Patient safety : perspectives on evidence, information and knowledge transfer

399 Pages·2014·7.019 MB·English

by  Zipperer, Lorri A.

Patient Safety
For Ellen
Patient Safety
Perspectives on Evidence,
Information and Knowledge
Transfer
Edited by
Lorri ZiPPerer
© Lorri Zipperer 2014
All rights reserved. No part of this publication may be reproduced, stored in a retrieval
system or transmitted in any form or by any means, electronic, mechanical, photocopying,
recording or otherwise without the prior permission of the publisher.
Lorri Zipperer has asserted her right under the Copyright, Designs and Patents Act, 1988, to
be identified as the editor of this work.
Published by
Gower Publishing Limited Ashgate Publishing Company
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British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging-in-Publication Data
Zipperer, Lorri A., 1959-
Patient safety : perspectives on evidence, information and knowledge transfer / by Lorri
Zipperer.
pages cm
Includes bibliographical references and index.
ISBN 978-1-4094-3857-1 (hbk) -- ISBN 978-1-4094-3858-8 (ebk) -- ISBN 978-1-4724-0243-1
(epub) 1. Hospital patients--Safety measures. 2. Medical errors--Prevention. I. Title.
RA965.6.Z57 2014
610.28’9--dc23
2013028766
ISBN 978 1 4094 3857 1 (hbk)
ISBN 978 1 4094 3858 8 (ebk – PDF)
ISBN 978 1 4724 0243 1 (ebk – ePUB)
III
Contents
List of Figures ix
List of Tables xi
About the Editor xiii
About the Contributors xv
Foreword xxix
Preface xxxv
List of Abbreviations xliii
Acknowledgements xlv
Part 1 Context for InnovatIon and
ImProvement
Chapter 1 Patient Safety: A Brief but Spirited History 3
Robert L. Wears, Kathleen M. Sutcliffe and Eric Van Rite
Chapter 2 Concepts, Context, Communication: Who’s on First? 23
Lorri Zipperer and Linda Williams
Chapter 3 Potential for Harm Due to Failures in the EI&K Process 35
Catherine K. Craven, Barbara Jones and Lorri Zipperer
Part 2 the role of evIdenCe, InformatIon
and Knowledge
Chapter 4 Information and Evidence Failures in Daily Work: How
They Can Affect the Safety of Care 49
Catherine K. Craven, Ross Koppel and Mark G. Weiner
Chapter 5 Leadership, EI&K and a Culture of Safety 69
Della Lin, Margo Farber and Judith Napier
vi Patient Safety
Chapter 6 Weakness in the Evidence Base: Latent Problems to
Consider and Solutions for Improvement 89
Amanda Ross-White, Affaud Anaïs Tanon and Sumant Ranji
Part 3 BuIldIng BloCK s of safety that
affeCt InformatIon, ev IdenCe and
Knowledge-sharIng
Chapter 7 Systems Thinking, Complexity and EI&K for Safe Care 109
Howard Fuller
Chapter 8 Aviation Contexts and EI&K Innovation: Reliability,
Teamwork and Sensemaking 129
Jeff Brown, Sara Tompson and Lorri Zipperer
Part 4 PraCtICal aPPlICatIons to dr Ive
eI&K Progress In the aCute Care
envIronment
Chapter 9 EI&K Sharing Mechanisms in Support of Patient Safety 151
Susan Carr, Barbara Olson and Lorri Zipperer
Chapter 10 Health Information Technology in Hospitals: Towards a
Culture of EI&K Sharing 173
Prudence Dalrymple and Debora Simmons
Chapter 11 Critical Intersections in Patient Safety: Evidence and
Knowledge Transfer at the Sharp and Blunt Ends 187
Julia M. Esparza, Melissa Cole and Gunjan Kahlon
Chapter 12 Patient and Families as Vital EI&K Conduits 205
Amy Donahue, Linda Kenney and Kathryn K. Leonhardt
Chapter 13 Humans and EI&K Seeking: Factors Influencing Reliability 223
Linda Williams and James P. Bagian
Part 5 future states
Chapter 14 Analyzing Breakdowns in the EIK Pathway 239
Barbara Jones, Mark Graber and Elaine Alligood
contentS vii
Chapter 15 A Case to Illustrate the Opportunity for Healthcare
in EI&K Enhancement 257
Grena Porto, Suzanne Graham and Lorri Zipperer
References 275
Glossary 327
Appendix 1 333
Appendix 2 337
Appendix 3 341
Appendix 4 345
Index 347
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List of Figures
1.1 Relative Frequency of the Phrase “Patient Safety” in English
Language Books Over Time: 1800‒2008 4
3.1 Fishbone Diagram Deconstructing Failures Potentially
Contributing to the Roche Incident 38
5.1 Sharp End, Blunt End, Blunt-Blunt End 71
5.2 Reason’s Swiss Cheese Model 73
5.3 Executive Leadership Provides the Tools and Training to Be
Effective in Patient Safety 75
7.1 Simple Causal Feedback Loop for an Alert Fatigue Situation 115
8.1 Complex Sociotechnical System 131
8.2 Ackoff’s Hierarchy 133
9.1 US Hospitals that Use Social Networking Tools – Updated
on December 2013 (n=1544) 155
10.1 Electronic EI&K Management in the Healthcare System 178
11.1 Critical EI&K Intersections EI&K: Misaligned Handoff 198
12.1 Parallel Roles in the EI&K Pyramid 206
13.1 EI&K Transfer to Improve Patient Care: Expected Process 229
13.2 EI&K Transfer to Improve Patient Care: Potential Failure Modes 229
13.3 FMEA Decision Tree 230
14.1 The SHEL Approach 243
14.2 A Specific Framework for Analyzing EI&K Breakdowns 243
14.3 EI&K Failure Root Causes in the Ellen Roche Case 245
14.4 Possible EIK Breakdowns in a Medical Literature Search 246
14.5 Potential Failures in the Information Seeking Process 247