In Conversation With… Lorri Zipperer, MA
Approach to Improving Safety
Setting of Care
Editor's note: Lorri Zipperer, principal at Zipperer Project Management, was a founding staff member of the National Patient Safety Foundation as their information projects manager. She has also been Cybrarian for AHRQ Patient Safety Network since its inception.
Dr. Robert M. Wachter: When the Internet started were you already a librarian?
Lorri Zipperer: I was working in the AMA's [American Medical Association] library at the time. We had to basically beg them to give us access to the Internet.
RW: I imagine there were librarians who not only weren't ready to change what they were doing, but also saw the Internet as an existential threat. Was that true, and did you worry about that at all?
LZ: It is true, and it's a legitimate fear. Many people think that everything you need is on Google, and everything you need is free. And that's just not true. That particularly plays out in fields where decision-making has real ramifications if the search results are incomplete. The case study for that had to do with a Johns Hopkins study participant. One of the factors, or hole in the Swiss cheese, contributing to this woman's death was an incomplete literature review strategy. It's a legitimate concern that individuals who think that they understand how to use these search tools may not be getting what they need. But when it goes through librarians or someone who's trained to do this work, there is a stopgap there. Somebody could look at this and say, "This search strategy is lousy, or it's full of bias. You're only looking for the things that are supporting what you're doing." When empowered to, librarians can be adamant about that because they understand that that's an important role they play. But now they often don't get to do that because the searching all happens outside of their purview. In the writing and teaching that I do, I try to help not only librarians see how their skills fit in from a safety perspective but also help nonlibrarians see why it is important to think in this way.
RW: As you think about what you've done in the last 20 or so years in the safety world, how has it been different than what you expected?
LZ: Well, one of the most exciting things about it, and one of the most frustrating things, is that I see connections between the safety sciences piece of how information, evidence, and knowledge fit into this in a way that I didn't really expect. When I first walked into it, so many needs were just traditional library needs, getting the literature together, putting content on a website, or making sure that researchers had the articles they needed to be able to move their work forward. Through access to the tremendous people that were around when NPSF [National Patient Safety Foundation] was formed, I had the opportunity to learn about systems thinking and high reliability and all the nuances that make this work challenging and important. Being able to do that and try to move that forward has been frustrating and exciting and enlightening because it's a really new way to think about how to make safety happen and be sustainable and spread.
RW: From your vantage point, what do you see as some of the emerging trends in the field? You would see it in a slightly different way than a frontline clinician or than a manager; you're seeing the information needs and the connections between things that we might not see.
LZ: I'm encouraged by the emphasis on teamwork because, in essence, it's essential that teams are aware of the knowledge in the room to make themselves more responsive to immediate threats and needs. Some of that mindfulness and awareness of what's going on around you is enabled by knowledge because you have experience with it. You don't see things the same way if you have never done it or never participated before.
RW: You were talking about how we still need librarians even in a world of Google. Do you think they will be needed in 10 or 15 years?
LZ: I've always seen the opportunity for librarians to be strategists when it comes to this. Librarians should see their role as providing an organizational learning conduit rather than as only a service provider. Other professionals (nurses or anybody who's really oriented to frontline work) don't always want to sit back and think about theory and strategy and how you apply it. I've talked to colleagues who understand where I come from. The pure technique around finding information may not be as necessary in 10 to 15 years. To some extent standard search tools are getting better all the time. If there's emphasis around understanding when the tool isn't good enough—and when you're not good enough with the tool—that's when you call the librarian. Whereas when individuals use PubMed occasionally to try to do a paper and need to find a couple of review articles, they don't need librarians to do that.
RW: Lucian Leape told me that the patient safety field was discovered by a librarian. When he went to the Harvard Library to try to look up information about patient safety and found nothing, the librarian suggested he look in other disciplines. When you heard that story, what did you think?
LZ: It's a great story. I use it often in my education classes around knowledge and also talking about metrics and the value of the work that librarians do. Back when I was doing lit reviews on a regular basis at the AMA, we counted how many searches we did, but counting doesn't really matter. Because in essence that exchange with Lucian was only one search, but it changed medicine.
Lucian wasn't embarrassed about needing help, and he went and he found somebody who could help him. That person didn't say, "It's not my job." The librarian provided a service, asked questions, and found what he needed in a way that opened the door to something new. It's a great application of the value of knowledge that people don't always think about when they ask a question. Because he went into the library and asked a question, siloes were broken down, and the librarian saw him or herself as a partner who could help answer this. These exchanges are often possible in health care and in other industries, but we haven't figured out the best way to ask those questions. Considering how to quantify the value of what librarians do is a huge challenge. Until you really know what the impact is, it's hard to understand how to articulate the value of what you're doing, particularly when you're being challenged by technologies that are less expensive and available 24/7, like Google.
RW: What do you think the AHRQ PSNet site has meant over its life?
LZ: I've been monitoring the patient safety literature since I started doing it at NPSF back when we could barely fill an update with 20 articles every 2 weeks, which of course is not an issue now. At that time, we didn't have the tools that we have now. I spent a lot of time talking to experts about what information and evidence they needed and got a sense of the broader range of what safety was about, along with the nuances about the field to develop the robust search and inclusion process that we have at PSNet. I'm glad that PSNet honors that broad range because it indicates that safety is not a one-shot deal. You don't get everything you need on safety by putting "patient safety" into any search engine anywhere, no matter how good it is.
I've been pleased with the efforts to translate not only evidence but also the information value of news stories and websites exploring safety and what happens in medicine so people don't have to spend their own time searching, which takes a lot of time. PSNet is doing this for people. We are getting them started. It's a real value to the field that PSNet is providing this in a way that is rich and robust. It gives people a place to get grounded and try to understand the elements that make up safety work. That's a huge contribution to the field. PSNet has evolved over time in that some topics are so mainstream that we're tired of looking at them, and some topics are messy and murky still. Is this a quality piece or a safety piece? It remains challenging to choose the most useful and the best content for people to see weekly. Over the course of the more than 10 years we've been doing this, we have found that there is always good and interesting work going on in the safety field. It's been an honor to be working on it. It's a great resource, and I hear that from many people as well. They appreciate it and use it on a regular basis.
RW: As you think about PSNet over the next 5 to 10 years, what does it need to evolve into?
LZ: I would really love to hear more about what people are using PSNet for. Stories of "Boy, that article on PSNet opened my eyes to x." Or, "I didn't realize that this was a problem until I saw it on PSNet." Some of those stories would connect us with the readers. It's always important to hear from somebody that your work is of value, and I have no doubt that what we're doing is of value. But if somebody called us and said, "I saw that article on PSNet and it saved a life." Or "I was able to hire a patient safety officer or three extra nurses (or whatever)"; to have that feedback would be powerful. With social media the way it is now, maybe someday we'll be able to capture some of those stories.
It would also be nice to think about how to make it more applicable to clinicians on the frontline. I don't know how to do that. "I used this to make a difference in my world," to build a story and knowledge piece would be exciting. It may be tricky, but being able to connect the dots would be an interesting build on what we're already doing well with evidence and information.
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