KNOWLEDGE WORKERS, LIBRARIANS AND SAFETY: OPPORTUNITIES FOR PARTNERSHIP

1. Safety Across High-Consequence Industries ConferenceSeptember 20-22, 2005. St Louis, MO KNOWLEDGE WORKERS, LIBRARIANS AND SAFETY:OPPORTUNITIES FOR PARTNERSHIP Lorri ZippererZipperer Project ManagementEvanston, Illinois lorri@zpm1.com

2. Information and Safe Care • Effective knowledge transfer is key to the provision of safe care • Teams use shared decision making, judgment and coordinated action in their daily work • Evidence and best practice for the field is rapidly changing

3. Definitions • Information • Knowledge • Knowledge transfer • Knowledge worker • Librarian / information professional

4. Value of a “New View” • Risks minimized due to effective knowledge and information management • Work teams and individuals informed and prepared • Sharp end / blunt end knowledge integrated to support transparency How do we get there?

5. Recognized Skills Outside the Box Typical • Infuse knowledge transfer into strategic goals and planning processes • Participate directly in R&D/clinical trial teams • Drive knowledge management • Facilitate / contribute to a learning culture • Respond to research requests • Select information tools and resources • Determine modes of delivery and organization • Train workforce to use information tools

6. Application of Skills Outside the Box Typical • Inform advocacy and policy development • Create web site design and content • Organize materials • Support speech and media campaigns • Review evidence-based medicine programs • Identify evidence for use at the point-of-care • Participate in non-library centric initiatives • Span boundaries between the front line staff and administration • Participate in clinical rounds

7. Organizational Learning • Implementation of knowledge management • Awareness of all levels and organizational dynamics • Sensitivity to external influences and lessons learned

8. Analysis of Process Impact • Proactive failure identification and analysis • NCPS Knowledge Transfer FMEA project • Work arounds

9. Normalization of Deviance • Acceptance of incomplete use of information and knowledge • Reliance on unreliable methods • Awareness of confirmation bias • Knowing when you “don’t know”

10. Moving Forward • Initiate multidisciplinary involvement • Build knowledge transfer components and support into safety initiatives • Provide opportunities for professional education and awareness

11. Continued Study • Information behavior and its effect on safety • Information transfer gaps and their affect on reliability • Safety innovations spread • Leadership knowledge needs in the clinical environment

12. People tend to see what they are able to deal with. If a team enlarges what it can do, then it may also enlarge what it will see. A team that sees more has a better chance to see small errors earlier and to do something about them. Small improvements in seeing can occur when individuals enlarge their personal repertories of what they can do. But larger improvements in seeing should occur when people with more diverse skills, experience, and perspectives think together in a context of respectful interaction. Karl Weick, 2002 Reduction of medical error through mindful interdependence. In: Rosenthal, M.M., Sutcilff, K.M (eds). Medical Error: What do We Know? What do We do? San Francisco; Jossey Bass. 2002

13. Continue the Conversation • Patient Safety: Focus on Information and Knowledge Transfer http://patientsafetylib.blogspot.com/ • Lorri Zipperer lorri@zpm1.com