1. KNOWLEDGE WORKERS, LIBRARIANS AND SAFETY: OPPORTUNITIES FOR PARTNERSHIP Lorri Zipperer Zipperer Project Management Evanston, Illinois lorri@zpm1.com Safety Across High-Consequence Industries Conference September 20-22, 2005. St Louis, MO

2. www.zpm1.com 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. www.zpm1.com Definitions Information Knowledge Knowledge transfer Knowledge worker Librarian / information professional

4. www.zpm1.com 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. www.zpm1.com Recognized Skills Respond to research requests Select information tools and resources Determine modes of delivery and organization Train workforce to use information tools 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 Typical Outside the Box

6. www.zpm1.com Application of Skills 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 Typical Outside the Box

7. www.zpm1.com Organizational Learning Implementation of knowledge management Awareness of all levels and organizational dynamics Sensitivity to external influences and lessons learned

8. www.zpm1.com Analysis of Process Impact Proactive failure identification and analysis  NCPS Knowledge Transfer FMEA project  Work arounds

9. www.zpm1.com 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. www.zpm1.com Moving Forward Initiate multidisciplinary involvement Build knowledge transfer components and support into safety initiatives Provide opportunities for professional education and awareness

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