tag:blogger.com,1999:blog-168018912024-03-13T23:49:50.945-05:00Patient Safety: Focus on Information and Knowledge TransferInformation and knowledge play an important role in the safe care of patients. Librarians and other information professionals are particularly well suited to partner with their institutions and patients to contribute to safe care.Lorri Zippererhttp://www.blogger.com/profile/14581758218514499201noreply@blogger.comBlogger82125tag:blogger.com,1999:blog-16801891.post-22301052031116931612016-10-08T14:07:00.001-05:002016-10-08T14:08:04.036-05:00Evidence As a Seed for Collaboration: Separating the Wheat from the Chaffby Lorri Zipperer, MA<br />
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I have been monitoring the patient safety literature for more than two decades now, first as the information project manager at the National Patient Safety Foundation, and for more than a decade as the <a href="https://psnet.ahrq.gov/perspectives/perspective/185/">development editor</a> for AHRQ Patient Safety Network. As those in patient safety might attest and applaud, the evidence base has gotten more robust over the years, spurred by increased funding for research and public interest in the topic.<br />
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This expanding wealth of literature creates a challenge for organizations and individual practitioners. The unintended consequence of this explosion is that there is more wheat to sift through. The growing set of materials makes tracking useful evidence more cumbersome while in turn increasing the messiness of <a href="http://www.bmj.com/content/353/bmj.i2139/rr-54">translating existing research</a> results into actions that make sense and conclusions that are credible. We know that just because it’s science doesn’t necessarily mean it’s <a href="http://www.newyorker.com/news/news-desk/the-mistrust-of-science">good science</a>.<br />
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We know that just because it’s published, identified, and shared within an organization, community, or team that evidence derived from science is not necessarily applied or able to be translated for use on the front line. (Zipperer 2016)<br />
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While somewhat editorial in nature, Dr. Shojania’s presentation brought nuance to seeing how the evidence exploring these areas can play a part in our understanding of them.<br />
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There are tools out there to help with creating awareness of materials, such as <a href="https://psnet.ahrq.gov/">AHRQ Patient Safety Network</a> and the NPSF <a href="https://npsf.site-ym.com/store/ViewProduct.aspx?id=5766945&hhSearchTerms=%2522%2522current+awareness%2522%2522">Current Awareness</a> subscription service. However, not only should organizations have individuals trained to monitor these resources, also the search for particular evidence needs to address local gaps in understanding and effectively disseminate the literature to decision makers. Someone in the organization should navigate this output in order to help their clinicians and executives apply it if it is going to enrich the design of interventions and implementation of programs and contribute to enhancing the reliability of their patient safety work.<br />
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We could all use someone like Dr. Kaveh Shojania to help translate what is written to help create actionable knowledge in health care.<br />
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Dr. Shojania—with whom I work in my role at AHRQ Patient Safety Network, as he is on the editorial team—has for three consecutive NPSF Congresses provided a thoughtful and provocative analysis of key articles and the trends they indicate for conference attendees. This year’s session, entitled “Hot Topics in Patient Safety: Selected Papers Advancing the Field in the Past Year,” did not disappoint. Dr. Shojania covered literature on 6 important topics:<br />
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<ul>
<li>Diagnostic errors</li>
<li>Rudeness’ impact on team performance</li>
<li>Trends in adverse events over time</li>
<li>Incident reporting</li>
<li>Fall prevention</li>
<li>Reducing high-risk prescribing in primary care, with a focus on the current opioid abuse/misuse epidemic in the US</li>
</ul>
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These themes should be no surprise to those in the patient safety community. While somewhat editorial in nature, Dr. Shojania’s presentation brought nuance to seeing how the evidence exploring these areas can play a part in our understanding of them. While some analysis of research design was applied, and the value of results was discussed, Dr. Shojania’s insights should enhance our ability to be more critical of what is published and by whom.<br />
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Imagine the opportunity that the sort of dialogue generated by this type of expert assessment could provide in an organization. The exercise could be brought to our care environments as more than a social or intellectually opportunity. If positioned as a patient safety improvement tactic, it could serve a more impactful role.<br />
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Dr. Shojania was challenged by an attendee, and his response provided thoughtful seeds for all of us who seek to partner to “plant” evidence-based solutions in the patient safety community garden. Imagine the learning and collaboration that could be generated in organizations if teams had these types of conversations on a regular basis, with accountability assigned to do something with the issues raised. Could the dialogues support increasing the transparency around sharing of ideas, forming of shared mental models, leveling of hierarchy, and engaging of individuals to form multidisciplinary teams to do research to reflect the frontline needs of improvers? Could be.<br />
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What tools, techniques, and team members do you use to identify, analyze, and infuse the most relevant literature to innovate and anchor patient safety efforts throughout your organization? Comment on this post below. Note: to post a comment you must be logged in. Register or log in.<br />
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Reference:<br />
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Zipperer L. Jones BB, Esparza JM, Wahr J. Evidence, information, and knowledge as elements of safe surgical care. In: Stahel P, ed. Surgical Patient Safety. New York: McGraw-Hill Education; in press.<br />
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Reused with permission.<br />
This content was originally written for and <a href="http://www.npsf.org/blogpost/1158873/251277/Evidence-As-a-Seed-for-Collaboration-Separating-the-Wheat-from-the-Chaff">published</a> by the National Patient Safety Foundation’s <a href="http://www.npsf.org/blogpost/1158873/Patient-Safety-Blog">P.S. Blog</a>.<br />
<br />Lorri Zippererhttp://www.blogger.com/profile/14581758218514499201noreply@blogger.com0tag:blogger.com,1999:blog-16801891.post-25037757625502637692016-05-06T12:12:00.002-05:002016-05-06T12:12:23.067-05:00Teamwork Grows Up.True teams work together and share what they know and what they learn to achieve safety.<br />
by Lorri Zipperer, MA<br />
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"Teamwork -- Teamwork -- that’s what counts!”<br />
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I was a cheerleader in junior high school. While it was fun at the time, that was enough of that.<br />
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Uninspired to take the same path in high school, I participated in both live theater and a variety of musical group activities (pep band, marching band, jazz band, symphonic band) that provided me with the chance to work with others toward shared goals. I thought I understood what teamwork was – until I grew up.<br />
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My first introduction to teamwork as a component of safety was as a staff member at the National Patient Safety Foundation. It was then that I was presented with the idea that teamwork was much more complicated than staying in line during marching practice. Granted, to be in a marching squad you had to commit to knowing your role, pay attention to what others were doing, achieve some level of reliable proficiency, give up your personal preferences as warranted for the greater good (is standing on a wind-swept football field in January in Chicago what any teenager wants to do?) and be aware that if you failed, the group could do poorly.<br />
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But, despite some similarities, teams and their role in safety go beyond that. In the safety sense of the word, teams rely on communication, mindfulness, and culture to enable their processes to be as highly reliable as possible during times of crisis. The focus on the flattening of hierarchy to encourage and support performance that is sensitive to, while capitalizing on, the humanness of people working together contributes to the reliability of collective action that expands beyond band practice in the 1970s. Trust and understanding create an environment that facilitates individual, group, and organizational learning from failures through a team’s commitment to feedback and open discussion.<br />
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It is no news to readers of this blog that team training models have been adopted from other high-risk industries to help health care evolve in the right direction. Commercial aviation and the military are the obvious examples. Given health care’s experiences with crew resource management and the Agency for Healthcare Research and Quality’s <a href="http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/index.html" target="">TeamSTEPPS</a> initiative, the idea of building teamwork skills and the expectation that clinicians develop professional competencies in this area serves the logical foundation to infusing team practice and improvement into the frontline of care delivery. People are taught to do this well because poor teamwork can be catastrophic.<br />
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Explicit attention to the team roles of health care executives came later. And patient safety leaders—as they have done in other instances—looked outside health care for successful models. The business world certainly has had C-suite members that walk-the-talk of teamness. With credibility and integrity, those who model team behaviors and enable a culture at their company that support teamness provide examples to emulate its value. They demonstrate for health care executives the importance of purposely training and engaging a wide range of staff as team members.<br />
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Business schools and executive books champion teamwork skills as a foundational competency. The language and ideas of how to recognize and practice those skills from the business literature always resonated with me, a non-clinician. From that field, one author of particular interest is Harvard Professor Amy Edmondson. Edmondson’s writings caught my eye early on in my safety career. Her discussions about how organizational, unit, and peer culture and leadership affect staff willingness to report errors was inspiring to see—at a time when the value of that approach wasn’t as universally accepted as it is now (Edmondson 1996).<br />
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I distinctly remember working hard to get copies of her early articles (read pre-World Wide Web as we know it today). I still have the hard copies of those reports. Once a librarian, always a librarian.<br />
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Professor Edmondson’s publishing output since then covers a range of topics that touch on patient safety. Her articles on organizational and individual learning from failure are core resources in my readings list (Edmondson 2008, 2011). They provide foundation to <a href="http://patientsafetylib.blogspot.com/2013/02/failing-in-order-to-succeed-part-1.html" target="">my belief</a> that knowledge management is a key driver of that learning. Edmondson’s 2012 Teaming is an excellent resource for considering how a culture of sharing what is known amongst people working closely together on a collective goal—no matter what box on the organizational chart represents them—is imperative to both team success and continuous learning (Edmondson 2012). She emphasizes that process, commitment, and leadership—both informal and at the executive level—must be present to translate learning into sustainable change in iterative constant fashion.<br />
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The sustained commitment to a culture of teams and teaming at variety of levels across a health care system can make that happen. True teams work together and share what they know and what they learn to achieve safety. Training and facilitating all health care workers—outside of rank and role—to participate in the cross-functional activity of teaming is vital to safety achievement. It offers health care yet another opportunity for synergy that presents clinicians, the organizations they work for and the patients they care for—with a chance to really make teamwork count.<br />
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<i>Reused with permission. </i></div>
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<i>This
content was originally written for and</i></div>
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<i> <a href="http://www.npsf.org/blogpost/1158873/245354/Teamwork-Grows-Up">published</a> by the
National Patient Safety Foundation’s <a href="http://www.npsf.org/blogpost/1158873/Patient-Safety-Blog" style="color: #1f497d;">P.S. Blog.</a></i><span style="color: #1f497d;"><o:p></o:p></span></div>
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<i>At the 2016 NPSF Patient Safety <a href="http://www.npsf.org/?page=programofevents">Congress</a>, the Lucian Leape Institute </i><i>will present a Keynote Session, </i>Teaming at the Heart of Safety<i>. </i><i>The presentation and panel discussion between Robert Wachter MD, Gary Kaplan MD and </i><i>Susan Edgman-Levitan will be will be led by Prof. Amy Edmondson.</i></div>
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References<br />
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Edmondson AC. 1996. Learning from mistakes is easier said than done: group and organizational influences on the detection and correction of human error. J Appl Behav Sci. 32:5-28.<br />
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Edmondson AC. 2008. The competitive imperative of learning. Harv Bus Rev. 86:60-67, 160.<br />
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Edmondson AC. 2011. Strategies of learning from failure. Harv Bus Rev. 89(4):48-55, 137.<br />
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Edmondson AC, Schein EH. 2012. Teaming: How Organizations Learn, Innovate, and Compete in the Knowledge Economy. San Franscisco, CA: Jossey-Bass.Lorri Zippererhttp://www.blogger.com/profile/14581758218514499201noreply@blogger.com0tag:blogger.com,1999:blog-16801891.post-70481834646336421222015-08-26T09:38:00.001-05:002015-08-26T09:38:06.224-05:00Intros to KM concepts from the NHS. Bravo and let's keep going!<div class="MsoPlainText">
Anne Gray, Knowledge Officer at the NHS shared this set of videos recently that I'd like to share here: In her words: the goal was to "encourage people to consider the importance of KM improve
quality of care, outcomes and patient experience." They are worth a look:</div>
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<a href="http://www.nhsiq.nhs.uk/capacity-capability/knowledge-and-intelligence/better-knowledge-better-care/bkbc-animations.aspx">http://www.nhsiq.nhs.uk/capacity-capability/knowledge-and-intelligence/better-knowledge-better-care/bkbc-animations.aspx</a><o:p></o:p></div>
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Of course I see things that could
be tweaked...but I embrace these as nice tools to introduce the concepts
associated with KM to a wide range of individuals. There are many professions/services
that can contribute to effective knowledge sharing in healthcare--none of which
are explicitly called out--so I don't think librarians, clinicians, informaticians or patients should feel left out
here. We all have knowledge to share, so let's not quibble and get defensive if our roles or professions aren't called out.<o:p></o:p></div>
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I have a challenge for the NHS thou. I am interested in how they are going to use these to
help healthcare understand how to:<o:p></o:p></div>
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1) measure the impact of true KM in the healthcare
environment.<o:p></o:p></div>
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2) support and implement a knowledge sharing culture and
how it concretely contributes to safe care<o:p></o:p></div>
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3) truly articulate the costs involved in changing
culture to support true knowledge sharing <o:p></o:p></div>
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4) implement strategies to create accountability for both
organizations and individuals that work in healthcare to share what they know<o:p></o:p></div>
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5) identify KM barriers and work through them in the same
fashion that healthcare approaches patient safety improvement barriers. If we
can present lack of knowledge sharing as a contributor to unsafe care--can
support for improvements be articulated in a way that generates support and
interest in sustainable change?<o:p></o:p></div>
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To those who might feel they already do this so why do we need to focus energy on KM -- respectfully, it doesn't move innovation forward for any
of us to say--we already do this, we do it well -- even thou we might. If we
can't articulate it, measure it and improve it the case hasn't been effectively
made. <o:p></o:p></div>
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<o:p>What stories are out there that translate what is being done concretely to manage and share knowledge (not data, not info and not evidence) as a component of safe, highly reliable care? Do tell, please, DO TELL! Don't keep that knowledge under a bushel! </o:p></div>
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Lorri Zippererhttp://www.blogger.com/profile/14581758218514499201noreply@blogger.com0tag:blogger.com,1999:blog-16801891.post-76548068828209226722015-07-24T11:23:00.002-05:002015-07-24T11:23:19.670-05:00Expert Insights for Info Pros to "Ratchet it up" for Patient SafetyThe following commentary was originally published earlier this year as a part of the "Whoo Says" article series on the NNLM/MidContinental Region web site<br />
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While the comments are closed on the original, they are open here. Please share your thoughts!<br />
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Lorri<br />
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Dear Whooo,<br />
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<i>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? </i>Wondering<br />
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Dear Wondering,<br />
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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.<br />
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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.<br />
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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<br />
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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.<br />
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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.<br />
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<b>Peer review of searches: </b>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.<br />
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<b>Complete the communication loop: </b>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.<br />
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<b>Clarity in reference interview: </b>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.<br />
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<b>Completeness of database selection: </b>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.<br />
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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 <a href="http://www.gowerpublishing.com/isbn/9781409438571">Patient Safety: Perspectives on Evidence, Information and Knowledge Transfer</a> edited by Lorri Zipperer in 2014.<br />
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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.<br />
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Sincerely,<br />
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Whooo<br />
_____________________<br />
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Jones B. Patient Safety: Librarians have nothing to do with that, right? April 2015. Plaines to Peaks Post. <a href="http://nnlm.gov/mcr/p2pp/2015/04/patient-safety-librarians-have-nothing-to-do-with-that-right/">http://nnlm.gov/mcr/p2pp/2015/04/patient-safety-librarians-have-nothing-to-do-with-that-right/</a><br />
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Weick K, Sutcliffe K. 2007. Managing the Unexpected: Resilient Performance in an Age of Uncertainty. San Francisco, CA: Jossey Bass.<br />
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Chassin MR, Loeb JM. High-reliability health care: getting there from here.<br />
Milbank Q. 2013;91:459-490.<br />
<a href="http://www.jointcommission.org/assets/1/6/Chassin_and_Loeb_0913_final.pdf">http://www.jointcommission.org/assets/1/6/Chassin_and_Loeb_0913_final.pdf</a> p. 462-3.<br />
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Tavris, Carol. Mistakes Were Made (But Not by Me): Why We Justify Foolish Beliefs, Bad Decisions, and Hurtful Acts. Harcourt, Inc. 2008.<br />
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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.<br />
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<i>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.</i><br />
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<br />Lorri Zippererhttp://www.blogger.com/profile/14581758218514499201noreply@blogger.com0tag:blogger.com,1999:blog-16801891.post-47415135264399153822015-05-21T14:58:00.004-05:002015-05-21T14:58:57.299-05:00What are the top three skills needed to drive knowledge sharing in healthcare today?<br />
Always interesting to hear from colleagues on these types of questions. Is knowledge management in healthcare "old news" for hospitals? I heard that indirectly from a librarian at a recent conference. Maybe -- but I guess it depends on how you define KM. If we look at knowledge as what the "knower knows" (Prusak and Davenport, 1999) and place its management in the sphere of safety science, high reliability and systems thinking -- I am not so convinced it is old news. Either way, what would you say are the primary skills to help make knowledge (not evidence, not info, not data) more usable, accessible and reliable as a resource to support high quality safe patient care?Lorri Zippererhttp://www.blogger.com/profile/14581758218514499201noreply@blogger.com0tag:blogger.com,1999:blog-16801891.post-63074927301918749312015-03-13T10:01:00.001-05:002015-03-13T10:01:47.367-05:00Evidence seeking and checklists: does it make sense?<div>
Atul Gawande's <a href="http://www.blogger.com/www.nytimes.com/2009/12/24/books/24book.html">The Checklist Manefesto</a> placed the use of <a href="http://www.psnet.ahrq.gov/primer.aspx?primerID=14" target="_blank">checklists</a> as failure prevention mechanisms in the laps of health care professionals and management worldwide, Since the book came out in 2009, checklists have now been planted in the minds of many in healthcare as tools to improve patient safety that typically wouldn't have considered them. </div>
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Take librarians, for example. "My work is too messy", they say, "to use a checklist."</div>
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I would submit that most of the functions that librarians deliver in the course of their work in hospitals are NOT complex -- but the world they function in is. (I would love to have that discussion with my peers in this forum -- if they are game. But I digress ... ). This isn't and shouldn't be taken as a insult--and I apologize up front if its received in that light. The notion of when a tool like a checklist is needed and **should** be used is an important question--and determining the type of process its being applied to is important. It certainly isn't useful to pile more paperwork and process into the daily work of anyone - especially if it doesn't really improve anything--or to do so for a process that is complex vs complicated. or even simple, for that matter.</div>
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For sake of discussion, I do think there may be applicability of a checklist in some areas of the clinical librarian / <a href="http://annals.org/article.aspx?articleid=713553" target="_blank">Informationist</a> domain, such as in the reference review process. For instance, gaps that happen due to communication failures, cognitive biases and production pressures should cause us to think about ways to make the reference interview process more reliable via structured communication tools and/or a checklist. Especially in an emergent situation.</div>
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I do also wonder if the checklist idea would be useful in an organizational.system sense. Let's face it: librarians aren't the only ones doing lit reviews in hospitals and, as demonstrated by the gaps in the lit review process at Hopkins that contributed to the research volunteer death some years back that are <a href="http://tinyurl.com/n6e4st2" target="_blank">discussed here</a>, we know it can result in failure if not completed effectively. Perhaps a tool that would enable more reliable searching no matter **who** does the work, would have multidisciplinary impact.</div>
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One example of a review tool that may serve as the model for a checklist to help examine the robustness and reliability of the search activities at the sharp end is the <a href="http://www.cadth.ca/en/resources/finding-evidence-is/peer-review-search-strat" target="_blank">CADTH Peer Review Checklist for Search Strategies</a>.<br />
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I would say IRB activity, systematic review support and similar "project and task flow" examples of evidence and information seeking may be "complicated" (ie "building the space shuttle") rather than "complex" (ie performing surgery, raising children) If we consider <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1121189/" target="_blank">complexity theory</a> in all of this, the CADTH tool (complicated task review) would probably benefit from the application of "local context" to help us all understand how to apply it in real time to shore up the effectiveness of search that frontline info seekers--librarians or others--undertake to inform info seeking actions that take place in a more complex context--in the midst of clinical decision making. </div>
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Its important for librarians, and the clinicians that require the best evidence/information to do their work in complex situations, to explore how such a checklist could be enabled to affect patient safety in this intersection of professions. Can we draw from existing safety tools and processes in other high-risk domains such as aviation and nuclear power plants-- to help enlighten a discussion around how the information/evidence identification, acquisition and dissemination process in hospitals can be made more "highly reliable" through the use of checklists?</div>
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Some food for thought:<a href="http://www.springerlink.com/content/6x37w435wp32203t/fulltext.pdf">http://www.springerlink.com/content/6x37w435wp32203t/fulltext.pdf</a></div>
Lorri Zippererhttp://www.blogger.com/profile/14581758218514499201noreply@blogger.com0tag:blogger.com,1999:blog-16801891.post-4962178703729947302015-02-18T17:42:00.001-06:002015-02-18T17:42:36.047-06:00The value of sharing stories ... a request to hear some!What Flavor Lifesaver are you?<br />
Barb Jones<br />
(used with permission: <a href="http://nnlm.gov/mcr/p2pp/2015/02/what-flavor-lifesaver-are-you/">http://nnlm.gov/mcr/p2pp/2015/02/what-flavor-lifesaver-are-you/</a> )<br />
<br />
As a health sciences librarian, your work buoys the diagnosis and treatment of many people in many different ways. What activities do you do that contribute to the safety of the patients treated in your hospital? Which of the following lifesavers apply to you?<br />
<br />
Orange – You are on the team that develops protocols for the various units in your hospital.<br />
<br />
Lime – You have worked with your nursing staff and your hospital has achieved Magnet status.<br />
<br />
Pineapple – You often work with the Quality Improvement team.<br />
<br />
Cherry – You attend the M & M meetings.<br />
<br />
Grape – You are a clinical librarian.<br />
<br />
There are several other lifesaver flavors, and many other library-related activities that contribute to the safety of hospital patients. Can you think of others that you are involved with? What flavor are YOU?<br />
<br />
Share your contributions with your colleagues! Contact Barb Jones (jonesbarb @health.missouri.edu or @BarbJones17) to tell your story. Or comment right here on this blog!Lorri Zippererhttp://www.blogger.com/profile/14581758218514499201noreply@blogger.com1tag:blogger.com,1999:blog-16801891.post-39456293467803871132014-07-25T10:38:00.001-05:002017-03-31T16:43:46.118-05:00Searching for stuff: patient safety, DXerror and RCA info. Places to startI had a colleague ask recently about finding information on root cause analysis in general and in getting started on diving into the diagnostic error evidence base. I recognize that this response is pretty quick and dirty and what I typically don't include on this blog -- but she liked it, so I thought others might as well.<br />
....<br />
<br />
I wrote ... This safety stuff is very messy to look for—as the language used to study, discuss and (ultimately) search for it varies due to the range of industries that touch it, where the materials reside and that the science of safety is evolving pretty rapidly.<br />
<br />
As with any patient safety topic—I always suggest that folks start with AHRQ’s Patient Safety Network:<br />
<a href="http://psnet.ahrq.gov/">http://psnet.ahrq.gov/</a>. Not because I help develop it – but it is a good entry way into primary safety topics, the medical literature (to look for MESH subject headings) and non-pubmed indexed materials.<br />
<br />
Check out the primers on both DxError, RCA and failure analysis – all three touch on your question:<br />
<a href="http://psnet.ahrq.gov/primer.aspx?primerID=12">http://psnet.ahrq.gov/primer.aspx?primerID=12</a><br />
<a href="http://psnet.ahrq.gov/primer.aspx?primerID=10">http://psnet.ahrq.gov/primer.aspx?primerID=10</a><br />
<a href="http://psnet.ahrq.gov/primer.aspx?primerID=24">http://psnet.ahrq.gov/primer.aspx?primerID=24</a><br />
<br />
Another tidbit if you REALLY want to have a more complete search strategy approach to a patient safety topic -- is to again draw from AHRQ. The released a comprehensive review of patient safety strategies last year: <a href="http://www.ahrq.gov/research/findings/evidence-based-reports/ptsafetyuptp.html">http://www.ahrq.gov/research/findings/evidence-based-reports/ptsafetyuptp.html</a><br />
<br />
There is one on DxError:<br />
<a href="http://www.ahrq.gov/research/findings/evidence-based-reports/services/quality/patientsftyupdate/ptsafetyIIchap35.pdf">http://www.ahrq.gov/research/findings/evidence-based-reports/services/quality/patientsftyupdate/ptsafetyIIchap35.pdf</a><br />
And what is REALLY helpful (again, if you are aiming to be comprehensive) the authors share the search strategies used to support the reviews in each chapter. See c78 to c80 for the search strategy for the DxError chapter.<br />
<a href="http://www.ahrq.gov/research/findings/evidence-based-reports/services/quality/patientsftyupdate/ptsafetyIIapc.pdf">http://www.ahrq.gov/research/findings/evidence-based-reports/services/quality/patientsftyupdate/ptsafetyIIapc.pdf</a><br />
<br />
The other thing about DxError is how you client defines it. Delay, over- and under-diagnosis, decision making, cognition, biases (availability and otherwise) etc all could play into a search—depending on what the person is really looking for.<br />
<br />
Lastly -- here is an article -- (wish it was free: the first author happens to be a contributor to my new Patient Safety book: <a href="https://www.routledge.com/products/9781409438571">https://www.routledge.com/products/9781409438571</a>: )-- that also provides some thinking about search in patient safety: <a href="http://qualitysafety.bmj.com/content/19/5/452">http://qualitysafety.bmj.com/content/19/5/452</a><br />
<br />
Now – this may be more than you want or need – but what I think is useful is the strategies not only give someone like you (and other librarians) a robust place to start, but it illustrates the complexity of searching for materials in the world of patient safety!<br />
<br />
Hope it helps.Lorri Zippererhttp://www.blogger.com/profile/14581758218514499201noreply@blogger.com0tag:blogger.com,1999:blog-16801891.post-44547979160132399932014-05-22T08:59:00.002-05:002014-05-22T08:59:52.621-05:00Middle managers as boundary spanners: a UK study of interestI have long believed that middle managers serve as boundary spanners (or knowledge conduits) – helping to connect the dots between departments, teams and organizations. I am curious to hear how the results of this new study from the UK might inform how organizations could work with middle management --or structure their role -- to improve the reliability of this knowledge sharing role to support high quality, safe care.<br />
<br />
Ward V, West R, Smith S, McDermott S, Keen J, Pawson R, et al.<br />
The role of informal networks in creating knowledge among health-care managers: a prospective case study. Health Serv Deliv Res 2014;2(12).<br />
<a href="http://www.journalslibrary.nihr.ac.uk/hsdr/volume-2/issue-12" target="">Information and free full tex</a>t<br />
<a href="http://www.journalslibrary.nihr.ac.uk/__data/assets/pdf_file/0008/117899/ScientificSummary-hsdr02120.pdf" target="">Summary</a><br />
<br />
A quick thought after a first glance at the publication:<br />
<br />
This report highlights the importance of the water cooler “method” of sharing knowledge. In the work reflected in my recent <a href="http://www.gowerpublishing.com/pdf/SamplePages/Knowledge-Management-in-Healthcare-CH3.pdf" target="">book</a> there has been concern voiced by front line care providers that there is little time to just talk to one another and that this could be detrimental to the safety and quality of care provided. I suspect that a lack of time on the administrative or “blunt” end for informal conversation (ideally face-to-face) could be detrimental as well.<br />
<br />
Will the findings inform a different EI&K service delivery model? And also how librarians—who may serve as middle management—see their roles differently as both boundary spanners and information, evidence and knowledge service providers?<br />
<br />
I look forward to diving into the report more deeply to identify other items of interest. In the meantime, sharing your thoughts here would be welcome.<br />
<br />
<br />
<div>
<br /></div>
Lorri Zippererhttp://www.blogger.com/profile/14581758218514499201noreply@blogger.com2tag:blogger.com,1999:blog-16801891.post-1158785999455974662014-05-05T10:32:00.000-05:002014-05-05T10:36:38.799-05:00Dialogue: a tool to facilitate the exchange of knowledgeToday’s environment for sharing information, evidence and knowledge is complicated--perhaps even complex. (A whole other topic all together ... for another time!) A variety of tools, styles, formats and time elements affect our ability to communicate clearly and efficiently. With the plethora of models that can be customized for specific needs, styles and wants, one would think communication would be more often successful – but its often not.<br />
<br />
One method relied upon to share information and knowledge (depending on how you define knowledge) is the written text – in whatever format it is delivered. I had a colleague once suggest to me that librarians needed to embrace "dialogue" as a tool to share knowledge rather than the provision of articles and other stagnate information and evidence artifacts.<br />
<br />
This is an intriguing idea. It certainly builds on the KM concepts outlined by Nancy Dixon in her 2000 book Common Knowledge (ISBN: 0875849040). In that classic text she promotes team discussion and feedback as mechanisms for knowledge transfer -- which highlighting that a structured process is what helps make it successful. So shouldn't others consider it too?<br />
<br />
This idea of transferring knowledge in small groups rings true in patient safety circles as well with the emphasis and interest in debriefs, patient and family-centered rounds, daily huddles, <a href="http://www.ncbi.nlm.nih.gov/pubmed/12528570">walkarounds</a> and regular team/unit meetings serving as knowledge transfer opportunities in the acute care environment. These communication mechanisms allow for knowledge and information to be shared as needed -- in a context that allows real-time impact of the knowledge and information shared to be acknowledged through action.<br />
<br />
In response to my colleague, then, can and should information professionals facilitate and contribute to the use of dialogue as a knowledge sharing activity? Should management and clinician leaders enable that engagement? If so, what is the best marriage of the librarians skill set with the function of dialogue? I recognize that at the sharp end it may be more difficult, but the closer librarians are to the clinical team the more likely it is to happen. Certainly participating in front line information exchange activities from time to time will help inform any dialogue that might result in trying to invigorate evidence, information and knowledge (EIK) services that seek to contribute to improving the reliability of care processes. Also participating in committees, not only from a service perspective but as an EIK strategist will strengthen partnerships and boundary spanning opportunities.<br />
<br />
Lastly -- dialogue is a key systems thinking tool. If info pros are to be realized as systems thinkers, shouldn't they be adept and comfortable demonstrating AND explaining the art of dialogue as a tool in THEIR information and knowledge sharing arsenal? I think so.Lorri Zippererhttp://www.blogger.com/profile/14581758218514499201noreply@blogger.com0tag:blogger.com,1999:blog-16801891.post-41754324373018773352013-12-16T08:23:00.001-06:002013-12-16T08:23:33.021-06:00Listservs: knowledge or info sharing? Effective use helps with both - a holiday jingle<br />
I recently began moderating a new email discussion list. Now -- one may say they are "old school" but for some communities they still serve a very useful function -- if used appropriately ;-).<br />
<br />
In the spirit of the holiday season, the following reminders fell into order to align with the familiar cadence of a traditional Christmas tune. You know how to fill in the blanks. Enjoy! And if you have a group that is in need of gentle reminders .... Feel free to redistribute (attribution is appreciated).<br />
<div class="MsoNoSpacing">
<b><br /></b></div>
<div class="MsoNoSpacing">
<b>12 ways of
listserv etiquette (sung to the tune of the 12 days of Christmas)</b></div>
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© Lorri Zipperer 2013<o:p></o:p></div>
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(thanks to Ruth Ryan and Susan Carr for their editorial
comments)<o:p></o:p></div>
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<br /></div>
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My first day
on the listserv, the moderator said to me…<o:p></o:p></div>
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A proof-read reply is preferred<o:p></o:p></div>
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<br /></div>
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My second day on
the listserv, the moderator said to me…<o:p></o:p></div>
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Please sign your name ... <o:p></o:p></div>
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<br /></div>
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My third day
on the listserv, the moderator said to me…<o:p></o:p></div>
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No “me too’s” ... <o:p></o:p></div>
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<br /></div>
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My fourth day
on the listserv, the moderator said to me…<o:p></o:p></div>
<div class="MsoNoSpacing">
This isn’t Twitter! ... <o:p></o:p></div>
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<br /></div>
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My fifth day
on the listserv, the moderator said to me…<o:p></o:p></div>
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Remove banners from other posts! ... <o:p></o:p></div>
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<br /></div>
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My sixth day on the
listserv, the moderator said to me…<o:p></o:p></div>
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No published attachments ... <o:p></o:p></div>
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<br /></div>
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My seventh day on the listserv, my moderator said to me:<o:p></o:p></div>
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Search archives for answers ... <o:p></o:p></div>
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<br /></div>
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My eighth day on the listserv, my moderator said to me:<o:p></o:p></div>
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Change “subject” as needed ... <o:p></o:p></div>
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<br /></div>
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My ninth day on the listserv, my moderator said to me:<o:p></o:p></div>
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Always be polite ... <o:p></o:p></div>
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<br /></div>
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My tenth day on the listserv, my moderator said to me:<o:p></o:p></div>
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Address as appropriate ... <o:p></o:p></div>
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<br /></div>
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My eleventh day on the listserv, my moderator said to me:<o:p></o:p></div>
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Curtail repetition ... <o:p></o:p></div>
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<br /></div>
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My twelfth day on the listserv, my moderator said to me:<o:p></o:p></div>
<br />
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Talk off-line and recap ... <o:p></o:p>Curtail repetition ... Address as appropriate ... Always be polite ... Change “subject” as needed ...Search archives for answers ... No published attachments ... Remove banners from other posts! ... This isn’t Twitter! ... No “me too’s” ... Please sign your name ... A proof-read reply is preferred.</div>
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<br /></div>
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Happy Holidays!</div>
Lorri Zippererhttp://www.blogger.com/profile/14581758218514499201noreply@blogger.com0tag:blogger.com,1999:blog-16801891.post-13912605332621562332013-07-10T11:46:00.000-05:002013-07-10T11:46:17.656-05:00Knowledge gathering important to evidence application in the innovation processThis freely available article illustrates a nice transition of the need for expertise in how Evidence, information and Knowledge play a role in innovating in health care.<br />
<br />
<a href="http://qualitysafety.bmj.com/content/early/2013/07/04/bmjqs-2012-001722.full.pdf" target="_blank">Incorporating evidence review into quality improvement: meeting the needs of innovators.</a><br />
Danz MS, Hempel S, Lim YW, Shanman R, Motala A, Stockdale S, Shekelle P, Rubenstein L.<br />
BMJ Qual Saf. 2013 Jul 5; [Epub ahead of print]<br />
http://qualitysafety.bmj.com/content/early/2013/07/04/bmjqs-2012-001722.full.pdf<br />
<br />
It includes some nice pointers for organizing a role for search experts (librarians or otherwise) to play a robust part in the innovation design process. The article highlights information (the sharing repackaged results), evidence review (identifying and qualifying what the science says works) and knowledge gathering (the contextual piece of WHY a proposed intervention MIGHT work in a particular environment and how it might be spread) as important parts of the overall innovation process.<br />
<br />
I submit, however, that the suggestions for improvement (pg 7 of the preprint) illustrate the importance of knowledge sharing skills as being a concrete part of the innovation process. To fully capitalize on the information and evidence expertise on the team knowledge has to be infused into the process from the beginning (ie asking the questions about what evidence is needed), translating what is found into information and then applying it in a way that helps the innovation spread to improve care.<br />
<br />
Can healthcare in general and patient safety specifically afford to not "rev-up" their efforts by strategically motivating improvement through building the knowledge piece into the innovation process from the 'get go?'<br />
<br />
I think not.<br />
<div>
<br /></div>
<br />Lorri Zippererhttp://www.blogger.com/profile/14581758218514499201noreply@blogger.com0tag:blogger.com,1999:blog-16801891.post-11966423651064369782013-04-04T11:09:00.000-05:002013-04-04T11:09:04.376-05:00Failing in Order to Succeed. Part 3 Failing is never really fun. Admitting it is even less fun. Although there is a move afoot to see failure as an opportunity to learn, it’s easier said than done. This 3-part article seeks to provide a provocative perspective on how to think about learning from unintentional failure through the use of evidence, information and knowledge (EI&K).<br />
<br />
<a href="http://patientsafetylib.blogspot.com/2013/02/failing-in-order-to-succeed-part-1.html" target="_blank">Part 1</a><br />
<a href="http://patientsafetylib.blogspot.com/2013/03/failing-in-order-to-succeed-part-2.html" target="_blank">Part 2</a><br />
<br />
<b style="mso-bidi-font-weight: normal;"><span lang="EN-GB" style="mso-ansi-language: EN-GB;">Failing in order to succeed: Part 3<o:p></o:p></span></b><br />
<br />
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-GB" style="mso-ansi-language: EN-GB;">Reaping the wild wind of failure<o:p></o:p></span></b></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-GB" style="mso-ansi-language: EN-GB;">By Lorri Zipperer<o:p></o:p></span></b></div>
<br />
<span lang="EN-GB" style="mso-ansi-language: EN-GB;">Lorri Zipperer<br />
Zipperer Project Management <br />
<a href="http://www.zpm1.com/">www.zpm1.com</a> <br />
Albuquerque, NM <br />
Copyright 2013<br />
<o:p></o:p></span>
<br />
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span lang="EN-GB" style="mso-ansi-language: EN-GB;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span lang="EN-GB" style="mso-ansi-language: EN-GB;">The ability
for organisations to reap the benefits of this unique skill concentration is,
alas unrealized at this time. Librarians and other information experts must
understand their organisation’s culture to apply this expertise to enrich its
learning from failure. An appreciation of the depth of what really happened
rather than taking a more superficial or cursory approach is required for
EI&K to genuinely be used to realize system-oriented learning after a
stumble.<o:p></o:p></span></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span lang="EN-GB" style="mso-ansi-language: EN-GB;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span lang="EN-GB" style="mso-ansi-language: EN-GB;">The real
loss is when failures replicate: both within the same organisation and amongst
those who need to learn from the experiences of others. For example, when
failures in medical care occur, an awareness of that incident is thought to
help minimize its occurrence elsewhere. “It won’t happen here” mentality,
problem denial and ignorance, and “doesn’t apply to me so it’s not useful”
approaches can scuttle chances to learn from the misfortune of others. True
tragedy can occur. Such blockades can be breeched through effective evidence,
information and knowledge sharing. <o:p></o:p></span></div>
<span lang="EN-GB" style="mso-ansi-language: EN-GB;"><o:p> </o:p></span><span lang="EN-GB" style="mso-ansi-language: EN-GB;"><o:p> </o:p></span><span lang="EN-GB" style="mso-ansi-language: EN-GB;"><o:p> </o:p></span><br />
<br />
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-GB" style="mso-ansi-language: EN-GB;">Next actions:<o:p></o:p></span></b></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span lang="EN-GB" style="mso-ansi-language: EN-GB;">These apply
to both organisational and individual “learning from failure” commitments<o:p></o:p></span></div>
<br />
<div class="MsoListParagraphCxSpFirst" style="margin: 0in 0in 0pt 0.25in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -0.25in;">
<span lang="EN-GB" style="font-family: Symbol; mso-ansi-language: EN-GB; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";"> </span></span></span><span lang="EN-GB" style="mso-ansi-language: EN-GB;">Design time to reflect on what was
done well and what could have been improved into processes. If the habit of
thinking about and discussing failure as a learning opportunity is hardwired in
to projects throughout their lifetime, the tougher ones that result in delay,
disruption and disaster will be more effectively and expertly dealt with.<o:p></o:p></span></div>
<br />
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0pt 0.25in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -0.25in;">
<span lang="EN-GB" style="font-family: Symbol; mso-ansi-language: EN-GB; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";"> </span></span></span><span lang="EN-GB" style="mso-ansi-language: EN-GB;">Dig deep to get to the second story
of failure / avoid blame and look at problems from a systems view<o:p></o:p></span></div>
<br />
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0pt 0.25in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -0.25in;">
<span lang="EN-GB" style="font-family: Symbol; mso-ansi-language: EN-GB; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";"> </span></span></span><span lang="EN-GB" style="mso-ansi-language: EN-GB;">Walk the talk: practice at home, at
school, at social events. Lots of little failures happen often so they’ll be
plenty of opportunities to hone the skills.<o:p></o:p></span></div>
<br />
<div class="MsoListParagraphCxSpLast" style="margin: 0in 0in 0pt 0.25in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -0.25in;">
<span lang="EN-GB" style="font-family: Symbol; mso-ansi-language: EN-GB; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";"> </span></span></span><span lang="EN-GB" style="mso-ansi-language: EN-GB;">Review additional reading and discuss
what is provocative with others.<o:p></o:p></span></div>
<br />
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<span lang="EN-GB" style="mso-ansi-language: EN-GB;"><o:p> </o:p></span></div>
<span lang="EN-GB" style="mso-ansi-language: EN-GB;">Additional
reading:<o:p></o:p></span><br />
<br />
<div class="MsoNormal" style="margin: 0in 0in 0pt; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">
<span lang="EN-GB" style="mso-ansi-language: EN-GB;">Choo CW. <a href="http://142.150.148.194/FIS/Courses/LIS2149/SMR.pdf" target="_blank">Information failures and organisational disasters</a>. Sloan Management review. Spring 2005;8-10. </span></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 0pt; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">
<span lang="EN-GB" style="mso-ansi-language: EN-GB;">Edmondson A. <a href="http://hbr.org/2011/04/strategies-for-learning-from-failure/ar/1" target="_blank">Strategies for learning from failure</a>. <em>Harvard Business Review</em>. April 2011;89:48-55.</span></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 0pt; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">
<span lang="EN-GB" style="mso-ansi-language: EN-GB;">"<a href="http://knowledge.wharton.upenn.edu/article.cfm?articleid=2869" target="_blank">Brilliant Mistakes":</a>
Finding Opportunity in Failures. <em>Knowledge@Wharton</em><span style="color: blue;"> </span></span></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span lang="EN-GB" style="mso-ansi-language: EN-GB;">Zipperer,
L. <a href="http://futureready365.sla.org/12/04/a-future-in-failure/" target="_blank">A future in failure? You bet</a>. SLA 365 blog. Dec, 2011<o:p></o:p></span></div>
Lorri Zippererhttp://www.blogger.com/profile/14581758218514499201noreply@blogger.com0tag:blogger.com,1999:blog-16801891.post-80802950393541106182013-03-08T10:37:00.001-06:002013-04-04T11:00:49.872-05:00Failing in order to succeed. Part 2:Failing is never really fun. Admitting it is even less fun. Although there is a move afoot to see failure as an opportunity to learn, it’s easier said than done. This 3-part article seeks to provide a provocative perspective on how to think about learning from unintentional failure through the use of evidence, information and knowledge (EI&K).<br />
<br />
<b>Failing in order to succeed. Part 2: </b><br />
<br />
Lorri Zipperer<br />
Zipperer Project Management <br />
<a href="http://www.zpm1.com/">www.zpm1.com</a> <br />
Albuquerque, NM <br />
Copyright 2013<br />
<br />
<b>Learning and the failure librarian</b>
<br />
<br />
It should be recognised that leadership is pivotal in ensuring a learning culture is in place. Despite the fact it seems trite to say so, everyone has a role in learning from failure. It isn’t just management’s role. Enabling effective and respectful learning from failure is not a solo gig. In looking at this phenomenon from the team perspective a new role could be envisioned that presents organisations with an opportunity to learn from missteps more successfully: the failure librarian. This role could be applied to support learning from either intentional or unintentional failure. The latter will require a new paradigm for the engagement of librarians in this work. <br />
<br />
Librarians are well suited to contribute to learning from failure by: <br />
<ul>
<li>
Being appreciative of leaders and administrators and what makes them tick </li>
<li>Understanding of organisational boundaries and silos and how to navigate them for knowledge and information identification; </li>
<li>Identifying external evidence that could help recognize factors contributing to failure, minimize their impact and inform next steps, and; </li>
<li>Distributing external stories of failure organisation-wide to raise awareness of problems plaguing others to proactively flag risk in-house.
</li>
</ul>
The failure librarian has to do more than identify, accumulate and disseminate stuff. They need to get into the muck of the failure experience to understand how EI&K could help transform the situation into a positive experience for their organisations based on trust, transparency and teamwork.
<br />
<br />
They have the additional qualification and position to understand how poor EI&K can contribute to failure. They are in an excellent position to raise awareness of gaps that others may not see due to the latency of the problems.
<br />
<br />
The failure librarian will have a heightened understanding of what makes EI&K work reliable. Knowing how to constructively discuss systemic EI&K weaknesses as a risk management tactic can be an invaluable asset. Once the individual sees failure through the prism of their own mistakes they are better able to share that story and avenues for improvement in a sensitive, impactful way. For example:
<br />
<br />
A staff member with whom a librarian has a good relationship emails her with a search query. At the librarian’s request, the colleague sends her the strategy they used for the work. The librarian looks it over. It’s not bad -- but has some problems that should be addressed for the search to be complete. The librarian does her own work, and shared her results but does not explain to her colleague how he could have done a better search. She assumes the colleague had talked to other peers to get in-house insights and gather knowledge on his project. He is busy and they are friends, so she decides against explaining her search strategy rather than making him look bad.
<br />
<br />
Two weeks later, while the librarian is out of town, the colleague does another search to support a rapid turnaround proposal for a new client. The requesting client dismissed the proposal upon review of its competitive analysis. The analysis on which it was based was incomplete—despite the fact that the staff involved worked hard on the information and evidence review for the project. Senior staff, who were not involved in the project -- were not interviewed and hence their knowledge was not applied. The company fires her colleague for the misstep.
<br />
<br />
The problems in this scenario beyond the obvious lack of a complete literature review could include the librarian’s:
<br />
<ul>
<li>Failure to provide feedback to her colleague to improve his work.</li>
<li>Failure to approach her peer to offer services and get directly involved in the project </li>
<li>Assumption that her colleague did not have the time to receive counsel to improve their search process, hence letting the opportunity for staff improvement fall to the wayside. </li>
<li>Assumption that her colleague had done knowledge gathering by discussing his project with in-house experts rather than recommending that as part of a standard process for project work. </li>
</ul>
<br />
Part 3 will describe next actions to the concept of the failure librarian to both organisational and individual commitments to learning from stumbles.
<br />
<br />
Part 1 is available <a href="http://patientsafetylib.blogspot.com/2013/02/failing-in-order-to-succeed-part-1.html" target="_blank">here</a>:
Lorri Zippererhttp://www.blogger.com/profile/14581758218514499201noreply@blogger.com0tag:blogger.com,1999:blog-16801891.post-79269924377406611202013-02-26T09:15:00.003-06:002016-04-08T09:24:00.075-05:00Failing in Order to Succeed: Part 1Failing is never really fun. Admitting it is even less fun. Although there is a move afoot to see failure as an opportunity to learn, it’s easier said than done. This 3-part article seeks to provide a provocative perspective on how to think about learning from unintentional failure through the use of evidence, information and knowledge (EI&K).<br />
<br />
<b>Failing in Order to Succeed: Part 1</b><br />
<b>See: <a href="http://patientsafetylib.blogspot.com/2013/03/failing-in-order-to-succeed-part-2.html" target="_blank">Part 2</a>, <a href="http://patientsafetylib.blogspot.com/2013/04/failing-in-order-to-succeed-part-3.html" target="_blank">Part 3</a></b><br />
<br />
By Lorri Zipperer<br />
Zipperer Project Management. Albuquerque, NM lorri@zpm1.com
<br />
Copyright 2013<br />
<br />
Failing is never really fun. Admitting it is even less fun. Although there is a move afoot to see failure as an opportunity to learn, it’s easier said than done. This article seeks to provide a provocative perspective on how to think about learning from unintentional failure through the use of evidence, information and knowledge (EI&K). It highlights the value of a systemic EI&K-centered approach to learning from failure. It also suggests how information and knowledge professionals -- through individual and organisational prisms -- can both potentially contribute to failures and enhance learning from them —for themselves, their clients and their peers.<br />
<b><br />Failure due to design or deviation<br /> </b>
There are two distinctly different types of failure: Failure as a part of the innovation process and failure due to mismatches in how systems and people interact. The strategy of planned failure to enhance innovation and new idea generation is the more recognised side of this coin. Let’s face it, the creatives in our midst get this. Prototype after prototype, whether you are the innovation shop IDEO, a master chief, or jazz quartet -- understanding the opportunities inherent in “picking themselves up, brushing themselves off, and starting all over again ” is an attitude many of us should adopt. In either situation however, how to optimize learning from the failed experience should not be left to chance.<br />
<br />
As typically construed, failure is not something most organisations and people want to have to experience. Even if organisations are enlightened and try to deal with the consequences of failure, most of us would recognize that it is rarely done well.<br />
<br />
However negative the outcome – the organisations and individuals involved need to be accountable to do something with the experience. This course is responsible, appropriate and right. It is through this mindset, that the experience of failure can be harnessed to enhance decision-making reliability and personal mastery. It motivates improvement and innovation. Failure can illustrate the sense of urgency to change dysfunctional organisational behaviour. Failure can stimulate changes in cultural norms and individual mental models. A robust commitment to learning from failure -- coupled with EI&K -- can heighten the effectiveness of the opportunities failure can present.<br />
<b><br />Failure needs a learning strategy to plant seeds</b>
<br />
There needs to be a strategy to optimize the learning opportunities inherent in failure. Strategy does not equal rhetoric or some sort of marketing scheme. Constructive reactions to failure won’t happen unguided. A plan enhanced by leadership, mentoring and a rich resource-base is required.<br />
<br />
Knowledge management and information professionals should be oriented, enabled and encouraged to play a role in that strategy. Leadership needs to hire those professionals with the skills and aptitude to do this work. We already know that they can apply their expertise to identify, connect and disseminate information and evidence. In addition, they will need a willingness to expand that aptitude with an eye toward enriching professional practice and organisational culture through tacit knowledge sharing. Information and knowledge professionals can illustrate and inform the viability of this learning opportunity by looking inward then applying what was uncovered at their organisation.<br />
<i><br />Individual prism</i>
<br />
We all have a readily-available mechanism from which to learn and test improvements-- the folly that we perpetrate and that is in our midst. We learn in how we react to it. We must start learning from our own missteps.<br />
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We can do that by:<br />
<br />
• Admitting when we screw up<br />
<br />
• Backing away from blame (either on yourselves or others)<br />
<br />
• Being aware of overconfidence and bias<br />
<br />
• Seeking opportunities to learn from personal blunders<br />
<br />
• Sharing learnings in a transparent way<br />
<br />
• Enlisting others to help minimize negative reactions to failure; and<br />
<br />
• Exploring opportunities for improvement both within and outside our box.<br />
<i><br />Organisational prism</i>
<br />
Organisations are messy places. The complexity of how organisations function as systems is replete with not only failure, but also obstacles that impede learning from failure. Our participation as “fallible humans” creates another layer in the organisational complexity. Information and knowledge professionals can help facilitate learning opportunities by:<br />
<br />
• Translating their personal experiences into test cases for unit and team improvement<br />
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• Using knowledge-sharing techniques to apply failure-ignited insights to tools, trainings, and tactics<br />
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• Infusing an awareness of failure into data, information and evidence-delivery strategy and technology development<br />
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• Being aware of the “systemness” of failure – that failure occurs in all parts throughout the system in multiple, varied ways - and bringing that knowledge to bear with organisational mission and goals in mind<br />
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Part 2 will submit there is a role for the information professional in assisting in learning from failure at an organizational level.Lorri Zippererhttp://www.blogger.com/profile/14581758218514499201noreply@blogger.com0tag:blogger.com,1999:blog-16801891.post-51337414043590377262013-01-18T14:14:00.000-06:002013-01-19T10:29:34.557-06:00Lack of use of evidence...can that REALLY be safe?Interesting from a safety perspective: <a href="http://bmjopen.bmj.com/content/2/5/e001220.full.pdf">barriers to the use of evidence</a>
I see that the lack of librarian involvement in patient safety and other clinical work - or reductions in budgets to bring the evdience to clinicians (via online subscriptions, contracting with info pros, etc) can't be a good thing for supporting safe practice. What do folks think? How many of you work with librarians on your safety teams to strategize ways to address this gap. Do tell!
Lorri Zippererhttp://www.blogger.com/profile/14581758218514499201noreply@blogger.com0tag:blogger.com,1999:blog-16801891.post-76311543003243269432013-01-17T13:39:00.001-06:002013-01-17T13:39:36.280-06:00March 13, 2013 Webcast: Librarians as partners in Dxerror preventionRegister now for the Medical Library Association's March 13th webcast, “Partnering to Prevent Diagnostic Error: Librarians on the Inside Track.”
<a href="http://www.mlanet.org/education/distance_ed/spring13/index.html">Click here</a> for more information and to sign up!
Lorri Zippererhttp://www.blogger.com/profile/14581758218514499201noreply@blogger.com0tag:blogger.com,1999:blog-16801891.post-57598796486171656662012-11-30T14:14:00.004-06:002012-11-30T14:14:34.301-06:00KMHCare Workshop: application deadline extended to Dec 7thI am very pleased to be able to present this multidiscplinary, team based workshop in Chicago in February of 2013.
Knowledge Management in Hospitals: Developing a team to test and ensure success.
This 1.5 day workshop will explore how corporate knowledge management techniques and processes are applied in a hospital/health system. Multidisciplinary participants will work together to craft a strategy to adopt an expanded role for librarians in hospital/health system. This expanded role will establish a foundation for librarians to support the clinical environment by providing excellent knowledge management techniques and processes.
Please click <a href="http://nnlm.gov/mcr/news_blog/2012/11/knowledge-management-workshop-scheduled-for-february-7-8-2012/">here</a> to learn more and apply.
Hope to see you in Chicago!Lorri Zippererhttp://www.blogger.com/profile/14581758218514499201noreply@blogger.com1tag:blogger.com,1999:blog-16801891.post-18581353774631260462012-10-19T07:54:00.001-05:002012-11-15T05:16:20.843-06:00Diagnostic Error: A Multidisciplinary ExplorationInstructors: Elaine Alligood, Mark Graber, Barb Jones, Linda Williams and Lorri Zipperer
Date: Thursday, November 15, 2012
Registration and pre-session coffee: 8:30 am; Session time: 9:00 am-4:00 pm
Diagnostic error, a major factor in patient harm also increases medical <a href="http://psnet.ahrq.gov/primer.aspx?primerID=12">costs</a>. A free, interactive workshop for medical decision makers and information professionals is being held on November 15th focusing on how multidisciplinary teams can contribute to the reduction of diagnostic error. This innovative session will highlight evidence-based processes and the collaborative roles of clinicians and their librarians/ informationists as they work together to reduce factors contributing to diagnostic error. This class is set for November 15, 2012 in Room LL05 at the Health Sciences and Human Services Library, University of Maryland Baltimore. Class time is from 9-4, which a break for lunch on your own.
Session content will cover:
•Team-oriented approaches to understanding the role of information and evidence in the diagnostic process.
•Case analysis and discussion of bias.
•Partnering of librarians/informationists with clinical staff to strategize improvements
•Application of failure analysis techniques to explore system and process improvement.
•Design of evidence sharing innovations to reduce diagnostic error.
•Strategies for implementation of proposed projects.
Multidisciplinary teams from organizations are encouraged to attend. MLA CE credits will be provided.
See <a href="http://nnlm.gov/sea/newsletter/2012/11/diagnostic-error-a-multidisciplinary-exploration-november-15-2012/? ">class description</a> for more information.Lorri Zippererhttp://www.blogger.com/profile/14581758218514499201noreply@blogger.com2tag:blogger.com,1999:blog-16801891.post-11739272618233374262012-07-26T11:52:00.000-05:002012-07-26T14:56:59.396-05:00Learning from the failures of others: stories, pls!The heartbreaking failure of the missed diagnosis of sepis that resulted in the death of Rory Staunton is creating quite a stir:
An infection, unnoticed, turns unstoppable.
Dwyer J. New York Times. July 11, 2012.
For links to the article and related stories click <a href="http://psnet.ahrq.gov/resource.aspx?resourceID=24775">here</a>:
How has your organization used this story to identify, access, share and generate:
>>Evidence (to understand the potential risks to patients)
>>Information (through creating tools to educate and raise awareness of the failures inherent in this incident)
>>Knowledge (opportunities to draw from the experience of personnel to support buy-in for change, shape solutions and enhance improvement efforts within the context of your organization).
Do tell! We'll all learn from your experience and tactics --but only if you share them.Lorri Zippererhttp://www.blogger.com/profile/14581758218514499201noreply@blogger.com0tag:blogger.com,1999:blog-16801891.post-4260163422281622222012-06-11T13:22:00.001-05:002012-06-11T13:22:29.635-05:00Fatigue as a culprit in blunt-end info/knowledge sharing failureI just came back from a great trip -- which resulted in jet lag. Yep - I am fatigued. It makes me wonder about the lack of discussion around understanding how blunt end fatigue can result in problems in safety due to ineffective or unreliable information and knowledge delivery. Granted, it would have a different impact on care processes, but could this be a "latent" failure? For example, the recent <a href="http://www.itspublicknowledge.info/applicationsandDecisions/Decisions/2012/201100433.asp ">discussion</a> about the Scottish health authority inaction on adverse clinical event reports. Could that be related to blunt end staff burnout and fatigue? How many of us in either safety or the information/knowledge fields work weekends and long hours to keep their projects progressing smoothly? Can that extra effort contribute to factors that could contribute to information failures?Lorri Zippererhttp://www.blogger.com/profile/14581758218514499201noreply@blogger.com0tag:blogger.com,1999:blog-16801891.post-60280151875200963182012-03-09T13:17:00.002-06:002012-03-09T13:20:16.749-06:00Info pros as strategists for patient safety EIK improvementAny thoughts here? Librarians have sensed the reality of the results reported below for years. How are they best translated to engage leadership (clinical and administrative) to bring librarians into safety work as partners in EIK (evidence, information and knowledge sharing) improvement -- both as expert searchers and strategists to minimize the latent failure of poor search results guiding decision making?<br /><br />Gardois P, Calabrese R, Colombi N, et al. <a href="http://www.ncbi.nlm.nih.gov/pubmed/22051126">Effectiveness of bibliographic searches performed by paediatric residents and interns assisted by librarians. A randomised controlled trial</a>. Health Info Libr J. 2011 Dec;28(4):273-84<br />http://www.ncbi.nlm.nih.gov/pubmed/22051126<br /><br />Any outside the box thinking would be of value, as this story is not being translated as effectively as it could be.Lorri Zippererhttp://www.blogger.com/profile/14581758218514499201noreply@blogger.com0tag:blogger.com,1999:blog-16801891.post-10905731929472539932011-12-06T13:08:00.004-06:002011-12-06T13:16:44.186-06:00A future in failure? You bet. Improving organizational sharing to enhance learning.Although this post was originally written for a librarian audience, I am sharing it here to illustrate that librarians are equipt to play a role in organizational learning from failure. Read on!<br /><br /><br />Reproduced from: <br />Special Librarians Association: Future Ready 365 blog<br /><a href="http://futureready365.sla.org/12/04/a-future-in-failure/">http://futureready365.sla.org/12/04/a-future-in-failure/</a><br /><br />Learning from failure is a key element of the systems thinker.1 <br /><br />As my colleague and SLA Board member Sara Tompson and I have touted, systems thinking sensibilities illustrate an opportunity for librarians and the organizations they serve2. To build onto the element of learning from failure that Edmondson3, Shumaker4 and others have stated it is important for an organization to learn, I’d like to suggest a new special librarian: the failure librarian.<br /><br />Organizations need to have a strategy in place to learn from their mistakes. Whether the mistakes are one at a time – as in health care – or affect a huge customer base (i.e. Netflix) the understanding of how information, evidence and knowledge can be brought to bear to understand what happened is critical. This approach looks at evidence to inform direction, identify risks, strategize new approaches, and gain from employee/participant experiences to enrich the decision making process. Who better to help with that then the special librarian, as: <br /><br />o We understand networking.<br />o We understand the value of information and how to find it.<br />o We understand what evidence will be most applicable where, when and for whom.<br />o We understand our leadership and what makes them tick.<br />o We understand how biases can affect decision making which enables us to seek to counteract them with good information and evidence5.<br />o We understand the boundaries and silos in our organizations and how to navigate them successfully to connect knowledge workers to enable innovation and problem solving. <br />o We understand that both explicit and tacit knowledge are important for decision making and seek to find both types of knowledge and respect the conduit no matter where it may exist in the organizational hierarchy.<br />o We understand that blame-free exploration into what went wrong is the only way to move improvement forward. <br />o We understand that mental models can both have negative and positive effects and seek to reveal those when they affect decision making and action amongst our staff, our peers and our management.<br />o We understand that a commitment to generating evidence-based solutions will enable them to be sustainable, efficient and effective.<br />o We understand we too can play a part in failure and seek to improve our own processes and behaviors to counteract those factors.<br /><br />Or at least we should.<br /><br />Our future has within its sights the potential as a positive force in many industries if we deeply understand these things and are ready to recognize failure as an opportunity to partner, innovate, and excel.<br /><br />1. Senge PM. The Fifth Discipline. New York, NY: Random House; 1990.<br />2. Zipperer L, Tompson S. <a href="http://findarticles.com/p/articles/mi_m0FWE/is_12_10/ai_n27098382/">“Systems thinking: a new avenue for involvement and growth.”</a> Information Outlook. (December 2006):16-20. <br /><br />3. Edmondson AC. <a href="http://hbr.org/2011/04/strategies-for-learning-from-failure/ar/1">Strategies for learning from failure</a>. Harv Bus Rev. April 2011;89:48-55. Av<br /><br />4. Schoemaker PJH. <a href="http://knowledge.wharton.upenn.edu/article.cfm?articleid=2869">'Brilliant Mistakes': Finding Opportunity in Failures</a>. Knowledge@Wharton<br /><br />5. Kahneman D, Lovallo D, Sibony O. <a href="http://hbr.org/2011/06/the-big-idea-before-you-make-that-big-decision/ar/1">Before you make that big decision... </a>Harv Bus Rev. June 2011;89:50-60, 137 <br /><br />Many thanks to my colleagues in the Rio Grande chapter who had a spirited conversation on the Edmondson article that contributed to the thinking that helped to generate this post, and Sara Tompson for editing the draft.Lorri Zippererhttp://www.blogger.com/profile/14581758218514499201noreply@blogger.com0tag:blogger.com,1999:blog-16801891.post-27088636938978827172011-08-28T14:53:00.007-05:002011-08-28T15:01:53.297-05:00Literature reviews, peer review and checklists ....This article is pretty interesting. I have been pitching the question of using checklists as reliablity tools in the EIK process for a while (with a fair amount of pushback and "deer in the headlights" reactions), and wondered what my colleagues here thought of the tool presented in the article.
<br />
<br /><a href="http://ejournals.library.ualberta.ca/index.php/EBLIP/article/view/7402/6436">An Evidence Based Checklist for the Peer Review of Electronic Search Strategies</a>
<br />Jessie McGowan, Margaret Sampson, Carol Lefebvre
<br />Evidence-based Libr Inform Pract. Vol 5, No 1 (2010); 149-154.
<br />http://ejournals.library.ualberta.ca/index.php/EBLIP/article/view/7402/6436
<br />
<br />The process/tool wasn't designed to serve as a "real time" checklist (like a pilot's or a <a href="http://www.youtube.com/watch?v=4IG8ItaTTzY">surgical time out</a>), but does it touch on things that may play out in the development of one. I also like the author's ascertain that peer review (in this sense) is a professional responsibilty rather than a luxury and should be approached as such. Granted this article doesn't discuss these ideas squarely in the context of safety, but perhaps it can help us start that dialogue?Lorri Zippererhttp://www.blogger.com/profile/14581758218514499201noreply@blogger.com0tag:blogger.com,1999:blog-16801891.post-33443091258651968132011-08-09T09:32:00.004-05:002011-08-09T09:43:39.115-05:00Bad handwriting effects EIK processes, too!I'll admit it - I have lousy handwriting. Can't spell well either. I wish social networking sites had spell check.
<br />
<br />But of course, my mistakes - whereas they are sometimes a tad embarrasing, don't have the potential to cause major harm or delay in medical care. A rant recently appeared on a librarians email discussion group about poor penmanship and citation accuracy from a physician who needed some articles. Given my "safety" perspective, I asked why the librarian didn't just wait until the physycian could be reached to clarify the messy citations -- rather than foraging around trying to use their skills (and limited time) to figure it out. By enabling this -- aren't we normalizing the ineffective behavior?
<br />
<br />I inherently know the answer (time, pride, frustration, hierarchy, etc) but aren't we enabling poor citation and request behavior by enabling it by making due? Theoretically, a patient's care COULD be in the balance. Maybe not this time, but next time, will the delay due to poor penmanship be more costly than the frustration and wasted time of a professional?
<br />
<br />A colleague on the list, Fred King, shared this bit of phrasology that addresses the handwriting dilemma.
<br />
<br />Neatness Counts
<br />
<br />Higgledy piggledy
<br />Sarah the resident
<br />write your prescriptions so
<br />they can be read.
<br />
<br />Patients affected by
<br />pharmacological
<br />illegibility
<br />could end up dead.
<br />
<br />Fred King
<br />Medical Librarian
<br />Washington Hospital Center
<br />fred.king@medstar.net
<br />
<br />It is with his permission, that I share it here.
<br />
<br />Lorri Zippererhttp://www.blogger.com/profile/14581758218514499201noreply@blogger.com0