Patient Safety: Physicians and Librarians - Partners in Change

Holly Ann Burt, MLIS, MDiv

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Patient Safety: Ongoing Problem

“I would give great praise to the physician whose mistakes are small, for perfect

accuracy is seldom seen… .”

Hippocrates, trans. by Francis Adams. On Ancient Medicine, Part 9; c. 400 BCE.

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Partnership Beginnings

In 1518, Henry VIII of England founded the Royal College of Physicians in London, which established a medical library in 1653Although this library was destroyed in the fire of 1666, others built on the concept.

In 1681, Sir Robert Sibbald received a Royal Charter to establish the Royal College of Physicians of Edinburgh; he started the medical library with his collection the following year

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Partnership Beginnings – 1700’s

In 1731, Benjamin Franklin opens the Library Company of Philadelphia, the first circulating library

In the United States, the first hospital public medical library was opened in 1763 in the Pennsylvania Hospital (1751) in Philadelphia

In 1788, the College of the Physicians of Philadelphia (1787) establishes the second medical library in the United States

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Partnerships – 1800’s

The personal collection of the Surgeon General of the US Army was formally established as a library in 1836 and would become the National Library of Medicine in 1956

1898: 120 medical libraries – 24 in medical societies – 12 in hospitals– 7 in pharmaceutical colleges – 1 in a veterinary

college– 5 in local and state Boards of Health– 45 public libraries have medical departments (“only a few are

efficient, stocked, and active”)– Remainder in library associations, museums, academic settings

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Medical Library Association

Association of Medical Libraries organized in 1898 in partnership with the

America Library Association (1876) and theAmerican Medical Association (1847);

becoming theMedical Library Association in 1907

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1847 – an Important Year

“All students or doctors who enter the wards for the purpose of making an examination must wash their hands thoroughly…”. Ignác Fülöp Semmelweis.

1847-1849.

National Medical Convention adopts a “Code of Medical Ethics” in 1847 and establishes the American Medical Association (AMA)

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Accreditation and Libraries

1913: American College of Surgeons (ACS) founded The ACS develops the Minimum Standard for Hospitals

(1917) and begins on-site inspections (1918) 1921: ACS Literary Research Department established

(becoming Library and Department of Literary Research by 1931)

1941: 16 Minimum Standards for other departments or services are added to Manual for Hospital Standards– Hospital Medical Library

1951: Updated Manual of Hospital Accreditation lists Required and Contingent (desirable, but not absolute prerequisites to accreditation) sections– Medical Library is under Contingent

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Accreditation

In 1951, – the American College of Physicians (ACP), – the American Hospital Association (AHA), – the American Medical Association (AMA), – and the Canadian Medical Association (CMA) – joined with the American College of Surgeons (ACS) to

Create the Joint Commission on Accreditation of Hospitals (JCAH),

– becoming JCAHO (Joint Commission on Accreditation of Healthcare Organizations) in 1987,

– and shortened to The Joint Commission in 2007

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Libraries and JCAH/JCAHO/TJC

In 1953, responsibility for the hospital standardization program passed from the from American College of Surgeons to The Joint Commission (JCAH)– Medical Library continued under Contingent

Social Security Amendments of 1965: voluntary accreditation by JCAH helped organizations meet Medicare and Medicaid certification requirements– Library services required for a health care institution

to be eligible for a hospital accreditation survey

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Changing Standards

The library standard continued from 1953-1993– Medical Library (1953)– Professional Library Services (1970) – Professional Library and Health Information Services (1993)

1994: Libraries were folded into Management of Information, Knowledge-Based Information (IM)

2003: the first National Patient Safety Goals included patient education – a librarian’s connection

From 2004 on, patient education was included under several standards

In 2009, CMS standards become more closely linked to those of TJC – and further from libraries

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Many Streams Flow to the River

Aviation– Aviation Safety Reporting System (ASRS) – 1975

Transportation– National Transportation Safety Board (NTSB) – 1966

Nuclear Energy Manufacturing

– Toyota Production System – 1977 – Six Sigma – 1995

Federal and State Laws Librarianship

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Patient Safety – 1970s

Clinical Librarianship – librarians on the floors with physicians began in 1971

Also in 1971, the National Library of Medicine establishes MEDLINE

Consumer Product Safety Act of 1972 Medical Device Amendments of 1976

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The First Manual

In 1979, in partnership with the Maryland Healthcare Education Institute, the ACS developed the first comprehensive Patient Safety Manual to improve safety by focusing organizational systems on patient care, establishing reporting systems and improving patient communications

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Patient Safety Vanishes

The second edition of the manual came out in 1985 – and the focus was now risk management

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Key Conference - 1996

Examining Errors in Health Care: Developing a Prevention, Education, and Research Agenda (the first multidisciplinary conference devoted to issues of patient safety across the health spectrum) – The American Association for the Advancement of

Science (AAAS)– American Medical Association (AMA)– JCAHO (The Joint Commission)– Annenberg Center for the Health Sciences

This event – Sparked revision of the (TJC) Sentinel Event policy– Announced the National Patient Safety Foundation

(NPSF), launched by the AMA in 1997

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Patient Safety: 2000

To Err is Human: building a safer health system (Released in 1999)

An Organisation with a Memory: report of an expert group on learning from adverse events in the NHS chaired by the chief medical officer

Iatrogenic Injury in Australia (2001)

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Death of a Volunteer

In 2001, Ellen Roche died during a clinical trial – The report of the investigative committee noted that

articles from 1953 to 1960 with key information about potential drug toxicity had not been identified in the literature search required by the institutional review board

In 2003, The National Library of Medicine merged three-quarters of the separated OLDMEDLINE database (1946-1965 citations) into PubMed

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Patient Safety Legislation

Tennessee Health Data Reporting Act of 2002 Colorado Revised Statute 13-25-135, 2003 Medicare Prescription Drug Act 2003 Patient Safety and Quality Improvement Act of

2005 American Recovery & Reinvestment Act of 2009

– Health Information Technology for Economic and Clinical Health Act (HITECH Act)

The Patient Protection & Affordable Care Act of 2010 and Health Care & Education Reconciliation Act of 2010 (Affordable Care Act)

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Librarians on the Move

Dr. Atul Gawande, keynote speaker at 2006 Medical Library Association annual meeting

Esparza, et al. The effect of a clinical medical librarian on in-patient care outcomes. 2013.

Marshall, et al. The value of library and information services in patient care: results of a multisite study. 2013.