I think the notion of high reliability is a powerful one. Eloquently outlined by such thinkers as Karl Weick and Kathleen Sutcliffe in Managing the Unexpected, high reliability organizations operate in dangerous, volatile, complex environments yet experience very few accidents – given what one would expect. Aircraft carriers, air traffic control centers and hospital emergency rooms are examples Weick and Sutcliffe use to illustrate the concept.
What role does knowledge transfer play in high reliability? I heard a story recently from a clinical colleague who knew of an experience at a hospital where an obstetrician, faced with an emergent situation he’d never run across before, “Googled” to find some direction very quickly. It worked for him, but is that really the most reliable method? According to Giustini's recent editorial in the 24-31 December issue of BMJ - it just might be. However, when you think of the number of hits Google – can pull up, isn’t the patient lucky the physician found was needed quickly. Should knowledge transfer, thou, to be highly reliable, rely on “luck?”
So, how does access to literature and knowledge affect reliability? Does keeping up with the barrage of new medical “evidence” affect reliability? How do we make sure the conduits for that evidence base remain reliable and informed? How can that be measured? How do medical teams - both clinical and otherwise - manage the relationships between people who need to work together to ensure reliabile, unbiased, fully informed knowledge sharing?
Just more to think about as we begin another year of addressing these and other important issues related to knowledge transfer and patient safety.
Maximize benefits of IV workflow management systems by addressing workarounds and errors. - ISMP Medication Safety Alert! Acute Care Edition. September 7, 2017;22:1-4.
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