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
Rosalind K. Lett, MLS, AHIP Knowledge Cartel
Let’s start with a tale about a clinical trial…
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The Clinical Trial
Healthy research volunteerIncomplete literature search doesn’t
reveal relative adverse drug effectsWoman dies due to involvement in
clinical trial
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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.
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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
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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.
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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)
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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
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An In-Sync Health Care Organization
Collaborative Environment Patient Focused Great Place to Work Plentiful Financial Resources (especially
for the library) Big Picture Thinking
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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.
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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!
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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
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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
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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
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More Impact
Facilitate integration of library services and expertise into the hospital
Disseminate innovations through understanding of a learning environment
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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)?
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Are you actively involved in preventing medication errors?
Patient Information Patient Education Consumer Health Information Drug Information
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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.
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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
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Challenges of Health Information Literacy?
English Literacy Levels Unreliable Resources Evaluation Skills
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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
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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
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Bad News
Online information greatly impacts peoples’ health choices
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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
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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.
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Tips - Explaining Information and Instructions Clearly
Repeat Provide Examples Be Specific Back up with
written/visual instructions
Ask about learning preference
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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.
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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
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Become an active & visible participant or supporter of:
Pharmacy & Therapeutics Committee Standardization Committee Patient Safety Committee Institutional Review Boards Quality Committee Medication Safety Committee
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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.
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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.
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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
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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
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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
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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
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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
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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
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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,
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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,
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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.
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Brainstorming & Strategizing
How can you impact Patient Safety when you return to your institutions?
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The End……