Proceedings of the 12th European Conference on Knowledge ...

Question
Does <strong>the</strong> lesson describe <strong>the</strong> backgrounds
<strong>of</strong> <strong>the</strong> stakeholders and <strong>the</strong> relationships
among <strong>the</strong>m?
Does <strong>the</strong> lesson mention <strong>the</strong> normal or best
practices that <strong>the</strong> participants should have
taken?
Are <strong>the</strong>re any instructions for learners on
how to use <strong>the</strong> knowledge properly? Can <strong>the</strong>
learners find out for how long <strong>the</strong> knowledge
is supposed to be valid?
Experience sharing
Does <strong>the</strong> lesson tell you what <strong>the</strong>
participants observed during <strong>the</strong> events?
Does <strong>the</strong> lesson convey <strong>the</strong> feelings <strong>of</strong> <strong>the</strong>
participants?
Reflective thinking
Does <strong>the</strong> lesson give any reasons for <strong>the</strong>
occurrence <strong>of</strong> <strong>the</strong> event given?
Does <strong>the</strong> lesson mention alternatives and
o<strong>the</strong>r possibilities? Does <strong>the</strong> lesson <strong>of</strong>fer
multiple points <strong>of</strong> view?
Does <strong>the</strong> lesson remind learners <strong>of</strong> <strong>the</strong>
special conditions or exceptions where <strong>the</strong>
recommendations may not be applicable?
Does <strong>the</strong> lesson challenge <strong>the</strong> underlying
assumptions?
Tony K. M. Lo and Patrick S.W. Fong
Analysis
All <strong>the</strong> stakeholders (participants, authors and learners)
are supposed to be medical personnel <strong>of</strong> <strong>the</strong> HKHA who
are familiar with hospital settings and working
environments. However, <strong>the</strong> identities <strong>of</strong> participants in
<strong>the</strong> individual event are not disclosed in <strong>the</strong> bulletin.
The best practices or proper procedures are explicitly
stated and repeatedly frequently in <strong>the</strong> bulletin in <strong>the</strong>
form <strong>of</strong> recommendations. The texts related to <strong>the</strong>
recommendations are put in a separate box in eyecatching
fonts or icons so as to enhance <strong>the</strong> impression
made on <strong>the</strong> learners. A case <strong>of</strong> wrong dosage is shown
in Figure 2.
No instructions for use are given. Learners are
supposed to obtain knowledge through reading <strong>the</strong>
bulletins. It is possible that some <strong>of</strong> <strong>the</strong> knowledge in <strong>the</strong>
bulletin may be outdated after a certain period. For
example, <strong>the</strong> introduction <strong>of</strong> a computer system for
medication may reduce mistakes due to poor
handwriting.
Participants’ observations are only indirectly reported. In
<strong>the</strong> case given in Figure 2, in which a nurse
administered <strong>the</strong> wrong drug based on a physician’s
verbal order, <strong>the</strong>re is no information about what <strong>the</strong>
nurse thought she had heard. Learners do not know
whe<strong>the</strong>r <strong>the</strong> nurse struggled to obey or violated <strong>the</strong>
physician’s order.
In most cases, only objective facts can be found in <strong>the</strong>
content <strong>of</strong> <strong>the</strong> bulletin. Participants’ feelings, such as
hesitation or surprise, are not conveyed.
The possible reasons are ei<strong>the</strong>r too superficial or limited
to just a couple <strong>of</strong> categories, such as wrong drug,
wrong strength, wrong dosage form, etc. Underlying
reasons cannot be found in <strong>the</strong> lessons. Taking <strong>the</strong> case
in Figure 2 as an example, it would be useful if learners
could find out why <strong>the</strong> physician gave a verbal order.
Was it because <strong>of</strong> an urgent situation, fatigue, or simply
carelessness?
Participants’ own opinions are missing from <strong>the</strong> bulletin.
Only authors’ viewpoints are mentioned, in <strong>the</strong> form <strong>of</strong>
recommendations. Special conditions or exceptions
where <strong>the</strong> recommendations may not be applicable are
also not found in this issue.
The issue does not attempt to challenge <strong>the</strong> underlying
assumptions <strong>of</strong> operations or reasons for <strong>the</strong> occurrence
<strong>of</strong> errors.
Table 2: Questions and analysis <strong>of</strong> <strong>the</strong> content <strong>of</strong> MIRP bulletin no. 25
7. Discussion and conclusion
Judging from <strong>the</strong> content <strong>of</strong> this single issue (no. 25), we find that <strong>the</strong> MIRP bulletin is fairly rich in
context, with <strong>the</strong> relationships among <strong>the</strong> stakeholders and <strong>the</strong> domain <strong>of</strong> <strong>the</strong> knowledge to be shared
well defined. Since <strong>the</strong> backgrounds <strong>of</strong> <strong>the</strong> stakeholders, or <strong>the</strong> target audience <strong>of</strong> <strong>the</strong> bulletin, are
clear, learners should be able to absorb <strong>the</strong> knowledge captured in <strong>the</strong> lessons. Never<strong>the</strong>less, <strong>the</strong>
authors are too concerned with <strong>the</strong> fact that <strong>the</strong> whole process should be anonymous and nonpunitive.
While it is understandable that anonymity can encourage people’s reporting, much important
contextual information may have been lost. For example, in <strong>the</strong> case <strong>of</strong> <strong>the</strong> wrong dose, <strong>the</strong> exact
time <strong>of</strong> <strong>the</strong> occurrence <strong>of</strong> <strong>the</strong> event may provide inspiration to learners. Apart from <strong>the</strong> staff who made
<strong>the</strong> mistake, information regarding who else was working in <strong>the</strong> ward may also be helpful in enabling
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