| Patient Safety Glossary Of Terms | |
| TERM | DEFINITION |
| Accident | An event that involves damage to a defined system that disturbs the ongoing or future output of the system |
| Active error | An error that occurs at the level of the frontline operator and whose effects are felt almost immediately |
| Adverse event | An event that results in unintended harm to the patient by an act of commission or omission rather than by the underlying disease or condition of the patient |
| Adverse | Describes a negative consequence that results in unintended injury or illness, which may or may not have been preventable |
| Adverse drug event | Any incident in which the use of a medication at any dose, a medical device, or a special nutritional product may have resulted in an adverse outcome in a patient |
| Adverse drug reaction | An undesirable response associated with use of a drug that either compromises therapeutic efficacy, enhances toxicity, or both |
| Associated with | Means it is reasonable to initially assume that the adverse event was due to the referenced course of care; further investigation and/or root cause analysis of the unplanned event may be needed to confirm or refute the presumed relationship |
| Communication | A process by which information is exchanged between individuals through a common system of symbols, signs, or behavior |
| Composite measure | A combination of two or more individual measures in a single measure that results in a single score |
| Culture | The integrated pattern of human knowledge, values, belief, and behavior that depends upon the capacity for learning and transmitting knowledge |
| Disability | A physical or mental impairment that substantially limits one or more of an individual’s major life activities |
| Effective | Providing care processes and achieving outcomes as supported by scientific evidence |
| Environment | The circumstances, objects, or conditions surrounding an individual |
| Error | The failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim (commission). This definition also includes failure of an unplanned action that should have been completed (omission). |
| Event | A discrete, auditable, and clearly defined occurrence |
| Failure to rescue | Death among patients with treatable serious complications |
| Fall | A sudden, unintended, uncontrolled downward displacement of a patient’s body to the ground or other object. |
| Handover | The accurate, clear, and complete communication about a patient’s condition, care, treatment, medications, services, and any recent or expected changes between different caregivers or providers |
| Harm | Any physical or psychological injury or damage to the health of a person, including both temporary and permanent injury |
| Healthcare acquired infection (HAI) | Infections that patients acquire while receiving treatment for medical or surgical conditions. They are associated with a variety of causes, including the use of medical devices, complications following a surgical procedure, transmission between patients and healthcare workers, or the result of antibiotic overuse. |
| Healthcare facility | Any licensed facility that is organized, maintained, and operated for the diagnosis, prevention, treatment, rehabilitation, convalescence, or other care of human illness or injury, physical or mental, including care during and after pregnancy. |
| Incident | A patient safety event that reached the patient, whether or not the patient was harmed. |
| Informed consent | A process of communication between a patient and healthcare professional that results in the patient’s authorization or agreement to undergo a specific medical intervention |
| Leadership | A process by which a person sets direction and influences others to accomplish a mission, task, or objective, and directs the organization in a way that makes it more cohesive and coherent |
| Mandatory reporting | Legal requirement for physicians and other professionals providing health services to report suspected incidents of abuse and neglect. |
| Medication error | Any error occurring in the medication-use process |
| Mitigation | An action or circumstance which prevents or moderates the progression of an incident towards harming a patient |
| Near miss | An event or a situation that did not produce patient harm, but only because of intervening factors, such as patient health or timely intervention |
| Outcome | In healthcare, an outcome may be measured in a variety of ways, but it tends to reflect the health and well-being of the patient and the associated costs of care |
| Patient centered | Providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions |
| Patient safety | The prevention and mitigation of harm caused by errors of omission or commission that are associated with healthcare, and involving the establishment of operational systems and processes that minimize the likelihood of errors and maximize the likelihood of intercepting them when they occur |
| Patient safety events | A process or act of omission or commission that resulted in hazardous health care conditions and/or unintended harm to the patient. |
| Patient safety practices | Discrete and clearly recognizable processes or manners of providing care that have an evidence base demonstrating that they reduce the likelihood of harm due to the systems, processes, or environments of care. |
| Preventable (event) | Describes an event that could have been anticipated and prepared for, but that occurs because of an error or other system failure |
| Process | The activities that constitute healthcare, usually carried out by professional personnel, but also including other contributions to care, particularly by patients and their families |
| Quality | The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge |
| Restraint | Any method of restricting a patient’s freedom of movement that: is not a usual and customary part of a medical diagnostic or treatment procedure to which the patient or his or her legal representative has consented; that is not indicated to treat the patient’s medical condition or symptoms; or that does not promote the patient’s independent functioning |
| Risk | Possibility of loss or injury |
| Safe practice | Practices that have been demonstrated to be effective in reducing the occurrence of adverse healthcare events |
| Safety | The condition of being free from harm or risk, as a result of prevention and mitigation strategies |
| Sentinel event | An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Such events are called “sentinel” because they signal the need for immediate investigation and response. |
| Serious (event) | Describes an event that results in death or loss of a body part, disability or loss of bodily function lasting more than seven days or still present at the time of discharge from an inpatient healthcare facility or, when referring to other than an adverse event, a non-trivial event |
| Structure | The conditions under which care is provided |
| Surgery | An invasive operative procedure in which skin or mucous membranes and connective tissue is incised or an instrument is introduced through a natural body orifice |
|
Surgery on the wrong body part |
Surgery performed on a body part that is not consistent with the correctly documented informed consent for that patient |
| Surgery performed on the wrong patient | Surgery performed on a patient that is not consistent with the correctly documented informed consent for that patient |
| Surgical site infection | An infection that occurs within 30 days of an operative procedure |
| Timely | Reducing waits and sometimes harmful delays for both those who receive and those who give care |
| Usually preventable (event) | Recognizes that some of these events are not always avoidable, given the complexity of healthcare; therefore, the presence of an event on the list is not an a priori judgment either of a systems failure or of a lack of due care |
