Flash showing methods of medication scheduling for patients, including traditional plastic pill boxes, pill boxes with alarms, digital pill boxes, pill organizers, medication blister packs, medication alerts via pager, Palm PDA devices, and modern Blackberry and Smartphone medication scheduling systems.

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April 2014
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Do Blister Packs Solve the Medication Compliance Problem?

USA Today recently reported on a study where medication blister packs were used to improve patient compliance. Blister packs are those cards of pills backed with foil that are used by many over the counter cold remedies. In this study the pharmacist tossed aside the normal pill bottles, and combined the patient’s daily medications into one set of custom blister packs. For each dose time, there is a pre-filled collection of medications to swallow. According to the researchers, compliance was much greater than normal; patients did a better job of taking their medications.

As an experienced pharmacist dedicated to the issues of patient adherence and medication compliance, I don’t have any problems with what was reported. However, I have a problem with what was not reported.

Blister packs have been around for years. They’ve mainly been used in nursing homes or similar care settings, but only one drug is packaged and dispensed per card. The multi-pill-per-cup idea reported by USA Today has been tried for many years by pharmacists independently trying to help their patients handle this complex task more easily at home. But there are many issues with the method which were not mentioned in the article. Here are some I am familiar with:

  • Cost: Even though this article implies that blister packs are a cost-effective means of packaging medications, the material cost they cite is only part of the overall cost:

The blister packs were cheap; each cost just 14 cents a month to produce

Wow! Fourteen cents sounds good, but 14 cents just pays for the actual packaging materials. I’ve used these “bingo cards” in my practice as a pharmacist and it takes the pharmacist a lot more time to divvy up an assortment of pills into each of the blister pack cups than it takes to fill pill bottles. This is a labor intensive process. Pharmacist/technician time is money, too. I can’t see how that additional cost could have been counted within that 14 cent accounting. Also, remember that modern pharmacies continue to improve efficiency through automation, and this custom blister pack approach can not be achieved with the same automated, computerized pill counting systems in place at pharmacies today. Someday maybe, but not today.

  • Expert Judgement: One of the real hard issues faced by patients taking multiple medications (often prescribed by different healthcare professionals), arises from the communications disconnect between those prescribing doctors. Often the specific instructions provided by separate doctors for different medications seem to contradict. One may say “take with food” while another is labeled “after meals”. While this may seem to be a trivial conflict to a trained healthcare practitioner (such as a pharmacist deciding how to prepackage those medications into a blister pack), it can stymie a conscientous patient trying her best to adhere to instructions. Again, the pharmacist loading custom blister packs is handling those sometimes complex decisions on behalf of the patient. Again, not included in that $0.14 cost estimate, and neither are the phone consultations a good pharmacist will initiate when truly conflicting instructions are discovered.
  • Errors and Liability: Whenever medication prescriptions are filled, there is a possibility of a filling error. Patient safety is addressed through quality control (check, double check) and it is safe to assume that more complex combinations bring more opportunities for filling errors (even if we don’t recognize that automated pill counters and pill inspection machines are already on the job in many pharmacies). With a custom blister pack, a pill may be left out by mistake, or 2 of the same pills may wind up in the same cup. How can anyone double check, or triple check that? And who shoulders the added responsibility for that additional Quality Control?
  • Flexibility: Not every prescription is a fixed, long-term solution. What happens if a doctor changes the patient’s meds in mid-month? What happens to the pre-packed blister cards that have already been made? Some pharmacies may pick up the unused blister packs and re-use the medications in a new assortment, but legally this is a gray area because the drugs have not been in pharmacist custody the whole time. Can they be safely re-distributed? Even to the same patient? There is also the obvious additional labor of collectng, breaking open, and re-packaging, which must be balanced against the alternative costs of simply throwing the unused drugs in the disposal. Some patients may be able to pick out pills that have been discontinued, or find a way to make it to the next delivery of properly configured blister packs, but, I wonder, will that aid in adherence or hurt it?
  • Safety: Prescribing doctors are not the only health practitioners concerned with drug safety. The intended patients are not the only people who handle these medications. Medications are packaged with disclosure documents describing side effects, hazard labels and even accidental poisoning data in some cases. Poison control technicians and their pharmacist directors have worked very hard to get these materials into the packages and onto the labels. If we “toss aside” the pill bottles and pre-package combinations, where is the documentation? The labeling of custom blister packs can get very complicated in order to comply with state and federal laws, thereby adding an additional layer of confusion to this “simplification” process.
  • Compliance: Packaging is not the only barrier or answer to compliance. Many patients will still need a reminder to take their medications, even if the blister pack does make it easier to adhere to the proper dosing regimen. I can imagine a new crop of questions that need to be answered, such as “I missed one dosage of everything. Do I play catch up and take all of them together, as soon as possible? Should I skip some, but be sure and immediately take others, and if so, which ones?”

Think about this: if the patient forgets to take a pill out of a bottle when it’s time to take a dose, wouldn’t it follow that the same patient might also forget to pop open the blister as well? What tells this person when it’s TIME to take a medication out of any container? Do they rely on some internal clock or daily routine to remind them? Do they set an alarm clock or use some other alerting device?

This system of blister packs certainly can help some patients, but I don’t think it is a universal compliance “answer”.

Finally, according to the report:

“Your grandmother isn’t going to take her pills if she doesn’t know why the doctor gave them to her”, says Allen Taylor

I’ve known plenty of conscientious patients who take a variety of pills routinely while having no idea what they are for or why the doctor prescribed them. This is exactly why I believe Medication Therapy Management services (Medicare Part D) is so vitally needed. Under the MTM scenario, an independent pharmacist serves as a patient advocate, and takes an unbiased look at all of the medications a patient is taking, at least once a year or every 6 months. That review provides additional expert judgement, helps in overall safety and quality control, and can facilitate the additional communications that might be needed when multiple medications are prescribed by separate doctors. Every patient should seek the services of a pharmacist/patient advocate who will look at the big picture and advise accordingly.


Comment from Joyce Mackens
Time: September 11, 2007, 9:12 am

I work at a nursing home in which a family member wants to package her moms medicine in blister packs. How can she purchase the materials for this?


Blister pack materials are not usually sold for individuals to repackage their own medications.   Most pharmacies that service nursing homes already have the necessary equipment and the expertise to do this properly.   There are labeling and storage requirements that must be met and in most cases, it’s best to find out which pharmacy is dispensing medications for this particular nursing home  and call them.   See if they can and will do the repackaging for an individual.  However, many older patients find it physically challenging and very frustrating to deal with blister packs themselves. 

Comment from Randy Wakefield
Time: February 21, 2008, 1:27 am

I provide Home Care services for child clients in my home which often have multiple meds that they have to take morning/evening. My pharmacy has a self-adhesive blister pack that I get from them and re-package their meds myself (pharmacy can not do this for me) so that their AM meds are all in one bubble and PM in another. I still supervise the meds as these are children but it makes it much easier than sorting though the many bottles for each child twice each day. It also insures that it is clear when a med is needed to be reordered.

Comment from Randy Wakefield
Time: February 21, 2008, 1:31 am

add this to the first item if you will:

The blister packs cost me $1.00 each from the pharmacy. I can buy 1000 for $300 which will save me a lot.

While I applaud the work you’re doing, Randy; and I commend you for your resourcefulness and efficiency; I must stress again that there is an inherent risk and liability – especially where children are concerned.  This kind of repackaging is difficult – even for trained professionals.   And there are labeling requirements that are probably not being met by your method.  That’s more than likely the reason the pharmacy can’t or won’t do that repackaging for you.   Be very, very careful!

Comment from Ray
Time: July 10, 2009, 1:30 pm

I understand the caveats that this website is pointing out, and I agree that all of these issues must be taken into consideration and addressed as appropriate.

I purchase boxes of “cold-seal” medication blister cards from http://www.drugpackage.com (their catalog number MA-MMCH-REF) and fill two week’s worth at a time for my elderly parents. This has been a very positive, effective way for them to get their medications properly. Before I started using the blister cards for them, it was a mess.

That said, I am very meticulous and double-check myself at least three times before I seal the medication blister cards. It is indeed a very time-consuming task, as I label the foil side of each pocket with the date and time of day the meds are to be taken, so there is no confusion or guessing on the part of my elderly parents. However, since this is for my parents, I am motivated to take the extra time and care to make sure everything is correct and clearly labeled and thus easy for them to identify. As pointed out elsewhere on this website, few pharmacies can take the time to do that task manually, and I believe that until there is some form of automation that the pharmacies can use to custom-fill and clearly label cards for each patient, I doubt the pharmacies will be able to provide this service for “free”.

Another advantage of a DILIGENT, CAREFUL, loving family member or caregiver filling these cards at home is that OTC meds (like baby aspirin, vitamins, stool softener, etc) that an elderly person also needs can also be included along with prescription meds for correct dosing of the OTC meds too. The pharmacies would have to charge you an arm and a leg for the OTC meds they dispense into the cards.

http://www.drugpackage.com also sells “starter kits” that include a thick holder made of cork (to hold the cards securely as they are filled and sealed), along with a roller on a handle to seal the cards easily, and a few empty cards. After the one-time purchase of the starter kit, I now just purchase boxes of the cold-seal cards in bulk, at $21 per box of 12 cards (not incl shipping). So for one person using a single card per week, the cost of these cards is approx $104/year per person, which in my mind is a bargain considering the benefits they can provide for some patients.

I buy the OTC meds in economical packages from Costco, and we have the prescribing doctor and the pharmacy in-synch so that the meds are delivered in 90-day increments. I keep all of the medicines at my house and fill two weeks worth of cards at a time and deliver them to my parents every two weeks (with one week’s card always in reserve at their house in case my arrival is delayed a day or two). All filled cards are dated so they can consume the cards in proper order based on date.

I have created a photo record and written a brief procedure of how I go about filling the cards, so that if something happened to me another family member can step in and take over the job without any hiccups (as an engineer, I am accustomed to producing detailed procedures and documentation for others to follow to produce products uniformly). I update the photo record of their current prescriptions each time there is a change. This makes it easy for a substitute person to clearly see the proper dosing to go into each pocket of the cards. It is a pain when the pharmacy switches drug manufacturers for generics, because the photo records must be updated frequently, but that’s life ;-)

This method is not for everyone, but if a person can and will take the time to do this correctly and with diligence, it can make a major positive difference to people like my elderly parents. By filling only two week’s worth of cards at a time, any changes in medication can be easily handled.

– Ray

Comment from Marcy Shutts
Time: November 19, 2009, 4:58 pm

My father is going into a nursing home this weekend. We have been informed by the home that his medicines need to be in blister packs and we are to order his medication from the home. BUT, my father qualifies under VA benefits for FREE medication. We have checked with the VA and have been informed that they do not put their medications in blister packs because of the large amount of prescriptions that they fill. This does not seem fair that we now have to pay for his meds. At this point, I am not sure if this can be turned in on his supplemental drug insurance, but prior to getting free medication, he went into the “donut hole” and had to pay. Do we have another alternative ?

Comment from Jerry Gray
Time: December 17, 2009, 3:46 am

As a patient, I hate the blister-packs. I need to have someone open them for me since they are so difficult to open. I will change pharmacies if I can to avoid blister-pack.

Comment from Dave Spector
Time: January 21, 2010, 1:46 pm

Our pharmacy has decided to steer people away from blister packs and introduce our customers to our DailyPax system.

DailyPax is safe, convenient and easy to use. A 30 day supply of medication is packaged in compliance strip packaging.

Each packet of medication is clearly marked with the time, date and medications included in each pack.

DailyPax is perfect for seniors, caregivers, active adults, travelers, and parents of school children/campers.

If you’d like more info on DailyPax please contact me @ rx@adlersrx.com.

Comment from Naomi
Time: September 4, 2011, 10:32 am

I have transplant medications and u keep them in a tray. But I often find pills at the plbottom of my purse or book bag is there a place that serve Irvington nj with these daily pax

Comment from ira lisogorsky
Time: January 12, 2014, 6:55 pm

im presently using mts 30 blisters im looking to save money .I do about 200-300 packing per week do u have an alternative for me and what price?

Comment from Susan Torrico
Time: January 21, 2014, 4:12 pm

Hello, Ira.

Sorry, I don’t have sources for supplies or pricing. You might look at Medicine-on-Time. [http://www.medicine-on-time.com/ or http://www.sortmymeds.com Good luck.

Warmest regards,


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