Patient Safety: Focus on Information and Knowledge Transfer

A future in failure? You bet. Improving organizational sharing to enhance learning.

2011-12-06T13:08:00.004-06:00

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!

Reproduced from:
Special Librarians Association: Future Ready 365 blog
http://futureready365.sla.org/12/04/a-future-in-failure/

Learning from failure is a key element of the systems thinker.1

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.

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:

o We understand networking.
o We understand the value of information and how to find it.
o We understand what evidence will be most applicable where, when and for whom.
o We understand our leadership and what makes them tick.
o We understand how biases can affect decision making which enables us to seek to counteract them with good information and evidence5.
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.
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.
o We understand that blame-free exploration into what went wrong is the only way to move improvement forward.
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.
o We understand that a commitment to generating evidence-based solutions will enable them to be sustainable, efficient and effective.
o We understand we too can play a part in failure and seek to improve our own processes and behaviors to counteract those factors.

Or at least we should.

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.

1. Senge PM. The Fifth Discipline. New York, NY: Random House; 1990.
2. Zipperer L, Tompson S. “Systems thinking: a new avenue for involvement and growth.” Information Outlook. (December 2006):16-20.

3. Edmondson AC. Strategies for learning from failure. Harv Bus Rev. April 2011;89:48-55. Av

4. Schoemaker PJH. 'Brilliant Mistakes': Finding Opportunity in Failures. Knowledge@Wharton

5. Kahneman D, Lovallo D, Sibony O. Before you make that big decision... Harv Bus Rev. June 2011;89:50-60, 137

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.

Literature reviews, peer review and checklists ....

2011-08-28T14:53:00.007-05:00

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.

An Evidence Based Checklist for the Peer Review of Electronic Search Strategies
Jessie McGowan, Margaret Sampson, Carol Lefebvre
Evidence-based Libr Inform Pract. Vol 5, No 1 (2010); 149-154.
http://ejournals.library.ualberta.ca/index.php/EBLIP/article/view/7402/6436

The process/tool wasn't designed to serve as a "real time" checklist (like a pilot's or a surgical time out), 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?

Bad handwriting effects EIK processes, too!

2011-08-09T09:32:00.004-05:00

I'll admit it - I have lousy handwriting. Can't spell well either. I wish social networking sites had spell check.

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?

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?

A colleague on the list, Fred King, shared this bit of phrasology that addresses the handwriting dilemma.

Neatness Counts

Higgledy piggledy
Sarah the resident
write your prescriptions so
they can be read.

Patients affected by
pharmacological
illegibility
could end up dead.

Fred King
Medical Librarian
Washington Hospital Center
fred.king@medstar.net

It is with his permission, that I share it here.

KM practice: from the corporate world to Hcare

2011-07-29T09:12:00.003-05:00

I have been working for a decade to help translate KM experience and know-how from the business sector to health care. Being self-employed, I never had the bandwidth or resources to do what you have done. This lit review should help enable thoughful evidence-based discussions of how we can best crosswalk lessons from business into healthcare to apply KM methods to patient safety.

Kothari A, Hovanec N, Hastie R, Sibbald S. Lessons from the Business Sector for Successful Knowledge Management in Health Care: A Systematic Review. BMC Health Serv Res. 2011 Jul 25;11(1):173. [Epub ahead of print]
http://www.ncbi.nlm.nih.gov/pubmed/21787403

Many thanks to the authors for their work.

Dx error and librarians -- the sequel!

2011-07-26T12:28:00.003-05:00

Nice that we are cued up to do this session again (in a 6 hour format instead of 4) in 2012 at MLA in Seattle:

Lorri Zipperer, Elaine Alligood, Linda Williams, and Barbara Bowers Jones. Diagnostic Error & Patient Safety—Team Up & Tackle It. Minneapolis, MN: Medical Library Association Annual conference: May 13, 2011
http://cech.mlanet.org/node/499

Do you have stories, better practices, ideas etc about how an understanding of cognitive bias and failure can inform the design of services and activities of librarians and information professionals in hospitals? If so, do tell! Any front line experiences we can fold into the expanded talk will be appreciated.

Hot off the Presses! Librarians on the KM team.

2011-04-23T11:10:00.003-05:00

Zipperer L, Amori G. Knowledge management: an innovative risk management strategy. J Healthc Risk Manag. 2011;30(4):8-14.

In this piece Geri and I advocate that a librarian be a part of the team to roll out a KM strategy. I'd love to here your thoughts on that, and wish I could provide the full text of the article to help faciliate the dialogue, but alas, cannot.

Latent Failure: No MESH heading for patient safety?

2011-03-25T10:16:00.010-05:00

There was a comment/query recently on a medical librarians listserv bemoaning the lack of a MESH (National Library of Medicines "Medical Subject Heading) on the distinct topic of patient safety. My responsed to the dialogue are repurosed below:

There is the rub, Stanley!

Patient safety is a really complex issue to track and it would be helpful to have a term that encompasses all the nuance, but perhaps a MESH term wouldn't be appropriate but instead a taxon around the topic or a defined hedge (clinical query) that would address these nuances when applied by learned searchers.

These documents illustrate the range of types of things that need to be looked at to do comprehensive research around patient safety:

http://psnet.ahrq.gov/resource.aspx?resourceID=2123

http://psnet.ahrq.gov/resource.aspx?resourceID=1599

http://psnet.ahrq.gov/resource.aspx?resourceID=19096

http://www.ncbi.nlm.nih.gov/pubmed/20457733

I wonder if some of the issues around this center on the fact that patient safety -- even for those of us who have been doing this for a long time
-
doesn't have concrete boundaries and so it would be hard to create a term that could encompass them all. Just ask a group of healthcare folks to define quality and then patient safety ...... that designation alone is stuff up for debate even a decade after "To Err is Human."

I think we need an entire set of terms --- there are several recognized taxonomies that take into account the range of ideas that need to be represented when tagging for "patient safety":

http://www.ncbi.nlm.nih.gov/pubmed/15723817

http://www.who.int/patientsafety/taxonomy/en/

PSnet collection taxonomy

But I recognize this opens up a whole new can of worms ----

AND

I have been tracking and watching the patient safety literature since 1997. Its very, very messy and anything that could be put in place to standardize the literature would be helpful. Then -- training would have to be done to make sure terms would be applied consistently -- as this lack of reliabilty represents a human factors and systems-level problem that is latent (in systems safety terms) in that people don't see the failure of finding things given how poorly applied the terms are.

Add to that the fact the "patient safety" is not even used consistently by the people who WRITE the articles --- let alone the marketing value of the term ....

This is such a good example of why you need PEOPLE to look at the literature and determine its usefulness and relevance. This point is important even - with clinical terms that are more tightly defined ....

______________

I appreciate the interest and concern librarians and other experienced researchers/informaticians take in recognizing the problems associated with accessing the exploding literature around safety. Measures to understand this problem and an awareness of it as a failure to report and a near miss to recognize (when caught in the process of searching oneself or in reviewing a clinicians search) may help address the problem.

The stone age didn't end cos we ran out of stones.

2011-03-24T09:37:00.003-05:00

Innovation consultant Sarah Fraser shared this link via Twitter -

The Value of the Stretch Goal The stoneage didn't end cos we ran out of stones.

What do we need to see the ticking clock regarding knowledge sharing and patient safety? Why isn't there more push, more competition, more accountabilty, more teamwork and more innovation around this point? Are the needs and the problems so latent that they are dismissed? Are innovators in this area suffering due the intense cultural issues surrounding sharing of tacit knowledge in the acute care environment and the challenges around measuring it?

Literature, librarians and leaping forward ....

2011-03-07T08:30:00.003-06:00

My colleague Linda Williams sent me this note and has allowed me to share it with you:

I’ve just finished reading Fire upon the Deep by Vernor Vinge. The heroine is Ravna Bergsndot, a librarian of the sort that I think we hope to inspire with our MLA course on diagnostic errors and the role of the librarian (see pg 13). I think that using Ravna’s personality, her intellect, and her library skills analogously to what we see librarians doing to improve diagnostic problem solving would be an interesting educational strategy. For some of our audience, when we suggest being part of patient rounds or attending case conferences or morbidity-mortality rounds, it may seem twenty light-years away from where they now work.

To illustrate over-confidence and confirmation bias:
Pg 178 " ‘Look under the surface, Pham. I think you'll find a whole lot of nothing.’ A dream of competence, too closely confronted.”

To make a point about the specialized, essential knowledge that a librarian brings to diangnostic decision making:

Pg. 182 Ravna realized this was not just a favor. She was the best person for this job. She knew humans, and she knew archive management. ...They would need an effective onboard database and strategy program....It was up to Ravna to decide what library materials to move to the ship, to balance the ease of local availablitlty against the greater resources that would be accessible over the ultrawave from Relay.

If emphasizing what it takes to be a librarian – especially when it is time to confront physicians about their own human limitations:

Pg 55 Looking back, Ravna Bergsndot saw it was inevitable that she become a librarian. [She] still wanted adventure. And there was a way to see into everything that humans in the Beyond could possibly understand: Ravna became a librarian.

To demonstrate the value of librarians being right in the thick of action:
Pg 56 So it was that Ravna Bergsndot ended up more than twenty light-years from home, at the network hub of a million worlds.

The book is hugely entertaining and wonderfully written. And in the end Ravna saves the world from destruction. In a way we’re asking librarians to be superheroes, too. There is one other quote that I’d forgotten about until now. She brings a bunch of children out of cold sleep knowing that she will have the responsibility of nurturing them. It is the kind of nurturing that I see us doing for the next generation of physicians. They are certainly more malleable than those who completed their training years ago. Some are learning to use meta-cognition and reflective practice to guard against confirmation bias and improve diagnostic skills. Those are the ones who will be eager to have a librarian on the patient care team.

Join us in May at MLA to learn more. Check out the speaker teams' article (pg 6) that came out in 2010 on how librarians can partner in healthcare to "tackle" Dx error.

CoPs as effective knowledge sharing tools

2010-12-09T11:36:00.001-06:00

I thought I'd share the citation to this short commentary that was just published:

Creating a more efficient healthcare knowledge market: using communities of practice to create checklists.
Lashoher A, Pronovost P. Qual Saf Health Care. 2010 Dec;19(6):471-2.
http://dx.doi.org/10.1136/qshc.2010.047308
Pubmed

What I like about this is it provides a nice example of why "knowledge" can be more helpful and actionable that "information" -- in this case guidelines -- and the usefulness of a knowledge sharing mechanims (ie CoP) to support better care and tools to make the care as reliable as possible (checklists).

Let me know what you think!

Another call to action!

2010-11-30T10:02:00.004-06:00

Temporal trends in rates of patient harm resulting from medical care.
Landrigan CP, Parry GJ, Bones CB, Hackbarth AD, Goldmann DA, Sharek PJ. N Engl J Med. 2010;363:2124-2134.

Free full text

NYT recap

Interesting study with not-so-surprising results: patient safety isn't improving as quickly as hoped -- even in hospitals that are highly engaged in improvement. Systemic solutions need to be in place to help ensure improvements - rather than only the launch of tools (ie checklists)

This patient safety improvement stuff is tough work, yet its frustrating to hear this.

I see the conclusion: “Further efforts are needed to translate effective safety interventions into routine practice and to monitor health care safety over time” as areas where librarians, informationistas, informaticians, etc can make an impact. There are knowledge access, knowledge sharing, evidence assess and sharing, data access and packaging issues that we in the info professions may be able to affect and improve, if the multidisciplinary teams driving improvement initiatives includes information and knowledge sharing experts (not just IT). It also means (in our sphere of influence) that wikis, SharepointTM, EBM etc are not the be all end all of our contributions -- we need to help others see how culture and work process is affected and made more reliable through effective information and knowledge sharing.

The effort continues ....

knowledge sharing and Dx Error - brainstorming librarians!

2010-09-01T16:09:00.004-05:00

Check out this free article that was just released:

Diagnostic Error in Acute Care
Pa Patient Saf Advis 2010 Sep;7(3):76-86.

The tables in here provide some analysis of system- and physician-level fixes to potentially help mitigate diagnostic error. Might it be a good exercise to have teams (including librarians, knowledge managers, HIT folks and clinicians) review one of the tables to discuss root causes for these problems related to information and knowledge sharing and submit ideas (beyond EBM) to improve the reliabiity of the process.

Any thoughts?

Failure as a teaching tool

2010-08-13T14:35:00.004-05:00

I had lunch yesterday with a colleague who was interested in navigating the alumni page at her university's library. She was new to using a library system and was anxious to learn so she could be self-sufficient in tracking down literature related to her work in patient-centeredness. Upon sitting down together with her computer in a noisy cafe, I began to talk her through all the ins and outs of using the system. As our conversation progressed, each quest for an article had a range of avenues to head down, tools to use, criteria to think about and ... opportunities for failure in getting what she needed. This was over lunch, yet the environment was loud, full of distractions (including a tremendous piece of key lime pie!) and we were pressed for time as she had an appointment. Does any of this ring a bell? As we picked up the crumbs from the gram cracker crust, I posed the question "Now do you see what I mean when I talk about the potential for failure in gathering information and knowledge in the clinical environment?" Needless to say, this example helped her to see what I have been saying all along.

We need to use information gathering failure in our training for evidence identification and acquisition -- otherwise the falsity that its easy will remain. this lack of awareness will continue to hamper efforts to understand the impact of these failures to learn about them, research them, mitigate them, fill the holes in the Swiss cheese, and improve the reliability of the process.

Bon Appetite!

Rudeness, safety and knowledge sharing

2010-07-13T10:16:00.005-05:00

So, who are there believes that it would be easy and effective to do knowledge audits, knowledge interviews, assessments or a basic reference interview with a "difficult" colleague? Certainly this represents a situation that many of us have dealt with. Expert opinion, field experience, and organizational guidelines suggest that rudeness and disruptive behavior are worth considering as they present barriers to safe, effective healthcare. Are librarians, info pros and others dealing with knowledge sharing being affected by this state of affairs? Do they in turn intimidate and belittle staff around them who may come to the library or training sessions? Are we talking about this as an element of our role in safe care? Should we be?

Reliability and information/knowledge sharing vulnerabilities

2010-06-28T09:23:00.003-05:00

Last week I was honored to present (with my able colleague Susan Carr / PSQH ) a webinar for the National Patient Safety Foundation. The slides for the session and an audio recording are available for 90 days. (You need to register to get at the material). I have been intrigued by the issues related to the lack of reliability and concreteness in how organizations and individuals access information and knowledge to further their safety work. I have written on it in the past and have been talking about it in a variety of forums for years. Why are we so overconfident that we are fully "up to speed" on safety and able to use the experience of our colleagues and the existing evidence to ensure our work is fully informed? Is it a consequence of google, over confidence, or arrogance? What is more troubling is that no one seems to be talking about it? Please listen in if you can, and view the slides and weigh in here. I'd appreciate the dialogue -- and imagine that some where along the road the person who is better equipped to be fully informed will appreciate our proactive exploration of the topic as well.

Librarians and checklists -- do they make sense?

2010-01-25T12:08:00.008-06:00

With the recent release of Atul Gawande's The Checklist Manifesto www.nytimes.com/2009/12/24/books/24book.html the idea of applying checklists as failure prevention mechanisms, I would imagine, has crossed the minds of many in health care that typically wouldn't be considering them.

Take librarians, for example.

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 ) The notion of when a tool like a checklist is needed and **should** be used is an important question. 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 and ends up resulting in workarounds that provide additional opportunites for failure.

For sake of discussion here, I do think there may be some applicability of a checklist in some areas of the domain, such as in the reference review process (in an emergent situation) or clinical informationist in context www.ncbi.nlm.nih.gov/pmc/articles/PMC64757/ rounding participation. Seems to me I saw I study a while back (gaps in the reference interview that happen due to communication failures, etc) that might provide some insights into ways to make that element of a librarians skill set more reliable via structured communication tools and/or a checklist.

I do also wonder if the checklist idea would be useful in a broader sense. Let's face it: librarians aren't the only ones doing lit reviews in hospitals and, as demonstrated by the gap in the lit reivew process www.ncbi.nlm.nih.gov/pubmed/11530164 at Hopkins that contributed to the research volunteer death some years back, 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.

I would say thou, that the examples of IRB participation, systematic review support and similar "project and task flow" examples may be "complicated" (ie "building the space shuttle") rather than "complex" (ie performing surgery, raising children) if we consider complexity theory in all of this.

Its important for librarians, and the clinicians that require the best evidence to do their work in complex situations, to explore how a checklist could be enabled to affect patient safety in this intersection of professions. I wonder what -- if anything can be drawn from existing safety tools and processes in place in other high-risk domains such as aviation and nuclear power plants-- to help enlighten a discussion around how the information identification, acquisition and dissemination process in hospitals become "highly reliable" through the use of checklists.

Some additional food for thought:
http://www.springerlink.com/content/6x37w435wp32203t/fulltext.pdf

A decade since to Err is Human and the role of librarians in patient safety

2009-12-01T10:43:00.002-06:00

There are discussions happening throughout health care this week around what has improved since "To Err is Human" was released a decade ago.

Do any librarians have any memories related to this event, that has been hailed by some as the launch of the "modern" patient safety movement? Any thoughts around what has happened to impact the librarians role in patient safety work since then? For non-librarians, do you have any thoughts on how your work with librarians may have changed in regard to your implementation of safety initiatives?

One step in the right direction was the development and distribution of the MLA policy around the librarian's role in patient safety earlier this year but I'd love to hear about changes at the organizational level.

My own work has demonstrated some uptake and improvements, but I'd love to hear some stories from the field.

Please share!

Knowledge brokers: an opportunity for evidence distribution improvement

2009-11-11T14:57:00.003-06:00

This article provides some interesting ideas around how knowledge brokering can be built into education and learning processes within an organization. I see that librarians and others with a tendency toward understanding information and knowledge needs and the ability to build and feed successful networks of knowledge workers could effectively fill this role.

I'd love to hear other thoughts on the matter .....

Dobbins M , Robeson P, Ciliska D, Hanna S, Cameron R , O'Mara L , DeCorby K, Mercer S
A description of a knowledge broker role implemented as part of a randomized controlled trial evaluating three knowledge translation strategies.
Implementation Science 2009, 4:23
The electronic version of this article is the complete one and can be found online at: http://www.implementationscience.com/content/4/1/23

Abstract
A knowledge broker (KB) is a popular knowledge translation and exchange (KTE) strategy emerging in Canada to promote interaction between researchers and end users, as well as to develop capacity for evidence-informed decision making. A KB provides a link between research producers and end users by developing a mutual understanding of goals and cultures, collaborates with end users to identify issues and problems for which solutions are required, and facilitates the identification, access, assessment, interpretation, and translation of research evidence into local policy and practice. Knowledge-brokering can be carried out by individuals, groups and/or organizations, as well as entire countries. In each case, the KB is linked with a group of end users and focuses on promoting the integration of the best available evidence into policy and practice-related decisions.

Results
KB activities were classified into the following categories: initial and ongoing needs assessments; scanning the horizon; knowledge management; KTE; network development, maintenance, and facilitation; facilitation of individual capacity development in evidence informed decision making; and g) facilitation of and support for organizational change.

Conclusion
As the KB role developed during this study, central themes that emerged as particularly important included relationship development, ongoing support, customized approaches, and opportunities for individual and organizational capacity development. The novelty of the KB role in public health provides a unique opportunity to assess the need for and reaction to the role and its associated activities. Future research should include studies to evaluate the effectiveness of KBs in different settings and among different health care professionals, and to explore the optimal preparation and training of KBs, as well as the identification of the personality characteristics most closely associated with KB effectiveness. Studies should also seek to better understand which combination of KB activities are associated with optimal evidence-informed decision making outcomes, and whether the combination changes in different settings and among different health care decision makers.

Diagnostic error prevention and EBM competencies

2009-11-01T10:29:00.003-06:00

Last week several colleagues are I were in attendance at the Diagnostic Errors in Medicine Conference in Hollywood. Thoughts and "ah-ahs" from that session will be shared here over time, but this initial post will focus on a breakout discussion we had there on how medical education can help prepare physicians to mitigate the opportunity for error by addressing the cognitive side of error.

One piece of that pie covered use of the evidence and what that means. We know that access to the evidence can effect care decisions, but what can it do to help address confirmation bias, inappropriate heuristics and misplaced reliance on the opinion of experts?

To help ingrain a respect for the need to know when you don't know, see the evidence as a tool to prevent diagnostic error, and recognize the need to evidence gathering to sometimes be a "team sport" the following competencies were collected for future discussion on this topic:

Medical students should learn and be capable of:

recognising uncertainty and knowledge gaps
anticipating the impact of bias impact on the information gathering and assessment process
coordinating a team and locating the expertise needed to collectively address the question at hand
identifying and locating the best evidence using the Internet or other information source
understanding how to work with a librarian or other qualified open-source research expert
considering items both in agreement with the clinical predetermination and others that allow for introspection, further research and dialogue as necessary.
Applying specificity, sensitivity, PPV, NPV, RR to the case at hand in a specific and deliberate manner
Sharing learnings using both formal (ie via policy or guideline development) and informal (ie social networks and face to face discussions) tactics to counteract similar bias within immediate network

Any thoughts on these ideas would be helpful as we work with the coordinators of the 2010 DEM session in Toronto to flesh these concept out more completely.

Legal issues around appropriate literature reviews

2009-09-01T07:29:00.004-05:00

I wanted to share this post from colleague from a hospital librarians' listserv. She provides some interesting points to explore how important appropriate and complete literature and evidence identification to the safety of the care process and instances where there was some legal leverage applied to underscore that importance.

Does this help support a defined role for librarians in a process that has been "googlized" to the point of removing it from "expert" hands and impacting its reliability?

Please, lets discuss!

I reproduce it here with her permission.

posted August 28, 2009

Colleagues,

With regard to [my colleague's] comment about the existence of legal cases and how much awards are made when physicians fail to provide appropriate care because of lack of information, the following case comes to mind. There was a case in 1983 in the state of Washington where three physicians were found negligent in a wrongful birth case when they failed to search the medical literature or to consult other sources of information concerning the relationship between birth defects and the drug dilantin. Physicians have a legal responsibility to research the literature. The case is described in – Harbeson v. Parke-Davis – “Medicine and Law”, 4(2):189-194. l985 (PMID 3999949). The Harbesons asked three different physicians about any adverse effects of taking Dilantin while Mrs. Harbeson was pregnant and taking Dilantin for epilepsy. The Harbesons then had two children who suffered from “fetal hydantoin syndrome” as a result of Mrs. Harbeson taking Dilantin during her pregnancies.

In an article by M. Skolnick in “Medicine and Law” 4(3):283-98, l985, (PMID 4010498), Skolnick writes “An important element in the courts decision was the physician’s failure to conduct a literature search or seek alternative opinions.” He also writes “Failure to search the appropriate scientific literature is an obvious breach of the broader duty to perform at the level of knowledge and practice in the physician’s clinical specialty. The duties defined by the doctrine of informed consent may be discharged only if the physician remains abreast of current information, and can communicate it to his patients.” He further writes that “Far greater emphasis in both teaching and testing is placed on memorizing facts than in processing information to solve problems.” Lastly, Skolnick writes about the Harbesons’ physicians that “They relied on what they remembered and the kind of information shared in their practice setting, and produced a human tragedy. Had these physicians been educated through a process which induced them to access and process current information, their approach to the Harbeson’s question might have been profoundly different.”

Although it is much easier in 2009 to do a literature search than it was in l983, physicians need to conduct literature searches to help answer clinical questions. It is also important for physicians to receive initial training in literature searching in medical school and then continuing education in literature searching the medical literature throughout their career. As a hospital librarian in a teaching hospital, I have often helped physicians conduct literature searches that impact patient care. I’ve also helped physicians search the literature for information that impacts a court decision on a medical case.

The case of Harbeson v. Parke Davis indicates that there is some legal precedence for physicians to perform literature searches to support their clinical decisions. Personal experience also has shown me that physicians today still need help and instruction in performing literature searches. The problem then is to document the impact on patient care and then communicate this to the hospital administrator in charge of the library. A number of studies have been published that demonstrate the value of the hospital library in supporting physicians in their clinical decision-making. The Vital Pathways initiative of MLA will also help to foster the value of the hospital librarian. Since l997, physicians and others have had free, online access to Medline through PubMed. Currently, many hospitals have access to full-text articles online. Despite this access to the medical literature, physicians still need and benefit from the expertise of medical librarians to help them search this vast literature.

To me therefore, the legal precedence for physicians to search the literature is already established and physician’s need for help in searching the medical literature is still present. I hope that as an organization we can continue to work on ways to alert hospital administrators of the need not only for a medical library but also of the need for medical librarians to assist physicians in their clinical decision-making. Free access to Medline through PubMed and access to many journals online is not an adequate substitute for the expertise and training that medical librarians can bring to all of the hospital staff that they serve.

Carol

Carol Jeuell, MSLS, AHIP
Children's Memorial Hospital, Chicago, IL
cjeuell@childrensmemorial.org

reducing the holes in the swiss cheese of access to evidence and knowledge.

2009-07-08T10:12:00.004-05:00

Interesting commentary in BMJ this past week:

Degos L, Amalberti R, Bacou J, Carlet J, Bruneau C. Breaking the mould inpatient safety. BMJ. 2009 Jun 29;338:b2585. http://dx.doi.org/10.1136/bmj.b2585

In this piece that calls for a broader approach to understanding and improving patient safety, the authors state:

"Safety may be defined as increasing the patient’s chance of receiving appropriate care that is in line with evidence based medicine. Any obstacle to such access is considered as a loss of chance and a potential failure of the health care system."

How many of our organization consider the potential failures associated with this statement?

Doesn't this quote beg for those of us that deal with the more explicit side of knowledge delivery (ie access to the published literature, guidelines etc) get more involved in helping organizations understand the obstacles to deliving care that is in line with evidence based medicine due to lack of access to the evidence that informs that care?

I recently had discussions with members of a team I work with that were frustrated with the lack of access to a primary scientific journal via their large academic insitutions library. We had to work around the system, ask yet another team member to send us what we needed. One article I need I still don't have. Good thing it wasn't for emergent clinical care, eh? Does that sort of inefficiency and evidence access failure have the potential to contribute to care problems? Interesting question.

We need to, as Susan Carr. editor of PSQH recently stated "shine our light" and weigh in on discussions involving access to knowledge and the "evidence" to understand how they impact safety. We should participate in blogs, online communities, and other tools to share what we know. If we have a seat at the "patient safety table" at our organizations, we should try and ask the right questions to help our peers and clinical colleagues understand this type of failure. We need to generate interest to help generate primary research opportunities and proactive failure analyses to understand how to best focus our efforts in this area.

If there are activities looking at the problems arrising from failure to access the appropriate bibliographic evidence in real time, please share your news about them here. I have to believe that someone out there is looking at this issue and is hopefully involving a myriad of professionals and individuals with personal (read patients and families) and work experience (read clinicians, administrators and "blunt end" professionals) in sorting out the problems. We all have a stake in making this piece of the safety pie less full of holes ;-).

Dialogue: a new tool for librarians to facilitate the sharing of knowledge

2009-06-11T10:49:00.002-05:00

Today’s environment for sharing information and knowledge is complicated. The variety of tools, styles, formats available affect our ability to communicate clearly and efficiently. Time is an issue as well. Nonetheless, with the plethora of technologies that can be customized for our specific needs, one would think communicating ideas would be easier – but alas, its not.

One method often relied upon to share the information and knowledge (Depending on how you define it) is the written text – in whatever format it is delivered. The management of explicit items is certainly the "mental model" most conjured up when librarianship is mentioned. But is that the only way we can contribute to knowledge sharing? Think again. I recently had a colleague profess that librarians needed to embrace dialogue as a tool to share knowledge rather than just providing articles and other explicit knowledge artifacts. He saw this as a way to remain viable in today's information rich environment.

This is an intriguing concept. It certainly builds on the KM notions outlined by Nancy Dixon in her book Common Knowledge (ISBN: 0875849040) where she present a structured process of team discussion and feedback as a mechanism for knowledge transfer in the corporate environment. So let’s think on how this concept might play out in health care.

Certainly the idea of transferring knowledge in small groups rings true in safety circles. With the recent interest in debriefs, daily huddles, collaborative rounding, walkarounds, and regular team / unit meetings, meeting to share "what the knower knows" enables a richness of exchange that helps create a mindfulness around both the work at hand and bigger picture issues that affect the safety of care. In addition, mindfulness is enhanced by these communication mechanisms that facilitate knowledge and information to be shared in real time in a context that allows for visible impact of that exchange.

In response to my colleague, then, can and should information professionals in health care facilitate and contribute to this activity? If you like this idea, then, what is the best marriage of our skill set with the function of dialogue? I recognize that it can’t happen always – especially at the sharp end of clinical care -- but the closer librarians are to the clinical team -- the more likely it is to happen. Certainly participating in these front line information exchange activities from time to time will inform any dialogue that takes place regarding information services. Having regular dialogue with front line staff may help improve the reliability of care process through more effective evidence delivery. A bridge to the "sharp end" dialogue process may be to participate in committee work. We should do this not only from a information service perspective but as an information and knowledge strategist. In addition – don’t forget to set up opportunities to talk to patients and families. Even if you don’t serve them directly, their needs and ideas should be folded into any health care knowledge sharing initiative: nothing about them, without them.

To close -- dialogue is also a key systems thinking tool. If info pros are to seen as systems thinkers, shouldn't’t they be comfortable demonstrating AND explaining the art of dialogue as a tool in THEIR information and knowledge sharing arsenal? I think so.

Dr House's knowledge sharing strategy.

2009-04-27T08:46:00.004-05:00

Any thoughts here? The poll that came out a few weeks back on TV doctors and their impact on the perception of physicians was interesting. For those of us who watch "House," we aren't surprised that Dr. Gregory House was seen by physicians as detrimental to their public persona.

However one feels about that, my query is more oriented to how House shares "what he knows" and thusly trains his staff to think the way he does -- both in good and bad ways. Now, I am not advocating that we all become gruff, pill popping professionals -- but what lessons can we learn from this character about effective knowledge transfer?

high reliablity in literature search work

2009-02-27T16:42:00.003-06:00

This issue has been of interest to me for a while.

Sampson M, McGowan J, Cogo E, Grimshaw J, Moher D, Lefebvre C.
An evidence-based practice guideline for the peer review of electronic search strategies.
J Clin Epidemiol. 2009 Feb 18. [Epub ahead of print]

The notion of the reliability of the evidence identification process has been of keen interest ever since the Hopkins IRB incident where a good intentioned researcher missed important information that was a part of the failure spiral that resulted in the death of a healthy research volunteer.

This article discussed the use of peer review and checklists (used to improve reliability in other facets of medical work) as a potential improvement mechanism for the evidence retrieval process. I hope by the time I get through the article, others have too - and we can chat about it here.

I hope Sampson and colleagues provide us all with backgound that will lend support to some failure analysis work in this area. I've been talking that up and pitching it for years --- perhaps a door will open now for the study this gap requires to fully understand it.

Nice example of CoP outcomes

2009-02-10T09:40:00.002-06:00

This free article illustrates some of the power of what can come from collaborative work for safety and quality improvement via the launch and support of a community of practice (CoP). As a knowledge sharing mechanism, I think CoPs can provide great opportunities for multidisplinary, multi-location teams to come together to get work done that might not get accomplished by one organization or one team.

Enjoy -

Alliance for Pediatric Quality: Creating a Community of Practice to Improve Health Care for America's Children
Paul V. Miles, Marlene Miller, Donna M. Payne, Robert Perelman, Mimi Saffer, Edward Zimmerman for the Alliance for Pediatric Quality
Pediatrics 2009; 123: S64-S66

KM in hospitals session

2009-01-15T07:35:00.004-06:00

I hope you'll join us for this session in Utah April 16-17th, 2009. We are excited about building on our successful 2007 Chicago workshop with a 1.5 event that engages teams from organizations (a librarian and a peer from outside the library) to help with developing KM strategies through the application of Appreciative Inquiry and Plan-Do-Study-Act mechanisms.

http://nnlm.gov/mcr/education/classes_knowledge_management.html

There is an application process for teams to be considered to participate and the deadline for submitting paperwork is Feb 6th.

Keeping track of external info to support internal learning

2009-01-07T16:55:00.002-06:00

I just wanted to bring these two articles to the group's attention:

Could it happen here? Learning from other organizations' safety errors.
Conway J. Healthc Exec. 2008;23:64-67.

Using external errors to signal a clear and present danger.
ISMP Medication Safety Alert! Acute Care Edition. November 6, 2008;13:1-2.

They both advocate for defined strategies to be implemented to help with the identification, dissemination and learning from published reports, news and stories about failure. I thought readers of this blog may find them useful in their efforts to get involved in safety work at their organizations.

Enjoy!

Social media and knowledge transfer in patient safety

2008-11-07T08:03:00.005-06:00

What draws patient safety people into using social media (defined as "a set of internet tools that enable a group of people with common interests to connect with one another to learn, play, work organize and socialize." 1

How can information professionals and library types help enable robust use of social media in this arena? What do users of social media WANT in an online community? What is the value proposition for this type of work? How do we engage busy practitioners, clinicians, risk managers, patients/families, librarians and other stakeholders to participate in an collaborative online environment? Do we have the time and funds to only rely on in-person and phone collaboration? It is a challenge to us as knowledge sharing professionals and "boundary spanners" to understand how to use this media as effectively as possible to support improvements in patient safety.

Any thoughts?

Any big, hairy audacious goals to share?

What are the "wicked questions" we must ask ourselves to move things along?

These should serve as interesting posts for us on this blog.

1) The Wisdom of Patients: Health Care Meets Online Social Media. Jane Sarasohn-Kahn. California Health Foundation. April 2008

Culture and knowledge management

2008-10-07T11:41:00.004-05:00

This article provides some thoughtful commentary on how culture and knowledge management intersect. For those of us in health care trying to affect knowledge transfer, I think the strategy of building projects that don't run upstream against the ingrained hierarchical culture, but get you in the door, per se, to establish tools that illustrate value, is a nice approach. Enjoy and share your thoughts!

‘Think of others’ in knowledge management: making culture work for you. (pdf)
Jay Liebowitz. Knowledge Management Research and Practice.2008;6:47-51.

Journal issue of interest

2008-08-17T16:12:00.002-05:00

September 2008, Volume 39, No. 4
Organizational Learning, Knowledge and Capabilities Conference Issue:
Guest Editors: Carole Elliott, Michael Rouse and Dusya Vera http://mlq.sagepub.com/content/vol39/issue4/

This looks interesting. I don't have access to the full text, but I would love to see articles focusing on these topics in the medical arena. We best get cookin' ;-).

Ask Me 3 implementation Stories

2008-07-31T08:57:00.002-05:00

I have a colleague who asks:

"Is anyone implementing or promoting the Ask Me 3 campaign (National Patient Safety Foundation), either at the institution or library level?

Would you be willing to share your experiences so far?

I searched the archives and found a few references to Ask Me 3, but nothing regarding programs in place.

Thanks for any information.

Laura Hickerson, MS, MLS, AHIP
Librarian, Connie Delaney Medical Library Valley View Hospital
1906 Blake Avenue
Glenwood Springs, Colorado 81601
970-384-6951 / lhickerson@vvh.org

Please share here or with Laura directly, so we can learn from your experiences.

Lack of access to older evidence via the published literature -- does this present a safety issue?

2008-07-29T14:10:00.003-05:00

I saw this recent study and thought a bit on how it might influence patient safety.

National Science Foundation. 2008. Research publications online: Too much of a good thing? July 18: Report abstract

I guess I see that an unintended consequence of this trend could be falure to find the best stuff for patient care and research. One of the factors in the Johns Hopkins research gap that resulted in the death of a healthy trial subject was lack of identification of older, yet relevant materials.

So shouldn't this trouble us?

Primary research opportunity - librarians, knowledge transfer and patient safety

2008-06-26T10:50:00.003-05:00

Colleagues:

Over the years I have expressed interest in looking at how knowledge management/transfer/sharing can affect patient safety. I think there is a lack of empirical "evidence" to help us and our colleagues really understand where the failures can happen in this process. We need these studies in order for us to fully design and implement effective and sustainable solutions!

There may be an opportunity out there to make some headway to fill that gap!

The World Health Organization's patient safety alliance has just announced a small grant program:

Small Grants for Patient Safety Research. WHO Alliance for Patient Safety.

They are looking for innovative ideas, new "young" researchers, multi-organizational projects --- which sounds good for those of us without primary research experience.

Areas of interest listed in the program's research priorities that may be most relevant to this blog's audience include:

Inadequate competencies, training and skills
Lack of appropriate knowledge and its transfer
Latent organizational failures
Health information technology and information systems

So - if anyone is up for working up an application, let's share some ideas here. There are a mix of folks that could make up the team -- librarians, researchers, human factors experis, organizational behaviorists, clinicans - maybe we can brainstorm some concepts and identify a group to submit a project. And I certainly recognize time constraints we all have --all the better reason to band together as appropriate.

Let's chat and thanks for considering this. I hope to hear from some of you.

Lorri

Knowledge management in medicine: a good read

2008-06-21T10:14:00.002-05:00

I recently had the opportunity to read this article:

Currie G, Waring J, Finn R. The the limits of knowledge management for UK public services modernization: the case of patient safeyt and service quality. Public Admin. 2008;86: 363-384.
Abstract

I really liked it because it provides a nice background discussion on:

what knowledge management is,
why knowledge management in the clinical environment is tough,
how the UK is using reporting mechanisms as knowledge management tools, and
what success should / can could look like.

The authors report on some observational research they did in the clinical environment to try and understand how the reporting function could actually play out 'in situ'. There work makes me think about trying to do similar projects with clinical collegues to try and discern other pieces of the knowledge transfer pie that need to be addressed to ensure reliable sharing of what we know to affect the safety of care.

Check it out and let me know what you think.

Insights from others

2008-06-13T08:45:00.003-05:00

I had the opportunity this week to speak at a KM Chicago meeting on opportunities for non-healthcare based info pros and Knowledge managers to contribute to improvements in knowledge sharing in the clinical healthcare environment. Lots of good thoughts, observations, ideas were kicked around ... but we needed more time!

I encourage others to hold similar dialogues in their organizations / professional communites. We all have a role in improving knowledge sharing to enhance patient safety. Please see this blog as one of your avenues for dissemination.

Hope to hear from you!

Facebook and Twitter as KM tools for health care?

2008-06-03T11:13:00.003-05:00

Are there any thoughts out there about the utility of Facebook and Twitter - for example - as being useful KM mechanisms for health care environments to embrace as KM tools?

I would like to see more exploration into the usefulness of these freely available tools as testing grounds for Community of Practice development and wondered what opinions or experiences were out there that we could draw from as an industry.

Let's brainstorm a bit!

Communities of Practice in Health Care

2008-04-21T11:40:00.002-05:00

This article discusses a Canadian CoP intiaitive that highlights the potential for this knowledge sharing strategy in the front lines of health care.

Communities of Practice: Creating Opportunities to Enhance Quality of Care and Safe Practices.
Debbie White, Esther Suter, I. John Parboosingh and Elizabeth Taylor.
Healthcare Quarterly, 11(Sp) 2008: 80-84

I would love to hear of other success stories that focus on CoPs as I think they have great potential for knowledge sharing to improve patient safety.

Lorri

Learning Organization assessment tool

2008-04-17T18:34:00.001-05:00

I wanted to share this article:

Garvin DA, Edmondson AC, Gino F.
Is yours a learning organization? Harv Bus Rev. 2008;86:109-116.

It's worth a look. They mention two examples that relate to the health care field. Edmondson has done a lot of work in the organizational behavior world in health care, so she is aware of the environment and how it can affect the way people in it interact. I love the fact the authors have crafted some measurable elements of a learning organziation, which of course, involves knowledge management, whether they use that word or not.

They also provide access to the tool they used and provide some benchmarks, which will be helpful for anyone trying to begin to understand how their organization learns, and if they efforts they put in place will have any impact over time.

One of the things I'd appreciate some discussion on is that they don't really differentiate between knowledge, information and evidence here. Do others feel that those terms need to be more explictly defined if we do any "deep dive" on the impact of KM initiatives and the professionals that faciltiate them?

Glad to be back!

Opportunity to contribute to safety improvements

2007-11-29T10:25:00.000-06:00

Another heparin error: learning from mistakes so we don’t repeat them.
ISMP Medication Safety Alert! November 29, 2007. 1-2

I am sure we have all heard about the recent Heparin overdose of the Quaid twins as it has gained a lot of press.

ISMP's take on how to help minimize reoccurrences of such errors is for organizations to be "mindful" of safety and fully adopt a learning culture. One of the strategies they suggest to help support a learning culture is for hospitals to be vigilant about learning from error EXTERNAL to their own organizations.

This strategy is one that librarians are well situated to impact through our research and networking skills. I hope that this article and the expertise and opinion of ISMP will be useful to those of you who are advocating for a role in your organization's patient safety efforts.

Knowledge management session announcement

2007-09-28T10:16:00.000-05:00

Knowledge Management in Hospitals: the Librarians Role

This 6-hour workshop will explore how the concepts of knowledge management as applied in the corporate environment could be realized in a hospital/health system. Participants will work together to craft a foundational strategy for adoption of an expanded role for librarians in hospital knowledge sharing efforts to support the clinical environment and its provision of high-quality care.

The purpose of the 6-hour interactive workshop is to:
• Engage participants to explore how a corporate-modeled knowledge management process might be enabled in hospitals.
• Craft a description of an optimal role for medical librarians in knowledge management.
• Share ideal examples of participation in knowledge sharing in hospitals – both traditional and expansive in nature -- from which to build a list of model activities. Tactics currently in the field include: building expertise directories, managing communities of practice, collecting and sharing best practices and stories to support clinical and organizational improvement.
• Draft processes to implement these tactics in hospitals to illustrate an expanded application of the expertise of information professionals, break down silos, share experiences and sustain organizational learning.
• Define how to test this role and measure its impact on the quality and safety of health care.
• Engage participants in testing in order to change and improve the role of librarians as partners in healthcare safety and quality.

Participants should commit to:
• Complete a modest amount of pre-work to prepare for the session (light introductory reading and 30-minute peer-to-peer pre-session interview).
• Engage with others in a positive way to ensure group interaction and consensus building.
• Partner with other participants to run a post-workshop pilot test of tactics described using the Plan-Do-Study Act concept.
• Review a white paper for broad dissemination to inform the profession and hospital leadership about knowledge management as an avenue for utilizing the expertise of the hospital librarian.
• Conduct a pilot project and report back to the group on their successes and “lessons learned” as a component of a learning session to be held in conjunction with the May 2008 MLA meeting in Chicago.

Audience: This session is primarily designed for hospital librarians. It will also interest corporate librarians, knowledge managers and hospital personnel with an interest in doing creative work to contribute to an understanding of how knowledge management can be applied in the acute care setting through modeling hospital corporate culture.

Date and time: Friday, November 16th, 2007 -- 10am to 4pm.

Cost: $20 (to cover working lunch and refreshments for the day).
Payment will be collected on site. Checks should be made out to: Resurrection Health Care.

Location: Our Lady of the Resurrection Medical Center
7th floor conference center
5645 West Addison Street, Chicago, IL 60634
Free parking available

To RSVP by November 5th contact: Beth Carlin, MALS, AHIP, Manager, Library Services
bcarlin@reshealthcare.org

The session will be limited to 30 participants to facilitate effective small group work.

For questions contact: Lorri Zipperer, Cybrarian and meeting facilitator.
Lorri@zpm1.com / 847-328-5075

This project has been funded in whole or in part with Federal funds from the National Library of Medicine, National Institutes of Health, Department of Health and Human Services, under Contract No. N01-LM-6-3503 with the University of Illinois at Chicago.

Info Failure Analysis

2007-07-25T08:48:00.000-05:00

Recently a colleague's quest to get a copy of an article while encountering erroneous automated responses regarding its free access illustrated one type of failure that can plague health care and potentially affect patient care.

What if this instance had been connected with a direct patient care emergency? What if it had been a clinician trying to find something after hours, just didn't have the time to figure out why access was denied, or didn't have colleagues (like other information providers) that would get him/her what they needed quickly?

Might I suggest that it would be an informative exercise to do a bit of proactive analysis of this type of situation to see what might be learned from it and teach our organizations about failures in the line of information access / knowledge transfer.

I've been working with colleagues at the VA's National Center for Patient Safety to develop a use of the
failure modes and effects analysis model

to help medicine understand these types of problems. But -- in the quest for safer patient care -- others should explore them as well. Please share your stories with us here.

Lorri

Lack of information support: impact on safety

2007-06-18T09:01:00.000-05:00

To support any discussions about the importance of having information and knowledge expertise available to support patient care, I share this analysis from my colleagues from the National Center for Patient Safety, who noted that in this recent ISMP analysis:

Fluorouracil Incident Root Cause Analysis Report.
Toronto, ON, Canada: Institute for Safe Medication Practices Canada. May 8, 2007.
http://psnet.ahrq.gov/resource.aspx?resourceID=5382

The lack of depth of information available in patient care is what struck them as they read this report. They state that sometimes you just have to get experts (like poison control people and information folks) into the mix because not all these things are easy to find by doing typical searches.

See Page 21 of the report(4th bullet most applicable)

Lack of information on medical management of previous fluorouracil overdoses

Information about the medical management of fluorouracil overdose was not readily available.

• Information about previous similar incidents is difficult to find or not available. The medical literature contains only scattered anecdotal reports. --Depends where you look.

• Sharing of information about adverse events in health care is not well developed.
Information in reporting programs for medication and device incidents is not transparent and is not consistently categorized using the same taxonomy, which increases the difficulty of accessing the limited information that is available. Again, depends where you look. Meyler's Side Effects of Drugs has all this information, easily retrievable. Information professionals are familiar with more resources than are other healthcare professionals.

• There is no standard definition for chemotherapy “overdose”. Fixed dose limits by agent cannot be reached because the drugs are dosed on an individual basis and the dosing rules vary by regimen.

• A poison information centre was not contacted for assistance. Immediate notification of a poison information centre might have yielded useful initial guidance and access to toxicology experts.

PAGE 35

Fluorouracil drug monograph not available in Compendium of Pharmaceuticals and Specialties

In the course of researching background information on fluorouracil, it was discovered that the Canadian manufacturer of fluorouracil injection, Mayne Pharma, has opted to include only a product description (instead of a complete monograph) in the Compendium of Pharmaceuticals and Specialties (CPS). As the CPS is often a “first check” source of drug information for health care professionals, this omission may make it more difficult for practitioners to quickly obtain information about potential adverse effects and management of toxic effects. A copy of the product monograph is included as a package insert with each vial of product; however this does not ensure availability of information to the end user for products (such as fluorouracil) that must be premixed by the pharmacy before dispensing.

Evidence-based information sharing standards change

2007-06-13T11:52:00.000-05:00

As you may be aware, the Joint Commission is in the process of what they are calling a “Standards Improvement Initiative (SII)”, which includes the deletion of IM.4.10 (Information-Based Decision Making) and IM.5.10 (Knowledge-Based Information). The elimination of both standards is detrimental to medical libraries, which in turn is detrimental to the provision of safe and fully information patient care. Leadership from the Medical Library Association are actively working to persuade the Commission to rethink this decision.

In the meantime, if anyone has strong feelings about this issue, please complete the proposed changes survey (See the link below.) In the survey, there are boxes to include comments and if you have data or published resources that illustrate the imporance of reliable access to the evidence in regards to patient safety, please include them and/or share them with us to help bolster any advocacy against the change.

http://www.jointcommission.org/Standards/SII/sii_im_personal_perspective.htm

CoP on Patient Safety for Librarians

2007-04-25T08:08:00.000-05:00

Last year I worked with collegues to develop a Community of Practice for Librarians on Patient Safety. I am now inviting you to join the modest initiative that has since then been launched at: https://librariansptsafetycop.wikispaces.com/

Please join us and help take this site from its infant stage to that of a robust, expert community that will share strategies and develop content to further the role of enhanced information and knowledge transfer in the reduction of medical error.

Regards,

Lorri

Defining KM in hospitals ... who is on the team?

2007-02-08T10:15:00.000-06:00

There was a conversation on medical librarians discussion list that addressed getting buy-in for work on knowledge management in hospitals. I wanted to share my response here.

I think this is an important need for the library profession to address within healthcare, but we first need to define what we mean and then see if it tracks with what both health care leadership and the clinical force thinks it is. I have been working on trying to translate these concepts effectively to engage health care in discussions on this topic, and it has been slow going. Only through improved dialogue will the translational work come together to help us really see and be able to measure the improvements and how they relate to the involvement of info pros. For example:

In some circles in medicine, KM tends to refer to patient records and decision support at the bedside. (see Davenport TH, Glaser J. Just-in-time delivery comes to knowledge management. Harv Bus Rev. 2002 Jul;80(7):107-11, 126.)

In other places -- notably the IHI 100,000 lives campaign (and recently launched 5 Million Lives Campaign) -- knowledge management is see as a component of their "framework for spread" that allows for the learning in the campaign hospitals to be spread throughout their organization and to others in medicine.

Massoud MR, Nielsen GA, Nolan K, Schall MW, Sevin C.
A Framework for Spread: From Local Improvements to System-Wide Change.
Cambridge, Massachusetts: Institute for Healthcare Improvement; 2006

The basic process IHI has implemented has been built -- as I understand it - on the ideas of a librarian, Nancy Dixon, and her book "Common Knowledge." (2000, HBSchool Press: ISBN: 0875849040.) It's a terrific book and I highly recommend it.

I have been advocating for an expanded role for librarians in this function for 10 years now. I see it as a key way we can contribute to safety improvements - through the sharing of stories, facilitating dialogue, convening learning groups and journal clubs, building knowledge maps, (Zipperer L, Gluck J, Anderson S: Knowledge maps for patient safety. Journal of Hospital Librarianship. 2002; 2(4): 17-35.), etc. As a patient safety fellow and as an alum of that group, I have been working on an assessment tool to try and understand how the process of knowledge management and transfer fits in with an organization's ability to learn - parts of that process certainly involve librarians in this important work.

It is a role I became convinced we could play early on in my work in patient safety--even developed a book proposal on it! - that alas has yet to be realized. I am VERY interested in seeing how a corporate model for knowledge management could play out in hospitals and how our profession can help implement it. I look forward to a continued "outside of the box" dialogue about this!

The IOM noted in 2004 that hospitals need to "use knowledge management practices to establish the organization as a "learning organization." (Keeping Patients Safe: transforming the work environment of Nurses (2004) IOM; pg 108.) The learning organization (born from systems thinkers) has been advocated is a key component to safety improvements in healthcare. There is a great need here -- it is a tremendous opportunity for us to play an empowered and effective role in improving the quality and safety of care.

Any experience from organizations on implementing knowledge mangaement programs, tools they may have created, teams put in place (hopefully involving librarians!) and other tidbits about realizing this in the field would be greatly appreciated.

Systems thinking and information work

2007-01-17T07:51:00.000-06:00

I wanted to share with you this article I wrote with my long-time friend and colleague Sara Tompson about the application of systems thinking to information and knowledge sharing work. As you might imagine, my interest in systems thinking came from its important role in improving medical error. I am interested in what you might think of this concept and its application a hospital environment.

Zipperer L, Tompson S. Systems thinking: a new avenue for involvement and growth. Info Outlook. December 2006;10:16-20.

Your thoughts are welcome.

The 2006 Survey of The Role of Information Professionals in Patient Safety

2006-11-07T07:52:00.000-06:00

Given the importance of effective information and knowledge delivery in medicine in relation to safe and effective patient care, we are interested in the opinions of librarians about how they feel they affect patient safety in their organizations. By asking you (if you work in an information capacity in your organization) or librarians you might work with to participate in our short survey (about 10 minutes to complete), we plan to:

1) Informally assess how information professionals are involved with patient safety initiatives,
2) Document how information professionals directly contribute to such initiatives by aligning themselves with this high-profile, leadership-valued issue.
3) Update our findings from the 2003 survey to mark improvements and note other important changes in the librarian activities related to patient safety work

To take the survey, pls visit:
www.surveymk.com/ps-libsurvey

Thank you for your time and your input! A drawing for an $25 Amazon gift certificate will take place for individuals who choose to leave their email addresses for this purpose.

Lorri Zipperer
Questions: lorri@zpm1.com

The impact of librarians on patient safety

2006-08-16T17:48:00.000-05:00

When I wrote my article on the role of librarians in patient safety for QSHC the editors made me take this comment out (see below) because it was anecdotal - even though I had a reference to an earlier interview from Lucian.

This is the example I use all the time about the importance - as tough as it is - for librarians to concern themselves with and figure out a way to track and measure the effect of the work they do. This story helps to illustrate why their management should be interested - in the IMPACT of the information and knowledge exchanges they facilitate rather than their focus "how many." On a sheet of paper about "how many searches did you do this month?" it would only be one tick mark. But look at the long term consequence!

Bravo to Bob Wachter and Lucian for sharing this story!

***************

From an interview with Lucian Leape. Complete interview here:http://webmm.ahrq.gov/perspective.aspx?perspectiveID=28.
RW = RobertWachtler, the interviewer, LL = Dr. Leape.

RW: As you were in the middle of that study, what was your sense of its potential?

LL: We always were convinced it was an important study, if nothing else,because of its magnitude. Looking at 30,000 patients gives you someclout. None of us had really thought much about the preventabilityissue, and nobody knew anything about systems, of course. We weren'tcompletely surprised by our results, because earlier work had shownsimilar findings. But we were, shall we say, dismayed to find that 4% ofpatients had adverse events. The surprise for me was that two thirds ofthem were caused by errors. I'll never forget-I went to the library oneday and did a literature search on what was known about preventingerrors, and I didn't find anything. And I went to the librarian andsaid, "I'm interested in how you prevent medical errors, and I've foundpapers about complications, but nothing much about errors." And I asked her to look over my search strategy because I was not finding anything.She looked at it and she said, "Well, your strategy looks all right.Have you looked in the humanities literature?" And I sort of looked ather and said, "The what?" I know what humanities are, mind you. But itreally never occurred to me. So she tried the same search strategy inthe humanities literature, and boom, out came 200 papers. I started toread them and discovered James Reason and Jens Rasmussen and all thosepeople. A year later, I came up for air and realized that we in healthcare could use this. If I didn't know how errors happen, most otherpeople wouldn't know it either. So I decided to write a paper.

RW: So, a medical school librarian set off the modern patient safetymovement?

LL: Ergo, there we go.

IOM report on medication errors

2006-07-21T09:16:00.000-05:00

Although this report is available now only in prepub version, it is highly likely to be influential.
One of the editors (Philip Aspden) was a speaker in the MLA webcast on patient safety last November.

Preventing Medication Errors: Quality Chasm Series.
Committee on Identifying and Preventing Medication Errors, Aspden P, Wolcott J, Bootman JL, Cronenwett LR, eds. Washington, DC: The National Academies Press; 2007.

I am anxious to look through it at find pearls that will inform and enhance the role of information and knowledge sharing in patient safety.

Watch here for further discussion after I read the report!

Lorri

Relationship between health literacy and medication errors

2006-06-21T09:51:00.000-05:00

I know that many of our colleagues in a variety of care and library settings are interested in health literacy, so I thought I'd share this review of current literature on the relationship between medication errors and literacy. The researchers found none, but encourage the field to continue studying the matter.

Warner A, Menachemi N, Brooks RG. Health literacy, medication errors, and health outcomes: is there a relationship? Hosp Pharm. 2006;41:542-551.

Does this present an opportunity for librarians to contribute to patient safety research?

Could be -

Beginning our Journey

2006-06-01T10:15:00.000-05:00

The MLA symposium on patient safety and librarianship is behind us now, and I can say that it went really quite well. We ended up with about 55 - 60 participants and had 10 speakers all together, which brought a nice mix of individuals into the event. Of course we ran out of time - each speaker could have gone on for much longer than the time allotted - but our goal was to present this issue to librarians from a variety of perspectives and help them think more broadly about safety from a safety science and cultural perspective, rather than provide "how to-s" and I think we were successful at that.

Our speakers seemed pleased with the opportunity to meet individuals outside their domains to understand patent safety from a different perspective. The presenter dinner we held for them the night before allowed for some networking between our group that we hope will provide for further exploration and "cross-pollination" between librarianship and pharmacy, hospital leadership, risk management, the VA and consumers in how librarians can contribute to safety. Several librarians came up to me after the session to say that they were there because their non-librarian colleagues in safety had suggested they attend, which was a positive thing. I hope they check in with those colleagues to talk about what they learned and to encourage more direct involvement and dialogue about patient safety work.

Also, for the first time since to Err is Human (that I am aware of), MLA had a nice range of papers presented on distinct patient safety roles for librarians and 6 posters (at quick glance). This profession is just beginning their journey to apply their expertise to safety -- so issues of culture, barriers, failure modes, human factors, etc didn't permeate the presentations and the applications were along traditional lines (literature review and support, pda training and content development) but I am very encouraged to see that platform now in place from which a deeper dialogue can be built.

I can only believe this is the beginning of some good stuff for patient safety in that we have yet another professional group coming into the fold to help us deal with the issue of medical error: librarians.

Bibilographic information and high reliability

2006-01-25T11:11:00.000-06:00

I think the notion of high reliability is a powerful one. Eloquently outlined by such thinkers as Karl Weick and Kathleen Sutcliffe in Managing the Unexpected, high reliability organizations operate in dangerous, volatile, complex environments yet experience very few accidents – given what one would expect. Aircraft carriers, air traffic control centers and hospital emergency rooms are examples Weick and Sutcliffe use to illustrate the concept.

What role does knowledge transfer play in high reliability? I heard a story recently from a clinical colleague who knew of an experience at a hospital where an obstetrician, faced with an emergent situation he’d never run across before, “Googled” to find some direction very quickly. It worked for him, but is that really the most reliable method? According to Giustini's recent editorial in the 24-31 December issue of BMJ - it just might be. However, when you think of the number of hits Google – can pull up, isn’t the patient lucky the physician found was needed quickly. Should knowledge transfer, thou, to be highly reliable, rely on “luck?”

So, how does access to literature and knowledge affect reliability? Does keeping up with the barrage of new medical “evidence” affect reliability? How do we make sure the conduits for that evidence base remain reliable and informed? How can that be measured? How do medical teams - both clinical and otherwise - manage the relationships between people who need to work together to ensure reliabile, unbiased, fully informed knowledge sharing?

Just more to think about as we begin another year of addressing these and other important issues related to knowledge transfer and patient safety.

Knowledge transfer failure analysis

2005-12-21T12:40:00.000-06:00

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

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

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

Competencies applied to KM work

2005-11-21T11:37:00.000-06:00

I recently spoke with a colleague who had recently been let go. As she reviewed her extensive experience, I thought of how well those could be applied to knowledge management. I am curious as to why some librarians don't see that connection right away!

Another colleague in the patient safety arena sent along this interesting article on how to make the best use of an organizations knowledge. There are some nice ideas in here. I especially appreciate the plug for the application of KM skills to health care. In addition, I see that the roles the author outlines could be applied to other professionals - this focuses on quality professionals -such as librarians, information managers and the like.

Let me know what you think!

Duke Okes. Corral Your Organization’s Knowledge One way to assess an organization’s performance is to determine how well it manages its critical knowledge. Quality Progrss. October 2005.

Translocational / translational knowledge transfer

2005-10-26T13:21:00.000-05:00

Playing Well with Others: “Translocational Research” in Patient Safety
by Robert M. Wachter, MD

NIH Launches Major Program to Transform Clinical and Translational ScienceOctober 12, 2005. Press Release - National Institutes of Health (NIH). Additional information.

I beleive these ideas present an opportunity for a unique positioning of the impact of knowledge management (KM) in scientific innovation. If we look at the transfer of knowledge and information as a way to diffuse and support creative, "outside the box" thinking to support patient safety and advances in the other sciences, what sort of a strategic positioning for KM does that require? Articulating this may provide our field with opportunities to have a more front and center role in the NIH program that follows Wachter's commentary.

Using colleagues as knowledge condiuts

2005-10-21T08:58:00.000-05:00

This article presents an interesting arguement that supports a concrete role for information professionals in clinical care. We all know that its easiest to ask a knowledgable colleague the answer to a question, but is it always the SAFEST thing to do?

Caution required when relying on a colleague's advice; a comparison between professional advice and evidence from the literature. Frederieke Schaafsma1 , Jos Verbeek2 , Carel Hulshof1 and Frank van Dijk1. BMC Health Services Research 2005, 5:59
http://www.biomedcentral.com/1472-6963/5/59

When we talk about high reliability in health care, it seems that this article illustrates that this way of getting answers may not be all its is touted to be. A behavior change is needed to build a working partnership with information professionals into the care process.

New Knowledge Transfer Roles

2005-10-21T08:56:00.000-05:00

Information behavior in the context of improving patient safety
Anu MacIntosh-Murray , Chun Wei Choo

Journal of the American Society for Information Science and Technology
Volume 56, Issue 12 , Pages 1332 - 1345
http://portal.acm.org/citation.cfm?id=1085017.1085025

I suggest that you read this interesting article. I have been watching the work of authors MacIntosh-Murray and Choo for some time. They have written on risk and information behaviors in the past and their thoughts run parallel to some of mine in regard to the role reliable information and knowledge transfer plays in creating safety and cultures that support safety. This article outlines several roles --boundary spanners is one I particularly like - that could be addressed by information professionals with the right training. Although they situate these roles on the clinical or sharp end of knowledge transfer , I see that librarians may well play these roles on the blunt end as well, helping to bridge gaps between hospital leaders and the clinicians.

Knowledge transfer and work arounds

2005-09-21T06:27:00.000-05:00

Thank you, Paul - for the selected list of materials on safety. (see welcome, post 2)

Of particular interest is "Fixing Health Care from the Inside, Today." Steven J. Spear. Harvard Business Review. Volume 83, #9, pg. 78-91. September 2005.

The speaker talks of work arounds and how they can become incideious factors that contribute to the unreliability of safe care. What information and knowledge seeking work arounds are prevelent in your environment? Ask yourselves the "Five Whys" behind the activity. What can be done to change them to make the information and knowledge transfer process more reliable?

Lorri

The corporate practice of KM and hospitals

2005-09-21T06:23:00.000-05:00

I was fortunate enough to attend the event recapped here last fall--and thrilled to have Jim Conway, a colleague and outside-the-box thinker when it comes to leadership and patent safety, actually MENTION knowledge management as a prospective tool to help leadership keep up with everything they need to know about patient safety! Note his comments in the transcripts section on Evidence headed up by Kaveh Shojania.

http://www.cmwf.org/usr_doc/IOM_transcript_Shojania.pdf

Thoughts on how to work with Leadership on this issue are appreciated.

Lorri

Welcome

2005-09-16T08:58:00.000-05:00

Welcome to Patient Safety: Focus on Information and Knowledge Transfer.

Patient safety is an exciting field. Here I hope to faciliate a multidisciplinary opportunity for the sharing of stories, successes and tools that illustrate the importance of effective information and knowledge delvery in patient safety. We can all learn from each other - so please invite patients, safety scientists, physicians, nurses, organizational behaviorists and others that you feel might be interested in the discourse to join us.

Let the conversation begin!