The current pharmacy adjacent to the Fort Knox PX was built in 1998-back when the post was at such a low point, there was fear of closing Fort Knox altogether. The post's daytime popula-tion (Soldiers and DA civilians) was roughly 10,000.

The PX pharmacy was designed as a satellite to the main pharmacy at Ireland Army Community Hospital and intended to shoulder some of the workload-300-400 prescriptions a day.

In addition, a PX pharmacy would give patients the convenience of dropping off a prescription, leaving to do grocery or PX shopping, then retrieving their medications-with one stop in the shopping complex.

By 2003, before the BRAC decisions were announced, the PX pharmacy was filling just slightly less than 4,000 prescriptions a month.

Of course, the installation has changed significantly. Due to the expansion which is being called the "big inhale," Fort Knox's population is now roughly 32,000 people, most of whom are military medical beneficiaries. In 2009, the PX pharmacy filled more than 20,000 prescriptions a month-a whopping 400 percent increase in work load in six years.

The mammoth increase can be attributed to several factors. Tough economic times combined with climbing drug prices and the increased use of medications in an aging population are driving some beneficiaries to travel long distances in order to exercise their prescription benefits from the Fort Knox pharmacies, rather than using their local civilian pharmacies. Patients come from Virginia, West Virginia, Tennessee, Ohio, Indiana, and the Kentucky outskirts.

"The increased volume combined with the small work space was increasing the chances of mistakes," said Capt. Walt Unruh, the acting pharmacy chief. "While we were concerned about the patient's increased wait time, we were more concerned about safety."

All that justified the recently-completed renovation at the PX pharmacy. The renovation required $80,000 in construction costs and $200,000 in automation updates.

The major automation investment was a set of filing cabinets that replaced the old system of placing all patients' medication bottles or containers in plastic bags that were then hung on a rack. When patients called for their filled prescriptions, the pharmacy technician had to search through the bags to find the right name.

The Intellicab system is essentially an automated filing cabinet, although the filed material is actually a small plastic tub with a radio frequency identification tag affixed. All the patient's medications are placed in a tub, then filed. When a patient calls for his prescription, the pharmacy tech scans the patient's military ID card, which transmits the information to the computer system. The pharmacy tech enters the correct action so the computer understands the patient is picking up his medication. Upon receiving the information, the Intellicab flashes a signal above the correct file drawer. After scanning their own bar-coded security badge, pharmacy techs can open a large vertical drawer, where the correct bin flashes as well. If the tech inadvertently pulled a wrong drug bin, a warning siren would sound.

The Intellicab system is just one of many checks and balances in the pharmacy to help eliminate medication errors.

"People get hung up on wait time, but it's all about safety," Unruh explained. "From start to finish, it takes an average of three or four minutes per prescription. Multiply that by at least 1,000 prescriptions per day and it's easy to see where the wait time comes from.

"Unfortunately, the number of prescriptions being processed isn't visible to the public, so it's difficult for patients to see where their prescriptions reside in the queue."

The bar codes on ID cards, medication bottles, hard-copy prescription papers, and even on the pharmacy staff ID badges are all designed to reduce human errors.

When a patient arrives at a window to drop off his prescriptions, the initial screening occurs. A pharmacy technician ensures that the patient is in the DEERS system, that he or she has a valid ID card, that the time frame for a renewal is appropriate, and that the requested drug is in the formulary (which is the medical name for those drugs kept in the pharamcy's inventory). If those conditions are all met, the prescription is accepted.

Another technician is responsible for entering the information and creating the first bar code identifier for the prescription. Then a third technician retrieves the now-coded prescription information and matches and fills the request with medication retrieved from one of several possible storage sites.

In some cases, an automated pill dispenser will drop the correct number of pills into a plastic bottle when the technician scans her own bar code information into the computer. In other cases, an infrared counter is used to ensure that the correct number of pills is dispensed from a large container into a smaller bottler. Each pill that passes through the neck of a funnel triggers an infrared counter.

In yet other instances, the correct pill count may be obtained on an electronic scale, which registers the count of pills by weight.

Once bar codes are again entered to document what was filled, who filled it, and for whom it was filled, then the medication in its RFID bin is passed to the quality control section. Again, bar codes are verified, and the pharmacist confirms that the pills in the bottle match the physical pictures of that medication as generated by the computer.

For example, if a patient should receive a high blood pressure pill that is a blue tablet (not a red capsule or a pink powder), when the pharmacist supplies the computer with the correct name of the medication the patient should receive, the pharmacist will see a picture of the pill in order to verify that the pills in that designated bottle are, indeed, the correct blue tablets. The pharmacist then passes the bin with its now activated RFID tag to the file area, where the bins wait to be stored in the cabinets.

All told, six people will be involved to complete one prescription, each one performing quality checks and rechecks as they go.

Due to the space required for the new prescription storage cabinet files and the need for a larger prescription processing area, the actual patient waiting area is smaller now. But the trade-off allows the staff to meet the workload in a much safer environment.

Unruh added that the pharmacy was never designed to be a long-term waiting area, but rather a convenience so patients could drop off prescriptions and then do other errands. The renovation created three more customer service windows, so when patients pick up their prescriptions, the time spent in the waiting area should be minimal.

On a typical day, 14 or 15 staff members process the load of roughly 1,000 prescriptions.

While patients should see shorter wait times from the moment they enter the PX pharmacy to retrieve a prescription, the actual time to turn around refills may be longer now. Unruh explained that the increased turnaround time for refills is due to the overall operational tempo of the Army and the hospital's continual staffing shortages. Four pharmacy staffers are currently deployed.

The renovations and improved work flow should help eliminate errors and increase patient safety, but Unruh said, "Give credit where credit is due; Greg Treadway, the pharmacy supervisor, and his staff, designed the work flow process. This is their brainchild.


"To help the pharmacy staff serve customers better and decrease waiting times, follow these suggestions.

* Peak hours are between 11 a.m. and 2 p.m. when the pharmacy is also trying to schedule lunch breaks for its employees. Try to avoid those times to reduce your wait.

* New prescriptions should be turned in several hours before the pharmacy closes if same day pick-up is desired.

* Patients may encounter longer processing times on days just before and after holidays. Customers who can't avoid refilling at those times should be prepared for a slightly longer wait.

* If your off-post care provider writes new prescriptions for medication that still has refills available, only request the medications actually needed. Staffers spend a great deal of time poring through lists to screen out medications that have been recently refilled.

* The most efficient method for obtaining new medications is for patients to drop off the prescription request in the morning, then return later in the day for pick-up.