Allen J. Vaida, PharmD, and Lorri Zipperer, MA

Inability to access and manage drug information effectively can directly affect the safety of medication administration. Landmark research studies demonstrate that 35% of all preventable adverse drug events (ADEs) are directly related to inadequate dissemination of drug information (Leape et al., 1995). Overall lack of knowledge about drug therapy was the most common cause of medication errors during both prescribing and administration, and dosing errors were by far the most frequent errors. One in six ADEs were caused by the combination of insufficient knowledge about usual drug doses combined with miscalculations or incorrect expression of measurement or drug concentration (Lesar et al., 1997). In addition, the wrong dose and wrong drug choice were most likely to cause serious injury to patients.

With ADEs occurring most frequently during drug prescribing (56%) and administration (34%), it is critical that accessible drug information be as available as possible to the prescriber and those administering medications (Bates et al., 1995). The 2007 Institute of Medicine report Preventing Medication Errors (released in July 2006) recommends that providers have access to comprehensive reference information concerning medications and related health data. The report goes on to cite two culprits in undermining safe medication use: barriers to pharmacological knowledge about medications and the patient's lack of information about their drugs and herbal supplements. In addition, it has recently been recognized that drug information resources are out of synch with safety and recall notices due to a lack of robust update processes that can respond to immediate changes in the industry (OIG, 2006; Strayer, 2006).

As noted by both patient safety and organizational change experts, it is important to draw from a wide range of individuals with different levels of expertise to combat failures in complex organizations. As a group, medical librarians understand the weaknesses and strengths of medical information resources, know how to identify and disseminate information in the clinical environment, and are trained to respond quickly to urgent information needs.

Key Elements of Safe Medication Use
The Institute for Safe Medication Practices (ISMP) identifies 10 key elements for safe medication use:

1. Patient Information
   
   
2. Drug Information
   
   
3. Communication of Drug Information
   
   
4. Labeling, Packaging, and Nomenclature
   
   
5. Drug Storage, Stock, and Distribution
   
   
6. Device Acquisition, Use, and Monitoring
   
   
7. Environmental Factors
   
   
8. Staff Competency and Education
   
   
9. Patient Education
   
   
10. Quality Processes and Risk Management

Published evidence supports the involvement of medical librarians in each of these 10 elements. This article, however, will explore opportunities for partnership with this distinct professional group by discussing ISMP's key element number 2: drug information. A medication error may result if a weakness exists in any of the following drug information points:

• Accessible and up-to-date drug references
  
  
• Healthcare provider and patient education on the use of references
  
  
• Understanding the dangers of an open formulary
  
  
• Standardized display of medication information
  
  
• Computer systems that can detect unsafe orders and offer clinical decision support
  
  
• A team-oriented relationship between clinicians and drug information professionals and/or medical librarians
  
  
• Well-organized personal or organizational information management strategies to protect from information overload

In 2004, ISMP and the Health Research and Educational Trust distributed a self-assessment survey on medication safety to all acute care hospitals in the United States (ISMP, 2004). The assessment contained more than 200 items that relate to safe medication use, and results were received from more than 1,600 hospitals. Table 1 lists results from several of the assessment items that addressed drug information.

These results show that many healthcare institutions lack standardized processes for handling drug information. It should be noted that the safety recommendations listed in the table will not involve undue hardship in personnel and financial resources. There are many examples in the literature that illustrate how a lack of up-to-date, appropriate access to or misinterpretation of drug information can lead to patient harm. In the following two cases, including the medical librarians in effective and proactive management of drug information resources could have mitigated the opportunity for adverse events.

Johns Hopkins (McLellan, 2001).
In a clinical trial in 2001, a research volunteer died because the research team's process for literature review failed to discover drug interactions. The literature sources that would have identified risks in the drug being tested were available but not in the freely-accessible Web-based database used by the researcher. Although the research team put forth a good-faith effort to review the literature, librarians were not involved in the Institutional Review Board's evidence review. The lack of professional expertise in this case was seen as contributing to its tragic outcome.

Lessons from Denver (Smetzer & Cohen, 1998)
An infant died when a medication was given by the wrong route of administration. Root cause analysis identified many latent failures in the system, including nurses checking an established reference text that lacked specific information on the drug they were about to administer. Other latent failures involved misreading health department recommendations for dosage of the medication and the fact that the nurses and pharmacist were unfamiliar with its dosing and administration requirements because the medication was non-formulary.

Role of the Medical Librarian
Medical librarians can play an expanded role in accessing and reviewing medication information and disseminating it to healthcare clinicians. Medical librarians can be included in the medication information process in the following ways:

• Review of evidence for off-label use of drugs.
  
  
• Development of systemized drug formularies.
  
  
• Oversight of up-to-date information in drug libraries, databases, and published resources (Strayer, 2006).
  
  
• Expert members of the clinical team (MLA, 2003).

To help drive improvements, librarians should be seen as resource and strategy experts in the reliability of information, as well as in identifying and disseminating knowledge at the unit and organizational level. They should have proactive, peer relationships with clinicians to encourage analyzing the drug information delivery process from a systems perspective. Assessing this component of healthcare delivery through a new lens will allow for the testing and implementation of improved processes for delivering these crucial evidence-based resources. To achieve this goal, medical librarians should be active and visible members of:

• Pharmacy and Therapeutics (P&T) Committees
  
  
• Standardization Committees
  
  
• Patient Safety Committees
  
  
• Institutional Review Board (IRB)
  
  
• Root Cause Analysis (RCA) teams
  
  
• Failure Mode and Effects Analysis (FMEA) teams
  
  
• Continuing education and staff training teams
  
  
• Walkrounds, clinical rounds, and other interaction with front-line teams
  
  
• Committees evaluating and/or implementing information technology (e.g., electronic prescribing, electronic health record)

Medical librarians were surveyed in 2003 about their activities in support of patient safety initiatives. The results indicate modest librarian involvement in IRBs, RCAs, FMEAs, and clinical rounding. Although the survey numbers were not fully representative of the field, the data indicate the need for increased involvement of leaders as advocates for the librarian's role in patient safety work (Zipperer & Sykes, 2004). Their involvement in presenting these activities as areas of growth for librarians will encourage a deeper understanding of failures in medical information delivery and their impact on patient safety. The survey is being repeated in the fall of 2006 to track improvements and gather more insight on the activities and best practices of the field. The new survey instrument, The 2006 Survey of the Role of Information Professionals inĘPatient Safety, is available at http://www.surveymk.com/ps-libsurvey.

Highlighting the Patient's Role
The IOM's 2007 report on reducing medication error emphasized involving patients and their families in reducing the impact of medication-related mistakes. The panel suggested that one avenue for improvement would be to use community resources to improve patients' knowledge of the medications they take. One such resource is the public library and its professional staff who can assist individuals with their medical information needs in a variety of environments. Whether at a hospital, university, or public location, librarians working closely with healthcare practitioners are particularly well suited to:

• Suggest readings for the patient.
  
  
• Clarify reputable resources to use and describe their characteristics.
  
  
• Train individuals to access resources on the Web to their best ability.

Unfortunately not every hospital has the resources to have a full-service library or a consumer information center staffed by a professional librarian. If they do exist in this environment, the librarians should be seen as partners with healthcare practitioners in arranging appropriate access to information for patients. In addition to the primary roles listed above, medical librarians in the clinical environment should have added training to:

• Inform patients about their right to ask questions and expect answers.
  
  
• Listen to consumers and refer their comments to physicians, nurses, and pharmacists.
  
  
• Uncover health literacy and general literacy weaknesses.
  
  
• Document information searches and results in the patient chart (Zipperer, Gillaspy, & Goeltz, 2005).
  
  
• Select consumer-oriented content and build patient-centered areas on hospital Web sites to provide vetted resources for patients related to the organization's mission and clinical areas.
  
  
• Participate in awareness training on the consumer's role in patient safety (Zipperer et al., 2006 ).
  
  
• Assist in RCA and FMEA processes.

Conclusion
Knowledge defects contribute to medication safety problems (IOM, 2007). These defects should not be viewed as shortcomings of the individual practicing at the sharp end but rather as a fault of the system to provide clinicians with appropriate information when they need it. Expanding the healthcare team to address the issue will allow for creative thinking, identification of latent opportunities for failure, enhanced evidence-sharing processes, and improved efforts to inform patients. Librarians should position themselves as advocates for information and knowledge exchange and present themselves as partners. Clinical and healthcare leadership should welcome them to participate in the work of creating safety. Once a part of the team, librarians can span boundaries between content developers and the clinical team, and between organizational staff and patients. Librarians can deliver the right information to the right person, at the right time, in the right place, in the right format. They can proactively identify failures that others may not see and develop strategies to learn from them. Their involvement will enrich the dialogue about resolving medication information knowledge gaps.