1. MLA Midwest/Midcontinental Chapter Joint Meeting October 14, 2007 Patient Safety: Librarian as Advocate http://nnlm.gov/training/patientsafety/advocacy.html Holly Ann Burt, MLIS, MDiv

2. Dr. Robert Wachter: 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 2

3. “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. Patient Safety: Ongoing Problem 3

4. 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 4

5. 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 (C 3 RS) – 2005 5

6. 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 6

7. How is Your Library Involved in Patient Safety (or how will it be)? 7

8. 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 Library Leadership 8

9. 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 Library Leadership 9

10. 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 Library Leadership 10

11. 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 Library Leadership 11

12. 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 Library Leadership 12

13. 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 Library Leadership 13

14. 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 Library Leadership 14

15. 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 Library Leadership 15

16. And …. Library Leadership 16

17. In Summary: All of the roles of the library ultimately support Patient Safety - Michelle Eberle, 2007 Library Leadership 17

18. Patient Safety: Librarian as Advocate http://nnlm.gov/training/patientsafety/advocacy.html Holly Ann Burt, MLIS, MDiv