Lucian and the Librarian
At this year’s Quality Colloquium, multidisciplinary approaches to safety and quality improvement were discussed in many sessions, with benefits cited in the context of leadership, education, scholarship, as well as care delivery.
I was reminded of my favorite example of the benefits of cross-fertilizing knowledge and information across disciplines. I thank Lorri Zipperer, who first introduced me to this story, which Lucian Leape (LL) related to Bob Wachter (RW) in an interview available from AHRQ’s Web M&M. I’ve come to think of this story as “Lucian and the Librarian” and hope that everyone working in safety and quality improvement becomes aware of it at some point.
RW: As you were in the middle of that study what was your sense of its potential?
LL: We always were convinced it was an important study, if nothing else, because of its magnitude. Looking at 30,000 patients gives you some clout. None of us had really thought much about the preventability issue, and nobody knew anything about systems, of course. We weren’t completely surprised by our results, because earlier work had shown similar findings. But we were, shall we say, dismayed to find that 4% of patients had adverse events. The surprise for me was that two thirds of them were caused by errors. I’ll never forget—I went to the library one day and did a literature search on what was known about preventing errors, and I didn’t find anything. And I went to the librarian and said, “I’m interested in how you prevent medical errors, and I’ve found papers about complications, but nothing much about errors.” And I asked her to look over my search strategy because I was not finding anything. She looked at it and she said, “Well, your strategy looks all right. Have you looked in the humanities literature?” And I sort of looked at her and said, “The what?” I know what humanities are, mind you. But it really never occurred to me. So she tried the same search strategy in the humanities literature, and boom, out came 200 papers. I started to read them and discovered James Reason and Jens Rasmussen and all those people. A year later, I came up for air and realized that we in health care could use this. If I didn’t know how errors happen, most other people wouldn’t know it either. So I decided to write a paper.
RW: So, a medical school librarian set off the modern patient safety movement?
LL: Ergo, there we go.