Patient Safety Resource Seminar: Librarians on the Front Lines
Bibliography
Contents
PowerPoint Presentation – Part I
PowerPoint Presentation – Part II
Recommended Reading
Articles Focusing on the Value of the Library in Patient Safety
Selected Articles on Patient Safety and Libraries and Librarians
Online Bibliographies
Recommended Books
Recommended Reading for Patients, Families and Patient Advocates
Additional Reading Lists
PowerPoint Presentation – Part I
Committee on Data Standards for Patient Safety, Board on Health Care Services.Committee on Data Standards for Patient Safety, Board on Health Care Services.Patient safety: achieving a new standard for care. Washington, DC: National Academies Press; 2004:30,32,34.
Cosby KS, Croskerry P. Profiles in patient safety: authority gradients in medical error. AcadEmerg Med. 2004 Dec;11(12):1341-1345. PMID: 15576526.
DeLisa JA. Physiatry: medical errors, patient safety, patient injury, and quality of care. Am J Phys Med Rehabil. 2004 Aug;83(8):575-583. PMID: 15277958.
Department of Health Expert Group.An organisation with a memory: report of an expert group on learning from adverse events in the NHS chaired by the chief medical officer. London: The Stationery Office; 2000.
Dorrian J, Hussey F, Dawson D. Train driving efficiency and safety: examining the cost of fatigue. J Sleep Res. 2007 Mar;16(1):1-11. PMID: 17309757.
Farquhar M. AHRQ Quality Indicators.Chapter 45. In: Hughes RG, ed. Patient safety and quality: an evidence-based handbook for nurses. Rockville, MD: Agency for Healthcare Research and Quality; 2008.
Furman C, Caplan R. Applying the Toyota Production System: using a patient safety alert system to reduce error. JtComm J Qual Patient Saf. 2007 Jul;33(7):376-386. PMID: 17711139.
Gleason KM, Groszek JM, Sullivan C, Rooney D, Barnard C, Noskin GA. Reconciliation of discrepancies in medication histories and admission orders of newly hospitalized patients. Am J Health Syst Pharm. 2004 Aug 15;61(16):1689-1695. PMID: 15540481.
Glossary.[Internet].Agency for Healthcare Research and Quality. (7 June 2013).
Gosbee JW. Human factors engineering and patient safety.Qual Safety Health Care. 2002 Dec; 11(4):352-354. PMID: 12468696.
Greenberg CC, Regenbogen SE, Studdert DM, et al. Patterns of communication breakdowns resulting in injury to surgical patients.J Am Coll Surg. 2007 Apr;204(4):533-540. PMID: 17382211.
Hickey EJ, Nosikova Y, Pham-Hung E, Gritti M, Schwartz S, Caldarone CA,Redington A, Van Arsdell GS. National Aeronautics and Space Administration"threat and error" model applied to pediatric cardiac surgery: error cyclesprecede ∼85% of patient deaths. J ThoracCardiovasc Surg. 2015Feb;149(2):496-505. PMID: 25726875.
Hippocrates. On Ancient Medicine, Part 9. 400 BC. Translated by Francis Adams. In: Stevenson DC, The Internet Classics Archive. Web Atomics.Available at:
Hoffman C, Beard P, Greenall J, U D, White J. Canadian Root Cause Analysis Framework: a tool for identifying and addressing the root causes of critical incidents in healthcare. Edmonton: CPSI; 2006:7.
Hwang RW, Herndon JH. Business case for patient safety.ClinOrthopRelat Res. 2007 Apr; 457:21-34. PMID: 17259896.
Kalra J. Medical errors: impact on clinical laboratories and other critical areas. ClinBiochem. 2004 Dec;37(12):1052-1062. PMID: 15589810.
Kapur N, Parand A, Soukup T, Reader T, Sevdalis N. Aviation and healthcare: a comparative review with implications for patient safety. JRSM Open. 2015 Dec2;7(1):2054270415616548. PMID: 26770817.
Kohn LT, Corrigan JM, Donaldson MS.To err is human: building a safer health system. Washington, DC: National Academy Press; 2000.
Kozer E, Scolnik, Macpherson A., et al. Variables associated with medication errors in pediatric emergency medicine. Pediatrics. 2002 Oct;110(4):737-742. PMID: 12359787.
LaPointe NM, Jollis JG. Medication errors in hospitalized cardiovascular patients.Arch Intern Med. 2003 Jun 23;163(12):1461-1466. PMID: 12824096.
Levis RJ. Address of the president: the Traditional Errors in Surgery. In: Transactions of the Medical Society of the State of Pennsylvania, at the thirty-ninth annual session, held at Philadelphia, June, 1888. Vol. XX. Philadelphia, PA: Wm J. Dornan;1888:39–53.
Malhotra S, Laxmisan A, Keselman A, Zhang J, Patel VL. Designing the design phase of critical care devices: a cognitive approach.J Biomed Inform. 2005 Feb:38(1):34-50. PMID: 15694884.
Matlow AG, Berte L. Sources of error in laboratory medicine. Lab Med. 2004 Jun;35(6):331-334.
McDonald CJ. Computerization can create safety hazards: a bar-coding near miss. Ann Intern Med. 2006 Apr 4;144(7):510-516.
Meyer JA, Silow Carroll S, Kutyla T, Stepnick LS, Rybowski LS.Hospital quality: ingredients for success overview and lessons learned. New York, NY: Commonwealth Fund; 2007.
MMS Committee on Quality of Medical Practice and Trinity Communications, Inc. Medical Errors and Perspectives on Patient Safety. Waltham, MA: Massachusetts Medical Society, 2007.
Oshimura JM, Downs SM, Saysana M. Family-centered rounding: can it impact the time of discharge and time of completion of studies at an academic children'shospital? HospPediatr. 2014 Jul;4(4):228-232. PMID: 24986992.
Reason J. Human error: models and management.BMJ.2000 Mar 18;320(7237):768-770. PMID: 10720363.
Runciman WB, Moller J. Iatrogenic injury in Australia: a report prepared by the Australian Patient Safety Foundation for the National Health Priorities and Quality Branch of the Department of Health and Aged Care of the Commonwealth Government of Australia. Adelaide: Australian Patient Safety Foundation; 2001.
Sazama K. Reports of 355 transfusion-associated deaths: 1976 through 1985. Transfusion.1990 Sep; 30(7):583-590. PMID: 2402771.
Scanning the headlines: patient safety.[Internet].American Hospital Association. (3/9/2016).
Sentinel Event. [Internet]. Joint Commission. (2 March 2016).
Slaughter FG. Immortal Magyar: Semmelweis, conqueror of childbed fever. New York: Schuman; 1950:70.
Specialization: Safety Science. Handbook 2009: Undergraduate Study. [Internet].University of New South Wales. (3 Oct 2011).
Spencer FC. Human error in hospitals and industrial accidents: current concepts. J Am Coll Surg. 2000 Oct;191(4):410-418. PMID: 11030247.
Taffinder NJ, McManus IC, Gul Y, Russell RC, Darzi A. Effect of sleep deprivation on surgeons' dexterity on laparoscopy simulator .Lancet. 1998 Oct 10; 352(9135):11911192. PMID: 9989749.
Thomas M, Morton R, Mackway-Jones K. Identifying and comparing risks in emergency medicine. Emerg Med J. 2004 Jul;21(4):469-472. PMID: 15208233.
Turnbull JE. Systems approach to error reduction in health care. Japan Med Assoc J. 2001 Sep; 44(9): 392-403.
Ulrich R, Zimring C. Role of the physical environment in the hospital of the 21st century: a once in a lifetime opportunity. Princeton, NJ: Robert Wood Johnson Foundation; 2004.
University of New South Wales. Specialization: safety science. Handbook 2009: Undergraduate Study. [Internet].(30Mar 2016). specialisations/2009/3448SafetyScience.html
Wachter R. In conversation with Lucian Leape, MD.WebM&M. 2006 Aug; Perspectives on Safety.
Weaver SJ, Lubomksi LH, Wilson RF, Pfoh ER, Martinez KA, Dy SM. Promoting a culture of safety as a patient safety strategy: a systematic review. Ann Intern Med. 2013 Mar 5;158(5 Pt 2):369-374. PMID: 23460092.
Webster CS. Nuclear power industry as an alternative analogy for safety in anaesthesia and a novel approach for the conceptualisation of safety goals.Anaesthesia 2005 Nov;60(11):1115-1122. PMID: 16229697.
Welton JM, Unruh L, Halloran EJ. Nurse staffing, nursing intensity, staff mix, and direct nursing care costs across Massachusetts hospitals. J Nurs Adm. 2006 Sep;36(9):416-425. PMID: 16969253.
Yee P. Brain cramp: the emergency physician's worst nightmare. Ann Emerg Med. 2002 Mar; 39(3):329-330. PMID: 11867991.
PowerPoint Presentation – Part II
Allen MP, Allison MM, Bandy MM, Kennedy JC, Sherwill-Navarro P. The Magnetjourney: opportunities for librarians to partner with nurses. J Med Libr Assoc.2009 Oct;97(4):302-307. PMID: 19851495.
America’s emergency care environment: a state by state report card, 2014 edition. [Internet].American College of Emergency Physicians. (6 Mar 2016).
Bae SH. Nurse overtime, working conditions, and the presence of mandatorynurse overtime regulations. Workplace Health Saf. 2012 May;60(5):205-214. PMID: 22587697.
Burt HA. Patient safety answers require outreach, in-reach and partnerships. J HospLibr. 2011; 11(4):366-378.
Continuing medical education:board-by-board overview. Chicago: Federation of State Medical Boards of the United States; 2015.
Continuing pharmacy education requirements. In: Survey of pharmacy law: including all 50 states, DC, Guam, and Puerto Rico. Mount Prospect, IL: National Association of Boards of Pharmacy; 2012:30-34.
Federally-Listed PSOs.[Internet]. Agency for Healthcare Research and Quality (9 March 2016).
Ehrenclou M: Critical conditions: the essential hospital guide to get your loved one out alive. Santa Monica, CA: Lemon Grove Press; 2008. ISBN: 0981524001 / 978-0981524009
Enlisting an advocate. [Internet] WakeMed. (21 Mar 2016)
Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W. Patients' and physicians' attitudes regarding the disclosure of medical errors. JAMA.2003 Feb 26;289(8):1001-1007. PMID: 12597752.
Gibson R. Role of the patient in improving patient safety.WebM&M. 2007 Mar; Perspectives on Safety.
Gosbee J. Human factors engineering and patient safety.Qual Safety Health Care. 2002 Dec; 11(4):352-354. PMID: 12468696.
Haerkens MH, Jenkins DH, van der Hoeven JG. Crew resource management in theICU: the need for culture change. Ann Intensive Care. 2012 Aug 22;2(1):39. PMID: 22913855.
Hanlon C, Sheedy K, Kniffin T, Rosenthal J. 2014 Guide to State Adverse Event Reporting Systems.Portland, ME: National Academy for State Health Policy; 2015.
Hicock L, Lewis J. Beware the grieving warrior: a child’s preventable death; a struggle for truth, healing, and change. Toronto; ECW Press; 2004. ISBN: 1550226738 / 9781550226737.
Mandatory overtime: Summary of State Approaches .[Internet].American Nurses Association. Jan 2012. (9March 2016).
Marx DA, Slonim AD. Assessing patient safety risk before the injury occurs: an introduction to sociotechnical probabilistic risk modelling in health care. QualSaf Health Care. 2003 Dec;12 (Suppl 2):ii33-8. PMID: 14645893.
Marshall JG, Sollenberger J, Easterby‐Gannett S, et al. The value of library and information services in patient care: Results of a multi‐site study. Journal of the Medical Library Association 2013 Jan;101(1):39‐46. PMID: 23418404
My Medicine List.[Internet].Minnesota Alliance for Patient Safety (MAPS). (26 Mar 2016).
National Patient Safety Goals.[Internet].The Joint Commission. (9 March 2016).
Patient safety map and toolkit.[Internet].National Academy for State Health Policy.(8 Mar 2016).
Patient Safety Primers.[Internet].Agency for Healthcare Research and Quality. (8 Mar 2016)
Potts HW, Anderson JE, Colligan L, Leach P, Davis S, Berman J. Assessing the validity of prospective hazard analysis methods: a comparison of two techniques. BMC Health Serv Res. 2014 Jan 27;14:41. PMID: 24467813.
Quality Chasm series: health care quality reports.[Internet]. National Academies Press. (18Mar 2016).
Questions are the Answer.[Internet].Agency for Healthcare Research and Quality. (5 Feb 2008).
Randmaa M, Mårtensson G, Leo Swenne C, Engström M. SBAR improves communication and safety climate and decreases incident reports due to communication errors in an anaesthetic clinic: a prospective intervention study. BMJ Open. 2014 Jan 21;4(1):e004268.PMID: 24448849.
Roizen MF, Oz MC.Joint Commission Resources. YOU: the smart patient: an insider’s handbook for getting the best treatment. New York: Free Press; 2006. ISBN: 0743293010.
Role of the patient advocate: a consumer fact sheet.[Internet].National Patient Safety Foundation.(21 March 2016)
Rosenthal K, Booth M. State Patient Safety Centers: a new approach to promote patient safety. Portland, ME: National Academy for State Health Policy; 2004.
Saitta N, Hodge SD Jr. Efficacy of a physician's words of empathy: an overviewof state apology laws. J Am Osteopath Assoc. 2012 May;112(5):302-306. PMID: 22582200.
Schroeder SJ. Picking up the PACE: a new template for shift report.Nursing. 2006 Oct;36(10):22-23. PMID: 17019325.
States with apology laws.[Internet].SorryWorks.(8March 2016).
Summary of states' policy toward disclosure.[Internet]. QuPS.org: Quality & Patient Safety. (7 June 2013).
Talking with your doctor: a guide for older people. Bethesda, MD: National Institute on Aging; 2010.
Turnbull JE. Systems approach to error reduction in health care. Japan Med Assoc J. 2001 Sep; 44(9): 392-403.
Wachter R. In conversation with Lucian Leape, MD.WebM&M. 2006 Aug; Perspectives on Safety.
Warner CJ, Walsh DB, Horvath AJ, Walsh TR, Herrick DP, Prentiss SJ, Powell RJ.Lean principles optimize on-time vascular surgery operating room starts anddecrease resident work hours. J Vasc Surg. 2013 Nov;58(5):1417-1422. PMID: 23827339.
Federal Laws Relating to Patient Safety
•Consumer Product Safety Act of 1972 (Oct 27, 1972); Public Law 92-573
•Medical Device Amendments of 1976 (May 28, 1976), Public Law 94-295
•Safe Medical Device Amendments of 1990 (November 28, 1990), Public Law 101-629
•National Literacy Act of 1991 (July 25, 1991), Public Law 102-73
•Health Insurance Portability and Accountability Act (HIPAA) (August 21, 1996), Public Law 104-191
•Healthcare Research and Quality Act of 1999 (December 6, 1999), Public Law 106-129
•Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (December 8, 2003), Public Law 108-173
•Patient Safety and Quality Improvement Act of 2005 (July 29, 2005), Public Law 109-41
•Health Care Safety Net Act of 2008. (October 8, 2008). Public Law. 110-355
•American Recovery and Reinvestment Act of 2009 (February 17, 2009), Public Law 111-5; with Title XIII: Health Information Technology for Economic and Clinical Health Act (HITECH) for electronic health records
•Affordable Care Act (ACA): Patient Protection and Affordable Care Act (March 23, 2010), Public Law 111-148; and the Health Care and Education Reconciliation Act of 2010. March 30, 2010. Public Law 111-152. 124
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This project has been funded in whole or in part with Federal funds from the National Library of Medicine, National Institutes of Health, Department of Health and Human Services,
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Recommended Reading
Articles Focusing on the Value of the Library in Patient Safety
Aitken EM, Powelson SE, Reaume RD, Ghali WA. Involving clinical librarians at the point of care: results of a controlled intervention.Acad Med. 2011 Dec;86(12):1508-1512. PMID: 22030761
Banks DE, Shi R, Timm DF, et al. Decreased hospital length of stay associated with presentation of cases at morning report with librarian support. J Med Libr Assoc. 2007 Oct; 95(4):381-387. PMID: 17971885.
Brandes S. Experience and outcomes of medical librarian rounding. Med Ref Serv Q. 2007 Winter; 26(4):85-92.PMID: 18086644.
Bryant SL, Gray A. Demonstrating the positive impact of information support on patient care in primary care: a rapid literature review. Health Info Lib J. 2006 Jun;23(3):118–125. PMID: 16706867.
Cuddy TM. Value of hospital libraries: the Fuld Campus study. J Med Libr Assoc. 2005 Oct; 93(4):446-449. PMID: 16239940.
Marshall JG, Sollenberger J, Easterby-Gannett S, et al. The value of library and information services in patient care: results of a multi-site study. J Med Libr Assoc. 2013 Jan; 101(1):39-46.
Medernach C, Frank J. Assessing the impact of information services in a regionalized health-care organization. Health Info Libr J. 2007 Dec;24Suppl 1:46-56. PMID: 18005294.
O'Connor P. Determining the impact of health library services on patient care: a review of the literature. Health Info Libr J. 2002 Mar;19(1):1-13. PMID: 12075845.
Weightman AL, Williamson J; Library & Knowledge Development Network (LKDN) Quality and Statistics Group. Value and impact of information provided through library services for patient care: a systematic review. Health Info Libr J. 2005 Mar;22(1):4-25.PMID: 15810928.
Selected Articles on Patient Safety and Libraries and Librarians
Burt HA. Patient safety answers require outreach, in-reach and partnerships. J HospLibrariansh. 2011; 11(4):366-378.
Cobus L. Integrating information literacy into the education of public health professionals: roles for librarians and the library. J Med Libr Assoc. 2008 Jan; 96(1):28–33. PMID: 18219378.
Garcia JL, Wells KK. Knowledge-based information to improve the quality of patient care. J Healthc Qual. 2009 Jan-Feb;31(1):30-35. PMID: 19343899.
Greco E, Englesakis M, Faulkner A, Trojan B, Rotstein LE, Urbach DR. Clinical librarian attendance at general surgery quality of care rounds (Morbidity and Mortality Conference). SurgInnov. 2009 Sep;16(3):266-269. PMID: 19717393.
Klem ML, Weiss PM. Evidence-based resources and the role of librarians in developing evidence-based practice curricula. J Prof Nurs. 2005 Nov-Dec;21(6):380-387. PMID: 16311234.
Kronenfeld M, Stephenson PL, Nail-Chiwetalu B, et al. Review for librarians of evidence-based practice in nursing and the allied health professions in the United States. J Med Libr Assoc. 2007 Oct;95(4):394-407. PMID: 1797188.
Kurup V, Hersey D. Perioperative librarian: luxury or necessity? CurrOpinAnaesthesiol. 2007 Dec; 20(6):585-589. PMID: 17989555.
Miranda GF, Vercellesi L, Pozzi E, Bruno F. Improving health communication: supporting the practice of health communication. Health Info Libr J. 2009 Mar;26(1):39–46. PMID: 19245642.
Pappas C. Hospital librarians' perceptions related to evidence-based health care. J Med Libr Assoc. 2008 Jul;96(3):235-238. PMID: 18654652.
Rankin JA, Grefsheim SF, Canto CC. Emerging informationist specialty: a systematic review of the literature. J Med Libr Assoc. 2008 Jul;96(3):194-206. PMID: 18654656
Rourke DR. The hospital library as a "magnet force" for a research and evidence-based nursing culture: a case study of two magnet hospitals in one health system. Med Ref Serv Q. 2007 Fall; 26(3):47-54. PMID: 17915630.
Schardt C.Health information literacy meets evidence-based practice. J Med Libr Assoc. 2011 Jan; 99(1):1–2.
Schwing LJ, Coldsmith EE. Librarians as hidden gems in a clinical team. Med Ref Serv Q. 2005 Spring; 24(1):29-39. PMID: 15760831.
Tod AM, Bond B, Leonard N, Gilsenan IJ, Palfreyman S. Exploring the contribution of the clinical librarian to facilitating evidence-based nursing. J ClinNurs. 2007 Apr; 16(4):621-629. PMID: 17402942.
Urquhart C, Turner J, Durbin J, Ryan J. Changes in information behavior in clinical teams after introduction of a clinical librarian service. J Med Libr Assoc. 2007 Jan;95(1):14–22.PMID: 17252062.
Vaida AJ, Zipperer L. Safe medication information delivery: the role of the medical librarian. Patient SafQualHealthc 2006 Nov/Dec; 3(6):42-45.
Wagner KC, Byrd GD. Evaluating the effectiveness of clinical medical librarian programs: a systematic review of the literature. J Med Libr Assoc. 2004 Jan;92(1):14-33. PMID: 14762460.
Welton NJ. University of Washington electronic medical record experience. J Med Libr Assoc. 2010 Jul;98(3):217-219. PMID: 20648254.
Winning MA, Beverley CA. Clinical librarianship: a systematic review of the literature. Health Info Libr J. 2003 Jun;20Suppl 1:10-21. PMID: 12757432.
Online Bibliographies
Dunn. K. Value of library and information services in patient care study: bibliography (1972-2009). New York: National Libraries of Medicine Middle Atlantic Region; 2009.
Hospital library standards and their value (1987-2016). [Internet].HLWIKI International. (9 Mar 2016).
Measuring the value and impact of health libraries and resources (1975-2007). Burnaby, BC: Electronic Health Library of British Columbia; 2007.
Recommended Books
Advances in patient safety. Rockville, MD: Agency for Healthcare Research and Quality; 2005-.
Nance J. Why hospitals should fly: the ultimate flight plan to patient safety and quality care. Bozeman, MT: Second River Healthcare Press; 2008.
National Academies Press. Quality Chasm series: health care quality reports from the institute of medicine. (26 Jan 2012).
Reason, J. Human error. Cambridge, MA: Cambridge University Press; 1999.
Shekelle PG, Wachter RM, Pronovost PJ, et al. Making health care safer II: an updated critical analysis of the evidence for patient safety practices. Evidence Report No. 211. AHRQ Publication No. 13-E001-EF. Rockville, MD: Agency for Healthcare Research and Quality; 2013.
Wachter R. Understanding Patient Safety. 2nd ed. New York, NY: McGraw-Hill; 2012.
Zipperer L. Patient safety: perspectives on evidence, information and knowledge transfer. London: Gower Publishing: 2014.
Recommended Reading for Patients, Families and Patient Advocates
Beck M. Bedside manner: advocating for a relative in the hospital. Wall Street J. October 28, 2008.
Berntsen KJ. The Patient’s guide to preventing medical error. Westport, CT: Praeger; 2004. ISBN: 0275982300.