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  • 04/16/10 NNLM
  • 04/16/10 NNLM
  • 04/16/10 NNLM   “ Father of modern medicine” and the author of the phrase “Do no harm”. {Hippocrates}   Dr. Richard J. Levis gave the Presidential Address to the Medical Society of the State of Pennsylvania on June 6, 1888. {Levis}   First of the Quality Chasm Series published by the Institute of Medicine and available online through the National Academies Press – {Kohn}
  • 04/16/10 NNLM Aviation: Many concepts for use in the healthcare system have come from aviation, for example the need for teamwork training for flight crews and in the operating room and human and machine interactions called human factors. Many of the current reporting systems are based on in part on the Aviation Safety Reporting System. {Frankel (2004)}{ Kao} FAA - ASAP - ASRS - ASHDI - DOD - NASA - NSRS -
  • 04/16/10 NNLM Transportation: The National Transportation Safety Board (NTSB) investigates accidents in the areas of Aviation, Highways, Marine and Pipeline & Hazardous Materials, and Railroads. Some today argue for the creation of a National Patient Safety Board along the same lines as the NTSB. Recent studies in fatigue in the railroad industry are making their way into the patient safety arena. {Dorrian}{Spencer} NTSB - FRA - C3RS - CIRAS -
  • 04/16/10 NNLM Nuclear/Manufacturing: Additional studies on human and machine interactions, the need for a safety culture and measuring process come from the nuclear energy and the manufacturing industries. Applications for patient safety come from a variety of sources. Nuclear {Webster}: NRC - CAIRS - Manufacturing {Spencer} Toyota {Furman} - Alcoa - health_safe_approach.asp GE {James} -
  • 04/16/10 NNLM
  • 04/16/10 NNLM The first step is recognizing that all the literature searches you do address aspects of patient safety. For some libraries, just making their administration aware of the work done in this area is a major watershed.
  • 04/16/10 NNLM Where are you already reaching your constituents in training and education? How can the existing programs be adjusted to include patient safety topics, issues and concerns? What new programs could and should be developed and for which groups? In orientation classes, at seminars, during resource council meetings, in other and individual settings. Helping develop the student curriculum Pointing to existing CE, CNE & CME requirements Sharing during reference services activities
  • 04/16/10 NNLM The next step is to moving beyond the physical library and into the institution itself. What existing patient safety organizations, committees, boards, meetings do you attend or can you get invitations to? Visit nursing stations, departments & people - For example, put icons on nursing computers Support Magnet Status & Joint Commission requirements
  • 04/16/10 NNLM OR lift up on later slides Create Information Pages for patients and families, and for employees and health professionals Include celebrations: “Good Catch”; System changes due to FMEA, other Lift up Current News, for example recent evidence based research (and provide recent articles/reports), benchmarking information, alerts Include availability of library/librarians Include reporting resources
  • 04/16/10 NNLM One of the most important advocacy activities may simply be in telling stories. What is happening and who is successful? How have patient safety solutions been found? What can be celebrated in the area of patient safety, improved health care, good catches, patient involvement?
  • 04/16/10 NNLM Examples
  • 04/16/10 NNLM
  • 04/16/10 NNLM Partnerships: for example between hospital and public libraries
  • 04/16/10 NNLM
  • 04/16/10 NNLM
  • Transcript

    • 1. Patient Safety: Librarian as Advocate Holly Ann Burt , MLIS, MDiv MLA Midwest/Midcontinental Chapter Joint Meeting October 14, 2007
    • 2.
      • 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.
    • 3.
      • “ 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
    • 4. 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
    • 5. 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 (C 3 RS) – 2005
    • 6. 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
    • 7.
      • How is Your Library
      • Involved in Patient Safety
      • (or how will it be)?
    • 8.
      • 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
    • 9.
      • 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
    • 10.
      • 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
    • 11.
      • 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
    • 12.
      • 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
    • 13.
      • 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
    • 14.
      • 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
    • 15.
      • 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
    • 16.
      • And ….
      Library Leadership
    • 17.
      • In Summary:
      • All of the roles of the library ultimately support Patient Safety
      • - Michelle Eberle, 2007
      Library Leadership
    • 18. Holly Ann Burt , MLIS, MDiv Patient Safety: Librarian as Advocate