Wednesday, December 21, 2005

Knowledge transfer failure analysis

What an interesting process failure analysis is? I have been working with my colleague Linda Williams at the National Center for Patient Safety on analyzing opportunities for failure in the knowledge transfer process. BTW, it’s an honor to work with Linda as her organization has embraced the notion of Failure Mode and Effects Analysis (FMEA) and applied it quite successfully within the health care domain at the clinical end -- I am sure much will be learned by looking at Knowledge Transfer through this lens.

In our preliminary work, we are currently focusing on the process clinicians use to fill a gap in their knowledge base and have noted such elements as consulting colleagues (see my posting below from October 21], accessing decision support systems and use of Google as parts of the process where failure can occur.

Linda and I will be presenting on this topic at the upcoming Medical Library Association symposium on patient safety to be held in May of 2006 and welcome any comments from the field as we shape the model we’ll be sharing with our colleagues there. I'll post more information on that session as it becomes available.


Joy Kennedy said...

Lorri--I enjoy your blog very much. I totally agree that "knowledge transfer" and lack of effection communication is at the heart of many patient safety problems. Every handoff of information is a potential problem. I'll look forward to your presentation at MLA.

I wondered if you'd seen this article about a technique for handoff communication developed by the nurses here at Northwest Community Hospital. Joint Commission Perpectives on Patient Safety, Dec. 2005, 5(12):9-10 "Case Study: Sharing Information at Transfers". They took the SBAR communication technique and adapted it to develop SHARED. As a "scripted" communication technique it has been used in several different settings in the organization with success. I'd like to see it trialed more widely. We're seeing simple communication tools like this work at the organization level. Have you found structured communication techniques as valuable in the Knowledge transfer process?

Lorri Zipperer said...

Joy - thanks for your note.

I think the notion of structured communications is one we can use to help the knowledge transfer and exhange process be more reliable. To look at it from our world, my colleague Sara Tompson [see more about Sara at: and I did some early thinking about how to make the reference interview process more reliable through the better understanding of communication failures that can impact the effectiveness of the exchange - using the FMEA approach. I think that the SBAR (Situation, Background, Assessment, Recommendation) technique -- although typically only used in emergent situations - would be another safety technique to think about appling to that piece of the knowledge transfer process as well. In the broader sense, I agree that its usefulness as a knowledge transfer "tool" would be interesting to measure and open this up to the group to discuss what metrics would be used and how teams might learn from this. The other thing I like about structuring the communication process is that everyone on the team has been trained on the reason for the structure - so there is an increased understanding of how and why it happens. Hense it might help clarify the reasons why librarians "ask so many questions" so clinicians and others working with our profession understand that.

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