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Patient Safety: Librarian as Advocate Holly Ann Burt , MLIS, MDiv. MLA Midwest/Midcontinental Chapter Joint Meeting October 14, 2007. Librarians are Key. Dr. Robert Wachter:

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Patient safety librarian as advocate http nnlm gov training patientsafety advocacy html l.jpg

Patient Safety: Librarian as Advocate

Holly Ann Burt, MLIS, MDiv

MLA Midwest/Midcontinental Chapter Joint Meeting

October 14, 2007

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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.

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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.

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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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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

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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

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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

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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

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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

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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

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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

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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

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Library Leadership

In Summary:

All of the roles of the library ultimately support Patient Safety

- Michelle Eberle, 2007

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Patient Safety: Librarian as Advocate

Holly Ann Burt, MLIS, MDiv