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About lzipperer

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    Patient safety and knowledge sharing entrepreneur that helps experts "get things done!"
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    Zipperer Project Management
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  1. Article Comment
    Nice related freely-available study: Safety concerns with consumer-facing mobile health applications and their consequences: a scoping review. Saba Akbar, Enrico Coiera,, Farah Magrabi. Journal of the American Medical Informatics Association. https://doi.org/10.1093/jamia/ocz175
  2. Community Post
    Thanks Clive -- Chris Collison is another "go to" resource for this type of info.
  3. Community Post
    Haydn -- I applaud you for trying to define "lessons learned." Its a tough one -- like so many other terms in the knowledge management realm. But defining what it is you are trying to track and develop systems to optimize is so important. Working with peers in your organization to build a shared mental model around use of terms will help to collectively build understanding and buy-in around what you aim to accomplish. These sources may help: Nick Milton is a leader in the KM field and this survey may give you some examples of language that could work: https://www.knoco.com/Knoco White Paper - Lessons Learned survey.pdf His handbook builds on these ideas with some practical instruction on moving forward with a lessons learned initiative: https://www.sciencedirect.com/book/9781843345879/the-lessons-learned-handbook another resource : NATO Lessons Learned Handbook: https://nllp.jallc.nato.int/iks/sharing public/nato_ll_handbook_2nd_ed_final_web.pdf Good luck in wrestling this one to the ground 😉
  4. Community Post
    Hi Jules - - great of you to try and focus this section of the community. Do you think its necessary or important here to define what we mean by leadership? Are we discussing "executives and decision makers" per se or any individual that embodies what leadership is about?
  5. Content Article
    Anniversaries are special. They acknowledge events from personal to the historic. I just celebrated an anniversary that met both those criteria: 25 years of marriage. I did so in a place marking the centennial of its designation as a national park – a true American wonder – the Grand Canyon. It goes without saying that the place is gobsmacking: it literally takes your breath away. It is no easy feat to navigate the options for what can be done while you are there – the food, the views, the trails, the crowds, the mules! To make the trip really monumental however, visitors and staff need to keep safety in mind. Just as clinicians, patients and families do while they are in the hospital. They need to get informed, prioritise activities and trust judgment to manage risk. Distributing good, freely available information The Grand Canyon Visitor’s centres and trail heads provide a cornucopia of maps, pamphlets and booklets highlighting options for activities. Making information and data available is key to keeping a visitor to the Canyon free from harm. Similar to trail maps noting loose rocks, unmaintained walkways and mudslide potential, the US Pennsylvania Patient Safety Authority (PSA) models the important mission of transparency by sharing what they learn about threats to safety. The organisation has been collecting and analysing adverse event and other data for 15 years. The Authority disseminates it not only to generate action within their state, but throughout healthcare. Their new open access journal, Patient Safety, continues down a trail established by the PSA newsletter. This work will help all of us progress by providing insights to manage both unseen and known obstacles to safety. Prioritising action Grand Canyon National Park offers a wide array of choices for visitors. If you only have a day or two in the region, prioritising what hike to take and when to go takes some planning. Just as in safety where the options, tools and improvement goals can become overwhelming. It is crucial to have a method to sort things out. In both instances there is so much to do! Recently the US Veterans Administration (VA) health system published a paper on the process they use to prioritise efforts in their system. They summarised an approach that rests on a foundation of learning practices that could be helpful for all of us to consider in moving forward. Trusting your gut My husband in his college days hiked down the Canyon to the Colorado river and back up three separate times. Those treks gave him experience that enabled him to know when “worry” was worth listening to as we ventured down a rugged, steep, trail during our visit. We went down and came back up into the Canyon safely. A recent study from the US, published in JAMIA Open, looked at the accuracy of nursing judgement as a barometer for patient deterioration. The “Worry Factor” proved to be a darn good signal – over 75% of deterioration situations were correctly identified by nurses ahead of time. Then there are the others Do you ever wonder “what the ???” when you see people doing something in a park – there are signs everywhere NOT to do ... but they do it anyway? Scampering up rocks behind the safety railing, feeding squirrels, trudging down a rocky trail in flip flops! Safety messages are posted all over the park in an effort to keep Grand Canyon visitors safe. Of course, humans being human, don’t always follow the advice due to arrogance, language issues or a myriad of factors – the distraction caused by the beauty and awe of the place being one of them. Same goes for healthcare. Unintended consequences of process and environment complexity can derail efforts to keep patients safe. Bureaucracy can undermine efforts to keep large systems resourced to provide high quality care delivery, as we heard in a recent examination of the US Indian Health Service. Despite efforts to monitor opioid prescribing practices of physicians, the behaviors are notoriously persistent. Transparency and accountability for failure, while heralded as core attributes of safe care, are not always available to patients. Patient safety and life are both grand adventures that we can navigate through the effective use of information, prioritisation and sound judgment. I hope you all have as good a partner in your journeys as I have had in mine.
  6. Content Article Comment
    Jules -- thanks for sharing this. I have heard from colleagues that systematic reviews aren't always that useful in day-to-day practice. How would you suggest they use this material to further their efforts on the front line to generate the use of simulation?
  7. Content Article
    “One small step for man ... “ 50 years on – we all recognise this phrase that accompanied one of the most famous descents in history: Neil Armstrong’s emergence from the lunar module toward his first step on the moon. The Apollo 11 moon landing represents an unparalleled accomplishment. Its characteristics resonate with patient safety professionals who look to space for inspiration. The Apollo programme experienced both triumphant achievement and catastrophic failure. The effort learned from mistakes, embraced teamwork, and considered human factors as part of its domain. Its workforce remained focused on a single goal. The effort embodied commitment, complicatedness and complexity. The 50th anniversary of these victories provides compelling parallels for error reduction efforts active today in healthcare in the US: Organisational learning systems NASA (National Aeronautics and Space Administration) is a learning system. Learning systems are developed and nurtured through common goals, leadership commitment and resource sustainability. They thrive through action generated by the application of data, evidence and knowledge. Likewise, the US Agency for Healthcare Research and Quality (AHRQ) has partnered with the US-based hospital and healthcare accreditation organisation, The Joint Commission, to disseminate analysed evidence compiled by the Evidence-based Practice Center (EPC) programme. These organisations are working together to transfer what is known into an actionable form through a series of articles to enhance the use of better practice and learning on the frontline. This programme and the article series are introduced in a recent commentary on the project. Coordinated action The Keystone Center represents the culmination of the work of patient safety’s own Neil Armstrong – Dr Peter Pronovost, known for his otherworldly (at the time) commitment to the checklist intervention. The Keystone Center initially coordinated and collected data to guide the implementation of the checklist concept in 70 intensive care units across the state of Michigan. Now the Center serves as the state’s mission control for hospital patient safety and quality. Leaders there raise awareness of success through the Speak-Up! award programme that acknowledges frontline healthcare staff for voicing their concerns and making care safer. The Center enables sharing of concerns that result in cost savings due to harm avoidance. A push in the right direction The Apollo programme applied technical sophistication, engineering and know-how to land a man on the moon and return safely to Earth within a decade. No small feat! Despite that imperative, both the module and the space programme needed a little boost now and again to get out of Earth’s orbit to complete its momentous undertaking. Patient safety has a similar call motivating its work – zero preventable harm. Some aim for ‘zero harm’ but is this achievable? Healthcare is very complex with multiple machine/human/machine interfaces. Clinicians, leadership and organisations still need a boost to design and use technology and data to support the workforce to improve care at the bedside. The mission-driven, Boston-based Betsy Lehman Center builds on a strong desire to prevent failures similar to those that took the life of its namesake – Betsy Lehman – the Boston Globe reporter who died in 1994 due to medication errors. The Center is a state agency that serves as mission control for its constituents. To help healthcare in Massachusetts move its safety work beyond the comfort of the status quo, they have recently convened a consortium to propel existing programmes towards new and aspirational achievement. On the dark side of the moon Of course, the Apollo programme suffered setback and tragedy. While I want to highlight successes in my Letter from America, I will also share stories of struggle to foster learning from what doesn’t work. News and narrative will often remind us of why continued work on safety improvement is fundamental. Diagnostic error is prevalent. A recent analysis of closed US medical malpractice claims found that delayed or missed diagnoses in three primary clinical areas – vascular events (such as strokes), infections (like sepsis) and cancer – substantially resulted in disability or death. You can take that to your mission control to motivate data collection, teamwork and effort to focus on diagnostic improvement in practice. Transparency is messy. The revelation of Neil Armstrong’s reported death in 2012 due to substandard medical care is sad for all kinds of reasons. It underscores persistent cultural influences that reduce the sharing of information related to poor care. This minimises our opportunity to learn from failure and support patients, families and clinicians involved in error. Organisational resistance to transparency about mistakes and the messiness of openness are challenges... even when the incident involves a patient with less name recognition. The Apollo programme and the 1969 lunar landing remains inspirational to this day. It behooves all of us who dream of contributing to something we once felt was impossible to engender the right spirit, resources and commitment to help get it done. The learning required for such accomplishment takes time, a culture that supports discussion and recognition of success. If we embrace contribution, collaboration and community, our small steps have the potential to contribute to the “giant leap” forward – to help us take off, realise achievement and return our patients safely home.
  8. Content Article Comment
    Judy -- you have nicely summarized how AARs serve as a source of knowledge sharing to help organizations learn--but I am not sure how they are optimized to do that in a real "human-centered" rather than "information sharing" way. Just developing and disseminating a report is a good thing, but the tacit knowledge that makes the AARs potentially so powerful as learning opportunities can get lost when the discussions are translated to an explicit object. How has your experience made AARs into a true knowledge transfer strategy throughout an organization?
  9. Community Post
    Root case analysis has its detractors but can still bring value to understanding deep-seated problems that affect the safety of care. Does anyone have a checklist of elements of an effective TRAINING strategy to bring staff on board with the process? Not how to do an RCA, but to bring a team to the skill competencies they need to do RCA? I'd appreciate hearing your experiences. Please tell your tales!
  10. Community Post
    Here is a good freely-available study on speaking up: A qualitative study of speaking out about patient safety concerns in intensive care units. Tarrant C, Leslie M, Bion J, Dixon-Woods M. Soc Sci Med. 2017;193:8-15. https://doi.org/10.1016/j.socscimed.2017.09.036
  11. Community Post
    I think this is an unexplored area that affects "blunt end staff" -- a lot. Granted, they aren't "laying of hands" and their burnout and bullying may not as directly affect clinical safety, but it does signify the lack of a safety culture. If we profess to fix the entire culture to enable safety--health care needs to see the negative impacts on non-clinical staff both in clinical and non-clinical environments as well. This is another good one: https://doi.org/10.1016/j.jsr.2017.12.015
  12. Community Post
    I think its also important to think about how the "toxic environment" burn the people out who end up trying to manage it--on both the sharp and the blunt end. This 1999 article from the Harvard Business Review is one of my favs on that topic: https://www.ncbi.nlm.nih.gov/pubmed/10539211 The full text should be free with registration https://hbr.org/1999/07/the-toxic-handler-organizational-hero-and-casualty