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

1. Patient Safety: Librarian as Advocate http://nnlm.gov/training/patientsafety/advocacy.html Holly Ann Burt, MLIS, MDiv MLA Midwest/Midcontinental Chapter Joint Meeting October 14, 2007

2. Librarians are Key • Dr. Robert Wachter: So, a medical school librarian set off the modern patient safety movement? • Lucian Leape, MD: Ergo, there we go. Wachter R. In conversation with Lucian Leape, MD. WebM&M. 2006(Aug): Perspectives on Safety. http://webmm.ahrq.gov/perspective.aspx?perspectiveID=28

3. Patient Safety: Ongoing Problem • “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.

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 (C3RS) – 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. Library Leadership • 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

9. Library Leadership • 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

10. Library Leadership • 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

11. Library Leadership • 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

12. Library Leadership • 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

13. Library Leadership • 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

14. Library Leadership • 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

15. Library Leadership • 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

16. Library Leadership • And ….

17. Library Leadership In Summary: All of the roles of the library ultimately support Patient Safety - Michelle Eberle, 2007

18. Patient Safety: Librarian as Advocate http://nnlm.gov/training/patientsafety/advocacy.html Holly Ann Burt, MLIS, MDiv