The following commentary was originally published earlier this year as a part of the "Whoo Says" article series on the NNLM/MidContinental Region web site
While the comments are closed on the original, they are open here. Please share your thoughts!
I am a hospital librarian who is very interested in keeping my library active and relevant to the needs of my hospital. Lately, I have been considering the issue of patient safety; my thoughts were triggered by hospital activities during this year’s Patient Safety Awareness Week, and Barb Jones’ call for feedback from librarians involved in patient safety initiatives. I thought about the work I do with various units and professions within my hospital, and how the overall goal is the safety and good health of our patients. I wonder if there is something I am overlooking, or missing in the patient safety discussion. I do lots of searches for quality improvement, protocols, and individual treatment. Is there more? Wondering
Thank you so much for writing, Wondering. I am glad to see that you are involved with a variety of units within your hospital and are considering the issue of patient safety as well as addressing specific inquiries that involve patient safety problems.
Since you have been observing the priorities of your hospital, you are probably aware of the emphasis on high reliability. Weick and Sutcliffe have written about how high reliability organizations function and stay safe. Their description of a HRO (high-reliability organization) is “an environment of ‘collective mindfulness’ in which all workers look for, and report, small problems or unsafe conditions before they pose a substantial risk to the organization and when they are easy to fix.”1 This description generally does not describe the conditions found in healthcare. “…in health care, uncoordinated and poorly designed and maintained mechanical systems (like medical device alarms) are tolerated, even though they are not safe. Intimidating behaviors suppress reporting and lead to additional unsafe behaviors as caregivers create workarounds to avoid repetitive exposure to intimidators. Errors are not seen as valuable information, essential to a hospital’s ability to improve patient safety.”2 Thus, I think you will agree that the current emphasis on high reliability is justified, and time spent on high reliability is time well spent.
I think all of us who work in hospitals can point out the validity of these statements. We see issues on nursing units, in the emergency department, in the hierarchy that occurs among the healthcare personnel, and in many other places. The question for us, Wondering, is whether we see any of these issues in the library or in library services provided. Every health sciences librarian I know truly believes that services provided by librarians lead to a higher quality of care. These librarians are conscientious, well-educated, and highly skilled professionals. However, they are all people and are subject to the same errors and lapses in judgment as members of any other profession.3
So, the answer to your question is yes, there is more. As conscientious professionals, librarians need to be sure to examine their own practices for small mistakes, workarounds, and potential for error. We need to be unafraid to find and admit our errors, and be willing to use those errors to learn how to perform in a highly reliable way. We need to examine our systems within the context of the larger hospital system to identify where the evidence/information we provide intersects with others, and ensure that intersection is fully functional. This is a continual effort; it cannot be addressed once and then put aside with the conviction that all is well.
All of this is pretty theoretical and abstract. To bring it down to the practical level, here are some examples of areas that librarians should address in the daily practice of their profession.
Peer review of searches: Do you ever have another librarian or information seeker review your search strategy and evaluate its effectiveness? Obviously, this is not practical for every search, and is difficult if you are a solo librarian. Maybe you can find someone in another hospital and ask your colleague to review your strategy for a difficult search or at a predetermined interval. You can offer to reciprocate which will ensure that both of you will benefit.
Complete the communication loop: When you perform a search for a user and deliver the results, do you attempt to close the communication loop and find out if your search was useful, and if so, why? All of the librarians I know have drawers full of compliments from users stating how wonderful the librarian’s service was. Few of those compliments state why the service was so useful. It is impossible to learn and improve without the knowledge of what is expected and what works.
Clarity in reference interview: Once you have received a search request, and you find when searching that you are not really clear about the specific need of the user, are you able to contact that person for clarification? Often complex topics require some dialogue to identify the precise need.
Completeness of database selection: When you are conducting a search, are you open to searching in multiple databases? What about the gray literature? What about in other disciplines? Medicine and healthcare are highly complex fields, and often the required “answer” is found in sources other than traditional medical sources. For instance, information on the reliability of medical equipment may be found in the engineering literature.
These are only a few of the ways librarians need to examine their processes and work to uncover error. For a more complete discussion of this topic, you may want to read the chapter “Analyzing Breakdowns in the EIK Pathway”4 in the recent text Patient Safety: Perspectives on Evidence, Information and Knowledge Transfer edited by Lorri Zipperer in 2014.
Thank you again for your question, Wondering. This is an issue that I care about very deeply, and I think that our profession should consider it seriously. I hope this has been helpful. Please write again if you have further questions.
Jones B. Patient Safety: Librarians have nothing to do with that, right? April 2015. Plaines to Peaks Post. http://nnlm.gov/mcr/p2pp/2015/04/patient-safety-librarians-have-nothing-to-do-with-that-right/
Weick K, Sutcliffe K. 2007. Managing the Unexpected: Resilient Performance in an Age of Uncertainty. San Francisco, CA: Jossey Bass.
Chassin MR, Loeb JM. High-reliability health care: getting there from here.
Milbank Q. 2013;91:459-490.
http://www.jointcommission.org/assets/1/6/Chassin_and_Loeb_0913_final.pdf p. 462-3.
Tavris, Carol. Mistakes Were Made (But Not by Me): Why We Justify Foolish Beliefs, Bad Decisions, and Hurtful Acts. Harcourt, Inc. 2008.
Jones BB, Graber M and Alligood, E. “Analyzing Breakdowns in the EIK Pathway” in Patient Safety: Perspectives on Evidence, Information and Knowledge Transfer. L. Zipperer, ed. Gower. 2014.
This story was originally published in the Vol 13 No 4 - April 2015 issue of the Plains to Peaks Post. It is used here with permission by the author. The Plains to Peaks Post is published quarterly by the National Network of Libraries of Medicine NNLM/MidContinental Region.
Medication errors with pediatric liquid acetaminophen after standardization of concentration and packaging improvements. - Brass EP, Reynolds KM, Burnham RI, Green JL. Acad Pediatr. 2018;18:563-568.
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