- Edited by Lorri Zipperer
Patient Safety: Perspectives on Evidence, Information and Knowledge Transfer provides background on the patient safety movement, systems safety, human error and other key philosophies that support change and innovation in the reduction of medical error. The book draws from multidisciplinary areas within the acute care environment to share models that support the proactive changes necessary to provide safe care delivery. The publication discusses how the tenets of safety (described in the beginning of the book) can be actively applied in the field to make evidence, information and knowledge (EIK) sharing processes reliable, effective and safe.
This is a wide-ranging and important book that is designed to raise awareness of the latent risks for patient safety that are present in the EIK identification, acquisition and distribution processes, structures, and systems of many healthcare institutions across the world. The expert contributors offer systemic, evidence-based improvement processes, assessment concepts and innovative activities to identify these risks to minimize their potential to adversely impact care. These ideas are presented to create opportunities for the field to design and use strategies that enable meaningful implementation and management of EIK. Their thoughts will enable healthcare staff to see EIK as a tangible element contributing toward sustainable patient safety improvements.
Contents: Foreword, Robert M. Wachter; Preface. Part 1 Context for Innovation and Improvement: Patient safety: a brief but spirited history, Robert L. Wears, Kathleen M. Sutcliffe and Eric Van Rite; Concepts, context, communication: who’s on first?, Lorri Zipperer and Linda Williams; Potential for harm due to failures in the EI&K process, Catherine K. Craven, Barbara Jones and Lorri Zipperer. Part 2 The Role of Evidence, Information and Knowledge: Information and evidence failures in daily work: how they can affect the safety of care, Catherine K. Craven, Ross Koppel and Mark G. Weiner; Leadership, EI&K and a culture of safety, Della Lin, Margo Farber and Judith Napier; Weakness in the evidence base: latent problems to consider and solutions for improvement, Amanda Ross-White, Affaud Anaïs Tanon and Sumant Ranji. Part 3 Building Blocks of Safety that Affect Information, Evidence and Knowledge-Sharing: Systems thinking, complexity and EI&K for safe care, Howard Fuller; Aviation contexts and EI&K innovation: reliability, teamwork and sensemaking, Jeff Brown, Sara Tompson and Lorri Zipperer. Part 4 Practical Applications to Drive EI&K Progress in the Acute Care Environment: EI&K sharing mechanisms in support of patient safety, Susan Carr, Barbara Olson and Lorri Zipperer; Health information technology in hospitals: towards a culture of EI&K sharing, Prudence Dalrymple and Debora Simmons; Critical intersections in patient safety: evidence and knowledge transfer at the sharp and blunt ends, Julia M. Esparza, Melissa Cole and Gunjan Kahlon; Patient and families as vital EI&K conduits, Amy Donahue, Linda Kenney and Kathryn K. Leonhardt; Humans and EI&K seeking: factors influencing reliability, Linda Williams and James P. Bagian. Part 5 Future States: Analyzing breakdowns in the EIK pathway, Barbara Jones, Mark Graber and Elaine Alligood; A case to illustrate the opportunity for healthcare in EI&K enhancement, Grena Porto, Suzanne Graham and Lorri Zipperer. References; Glossary; Appendices; Index.
About the Editor: Lorri Zipperer, Cybrarian, is the principal at Zipperer Project Management in Albuquerque, NM. Lorri was a founding staff member of the National Patient Safety Foundation (NPSF) as the information project manager. Lorri is an American Hospital Association/NPSF Patient Safety Leadership Fellowship alumnus. She has been recognized by the US based organizations, the Institute for Safe Medication Practices (ISMP) and the Medical Library Association (MLA), for her project work and writing exploring the roles of librarians in medical error reduction.
Reviews: ‘It goes without saying that providing safe care to patients in our complex healthcare system depends on reliable data and clearly communicated information. However, knowledge management is a complicated field in its own right. Patient Safety: Perspectives on Evidence, Information and Knowledge Transfer is an ambitious, important book that examines the complex intersection between patient safety and evidence, information and knowledge transfer (EI&K). Editor Lorri Zipperer has expertise in both patient safety and EI&K and it shows in this impressive work. Not only has she recognized the need for a thoughtful, clear-eyed exploration of EI&K’s promise for moving health care closer to a culture of safety, but also has taken on the challenge of making sense of the intersection between two distinct, complicated fields. She has assembled an impressive list of contributors who provide needed background before examining potential EI&K failures and the improvement processes to address them. The authors also describe synergies between these two complex fields, and suggest future research directions.'
Joanne Turnbull, PhD, Executive Director Emerita, National Patient Safety Foundation
'The published literature on patient safety principles is largely anecdotal and the evidence based knowledge in the field remains scarce. Lorri Zipperer, the editor of this new and
groundbreaking book, has to be commended for her effort in providing a fresh
perspective on the impact of “EI&K“ (Evidence, Information, Knowlegde) principles for
patient safety. The new book appears to successfully complete the daunting task of
extrapolating the "dry" theoretical aspects of interest to librarians and patient safety
professionals, to relevant clinical processes and applications of interest to practicing
physicians (including surgeons). …Beyond a doubt, this meritorious work was desperately needed, and will hopefully allow to foster the “buy-in“ and support by healthcare providers in sustaining and growing the current global momentum of the patient safety initiative.' Philip Stahel, Patient Safety in Surgery
'The authors confront the yawning gap between our highly structured (and lavishly funded) system for adding research evidence to the body of medical knowledge, and the crucial but much neglected process of getting that evidence into the hands of providers and patients, when and where it’s needed, in the messy world of clinical care. It’s time we listened to them.’
Frank Davidoff, Editor Emeritus, Annals of Internal Medicine
‘From deep history to future prospects, the authors lay out the shortcomings of current evidence-seeking and pull together disparate concepts to show how to improve systems and practice through effective deployment of evidence, information and knowledge. This thoughtful, multidimensional book will be an important contribution to the literature of patient safety.’
Helen Haskell, President, Mothers Against Medical Error
‘The authors provide the historical context of the patient safety movement but move beyond that by exploring the necessary strategies that learning organizations need to apply to their safety efforts. Offering practical tools as well as compelling stories, the authors also establish the essential role of librarians and other information specialists in improving patient safety throughout the continuum of care.’
Margaret Bandy, Exempla Saint Joseph Hospital, USA
‘…a carefully orchestrated series of chapters written by experts in different aspects of patient safety. In examining how approaches to EI&K can enhance or undermine patient safety, Zipperer and her co-authors - 34 contributors in all - explore systems thinking, complexity, high reliability, health information technology, the role of patients and families, and other core concepts. The dangers of superficiality, insularity, and exclusion are recurring themes. ...By demonstrating that an effective approach to accessing and sharing evidence, information, and knowledge plays a crucial role in patient safety, Zipperer brings an underappreciated vulnerability to our attention and helps us begin to fill the gap.’ PSQH Blog
Lorri Zipperer on LinkedIn
Extracts from this title are available to view:
Full contents list
About the editor
Chapter 3 - Potential for Harm Due to Failures in the EI&K Process