# Presentation: 909578

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

- October 14, 2007

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

**Holly Ann Burt**, MLIS, MDiv

## “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.

- 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**

**Notes:**
Dr. Richard J. Levis

## Aviation Industry
Federal Aviation Authority (FAA): Aviation Safety Reporting System (ASRS) – 1975 
National Aeronautics and Space Administration (NASA) : NASA Safety Reporting System (NSRS) – 1987
Transportation Industry
National Transportation Safety Board (NTSB) – 1966 

**Aviation Industry**
- Federal Aviation Authority (FAA): Aviation Safety Reporting System (ASRS) – 1975
- National Aeronautics and Space Administration (NASA) : NASA Safety Reporting System (NSRS) – 1987
**Transportation Industry**
- National Transportation Safety Board (NTSB) – 1966

## 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

**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

## Dr. Robert Wachter: 
	So, a medical school librarian set off the modern patient safety movement?

Lucian Leape, MD: 
	Ergo, there we go.

**	****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

## How is Your Library 
Involved in Patient Safety
(or how will it be)?

**Involved in Patient Safety**
**(or how will it be)?**

**Librarians are Key**

## 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

- 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

**Librarian 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

- 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

**Librarian Leadership**

## Encouraging Patient Involvement
Individual Advocacy
Seeking and sharing information
Patient Advocate
Going with the patient, asking questions
Patient Representative
In hospitals and other institutions
Patient Participant/Activist
With local, state, national and international organizations

**Individual Advocacy**
- Seeking and sharing information
**Patient Advocate**
- Going with the patient, asking questions
**Patient Representative**
- In hospitals and other institutions
**Patient Participant/Activist**
- With local, state, national and international organizations

**Librarian Leadership**

**Notes:**
Individual Advocacy {Gibson}
Patient Advocacy {NPSF} 
Patient Representative {Frankel (2005)}
   More and more hospitals are including patient representatives on committees, boards and even rounds.  
   Some hospitals include patient families in their studies of events (e.g. root cause analysis) {Munch}
Patient Participant/Activist  {Gibson} 
   Being aware of legislation, being on discussion lists, participating in groups

## 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

- 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

**Librarian 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 

**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

**Librarian 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
Policies, Procedures, Employee Handbooks

**Through Alert Services**
- Recalls, Tables of Contents, Clinical Alerts, Drug Updates, Diseases and Treatments
**Supporting Institutional Resources and Needs **
- Balanced Score Card, Indicators, Legislation
- Policies, Procedures, Employee Handbooks

**Librarian Leadership**

## On the Website
Information Pages
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

**Information Pages**
- 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

**Librarian 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

**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

**Librarian Leadership**

## And MORE:  
Health Fairs 
Mishap Mansion/Room of Horrors
Patient Safety Awareness Week
In the community
Assist at community affairs department projects
Accept speaking engagements
Serve as Community Liaison to professional advisory committees

**Health Fairs **
- Mishap Mansion/Room of Horrors
- Patient Safety Awareness Week
**In the community**
- Assist at community affairs department projects
- Accept speaking engagements
- Serve as Community Liaison to professional advisory committees

**Librarian Leadership**

## 
And ....

**And ....**

**Librarian Leadership**

## In Summary:

All of the roles of the library ultimately support Patient Safety

- Michelle Eberle, 2007

** **
**All of the roles of the library ultimately support Patient Safety**
**- Michelle Eberle, 2007**

**Librarian Leadership**

## Holly Ann Burt, MLIS, MDiv

- Holly Ann Burt, MLIS, MDiv