Rosalind K. Lett, MLS, AHIP Knowledge Cartel Safety First: Proactive Approaches to Patient Safety

Rosalind K. Lett, MLS, AHIP Knowledge Cartel

Safety First:

Proactive Approaches to Patient Safety


Let’s start with a tale about a clinical trial…


The Clinical Trial

Healthy research volunteerIncomplete literature search doesn’t

reveal relative adverse drug effectsWoman dies due to involvement in

clinical trial


Why did this happen? Possible failures include…

Researcher overconfident about research skills

Inaccessibility of librarians Incomplete search methodology Researcher didn’t know what he didn’t

know Researcher didn't’ t realize the value of

the librarian.


Why, why, why?

Researcher was pressured, tired, interrupted

Missed cues in the literature reviews No double-check of results with the

experts Lack of awareness of library services Lack of full text availability


What impact did this clinical trial have on medical libraries

It gave us a case to site when we attempt to justify our value & ….

It helps us confidently explain

why it’s critical that medical librarians be included in patient safety issues and committees.


Closing the Chasm

“Between the health care we have and the health care we could have lies not just a gap, but a chasm”

IOM, “Crossing the Quality Chasm” (2001)


An organization totally in-sync with patient safety. What’s it look like? A place with no needless: Deaths Pain Delays Helplessness Waste Medication Errors Misdiagnosis


An In-Sync Health Care Organization

Collaborative Environment Patient Focused Great Place to Work Plentiful Financial Resources (especially

for the library) Big Picture Thinking


What is Big Picture Thinking?

It’s a process of taking a step back and evaluating all of the potential issues that may make a proposed project difficult to make a reality.


What does BIG PICTURE THINKING DO?

Moves Us From the Immaterial to the Important.

Moves Us From Apathy To Action! Moves Us from Fear to Fantasizing

about the possibilities!


Where is our greatest potential to facilitate Big Picture Thinking? Breaking down complex problems

involves helping health care providers see the connectedness of the “big picture” and not just their part

Recurring problems or those that have been made worse by past attempts to fix them

Problems where solutions are not obvious


So…. What does that have to do with me?

“ONLY by changing how we interact can shared visions, shared understanding, and new capacities for coordinated action be established;”

Senge (1994) as quoted in Ray


How can medical librarians impact patient safety?

Help find new ways of looking at things Encourage information/knowledge

sharing to minimize uninformed decisions

Drive desire to seek deeper understanding of complex situations

Open doors to collective thinking and partnerships


More Impact

Facilitate integration of library services and expertise into the hospital

Disseminate innovations through understanding of a learning environment


Are you making an impact?

Is your library interconnected? Can you identify the key stakeholders to

partner with? Do you have a personal mastery of “the

big picture?” Do you routinely have dialogues with

other departments, (IT, physicians and/or administration)?


Are you actively involved in preventing medication errors?

Patient Information Patient Education Consumer Health Information Drug Information


Health literacy is a issue that affects patient safety

90+ Million American suffer from low health literacy

Inadequate literacy increases hospitalization by 50%

JAMA study reveals 39% of patients could not understand simple instructions on a pill bottle.

Rosalind K. Lett MLS, AHIP Knowledge Cartel

Are You Promoting Health Information Literacy?

Recognize health information need

Identify likely information sources

Search the information sources to retrieve relevant information

Evaluate the quality of the information

Use the information to make good health decisions


Challenges of Health Information Literacy?

English Literacy Levels Unreliable Resources Evaluation Skills


English Literacy Levels

Most health materials are written at the 10th grade level or above

In the U.S., approx. 48% of adults read at or below the 8th grade reading level


Unreliable Resources

People tend to: Search independently rather than seek

advice about web sites to use Trust in most or all information found on

the web Don’t know when they’re seeing wrong

or misleading health information on the web


Bad News

Online information greatly impacts peoples’ health choices


Evaluation Skills

Few people check “about us” sections, disclaimers or disclosure statements.

People usually chose one of the first results displayed by the search engine.

Most people don’t remember which websites they retrieved information from


How Can Medical Librarians Address These Challenges? Identify quality health education materials

written at varying literacy levels, in various formats and in other languages.

Limit use of medical jargon. Direct consumers/patients to trusted health

education web sites. Instruct consumers/patients to evaluate health

education materials for authority, bias, and currency.

Explain information and instructions clearly.


Tips - Explaining Information and Instructions Clearly

Repeat Provide Examples Be Specific Back up with

written/visual instructions

Ask about learning preference


Before/After “Plain Language”

Before The Dietary Guidelines for Americans

recommends a half hour or more of moderate physical activity on most days, preferably every day. The activity can include brisk walking, calisthenics, home care, gardening, moderate sports exercise, and dancing.

After Do at least 30 minutes of exercise, like brisk

walking, most days of the week.


How can you support patient education?

Suggest lay level materials for patients Inform patients of their right to ask

questions and expect answers Listen to what patients are saying and

refer them to health care providers Facilitate patients understanding of

medical conditions, procedures, and their options for care


Become an active & visible participant or supporter of:

Pharmacy & Therapeutics Committee Standardization Committee Patient Safety Committee Institutional Review Boards Quality Committee Medication Safety Committee


50% of Rx Drugs are not being taken correctly

This leads to serious medical complications, hospitalization, additional medicines, loss of work, and sometimes death,

It’s Not the Patient’s Fault This is why patients need accurate and

easy-to-understand information about managing their treatment.


What proactive approaches can medical librarians take:

Develop patient safety awareness programs

Partner – Public Library, Community Assist consumers in understanding what

patient safety is about from several perspectives.


Focus on Preventing Medication Errors

Develop a monthly newsletter on preventing medical errors

Proactively supply the hospital staff with the latest literature related to medication safety


Use JCAHO Standards to Support Patient Safety

Leverage accreditation standards (medication management)

Develop routine evaluations of the literature Keep it short Select the best information Insert clip art to attract attention Discuss recurring themes


Internal Review Boards

Become a member of the IRB (internal review board)

Have a contingency plan to insure continued support

Provide comprehensive searches, articles, filtering and citations

Provide as much info as possible to support meeting discussions


PDA’s

Use PDA’s to enhance patient safety through better communication and documentation

Advocate for PDA use in clinical environments

Provide assistance in establishing patient safety criteria


Patient Safety Forums

Use National Medical Librarian’s Month or Nat'l Library Week to develop day long patient safety forums

Have speakers present talks to support adopting a culture of safety

Develop patient safety handouts and information about ways the library supports patient safety

Distribute handouts at all types of meetings, and venues


Library Presentations

Make presentations at hospital wide meetings of knowledge-based information sources of value to those involved in patient safety

Conduct live demonstrations using examples specific to a variety of patient safety issues

Informally answer questions, provide take home points


Help Develop Patient and Employee Safety Fairs Fire Safety Occupational Safety Security (identity theft) Back Safety Needle stick Medication Information Tables Feature patient education & consumer

health information, books, journal, videos,


Other Proactive Ideas

Work with your informatics team to develop patient portals

Develop evidence-based search strategy website on top diseases seen by hospitalist and other groups

Work closely with Patient Safety and/or Medication Safety Committee, Performance Improvement Staff, & Medical Affairs,


More Proactive Ideas

Become the clinical librarian for patient safety

Learn the language and concepts of safety (patients, visitors, staff)

Exploit current awareness tools Selectively, push full text information to

committee members Track library efforts to support patient

safety.


Brainstorming & Strategizing

How can you impact Patient Safety when you return to your institutions?


The End……

Documents

Rosalind K. Lett, MLS, AHIP Knowledge Cartel Safety First: Proactive Approaches to Patient Safety