Patient Safety For Ellen Patient Safety Perspectives on Evidence, Information and Knowledge Transfer Edited by Lorri ZiPPerer © Lorri Zipperer 2014 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise without the prior permission of the publisher. Lorri Zipperer has asserted her right under the Copyright, Designs and Patents Act, 1988, to be identified as the editor of this work. Published by Gower Publishing Limited Ashgate Publishing Company Wey Court East 110 Cherry Street Union Road Suite 3-1 Farnham Burlington, VT 05401-3818 Surrey, GU9 7PT USA England www.gowerpublishing.com British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data Zipperer, Lorri A., 1959- Patient safety : perspectives on evidence, information and knowledge transfer / by Lorri Zipperer. pages cm Includes bibliographical references and index. ISBN 978-1-4094-3857-1 (hbk) -- ISBN 978-1-4094-3858-8 (ebk) -- ISBN 978-1-4724-0243-1 (epub) 1. Hospital patients--Safety measures. 2. Medical errors--Prevention. I. Title. RA965.6.Z57 2014 610.28’9--dc23 2013028766 ISBN 978 1 4094 3857 1 (hbk) ISBN 978 1 4094 3858 8 (ebk – PDF) ISBN 978 1 4724 0243 1 (ebk – ePUB) III Contents List of Figures ix List of Tables xi About the Editor xiii About the Contributors xv Foreword xxix Preface xxxv List of Abbreviations xliii Acknowledgements xlv PART 1 CONTEXT FOR INNOVATION AND IMPROVEMENT Chapter 1 Patient Safety: A Brief but Spirited History 3 Robert L. Wears, Kathleen M. Sutcliffe and Eric Van Rite Chapter 2 Concepts, Context, Communication: Who’s on First? 23 Lorri Zipperer and Linda Williams Chapter 3 Potential for Harm Due to Failures in the EI&K Process 35 Catherine K. Craven, Barbara Jones and Lorri Zipperer PART 2 THE ROLE OF EVIDENCE, INFORMATION AND KNOWLEDGE Chapter 4 Information and Evidence Failures in Daily Work: How They Can Affect the Safety of Care 49 Catherine K. Craven, Ross Koppel and Mark G. Weiner Chapter 5 Leadership, EI&K and a Culture of Safety 69 Della Lin, Margo Farber and Judith Napier vi PATIENT SAFETY Chapter 6 Weakness in the Evidence Base: Latent Problems to Consider and Solutions for Improvement 89 Amanda Ross-White, Affaud Anaïs Tanon and Sumant Ranji PART 3 BUILDING BLOCKS OF SAFETY THAT AFFECT INFORMATION, EVIDENCE AND KNOWLEDGE-SHARING Chapter 7 Systems Thinking, Complexity and EI&K for Safe Care 109 Howard Fuller Chapter 8 Aviation Contexts and EI&K Innovation: Reliability, Teamwork and Sensemaking 129 Jeff Brown, Sara Tompson and Lorri Zipperer PART 4 PRACTICAL AppLICATIONS TO DRIVE EI&K PROGRESS IN THE AcUTE CARE ENVIRONMENT Chapter 9 EI&K Sharing Mechanisms in Support of Patient Safety 151 Susan Carr, Barbara Olson and Lorri Zipperer Chapter 10 Health Information Technology in Hospitals: Towards a Culture of EI&K Sharing 173 Prudence Dalrymple and Debora Simmons Chapter 11 Critical Intersections in Patient Safety: Evidence and Knowledge Transfer at the Sharp and Blunt Ends 187 Julia M. Esparza, Melissa Cole and Gunjan Kahlon Chapter 12 Patient and Families as Vital EI&K Conduits 205 Amy Donahue, Linda Kenney and Kathryn K. Leonhardt Chapter 13 Humans and EI&K Seeking: Factors Influencing Reliability 223 Linda Williams and James P. Bagian PART 5 FUTURE STATES Chapter 14 Analyzing Breakdowns in the EIK Pathway 239 Barbara Jones, Mark Graber and Elaine Alligood CONTENTS vii Chapter 15 A Case to Illustrate the Opportunity for Healthcare in EI&K Enhancement 257 Grena Porto, Suzanne Graham and Lorri Zipperer References 275 Glossary 327 Appendix 1 333 Appendix 2 337 Appendix 3 341 Appendix 4 345 Index 347 www.gowerpublishing.com/ebooks We hope you enjoy this ebook with its interactive features and the wealth of knowledge contained within it. We’d love to keep you informed of other Gower books available to you from your chosen provider. Why not join our monthly email newsletter? 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List of Figures 1.1 Relative Frequency of the Phrase “Patient Safety” in English Language Books Over Time: 1800‒2008 4 3.1 Fishbone Diagram Deconstructing Failures Potentially Contributing to the Roche Incident 38 5.1 Sharp End, Blunt End, Blunt-Blunt End 71 5.2 Reason’s Swiss Cheese Model 73 5.3 Executive Leadership Provides the Tools and Training to Be Effective in Patient Safety 75 7.1 Simple Causal Feedback Loop for an Alert Fatigue Situation 115 8.1 Complex Sociotechnical System 131 8.2 Ackoff’s Hierarchy 133 9.1 US Hospitals that Use Social Networking Tools – Updated on December 2013 (n=1544) 155 10.1 Electronic EI&K Management in the Healthcare System 178 11.1 Critical EI&K Intersections EI&K: Misaligned Handoff 198 12.1 Parallel Roles in the EI&K Pyramid 206 13.1 EI&K Transfer to Improve Patient Care: Expected Process 229 13.2 EI&K Transfer to Improve Patient Care: Potential Failure Modes 229 13.3 FMEA Decision Tree 230 14.1 The SHEL Approach 243 14.2 A Specific Framework for Analyzing EI&K Breakdowns 243 14.3 EI&K Failure Root Causes in the Ellen Roche Case 245 14.4 Possible EIK Breakdowns in a Medical Literature Search 246 14.5 Potential Failures in the Information Seeking Process 247 This page has been left blank intentionally List of Tables 2.1 Collections of Murky Terms 27 2.2 Risk Management/Patient Safety (Adapted from Youngberg 2011: 9) 31 7.1 Symbols in a Systems Thinking Causal Loop Diagram 115 7.2 Team EI&K Use from Simple to Chaotic 124 8.1 EI&K in Two Contexts 135 8.2 Selected Aviation Safety Strategies Applied to Healthcare EI&K Processes 137 9.1 Selected EI&K Tools and Mechanisms by Primary Function 158 11.1 EI&K Sharing in Healthcare: Select Examples 189 12.1 Patient/Family EI&K Roles and Actions 207 13.1 Selected Hierarchy of Actions: Information Seeker Examples 233 14.1 Doctors, Umpires, and EI&K Seekers – An Abridged Exploration (Zipperer and Williams 2011; Adapted from Graber 2007) 249 15.1 Selected EI&K Categorization’s of Reason’s (2004) Analysis of Toft-reported Failures (2001) 260 15.2 EI&K Categorizations of Selected Kaiser Permanete Tactics Responding to the 2005 Vincristine Incident 262 This page has been left blank intentionally About the Editor Lorri Zipperer, Cybrarian, is the principal at Zipperer Project Management, in Albuquerque, New Mexico. Lorri has been in the information and knowledge management field for over two decades, over half of which have been focused on patient safety. She was a founding staff member of the National Patient Safety Foundation as the information project manager. Lorri currently works with clients to provide patient safety information, knowledge-sharing, project management and strategic development guidance. Lorri has recently led projects in patient safety educational tool development, publication evidence identification and organizational knowledge access improvement. She currently serves as the Cybrarian for the Agency for Healthcare Research and Quality’s Patient Safety Network collaborating with the multidisciplinary editorial and production team since the launch of the site in 2005. She was recognized that same year with a 2005 Institute for Safe Medication Practices Cheers Award for her work with librarians, libraries and their involvement in patient safety. She has initiated and published two national surveys of librarians on their role in patient safety work to map the evolution of that role over time. Ms Zipperer’s expertise was highlighted in the June 2009 Medical Library Association policy on the role of librarians in patient safety. She has launched blogs, online groups and communities of practice to support sharing of information and knowledge to facilitate safety and quality improvement among her peers. Ms. Zipperer was a 2004‒2005 Patient Safety Leadership Fellow where she explored how information and knowledge transfer behaviours affect a learning culture. She has participated in research to explore the process of knowledge-sharing both at the bedside and with clinical teams. In 2007 and 2009, she was funded by regional offices of the National Network of Libraries of Medicine to work with her colleagues in acute care environments to facilitate avenues for implementation of knowledge-sharing initiatives. More recently Lorri has participated in a series of workshops looking at systematic and cognitive impacts that evidence, information and knowledge can have on xiv PATIENT SAFETY decision-making in diagnostic error. She has designed and co-facilitates an interprofessional workshop on knowledge-sharing in hospitals which has been noted by attendees as being “transformational”. Lorri earned her Masters of Arts in library and information studies from Northern Illinois University. She has served as an adjunct professor for library management at the university level. Lorri has received honours from the library and information science community and has been published on topics such as alternative roles for librarians, patient safety, collaboration, systems thinking and knowledge management.