What I’m Reading Now

By Susan Carr

Patient Safety: Perspectives on Evidence, Information and Knowledge Transfer

  Patient Safety: Perspectives on Evidence, Information and Knowledge Transfer
 

Lorri Zipperer, Editor

London, UK: Gower Publishing
2014. ISBN: 9781409438571

First, I must disclose a conflict of interest: I am co-author of one chapter in this edited collection, and the editor, Lorri Zipperer, is a close friend and colleague. I was pre-disposed to like this book, and as I spend more time with the other chapters, my respect for Lorri’s vision and the resulting text continues to grow.

Efforts to improve patient safety should be informed by the best evidence, information, and knowledge (EI&K) available, but often they are not. This is a familiar, if unexamined, problem in this time of “information overload,” but first I should review how the terms EI&K are defined and used in the book. These terms are common but not often used in the safety and quality improvement literature as precisely as they are in Patient Safety:

  • Evidence is the result of research, of tested hypotheses, such as trials and studies published in peer-reviewed publications across all disciplines (not just medicine).
  • Information is data that has been analyzed, organized, and printed/presented for a specific use.
  • Knowledge is what individuals know, either implicitly or explicitly. Knowledge is dynamic, with elements of action or experience.

Many of us are familiar with the challenge posed by the abundance of evidence, information, and knowledge currently available about all things. It is exhilarating that we live in a time of rich and increasingly available resources, but it is rarely self-evident how best to access the EI&K we need or easy to feel confident that we’ve found the best advice on a given subject. How do we know, for example, that what we really need is on page 10 or 25 of our Google search results or will only appear if we use a particular search word. Social media such as Twitter and email discussion groups have made experts more accessible than ever, but knowing who has the answer to your question, having the time to search, and simply knowing where to begin, is not always easy. These challenges exist in patient safety, too, with potentially profound implications for patients and all who are involved in their care.

The story of Ellen Roche is one example of a failure in EI&K that had grave consequences and ultimately provided the inspiration for this book (which is dedicated to Roche). Roche was a healthy 24-year-old technician at Johns Hopkins when she volunteered in 2001 to participate in a clinical trial. She showed symptoms of a reaction the day after receiving the agent used in the trial and died not quite one month later. It was determined that the agent used, hexamethonium, was known to have toxic properties, but that information had not been accessed by responsible parties prior to the clinical trial. Other participants also showed symptoms of adverse reactions, but the implications were not examined, and the trial was not interrupted. After Roche’s death, internal review found that the principle investigator’s search of the medical literature for hexamethonium had not found evidence of toxicity, but a search for potential risks performed by medical librarians during the investigation did. This and other failures that contributed to Ellen Roche’s death are examined in detail in Patient Safety. (Click here for free access to that chapter.)

Zipperer’s book is 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. The book is full of examples of how limitations such as searching only peer-reviewed journals, talking only among a small and predictable group of colleagues, or being afraid to ask for help lead to unreliable choices and unsafe care. Many of these lessons include themes consistent with what we know about organizational cultures that promote patient safety. Applying them to EI&K opens new awareness and potential for improvement. 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.

Also worth a look…

On a related topic, Gower has published Knowledge Management in Healthcare, also conceived of and edited by Lorri Zipperer.