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Report on Online NN/LM Class “Patient Safety Resource Seminar: Librarians on the Front Line”

by Nancy Crossfield
Library Services Manager, William O. Owen Medical Library
Saint Agnes Medical Center
Fresno, CA

A five-week online class titled “Patient Safety Resource Seminar: Librarians on the Front Line” was taught in November-December 2012, with instructor Holly Burt, NN/LM Greater Midwest Region Outreach & Exhibits Coordinator. The course is based on a variety of materials freely available from the National Library of Medicine. I participated with librarians from around the country, including several from our region; Heidi Mortensen, Peggy Makie, Beverly McLeod, Lisa Olson, Carol Attwood, and Billie White. Following is a brief overview of the class content, including some useful links.

The Institute for Healthcare Improvement estimates that 15 million incidences of patient harm occur in U.S. hospitals every year; approximately 40,000 each day. These could be due to medication errors, wrong-site surgeries, diagnostic errors or delays, healthcare-acquired infections (HAIs), or preventable falls and injuries. Fortunately, patient safety improvement programs have been gaining visibility and traction since the Institute of Medicine published To Err is Human (2000) and Crossing the Quality Chasm (2001). Hospitals applied and are expanding successful quality concepts from the military, other agencies, and industry, such as crew resource management, “walk the deck,” confidential incident reporting, and procedure checklists.

Several heart-wrenching stories of patient death or injury caused by medical errors focused public attention on this issue, too. Patient advocacy and consumer health groups, such as the Josie King Foundation and the National Patient Safety Foundation, now work to publicize problems, educate both the public and health providers, and advocate for greater patient safety. Safety statistics, such as those provided by Hospital Safety Score and CalHospitalCompare.org, are increasing transparency. Finally, legislation at both state and federal levels provided added encouragement for change. The 2005 Patient Safety and Quality Improvement Act was one example, creating Patient Safety Organizations to collect and analyze data, with the goal of improving quality and safety of patient care.

The result has been a seismic shift in health care. Electronic health records have moved from a novelty to a cornerstone of safety initiatives. Autocratic and punitive staffing models are being replaced with a culture of safety that permeates entire institutions. Teamwork replaces autocracy, “just culture” and close-call reporting replace punitive reactions, and an increased recognition of the importance of systems design and behavioral engineering replaces focus on isolated incidents and assigning individual blame for errors. Patients and their supporters are becoming confident advocates for their own care, something unimaginable twenty years ago.

Medical librarians are becoming involved with all of these changes, too, from literature searches to committee participation to community outreach. PubMed searches provide background for root cause analyses and sentinel event investigations. Librarians often select evidence-based medicine databases, link them, and train staff in their use. We may be involved in patient safety efforts in-house or as partners with other community groups.

Continuing education classes are especially useful when they allow participants to apply knowledge to their own institutions and then share it with the class. Topics and some final projects in this seminar covered:

  • Consumer health (safety materials for patients and families – preventing falls, surgical site infections, or medication errors),
  • Safety advocacy (librarian involvement in hospital safety activities – laying groundwork for presentations on HAI reporting requirements, working with risk and accreditation officers), and
  • Patient safety instruction for library constituents (consolidating safety initiatives onto one hospital intranet page, compiling safety resources available on Internet sites or in the library, creating brochures introducing safety topics to medical students, and creating a patient safety map as a teaching tool).

There are so many possibilities and ways for us to help improve patient safety! Here are just a few Internet sites if you wish to learn more:

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