Knowledge Concept

     Knowledge is the condition of being aware of something. In many incidents, we see a "missing knowledge" pattern where information, if known by one of the participants in the incident, might have dramatically changed the outcome. There are potentially many reasons why people are not aware of information. Sometimes a person has inaccurate, or "buggy," knowledge (e.g., a novice nurse does not know that a door needs to be open in order to protect a "reverse isolation" patient from infection). Sometimes some are aware of information, but not everyone (e.g., a clerk knows a surgery is cancelled, but not the surgeon). Sometimes information is potentially available, but is not accessed (e.g., on the 80^th page of a 150-page medical record, an allergic reaction to penicillin is documented). Sometimes information is available, but people miss it because they are focused on other tasks (e.g., an oxymeter alarm goes off which is often a "false alarm" and so the nurse has learned over time not to detect the alarm sound). Each of these explanations for missing knowledge requires different strategies for improving patient safety.