A decade since to Err is Human and the role of librarians in patient safety

There are discussions happening throughout health care this week around what has improved since "To Err is Human" was released a decade ago.

Do any librarians have any memories related to this event, that has been hailed by some as the launch of the "modern" patient safety movement? Any thoughts around what has happened to impact the librarians role in patient safety work since then? For non-librarians, do you have any thoughts on how your work with librarians may have changed in regard to your implementation of safety initiatives?

One step in the right direction was the development and distribution of the MLA policy around the librarian's role in patient safety earlier this year but I'd love to hear about changes at the organizational level.

My own work has demonstrated some uptake and improvements, but I'd love to hear some stories from the field.

Please share!

Knowledge brokers: an opportunity for evidence distribution improvement

This article provides some interesting ideas around how knowledge brokering can be built into education and learning processes within an organization. I see that librarians and others with a tendency toward understanding information and knowledge needs and the ability to build and feed successful networks of knowledge workers could effectively fill this role.

I'd love to hear other thoughts on the matter .....

Dobbins M , Robeson P, Ciliska D, Hanna S, Cameron R , O'Mara L , DeCorby K, Mercer S
A description of a knowledge broker role implemented as part of a randomized controlled trial evaluating three knowledge translation strategies.
Implementation Science 2009, 4:23
The electronic version of this article is the complete one and can be found online at: http://www.implementationscience.com/content/4/1/23

Abstract
A knowledge broker (KB) is a popular knowledge translation and exchange (KTE) strategy emerging in Canada to promote interaction between researchers and end users, as well as to develop capacity for evidence-informed decision making. A KB provides a link between research producers and end users by developing a mutual understanding of goals and cultures, collaborates with end users to identify issues and problems for which solutions are required, and facilitates the identification, access, assessment, interpretation, and translation of research evidence into local policy and practice. Knowledge-brokering can be carried out by individuals, groups and/or organizations, as well as entire countries. In each case, the KB is linked with a group of end users and focuses on promoting the integration of the best available evidence into policy and practice-related decisions.

Results
KB activities were classified into the following categories: initial and ongoing needs assessments; scanning the horizon; knowledge management; KTE; network development, maintenance, and facilitation; facilitation of individual capacity development in evidence informed decision making; and g) facilitation of and support for organizational change.

Conclusion
As the KB role developed during this study, central themes that emerged as particularly important included relationship development, ongoing support, customized approaches, and opportunities for individual and organizational capacity development. The novelty of the KB role in public health provides a unique opportunity to assess the need for and reaction to the role and its associated activities. Future research should include studies to evaluate the effectiveness of KBs in different settings and among different health care professionals, and to explore the optimal preparation and training of KBs, as well as the identification of the personality characteristics most closely associated with KB effectiveness. Studies should also seek to better understand which combination of KB activities are associated with optimal evidence-informed decision making outcomes, and whether the combination changes in different settings and among different health care decision makers.

Diagnostic error prevention and EBM competencies

Last week several colleagues are I were in attendance at the Diagnostic Errors in Medicine Conference in Hollywood. Thoughts and "ah-ahs" from that session will be shared here over time, but this initial post will focus on a breakout discussion we had there on how medical education can help prepare physicians to mitigate the opportunity for error by addressing the cognitive side of error.

One piece of that pie covered use of the evidence and what that means. We know that access to the evidence can effect care decisions, but what can it do to help address confirmation bias, inappropriate heuristics and misplaced reliance on the opinion of experts?

To help ingrain a respect for the need to know when you don't know, see the evidence as a tool to prevent diagnostic error, and recognize the need to evidence gathering to sometimes be a "team sport" the following competencies were collected for future discussion on this topic:

Medical students should learn and be capable of:

• recognising uncertainty and knowledge gaps
• anticipating the impact of bias impact on the information gathering and assessment process
• coordinating a team and locating the expertise needed to collectively address the question at hand
• identifying and locating the best evidence using the Internet or other information source
• understanding how to work with a librarian or other qualified open-source research expert
• considering items both in agreement with the clinical predetermination and others that allow for introspection, further research and dialogue as necessary.
• Applying specificity, sensitivity, PPV, NPV, RR to the case at hand in a specific and deliberate manner
• Sharing learnings using both formal (ie via policy or guideline development) and informal (ie social networks and face to face discussions) tactics to counteract similar bias within immediate network

Any thoughts on these ideas would be helpful as we work with the coordinators of the 2010 DEM session in Toronto to flesh these concept out more completely.

Legal issues around appropriate literature reviews

I wanted to share this post from colleague from a hospital librarians' listserv. She provides some interesting points to explore how important appropriate and complete literature and evidence identification to the safety of the care process and instances where there was some legal leverage applied to underscore that importance.

Does this help support a defined role for librarians in a process that has been "googlized" to the point of removing it from "expert" hands and impacting its reliability?

Please, lets discuss!

I reproduce it here with her permission.

posted August 28, 2009

Colleagues,

With regard to [my colleague's] comment about the existence of legal cases and how much awards are made when physicians fail to provide appropriate care because of lack of information, the following case comes to mind. There was a case in 1983 in the state of Washington where three physicians were found negligent in a wrongful birth case when they failed to search the medical literature or to consult other sources of information concerning the relationship between birth defects and the drug dilantin. Physicians have a legal responsibility to research the literature. The case is described in – Harbeson v. Parke-Davis – “Medicine and Law”, 4(2):189-194. l985 (PMID 3999949). The Harbesons asked three different physicians about any adverse effects of taking Dilantin while Mrs. Harbeson was pregnant and taking Dilantin for epilepsy. The Harbesons then had two children who suffered from “fetal hydantoin syndrome” as a result of Mrs. Harbeson taking Dilantin during her pregnancies.

In an article by M. Skolnick in “Medicine and Law” 4(3):283-98, l985, (PMID 4010498), Skolnick writes “An important element in the courts decision was the physician’s failure to conduct a literature search or seek alternative opinions.” He also writes “Failure to search the appropriate scientific literature is an obvious breach of the broader duty to perform at the level of knowledge and practice in the physician’s clinical specialty. The duties defined by the doctrine of informed consent may be discharged only if the physician remains abreast of current information, and can communicate it to his patients.” He further writes that “Far greater emphasis in both teaching and testing is placed on memorizing facts than in processing information to solve problems.” Lastly, Skolnick writes about the Harbesons’ physicians that “They relied on what they remembered and the kind of information shared in their practice setting, and produced a human tragedy. Had these physicians been educated through a process which induced them to access and process current information, their approach to the Harbeson’s question might have been profoundly different.”

Although it is much easier in 2009 to do a literature search than it was in l983, physicians need to conduct literature searches to help answer clinical questions. It is also important for physicians to receive initial training in literature searching in medical school and then continuing education in literature searching the medical literature throughout their career. As a hospital librarian in a teaching hospital, I have often helped physicians conduct literature searches that impact patient care. I’ve also helped physicians search the literature for information that impacts a court decision on a medical case.

The case of Harbeson v. Parke Davis indicates that there is some legal precedence for physicians to perform literature searches to support their clinical decisions. Personal experience also has shown me that physicians today still need help and instruction in performing literature searches. The problem then is to document the impact on patient care and then communicate this to the hospital administrator in charge of the library. A number of studies have been published that demonstrate the value of the hospital library in supporting physicians in their clinical decision-making. The Vital Pathways initiative of MLA will also help to foster the value of the hospital librarian. Since l997, physicians and others have had free, online access to Medline through PubMed. Currently, many hospitals have access to full-text articles online. Despite this access to the medical literature, physicians still need and benefit from the expertise of medical librarians to help them search this vast literature.

To me therefore, the legal precedence for physicians to search the literature is already established and physician’s need for help in searching the medical literature is still present. I hope that as an organization we can continue to work on ways to alert hospital administrators of the need not only for a medical library but also of the need for medical librarians to assist physicians in their clinical decision-making. Free access to Medline through PubMed and access to many journals online is not an adequate substitute for the expertise and training that medical librarians can bring to all of the hospital staff that they serve.

Carol

Carol Jeuell, MSLS, AHIP
Children's Memorial Hospital, Chicago, IL
cjeuell@childrensmemorial.org

reducing the holes in the swiss cheese of access to evidence and knowledge.

Interesting commentary in BMJ this past week:

Degos L, Amalberti R, Bacou J, Carlet J, Bruneau C. Breaking the mould inpatient safety. BMJ. 2009 Jun 29;338:b2585. http://dx.doi.org/10.1136/bmj.b2585

In this piece that calls for a broader approach to understanding and improving patient safety, the authors state:

"Safety may be defined as increasing the patient’s chance of receiving appropriate care that is in line with evidence based medicine. Any obstacle to such access is considered as a loss of chance and a potential failure of the health care system."

How many of our organization consider the potential failures associated with this statement?

Doesn't this quote beg for those of us that deal with the more explicit side of knowledge delivery (ie access to the published literature, guidelines etc) get more involved in helping organizations understand the obstacles to deliving care that is in line with evidence based medicine due to lack of access to the evidence that informs that care?

I recently had discussions with members of a team I work with that were frustrated with the lack of access to a primary scientific journal via their large academic insitutions library. We had to work around the system, ask yet another team member to send us what we needed. One article I need I still don't have. Good thing it wasn't for emergent clinical care, eh? Does that sort of inefficiency and evidence access failure have the potential to contribute to care problems? Interesting question.

We need to, as Susan Carr. editor of PSQH recently stated "shine our light" and weigh in on discussions involving access to knowledge and the "evidence" to understand how they impact safety. We should participate in blogs, online communities, and other tools to share what we know. If we have a seat at the "patient safety table" at our organizations, we should try and ask the right questions to help our peers and clinical colleagues understand this type of failure. We need to generate interest to help generate primary research opportunities and proactive failure analyses to understand how to best focus our efforts in this area.

If there are activities looking at the problems arrising from failure to access the appropriate bibliographic evidence in real time, please share your news about them here. I have to believe that someone out there is looking at this issue and is hopefully involving a myriad of professionals and individuals with personal (read patients and families) and work experience (read clinicians, administrators and "blunt end" professionals) in sorting out the problems. We all have a stake in making this piece of the safety pie less full of holes ;-).

Dialogue: a new tool for librarians to facilitate the sharing of knowledge

Today’s environment for sharing information and knowledge is complicated. The variety of tools, styles, formats available affect our ability to communicate clearly and efficiently. Time is an issue as well. Nonetheless, with the plethora of technologies that can be customized for our specific needs, one would think communicating ideas would be easier – but alas, its not.

One method often relied upon to share the information and knowledge (Depending on how you define it) is the written text – in whatever format it is delivered. The management of explicit items is certainly the "mental model" most conjured up when librarianship is mentioned. But is that the only way we can contribute to knowledge sharing? Think again. I recently had a colleague profess that librarians needed to embrace dialogue as a tool to share knowledge rather than just providing articles and other explicit knowledge artifacts. He saw this as a way to remain viable in today's information rich environment.

This is an intriguing concept. It certainly builds on the KM notions outlined by Nancy Dixon in her book Common Knowledge (ISBN: 0875849040) where she present a structured process of team discussion and feedback as a mechanism for knowledge transfer in the corporate environment. So let’s think on how this concept might play out in health care.

Certainly the idea of transferring knowledge in small groups rings true in safety circles. With the recent interest in debriefs, daily huddles, collaborative rounding, walkarounds, and regular team / unit meetings, meeting to share "what the knower knows" enables a richness of exchange that helps create a mindfulness around both the work at hand and bigger picture issues that affect the safety of care. In addition, mindfulness is enhanced by these communication mechanisms that facilitate knowledge and information to be shared in real time in a context that allows for visible impact of that exchange.

In response to my colleague, then, can and should information professionals in health care facilitate and contribute to this activity? If you like this idea, then, what is the best marriage of our skill set with the function of dialogue? I recognize that it can’t happen always – especially at the sharp end of clinical care -- but the closer librarians are to the clinical team -- the more likely it is to happen. Certainly participating in these front line information exchange activities from time to time will inform any dialogue that takes place regarding information services. Having regular dialogue with front line staff may help improve the reliability of care process through more effective evidence delivery. A bridge to the "sharp end" dialogue process may be to participate in committee work. We should do this not only from a information service perspective but as an information and knowledge strategist. In addition – don’t forget to set up opportunities to talk to patients and families. Even if you don’t serve them directly, their needs and ideas should be folded into any health care knowledge sharing initiative: nothing about them, without them.

To close -- dialogue is also a key systems thinking tool. If info pros are to seen as systems thinkers, shouldn't’t they be comfortable demonstrating AND explaining the art of dialogue as a tool in THEIR information and knowledge sharing arsenal? I think so.

Dr House's knowledge sharing strategy.

Any thoughts here? The poll that came out a few weeks back on TV doctors and their impact on the perception of physicians was interesting. For those of us who watch "House," we aren't surprised that Dr. Gregory House was seen by physicians as detrimental to their public persona.

However one feels about that, my query is more oriented to how House shares "what he knows" and thusly trains his staff to think the way he does -- both in good and bad ways. Now, I am not advocating that we all become gruff, pill popping professionals -- but what lessons can we learn from this character about effective knowledge transfer?