 5.7 ± 2.9 medications, p < 0.0001). DR and ER formulations were in 150 packs. Conclusion: The majority of dispensed medication organizers included 1PCK medications. Upon dispensing, patients should be questioned for possible proximity exposures. Additionally, they should receive education on medication safety for children that may be in proximity of the medications during home, work, or social activities.

BackgroundProvision of antiretrovirals (ARVs) for pediatric patients who require HIV post-exposure prophylaxis (PEP) poses many challenges. Many pharmacies do not stock pediatric formulations of ARVs. Prior authorizations and misunderstanding of medication quantity and urgency can delay filling and result in treatment interruptions, risking PEP’s efficacy. While 3-day starter packs are standard of care for patients prescribed PEP in the Emergency Department (ED), we are not aware of programs designed to ensure pediatric patients receive the full 28-day course.MethodsAt Boston Medical Center using the Model for Improvement with Plan-Do-Study-Act (PDSA) cycles, we implemented three key interventions: 1) Initiation of “Meds-in-Hand” for patients prescribed PEP during outpatient pharmacy business hours in which the entire course of ARVs is dispensed and handed to the patient in the ED; 2) Establishment of a troubleshooting PEP group email chain for medication receipt after a starter pack is given; and 3) Creation of an ED-Pharmacy workflow to help providers avoid logistic prescription errors. Using run charts, we tracked the proportion of patients who received Meds-In-Hand or a 3-day starter pack over time, and identified delays in full PEP course receipt.ResultsOf the 29 courses of HIV PEP prescribed from our Pediatric ED during 2016, with mean age 16 years (range 1–22 years), the proportion of patients with delays in prescription pick-up that would result in gaps in therapy decreased from 45% (5/11) to 6% (1/18) during the intervention period (Figure 1). During 2 of 5 pre-intervention months, one patient left the ED without a starter pack; all patients in the invention period left with either a starter pack or Meds-In-Hand. Of patients seen during pharmacy business hours, 50% (2/4) during PDSA cycle 2 and 100% (3/3) during cycle 3 received the full 28-day medication course before leaving the ED.ConclusionPatient care measures improved with a multi-disciplinary team approach involving pharmacy, pediatric infectious diseases, and ED improvements in communication and coordination of care. This quality improvement initiative demonstrates simple collaborative interventions to reduce critical delays in HIV prevention for a vulnerable population.Disclosures All authors: No reported disclosures.

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Pediatric human immunodeficiency virus post-exposure prophylaxis is frequently indicated, but delays in medication receipt are common. Using plan-do-study-act cycles, we developed a multidisciplinary collaboration to reduce critical process delays in our pediatric emergency department. Interruptions decreased from a median 1 per month pre-intervention to zero per month during the intervention.