I had lunch yesterday with a colleague who was interested in navigating the alumni page at her university's library. She was new to using a library system and was anxious to learn so she could be self-sufficient in tracking down literature related to her work in patient-centeredness. Upon sitting down together with her computer in a noisy cafe, I began to talk her through all the ins and outs of using the system. As our conversation progressed, each quest for an article had a range of avenues to head down, tools to use, criteria to think about and ... opportunities for failure in getting what she needed. This was over lunch, yet the environment was loud, full of distractions (including a tremendous piece of key lime pie!) and we were pressed for time as she had an appointment. Does any of this ring a bell? As we picked up the crumbs from the gram cracker crust, I posed the question "Now do you see what I mean when I talk about the potential for failure in gathering information and knowledge in the clinical environment?" Needless to say, this example helped her to see what I have been saying all along.
We need to use information gathering failure in our training for evidence identification and acquisition -- otherwise the falsity that its easy will remain. this lack of awareness will continue to hamper efforts to understand the impact of these failures to learn about them, research them, mitigate them, fill the holes in the Swiss cheese, and improve the reliability of the process.
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.
1 day ago