Searching for stuff: patient safety, DXerror and RCA info. Places to start

I 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.
....

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.

As with any patient safety topic—I always suggest that folks start with AHRQ’s Patient Safety Network:
http://psnet.ahrq.gov/. 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.

Check out the primers on both DxError, RCA and failure analysis – all three touch on your question:
http://psnet.ahrq.gov/primer.aspx?primerID=12
http://psnet.ahrq.gov/primer.aspx?primerID=10
http://psnet.ahrq.gov/primer.aspx?primerID=24

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: http://www.ahrq.gov/research/findings/evidence-based-reports/ptsafetyuptp.html

There is one on DxError:
http://www.ahrq.gov/research/findings/evidence-based-reports/services/quality/patientsftyupdate/ptsafetyIIchap35.pdf
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.
http://www.ahrq.gov/research/findings/evidence-based-reports/services/quality/patientsftyupdate/ptsafetyIIapc.pdf

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.

Lastly -- here is an article --  (wish it was free: the first author happens to be a contributor to my new Patient Safety book: https://www.routledge.com/products/9781409438571: )-- that also provides some thinking about search in patient safety: http://qualitysafety.bmj.com/content/19/5/452

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!

Hope it helps.

Middle managers as boundary spanners: a UK study of interest

I 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.

Ward V, West R, Smith S, McDermott S, Keen J, Pawson R, et al.
The role of informal networks in creating knowledge among health-care managers: a prospective case study. Health Serv Deliv Res 2014;2(12).
Information and free full text
Summary

A quick thought after a first glance at the publication:

This report highlights the importance of the water cooler “method” of sharing knowledge. In the work reflected in my recent book 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.

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?

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.

Dialogue: a tool to facilitate the exchange of knowledge

Today’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.

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.

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?

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, walkarounds 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.

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.

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.

Listservs: knowledge or info sharing? Effective use helps with both - a holiday jingle

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 ;-).

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).

12 ways of listserv etiquette (sung to the tune of the 12 days of Christmas)

© Lorri Zipperer 2013

(thanks to Ruth Ryan and Susan Carr for their editorial comments)

My first day on the listserv, the moderator said to me…

A proof-read reply is preferred

My second day on the listserv, the moderator said to me…

Please sign your name ... 

My third day on the listserv, the moderator said to me…

No “me too’s” ... 

My fourth day on the listserv, the moderator said to me…

This isn’t Twitter! ... 

My fifth day on the listserv, the moderator said to me…

Remove banners from other posts! ... 

My sixth day on the listserv, the moderator said to me…

No published attachments ... 

My seventh day on the listserv, my moderator said to me:

Search archives for answers ... 

My eighth day on the listserv, my moderator said to me:

Change “subject” as needed ... 

My ninth day on the listserv, my moderator said to me:

Always be polite ... 

My tenth day on the listserv, my moderator said to me:

Address as appropriate ... 

My eleventh day on the listserv, my moderator said to me:

Curtail repetition ... 

My twelfth day on the listserv, my moderator said to me:

Talk off-line and recap ... 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.

Happy Holidays!

Knowledge gathering important to evidence application in the innovation process

This 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.

Incorporating evidence review into quality improvement: meeting the needs of innovators.
Danz MS, Hempel S, Lim YW, Shanman R, Motala A, Stockdale S, Shekelle P, Rubenstein L.
BMJ Qual Saf. 2013 Jul 5; [Epub ahead of print]
http://qualitysafety.bmj.com/content/early/2013/07/04/bmjqs-2012-001722.full.pdf

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.

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.

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?'

I think not.

Failing 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).

Part 1
Part 2

Failing in order to succeed: Part 3

Reaping the wild wind of failure

By Lorri Zipperer

Lorri Zipperer
Zipperer Project Management
www.zpm1.com
Albuquerque, NM
Copyright 2013

 

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.

 

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.

   

Next actions:

These apply to both organisational and individual “learning from failure” commitments

·       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.

·       Dig deep to get to the second story of failure / avoid blame and look at problems from a systems view

·       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.

·       Review additional reading and discuss what is provocative with others.

 

Additional reading:

Choo CW. Information failures and organisational disasters. Sloan Management review. Spring 2005;8-10.

Edmondson A. Strategies for learning from failure. Harvard Business Review. April 2011;89:48-55.

"Brilliant Mistakes": Finding Opportunity in Failures. Knowledge@Wharton

Zipperer, L. A future in failure? You bet. SLA 365 blog. Dec, 2011

Failing 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).

Failing in order to succeed. Part 2:

Lorri Zipperer
Zipperer Project Management
www.zpm1.com
Albuquerque, NM
Copyright 2013

Learning and the failure librarian

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.

Librarians are well suited to contribute to learning from failure by:

• Being appreciative of leaders and administrators and what makes them tick
• Understanding of organisational boundaries and silos and how to navigate them for knowledge and information identification;
• Identifying external evidence that could help recognize factors contributing to failure, minimize their impact and inform next steps, and;
• Distributing external stories of failure organisation-wide to raise awareness of problems plaguing others to proactively flag risk in-house.

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.

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.

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:

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.

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.

The problems in this scenario beyond the obvious lack of a complete literature review could include the librarian’s:

• Failure to provide feedback to her colleague to improve his work.
• Failure to approach her peer to offer services and get directly involved in the project
• 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.
• 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.

Part 3 will describe next actions to the concept of the failure librarian to both organisational and individual commitments to learning from stumbles.

Part 1 is available here:

Failing in Order to Succeed: Part 1

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).

Failing in Order to Succeed: Part 1
See: Part 2, Part 3

By Lorri Zipperer
Zipperer Project Management. Albuquerque, NM lorri@zpm1.com
Copyright 2013

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.

Failure due to design or deviation
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.

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.

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.

Failure needs a learning strategy to plant seeds
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.

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.

Individual prism
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.

We can do that by:

• Admitting when we screw up

• Backing away from blame (either on yourselves or others)

• Being aware of overconfidence and bias

• Seeking opportunities to learn from personal blunders

• Sharing learnings in a transparent way

• Enlisting others to help minimize negative reactions to failure; and

• Exploring opportunities for improvement both within and outside our box.

Organisational prism
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:

• Translating their personal experiences into test cases for unit and team improvement

• Using knowledge-sharing techniques to apply failure-ignited insights to tools, trainings, and tactics

• Infusing an awareness of failure into data, information and evidence-delivery strategy and technology development

• 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

Part 2 will submit there is a role for the information professional in assisting in learning from failure at an organizational level.

Lack of use of evidence...can that REALLY be safe?

Interesting from a safety perspective: barriers to the use of evidence 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!

March 13, 2013 Webcast: Librarians as partners in Dxerror prevention

Register now for the Medical Library Association's March 13th webcast, “Partnering to Prevent Diagnostic Error: Librarians on the Inside Track.” Click here for more information and to sign up!

KMHCare Workshop: application deadline extended to Dec 7th

I 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 here to learn more and apply. Hope to see you in Chicago!

Diagnostic Error: A Multidisciplinary Exploration

Instructors: 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 costs. 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 class description for more information.

Learning 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 here: 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.

Fatigue as a culprit in blunt-end info/knowledge sharing failure

I 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 discussion 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?

Info pros as strategists for patient safety EIK improvement

Any 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?

Gardois P, Calabrese R, Colombi N, et al. Effectiveness of bibliographic searches performed by paediatric residents and interns assisted by librarians. A randomised controlled trial. Health Info Libr J. 2011 Dec;28(4):273-84
http://www.ncbi.nlm.nih.gov/pubmed/22051126

Any outside the box thinking would be of value, as this story is not being translated as effectively as it could be.

A 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!


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 ....

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!

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

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!

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.