**Patient Safety: Librarian as Advocate**

<http://nnlm.gov/training/patientsafety/advocacy.html>

**Instructors Guide**

**Course Preparation**

**Handout ahead of time:**

Agenda

Patient safety at your institution: where to connect

Patient Safety Advocacy Suggestions

Group Discussion Composite: Resources Medical Librarians Can Offer

Bibliography

**Also needed:**

Projector for PowerPoint

**Personalize:**

PowerPoint

-   Part I -- Include your name, the date, and the organization to which
    you are presenting the program on the first side

Other handouts may be included as desired

**SCRIPT NOTES** (also on the slides)

**Introductory slides**

[Hippocrates]{.underline}

"Father of modern medicine" and the author of the phrase "Do no harm".
{Hippocrates}

[Traditional Errors in Surgery.]{.underline}

Dr. Richard J. Levis gave the Presidential Address to the Medical
Society of the State of Pennsylvania on June 6, 1888. {Levis}

[To Err is Human]{.underline}

First of the *Quality Chasm Series* published by the Institute of
Medicine and available online through the National Academies Press --
www.nap.edu {Kohn}

**Sources of Patient Safety Concepts**

Many concepts for use in the healthcare system have come from the
aviation and transportation industries, for example the need for
teamwork training for flight crews, error reporting systems, and how to
investigates accidents

Aviation Industry {Frankel (2004), Kao}:

> FAA - http://www.faa.gov/
>
> ASRS - http://asrs.arc.nasa.gov/
>
> NASA - http://www.nasa.gov/
>
> NSRS - http://www.hq.nasa.gov/office/codeq/nsrs/

Transportation {Spencer}:

> NTSB - http://www.ntsb.gov/

\_\_\_\_\_\_

Understanding safety cultures and the need for measuring processes come
for other industries.

Nuclear Industry {Webster}:

NRC - http://www.nrc.gov/

CAIRS - http://hss.energy.gov/csa/analysis/cairs/

Manufacturing Industry{Spencer}:

Toyota {Furman} - http://www.toyota.co.jp/en/vision/production_system/

Alcoa -
http://www.alcoa.com/global/en/about_alcoa/sustainability/health_safe_approach.asp

GE {James} - http://www.ge.com/annual97/sixsigma/

**Librarians are Key**

> From "In conversation with Lucian Leape", father of the modern patient
> safety movement. {Wachter}

**Dr. Robert Wachter, Editor, AHRQ WebM&M:** As you were in the middle
of that study, what was your sense of its potential?

**Dr. Lucian Leape:** We always were convinced it was an important
study, if nothing else, because of its magnitude. Looking at 30,000
patients gives you some clout. None of us had really thought much about
the preventability issue, and nobody knew anything about systems, of
course. We weren\'t completely surprised by our results, because
[earlier work](http://psnet.ahrq.gov/resource.aspx?resourceID=1586) had
shown similar findings. But we were, shall we say, dismayed to find that
4% of patients had adverse events. The surprise for me was that two
thirds of them were caused by errors. I\'ll never forget---I went to the
library one day and did a literature search on what was known about
preventing errors, and I didn\'t find anything. And I went to the
librarian and said, \"I\'m interested in how you prevent medical errors,
and I\'ve found papers about complications, but nothing much about
errors.\" And I asked her to look over my search strategy because I was
not finding anything. She looked at it and she said, \"Well, your
strategy looks all right. Have you looked in the humanities
literature?\" And I sort of looked at her and said, \"The what?\" I know
what humanities are, mind you. But it really never occurred to me. So
she tried the same search strategy in the humanities literature, and
boom, out came 200 papers. I started to read them and discovered [James
Reason](http://psnet.ahrq.gov/resource.aspx?resourceID=1592) and [Jens
Rasmussen](http://psnet.ahrq.gov/resource.aspx?resourceID=1491) and all
those people. A year later, I came up for air and realized that we in
health care could use this. If I didn\'t know how errors happen, most
other people wouldn\'t know it either. So I decided to write a paper.

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

**LL:** Ergo, there we go.

**Librarian Leadership**

[In Training & Education (including CE and CME)]{.underline}

> 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

[On the Website -- Current News]{.underline}

Lift up Current News, for example recent evidence based research (and
provide recent articles/reports), benchmarking information, alerts

Include celebrations: "Good Catch"; System changes due to FMEA, other

> Include availability of library/librarians
>
> Include reporting resources

[Connect and Educate]{.underline}

> Visit nursing stations, departments & people
>
> For example, put icons on nursing computers
>
> Support Magnet Status & JCAHO IM requirements

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| ![](medi  | **National Network of Libraries of Medicine -        |   |
| a/image1. | Greater Midwest Region**                             |   |
| wmf){widt |                                                      |   |
| h="0.8in" | *Funded by the National Library of Medicine under    |   |
| h         | contract NO1-LM-6-3503 with the*                     |   |
| eight="0. |                                                      |   |
| 53125in"} | *University of Illinois at Chicago Library of the    |   |
|           | Health Science*s                                     |   |
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