MLA Midwest/Midcontinental Chapter Joint Meeting

October 14, 2007

Patient Safety: Librarian as Advocate http://nnlm.gov/training/patientsafety/advocacy.html

Holly Ann Burt, MLIS, MDiv

Dr. Robert Wachter:

So, a medical school librarian set off the modern patient safety movement?

Lucian Leape, MD:

Ergo, there we go.

Librarians are Key

Wachter R. In conversation with Lucian Leape, MD. WebM&M. 2006(Aug): Perspectives on Safety. http://webmm.ahrq.gov/perspective.aspx?perspectiveID=28

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“I would give great praise to the physician whose mistakes are small, for perfect accuracy is seldom seen… .” Hippocrates, trans. by Francis Adams. On Ancient Medicine, Part 9; c. 400 BCE.

Traditional Errors in Surgery. Levis RJ. Presidential Address, Medical Society of the State of Pennsylvania on June 6, 1888. JAMA. 1888 (Jun 23);10(25):790-791.

To Err is Human: Building a Safer Health System. Kohn LT, Corrigan JM, Donaldson MS. Washington, DC: National Academy Press; 2000.

Patient Safety: Ongoing Problem

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Sources of Patient Safety Concepts

Aviation Industry– Federal Aviation Authority (FAA)

Aviation Safety Reporting System (ASRS) – 1975 Aviation Safety Action Program (ASAP) – 2000

– National Aeronautics and Space Administration (NASA)

NASA Safety Reporting System (NSRS) – 1987

– Department of Defense (DOD) Patient Safety Center (Armed Forces Institute

Pathology) – 2001

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Sources of Patient Safety Concepts

Transportation Industry– National Transportation Safety Board (NTSB) –

1966 – UK Railway Industry

Confidential Incident Reporting & Analysis System (CIRAS) – 1996

– Australian Transport Safety Bureau (ATSB) Confidential Marine Reporting Scheme (CMRS) – 2004

– Federal Railroad Administration (FRA) Confidential Close Call Reporting System (C3RS) – 2005

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Sources of Patient Safety Concepts

Nuclear Energy Industry– US Nuclear Regulatory Committee (NRC) – 1974 – Computerized Accident Incident Reporting and

Recordkeeping System (CAIRS) -1975

Manufacturing Industry – Toyota Production System – 1977 – Alcoa Aluminum: Safety Culture – 1987 – General Electric: Six Sigma - 1995

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How is Your Library

Involved in Patient Safety

(or how will it be)?

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With Literature Searches– Stat for Emergency Room– Nursing Education Department– Monthly Infection Control Reports– Drug Use and Clinical Adverse Events– Patient/Family Questions– Specifics Adverse Events, FMEAs, RCAs– Research Studies

Library Leadership

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In Training & Education– Student Curriculum development– CME/CNE/CE requirements assistance – Including patient safety when focusing on

computer skills, EMB, searching, etc.– During orientation classes and introductions– On-line tutorials and resources preparation– In reference services, e.g. with patients and

families, health professionals

Library Leadership

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Participation– On Patient Safety committees, teams and boards– Attending related M&Ms, councils, committees

and meetings– (Hospitals:) On Rounds, providing RCA support

Connect and Educate– Safety Officers, Advocates and Directors– Executives: CEO, CNO, CME and others– Institutional leaders: Directors, Lawyers, Liaisons

Library Leadership

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Creating & Sharing Information– Through Alert Services

Recalls, Tables of Contents, Clinical Alerts, Drug Updates, Diseases and Treatments

– Supporting Institutional Resources and Needs Balanced Score Card, Indicators, Legislation Magnet Status, Joint Commission preparations Policies, Procedures, Employee Handbooks

Library Leadership

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Creating & Sharing Information– For Patient Education

Brochures, Flyers, Surveys Supporting nurses and patient educators

– In Telling Stories Of library involvement, institutional

successes, individual joys or concerns In Newsletters, on Blogs, with Articles,

through the Intra- or Internet

Library Leadership

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On the Website– Information Pages

On library contributions to patient safety For patients and families For advocates and liaisons For health professionals and first responders For students and researchers For institutional leadership - executives,

directors, managers, officers, and others For those involved with legislation issues

Library Leadership

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On the Website– Current News

Evidence Based & Benchmarking information Alerts – Clinical, Drug, Consumer, etc. How the Institution is involved in patient

safety; Institutional progress in specific areas Patient Safety Campaigns Legislation affecting the institution (Hospitals:) Good Catch Librarians making a difference

Library Leadership

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And MORE: – Health Fairs

Mishap Mansion/Room of Horrors Patient Safety Awareness Week

– In the community Assist at community affairs department

projects Partner with other libraries Serve as Community Liaison to professional

advisory committees

Library Leadership

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And ….

Library Leadership

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In Summary:

All of the roles of the library ultimately support Patient Safety

- Michelle Eberle, 2007

Library Leadership

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Patient Safety: Librarian as Advocate http://nnlm.gov/training/patientsafety/advocacy.html

Holly Ann Burt, MLIS, MDiv