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Pendragon Forms Case Study

Pharmacy Error Tracking

 

Scenario:

Pendragon Forms is used to collect information on pharmacy medication exceptions and to streamline pharmacy operations.

 

Case Study

Developer/Location:

Matthew York, CPhT

Walter Reed Army Medical Center

Washington, DC

 

Overview:

Walter Reed Army Medical Center1 is a 670-bed tertiary care medical center located in Washington, D.C. that serves a community of approximately 300,000 active duty military, retired military, and family members of both. 

 

Pharmaceutical services are provided 24 hours a day, 7 days a week, by a staff of commissioned pharmacy officers, civil service pharmacists, civil service pharmacy technicians, enlisted technicians, contract pharmacists, supply technicians, and other administrative personnel

Inpatient pharmacy satellites offer decentralized unit dose drug distribution and complete sterile product services to all nursing units. 

 

Installation:

Pendragon Forms applications are used to document Dispensed Medication Errors (Type 1 and 2) and Internal Medication Errors (Type 3) for hospital patients, and to automate pharmacy operations.

 

Forty clinical pharmacists, supervisors, officers, and NCOICs use handheld devices with Pendragon Forms applications and other clinical reference manuals.  When exceptions occur, one of five forms is used to collect information on the drug, dosage and patient.  Where possible, drop down menus and checkboxes have been  used to speed information collection.  Synchronized data is used for reporting and trend analysis.

 

In addition to error tracking applications, the pharmacy is developing an expiration date form that incorporates bar code scanning and will eliminate the need for a monthly physical inventory.  As medications are placed on the shelves, each bottle will be scanned, and automatically associated with the NDC#, drug name and strengthThen the individual who is stocking only has to enter the expiration date, and synchronize the form.

 

Data from this form will be used to generate an expired meds report so a staff member may pull specific expired meds instead of having to go through the entire inventory monthly.
 

 

Forms Development Time:

Less than 1-2 days

 

 

Before Pendragon Forms:

Prior to using Pendragon Forms, Type I and Type II errors were tracked using paper forms.  Type III errors were not tracked. 

 

Benefits:

  • Capture data on errors that were not tracked

  • Easily analyze the data and identify error trends

  • Use the PDAs for clinical reference materials

  • Faster reporting

  • Eliminate monthly physical expiration inventory

 

Note 1: Background information on Walter Reed Hospital and Pharmacy,  provided by the Army Pharmacy website http://www.wramc.army.mil/

 

 

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