Design of admission medication reconciliation technology: a human factors approach to requirements and prototyping.

OBJECTIVE: Our objectives were to (1) develop an in-depth understanding of the workflow and information flow in medication reconciliation, and (2) design medication reconciliation support technology using a combination of rapid-cycle prototyping and human-centered design. BACKGROUND: Although medication reconciliation is a national patient safety goal, limitations both of physical environment and in workflow can make it challenging to implement durable systems. We used several human factors techniques to gather requirements and develop a new process to collect a medication history at hospital admission. METHODS: We completed an ethnography and time and motion analysis of pharmacists in order to illustrate the processes used to reconcile medications. We then used the requirements to design prototype multimedia software for collecting a bedside medication history. We observed how pharmacists incorporated the technology into their physical environment and documented usability issues. RESULTS: Admissions occurred in three phases: (1) list compilation, (2) order processing, and (3) team coordination. Current medication reconciliation processes at the hospital average 19 minutes to complete and do not include a bedside interview. Use of our technology during a bedside interview required an average of 29 minutes. The software represents a viable proof-of-concept to automate parts of history collection and enhance patient communication. However, we discovered several usability issues that require attention. CONCLUSIONS: We designed a patient-centered technology to enhance how clinicians collect a patient's medication history. By using multiple human factors methods, our research team identified system themes and design constraints that influence the quality of the medication reconciliation process and implementation effectiveness of new technology. KEYWORDS: Evidence-based design, human factors, patient-centered care, safety, technology.

Evaluation of cognitive behavioral therapy/motivational enhancement therapy (CBT/MET) in a treatment trial of comorbid MDD/AUD adolescents.

OBJECTIVE: Behavioral therapies developed specifically for co-occurring disorders remain sparse, and such therapies for comorbid adolescents are particularly rare. This was an evaluation of the long-term (2-year) efficacy of an acute phase trial of manualized cognitive behavioral therapy/motivation enhancement therapy (CBT/MET) vs. naturalistic treatment among adolescents who had signed consent for a treatment study involving the SSRI antidepressant medication fluoxetine and CBT/MET therapy for comorbid major depressive disorder (MDD) and an alcohol use disorder (AUD). We hypothesized that improvements in depressive symptoms and alcohol-related symptoms noted among the subjects who had received CBT/MET would exceed that of those in the naturalistic comparison group that had not received CBT/MET therapy. METHODS: We evaluated levels of depressive symptoms and alcohol-related symptoms at a two-year follow-up evaluation among comorbid MDD/AUD adolescents who had received an acute phase trial of manual-based CBT/MET (in addition to the SSRI medication fluoxetine or placebo) compared to those who had received naturalistic care. RESULTS: In repeated measures ANOVA, a significant time by enrollment status difference was noted for both depressive symptoms and alcohol-related symptoms across the two-year time period of this study, with those receiving CBT/MET demonstrating superior outcomes compared to those who had not received protocol CBT/MET therapy. No significant difference was noted between those receiving fluoxetine vs. those receiving placebo on any outcome at any time point. CONCLUSIONS: These findings suggest long-term efficacy for an acute phase trial of manualized CBT/MET for treating comorbid MDD/AUD adolescents. Large multi-site studies are warranted to further clarify the efficacy of CBT/MET therapy among various adolescent and young adult comorbid populations.

Briefing guide study: preoperative briefing and postoperative debriefing checklists in the Veterans Health Administration medical team training program.

BACKGROUND: The purpose of this study was to examine the outcomes of checklist-driven preoperative briefings and postoperative debriefings during the Veterans Health Administration (VHA) medical team training program. METHODS: A briefing score (1, never started; 2, started then discontinued; 3, maintained on original targeted cases; 4, expanded to other services; 5, briefing all cases, all services) was established at 10.1 ± .3 months after introduction of the checklist. Outcomes included antibiotic and deep venous thrombosis prophylaxis compliance rates before and after use of the checklist. RESULTS: Antibiotic (97.0% ± .1% vs 92.1% ± 1.5%; P = .01) and deep venous thrombosis (95.7% ± .8% vs 85.1% ± 4.6%; P = .05) prophylaxis compliance rates were higher after initiation of a surgical checklist. CONCLUSIONS: Checklist-driven preoperative briefings and postoperative debriefings are associated with improvements in patient safety for surgical patients.