Patient Safety Glossary

PATIENT SAFETY ORGANIZATION

TERMINOLOGY AND ACRONYMS

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Active Error

An error that occurs at the point of contact. Active errors are generally readily apparent (e.g., pushing an incorrect button, ignoring a warning light) and almost always involve someone at the front line. Active failures are sometimes referred to as errors at the sharp end.

ADE – Adverse Drug Event

An adverse event involving the use of medications or the failure to use appropriate medications when indicated.

Administration Error

An error in the phase of the medication use process where the drug product and patient interface.

ADR – Adverse Drug Reaction

An adverse effect produced by the use of a medication in the recommended manner. ADRs may range from “nuisance effects” (e.g., dry mouth with anticholinergic medications) to severe reactions, such as anaphylaxis to penicillin.

AE – Adverse Event

Any injury caused by medical care. An adverse event does not imply error, negligence or poor quality care, but indicates that an undesirable clinical outcome resulted from some aspect of diagnosis or therapy, not an underlying disease process.

AHRQ

Agency for Healthcare Research and Quality  www.ahrq.gov

Bar Code

graphic representation of data (alpha, numeric, or both) that is machine readable; a method of encoding numbers or alphabetic characters using wide and narrow bars and spaces according to a set of rules called symbols. Scanning of a bar code gives instant access to information in an associated database.

Benchmark

In healthcare, a benchmark is the best in industry measurement that can lead to superior performance.  Three principles of benchmarking are maintaining quality, customer satisfaction and continuous improvement.

Blunt End

The “blunt end” refers to the many layers of the health care system not in direct contact with patients, but which influence the personnel and equipment at the point of contact, the “sharp end”. The blunt end refers to those who set policy, manage health care institutions, design medical devices, and other people and forces, which, though removed from direct patient care, affect how care is delivered.

Call out

A strategy used to communicate important or critical information.

Check-Back

A process of using closed-loop communication to ensure that information conveyed by the sender is understood by the receiver as intended.

Close Call

An event or situation that did not produce patient injury, but only because of chance. The close call may be attributed to the robustness of the patient or a fortuitous, timely intervention. Close calls are also called “near miss” incidents.

Competency

An event or situation that did not produce patient injury, but only because of chance. The close call may be attributed to the robustness of the patient a fortuitous, timely intervention. Close calls are also called “near miss” incidents.

Complexity Science (or Complexity Theory)

An approach to understanding the behavior of systems that exhibit non-linear dynamics, or the ways in which some Adaptive systems produce novel behavior not expected from the properties of their individual components. Such behaviors emerge as a result of interactions between agents at a local level in the complex system and between the system and its environment.

CPOE (Computerized Physician Order Entry)

A computer based system for ordering medications and/or other tests in which physicians directly enter orders into a computer system.

Crew Resource Management (CRM)

A range of approaches to training groups, originally developed in aviation, to function as teams, rather than as collections of individuals that emphasizes the role of “human factors” and the impact of different management styles and organizational cultures in high-stress, high-risk environments.  Also referred to as Crisis Resource Management.

Critical Incidents

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