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 the multidisciplinary areas within the acute care environment to provide models that support proactive changes in how team-based improvement efforts can affect the knowledge provision necessary to support safe care delivery. The publication discusses how the tenets of safety (described in the beginning of the book) have been or can be actively applied in the field. Tools and case studies, in addition to a brief discussion of core resources, are included.
The key objectives of the book:
• To inform healthcare leadership, clinical directors, risk managers and information professionals of the intersection between key patient safety philosophies and information, evidence and knowledge delivery mechanisms that support medical error reduction.
• To raise awareness of the potential for systemic and individual information and knowledge sharing failures that are latent in the health care delivery process.
• To explore the application of systemic improvement processes and tools to identify opportunities to reduce risk and potential for failure.
• To provide evidence-based recommendations for health care information professionals and, with the knowledge they need to position themselves as partners with healthcare providers and leadership
• To illustrate how expertise from information and knowledge professionals folds into elements and language of the safety sciences
• To submit innovative activities and measures that illustrate a tangible contribution to patient safety from the knowledge transfer field.
Contents: Introduction; Foreword, Robert M. Wachter; Part 1 Context for Innovation and Improvement: Patient safety: a brief but spirited history, Robert L. Wears, Kathleen M. Sutcliffe and Eric Van Rite; Terms and theories: developing a shared mental model, 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 C. Weiner; Leadership, EI&K and a culture of safety, Della M. 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 L. Olsen and Lorri Zipperer; Health information technology in hospitals: towards a culture of EI&K sharing, Prudence W. Dalrymple and Deborah 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 EI&K conduits: a vital resource, Amy E. Donahue, Linda Kenney and Kathryn K. Leonhardt; Human factors, information professionals and EI&K, Linda Williams and James P. Bagian. Part 5 Future States: Breakdowns in the EI&K 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. Part 6 Resources; References; Appendixes; Glossary; Index.
About the Editor: Lorri Zipperer, Cybrarian is the principal at Zipperer Project Management, in Albuquerque, NM. 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 AHRQ's Patient Safety Net. She was recognized 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 2 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 enable sharing of information and knowledge to facilitate safety and quality improvement amongst her peers.
Lorri's knowledge management efforts focus on bringing multidisciplinary teams together to explore and enable effective knowledge transfer. Her commitment to understanding how systems thinking affects knowledge and information management culminated in several outputs to generate innovation and improvement in the melding of these disciplines. Ms. Zipperer was a 2004-2005 Patient Safety Leadership Fellow where she explored how information and knowledge transfer behaviors 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. In 2008, Ms Zipperer worked with the WHO Patient Safety to envision an effective knowledge sharing role for that organization. She has designed and co-facilitates a interprofessional workshop on knowledge sharing in hospitals http://cech.mlanet.org/node/390 In addition, Ms Zipperer has recently contributed chapters on knowledge sharing work for medical librarians and systems thinking as a strategic development approach to a core library management publications both scheduled for publication in 2011.
She is a published author in alternative roles for librarians, patient safety, medical reference, information management and visioning. She currently consults on information and knowledge management, publication and content creation, patient safety awareness and terminology development issues.
Lorri earned her MA in library and information studies from Northern Illinois University. She has received honors from the library and information science community for her publishing work. In addition to her consultant commitments, she has served as an adjunct professor for library management at the university level. Lorri is also active professionally by filling both elected and invited positions within the Special Libraries Association.