Veterans Affairs & Military Medicine 2010-2011


Veterans Affairs & Military Medicine 2010-2011



if you are a practicing pharmacist, you’ve probably heard “has any-body seen or been working on Mr. XYZ’s prescription?” Meanwhile, your patients are spending uncomfortable minutes watching your clerks rummage through will call bins or bags looking for prescriptions that may or may not be filed correctly. Worse than this, your patient calls or returns to the counter and you discover that their prescription(s) have been accidentally mis-bundled with another’s medication (commonly known as “bundling errors”) or that your clerk accidentally picked the wrong Mr. XYZ’s prescription off the shelf (commonly known as “picking errors”).

Some reports say that bundling errors and picking errors account for over 40 percent of the remaining errors in pharmacy. However, our experience shows this may be a conservative estimate, and that these types of errors (including “near misses”) may account for as high as 60 percent of the remaining errors in the pharmacy.


Previous logic held that it wasn’t a big deal if you had a bundling error or picking error as long as the patient wasn’t harmed. However, this myth was shattered by the precedent-setting case of Kilgore v. Wal-Mart, in 2004. Mr. John Kilgore received medication intended for another “Kilgore” and actually took the incorrect medications for a few days. Admittedly, Kilgore was not physically harmed; however, he successfully sued Wal-Mart for “post-traumatic stress dis-order” and was awarded $840,000 after appeal. Although not widely publicized, this case set a new standard of practice for pharmacists. Now, damage from picking and bundling errors need only scare your patients.

Adding to this liability are the new HIPAA rules as applied by some practitioners today. Handing out the wrong per-son’s medication now becomes a HIPAA violation, which requires notification to all parties concerned. You can see that picking errors and bundling errors must be taken seriously.


Conventional methods implement “off-the-shelf” barcode scanning as a final answer. These solutions have pharmacy technicians and clerks scanning prescriptions in work-flow and ultimately out to the customer. The fallacy with this logic is that you are still dependent on humans doing the scanning. Plus, to truly track all prescriptions through multiple work stations, a prescription can be scanned more than 7 times before it is dispensed to the patient. Imagine filling 1,000 prescriptions per day and scanning each prescription 7 times at multiple work-stations. One technicians says, “… please, sir, don’t bring me any more technology. I can’t get my work done because all I do is scan all day.” Even with this much scanning, most systems today leave clerks to rummage through a common will call holding area for different patients.


Historically, and currently, prescriptions are filed in large bins, shelves or bags – alphabetically by the patient’s last name or randomly by the last two digits of the patient’s social security number. This process requires a labor-intensive and error-prone visual search process to find the correct prescriptions for a given patient.

GSL’s IntelliCabsTM utilize real-time RFID technology in intelligent cabinets and workflow to monitor and assist worker performance. To date and after a lengthy search on the Web, no other company has been granted “Design” and “Utility” patents specifically targeting this error-prone area.
GSL imbeds an RFID chip into their workflow baskets, known as “SmartBaskets.” Prescriptions are then individually “associated” to the baskets. While doing the basket association, GSL makes use of its Pharmacy Management System (PMS) interface to verify that no two patients’ prescriptions are accidentally bundled within the same SmartBasket, leading to a reduction in mis-bundling of prescriptions. Associated baskets are then filed anywhere within the “IntelliCab.” RFID readers that have been placed in every cell automatically record the presence of and where the SmartBasket has been placed. This leads to faster and more efficient prescription filing as well as an elimination of misfiled or lost prescriptions.

For retrieval of prescriptions, GSL has implemented “Smart” “Pick to the light” (PTL) technology. With the aid of lights, sound and RFID technology, the IntelliCabs are able to monitor in real time that the worker has indeed retrieved the correct prescription(s). Eliminating rummaging, retrieval times are greatly reduced. Overlaying real-time RFID – PTL technology, “picking errors” have nearly been eliminated.

GSL’s IntelliSysTM software records the time prescriptions are scanned into the sys-tem and “time stamps” them. Time stamping and the addition of IntelliCabs dramatically shorten the time required for identifying and isolating “aged” prescriptions in Will Call. With a press of a button, all aged prescriptions can be identified and quickly removed.

To address accountability, GSL has implemented the requisite use of RFID user’s badges. The system will record all user access and activity going in and out of the IntelliCabs on a real-time basis. “High valued” will call meds can now be stored into the IntelliCabs, thus eliminating current labor intensive “segregation models.”

Since the system’s first installation at Blanchfield Army Community Hospital, Fort Campbell, Ky., IntelliCabs have been installed in more than 20 Army pharmacies. After nearly 2.5 million prescriptions processed through IntelliSys-IntelliCab System, it is safe to say that Bundling and Picking Errors have been nearly eliminated. IntelliCabs are also being piloted at Kaiser Permanente, several retail locations and Oregon Health Sciences University Hospital (OHSU). Dan Kennedy, Assistant Director at OHSU, says about selling errors “… you don’t have to be busy to make errors, you just have to be human. After we installed In-telliCabs, there have been none.”


GSL is the leader in developing RFID enabled technologies to track prescriptions in pharmacy workflow and will call. GSL’s IntelliSysTM software combined with its flag-ship IntelliCabsTM is the first of a long line of “real time” pharmacy products focused on improving accountability, accuracy, and efficiency. These RFID based hardware and real-time processes will and have helped pharmacists and technicians perform faster, be more accurate and serve their patients better. To contact GSL: