Information behavior in the context of improving patient safety

safety and adverse events will be used for improvement and organizational learning, we know little about how this actually happens in patient care settings. This study examines how organizational and professional practices and beliefs related to patient safety influence (1) how health care providers and managers make sense of patient safety risks and adverse events, and (2) the flow and use of information for making improvements. The research is based on an ethnographic case study of a medical unit in a large tertiary care hospital in Canada. The study found that front-line staff are task driven, coping with heavy workloads that limit their attention to and recognition of potential information needs and knowledge gaps. However, a surrogate in an information-related role—an " information/change agent " —may intervene successfully with staff and engage in preventive maintenance and repair of routines. The article discusses four key functions of the information/change agent (i.e., boundary spanner, information seeker, knowledge translator , and change champion) in the context of situated practice and learning. All four functions are important for facilitating changes to practice, routines, and the work environment to improve patient safety. Introduction Over the last 15 years there has been a growing surge of interest in the topics of patient safety and the incidence of hospital-related injuries and adverse events. Researchers have estimated that in approximately 3% to 16% of inpatient admissions some form of medically related injury occurs and that half those injuries are preventable the Agency for Healthcare Research and Quality set out a challenge in the form of a research agenda for improving patient safety and learning from medical errors. The agenda includes two questions that are directly related to information behavior in clinical settings: " How can useful information be provided to those who can act (e.g., consumers, providers and provider organizations, purchasers, states, and oversight organizations)? " and " How can we encourage the adoption and use of safety information? " (Meyer, Foster, Christup, & Eisenberg, 2001, p. xvi). To answer these questions we must first understand how information about risks to patient safety and adverse events is perceived and handled in health care organizations. How do health care providers make sense of and use such information as part of their day-today work? This article presents a case study of the flow of information in a patient care unit in an acute care hospital and highlights the functions of …